Kerry Manson, Sunil Lad and Marisol Cavieres, 2017. Developing a CAT understanding of Anti-Social Personality Disorder (ASPD). Reformulation, Summer, pp.42-48.
The prevalence of Anti-Social Personality Disorder (ASPD) has been found in up to 47% of males and 21% of females in prison (Fazel & Danesh, 2002), whereas in the community, rates are estimated at 2-3% (Moran, 1999). It is generally recognised that individuals with ASPD are difficult to work with; those who meet criteria rarely seek treatment as well as many services being reluctant to work with this group. When people do engage there is often poor engagement and difficulty in establishing a therapeutic relationship (Glenn et al, 2013). Additionally, ASPD is associated with greater levels of violent recidivism (Craissati & Sindall, 2009; Fridell et al., 2008).
The current Offender Personality Disorder Pathway (NOMS and NHS England, 2015) has led to the development of a number of sites within the prison estate being commissioned to offer those with complex problems and presentations of ASPD and Borderline Personality Disorder (BPD) support and psychological interventions, occupational therapy and the development of a psychological formulation to understand their problems and for this to be shared with practitioners working with that individual. Psychological interventions include a trial of Mentalization Based Therapy (Bateman and Fonagy, 2008) with men with ASPD in the community as part of the Offender Personality Disorder Pathway, as well as accredited offending behaviour programmes offered by the Prison Service mainly using Cognitive Behaviour Therapy principles such as the CHROMIS programme (see Tew and Atkinson, 2013 for an overview).
There is a dearth of research and evidence focusing on psychological interventions for ASPD, and it is widely recognised that interventions that exist are limited in their efficacy for ASPD. Guidance by NICE states that offending behaviour programmes such as Reasoning and Rehabilitation offered a reduction in symptoms related to aggression and impulsivity, but for the authors of this paper these programmes do not address how these symptoms are often a response to an underlying trauma. The societal and economic cost of ASPD is vast. Individuals with these traits will present to criminal justice, drug and alcohol and mental health settings. Additionally the victims that ASPD creates also present to health services due to the harm caused to them, thus perpetuating a cycle of trauma.
The authors of this paper have worked clinically, and through providing supervision to staff, for men who have offended and have been detained within the prison or mental health system. Our conversations began in early 2016, about how helpful it would be if we could capture a relational approach to this client group, more specifically men in prisons who elicit strong reactions in others, are hard to engage and work with, yet pose significant risk to others including the public. Most would meet the Diagnostic and Statistical Manual of Mental Disorders (DSM) V diagnostic criteria for ASPD, which as it currently stands provides a list of behavioural characteristics but does not offer insights into underlying explanations as to the reasons why these men developed antisocial ways of relating and continue to do so in spite of being incarcerated for their offences. In many cases they are offered different therapeutic interventions with limited outcomes (Duggan et al. 2007; Gibbon et al. 2010; National Institute for Health and Clinical Excellence 2009; Warren et al. 2003).
Our conversations have often raised more questions than answers, particularly about the diversity of this client group and how we adequately begin to capture this within a CAT framework. We have begun by describing key reciprocal roles we have noticed about how these men tend to relate; how they anticipate and develop relationships, get their needs met and manage intolerable feelings. We are also grappling with the dimension/construct of psychopathy; what does this mean in practice and does this construct help us further understand some of our client group and the challenges and risks they pose to others?
The hope is that with a developing reformulation we can anticipate better what will be enacted within the helping, custodial, peer and other relationships, which currently form the basis of the men’s day-to-day relationships. We would like to expand this understanding to help identify likely reciprocal role enactments and how staff can be helped to make sense of the powerful and at times disabling counter transference emotions they may experience within the ostensibly helping relationship. We are also mindful of the wider organisation of the prison system and what reciprocal roles are re-enacted at this organisational level, which will also affect a client’s ability to engage with staff and impacts on their participation in individual and group programmes within the prison. Withers (2008) observed that for people with a personality disorder, and more so for those with forensic histories, often had unhelpful experiences with services, ending in acrimony, with a client’s problematic behaviours often escalating within this context.
This paper focuses on men, as this represents the clinical experience of the three authors. The scope of this initial paper is to present the beginnings of a CAT model for understanding the relational difficulties of men in prison with an ASPD diagnosis/ traits, by identifying key reciprocal roles and common themes pertinent to this client group; what it means for our client group, and those attempting to engage with them.
It is easy to see why there is overlap between the diagnostic criteria for ASPD, Narcissistic Personality Disorder (NPD) and Psychopathy. The DSM-V diagnosis for antisocial personality disorder states that the individual must have significant impairments in personality functioning manifest by impairments in both self-functioning (associated with Identity and/or self-direction) and in interpersonal functioning (associated with lack of empathy and/or intimacy). These aspects are described in more detail and include lack of remorse after hurting or mistreating another; incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others. The associated pathological traits are categorized within the domains of antagonism (manipulativeness, deceitfulness, callousness and hostility), and disinhibition (irresponsibility, risk taking, impulsivity). It is recognised that this group is heterogeneous as only the ‘presence of pathological personality traits’ is needed in addition to the other criteria outlined; that is; at least 18 years old, not in the context of another mental illness, and conduct disorder present before the age of 15, for a diagnosis to be made (American Psychiatric Association, 2013). DSM-V identifies common features of NPD as inflated self-esteem, interpersonal expansive imagination, and deficient social conscience. The Department of Health and Ministry of Justices’ document, ‘Working with Personality Disordered Offenders (Ministry of Justice, 2011) states that psychopathy as described by Robert Hare’s Psychopathy Checklist (PCL-R) could be thought of as a particularly severe subset of ASPD with additional narcissistic, paranoid, sadistic and/or borderline traits. Individuals identified with traits of ASPD engage in repetitive, irresponsible, delinquent and criminal behaviour (Glenn et al, 2013) that habitually violate the rights of others without remorse (DSM V).
When working clinically with ASPD presentations it is also important to recognise that psychopathy overlaps with ASPD. And that this may have an implication in treatment, as emotional and behavioural responses to stressors may underlie and explain the complex picture that is often observed. Despite the overlap differences are observed between clients with a diagnosis of ASPD and psychopathy. In a review Glenn et al (2013) found reduced prefrontal gray matter between those with ASPD with psychopathy compared to those who don’t meet criteria for having psychopathic traits and only ASPD, which may indicate that there are a range of psychological mechanisms and pathways for the behaviours observed.
It is widely accepted within the literature that there are associations between childhood experiences of abuse (physical, sexual and neglect) with the development of ASPD (Horwitz et al, 2001). Individuals subjected to early experiences of bullying, abuse and neglect can become highly sensitive to threats of rejection or criticism from the outside world and can quickly become self-attacking. They can experience both their external and internal worlds as easily becoming hostile (Gilbert, 2009). How this is expressed is important to be considered as DSM criteria focuses on observable behaviour rather than the impact these experiences may have personality structure (Ogloff, 2006).
We are interested on the impact of early developmental relationships (e.g. trauma and neglect, multiple caregivers, the roles of extended family, peers and wider society) that have been internalised, and how these relational experiences contribute to a client’s complex presentation within forensic settings. The next step for our conversations, to be developed within a future article, include teasing out the key themes associated with procedural learning internalised from these damaging early experiences, and the interpersonal and intrapersonal procedures developed to cope and survive and continue to be re-enacted within the men’s current relationships. Are there particular developed ways of coping and relating that are pertinent to this client group, that resonate with the behavioural characteristics synonymous with ASPD? The high prevalence of drug and alcohol use in this client group (42% to 95%; Uzun et al, 2006) is of importance in gaining a fuller understanding of the role of dissociative processes and impact of this for the individual, and his victim.
A CAT perspective:
CAT draws on cognitive, object relations theories, and the work of Vygotsky and Bakhtin (as described in Ryle, 1990; Ryle and Kerr, 2002) in the development of its key theoretical concepts, where interpersonal experience lies at the heart of the development of the self, beginning with how early relationships with caregivers and others are made sense of and internalised by the child. Crucially the whole relationship comprising of both roles are internalised; the child’s experience of receiving care and the parent/carer’s way of relating to the child, which in CAT is referred to as a reciprocal role (RR). Reciprocal roles can only be inferred via the reciprocal role procedures (RRP), that is, one cannot occupy a role without enacting it procedurally. The RRP is a sequence of, appraisal, emotion, aim, action, consequence and re-appraisal. Through repeated experiences over time, the child acquires a repertoire of RRP’s forming the structures of the self (Pollock and Stowell-Smith 2006). Each reciprocal role procedure (RRP) can be enacted in three different ways: others do it to me, I do it to myself, I do it to others (Catalyse 2013).
Recognition and utilisation of the transference and counter transference within the helping relationship/therapeutic alliance is an important tool within CAT, and is conceptualised as a reciprocal role re-enactment. It allows problematic RR’s to be identified and worked with in the here-and-now, which may otherwise undermine the development of a trusting, collaborative relationship, and reinforce damaging and risky ways of relating. For the forensic population, where individuals have a history of violent and or sexual offending, it is also vital to understand offending behaviour from a relational viewpoint due to the nature of offending as an interpersonal act between perpetrator and victim, and to identify the reciprocal roles enacted within the offence; whilst also holding in mind that many within this client group have also been victims. This group of men are less likely to have a coherent understanding of themselves, or self reflective ability as to why they can behave in violent ways to others. The concept of self-states and the sequential self states diagram (SSSD), a reformulatory mapping tool derived from the multiple self states model (Ryle 1997) can usefully be applied to aid understanding the complexity of this client group.
The multiple self states model (MSSM) was developed as a result of the practical difficulties that arose within Ryle’s therapeutic work in “understanding and reformulating more seriously disturbed patients” and offers a trauma-based conceptualisation of identity disturbance (Ryle 1997). In this paper he theorised three levels of damage which occurred as a result of significant abuse and/or deprivation. Level 1 damage is characterised by a restrictive and distorted reciprocal role repertoire with the occurrence of a limited number of extreme reciprocal roles such as abusing to abused, abandoning to abandoned/neglected, which are re-enacted in relationships with others, and oneself. Level 2 damage relates to the disruption of integrating procedures, resulting in abrupt switches between self states, associated with partial dissociation of aspects of their experience, as opposed to having smooth transitions between a range of different RRs. Level 3 damage refers to impaired and interrupted self-reflection, where there is little capacity to take an observing stance towards the self. The SSSD can facilitate a more integrated awareness of all aspects of the self, including the linking procedures associated with switches between different states of mind. This also provides a map of the emotional landscape for the worker, to help navigate the at times powerful countertransference feelings elicited, recognise the RRs being enacted, and to offer a non-collusive response to the client in that moment. Similar advances have taken place in the development of a CAT model for Narcissistic personality disorder, NPD (Ryle, 2002; Ryle and Kerr 2002) where the two contrasting self states are concerned with admiration (admiring-admired) and contempt when admiration is not forthcoming, or the client is exposed or challenged (contemptuous/dismissive-contemptible/humiliated).
Therefore the self-state is a useful concept to understand individuals’ early life experiences that often remain unformulated, out of awareness and partially dissociated from by those with ASPD and those working with them. It helps to make sense of the extreme switches between different states of mind that can occur. Where there is limited access to memory or recognition of how an individual is when in a different state of mind, it can result in a fragile, fragmented and un-integrated sense of self. If this continues to be unrevised it means damaging RRP’s continued to be enacted in relationships with no new learning about the consequences to others and self being internalised.
Shannon, Willis and Potter (2006) described a range of fragile states as well as fixed identities of aggressive men within their clinical practice, and considered these within wider societal terms. They introduced a model which draws on existing CAT understanding of borderline personality disorder (BPD) and narcissistic personality disorder (NPD), in which aggressive men appeared to alternate between warding off threats to self-esteem by seeking dominant grandiose positions in relation to others, and by seeking ideal care. These positions were depicted within a broken egg framework (in Pollock 2006), which identified various partially dissociated self states, and depicted the rejecting abandoning-abandoned/rejected needy self state as the dreaded place for these men, with the omnipotent avenger or fearless protector as the desired place. Within the same publication, Pollock’s case example described a CAT reformulation for his therapeutic work with a “psychopathic” rapist, which captured the predatory nature of the person’s offending reciprocal roles (RRs), with themes of preying-preyed (“pouncing cat-mouse”), as well as exploiting the other through manipulating-manipulated/taken, as extreme responses to being rejected (Pollock, 2006). Similar reciprocal role themes of punishing/abusing-punished/abused were described by Withers (2010) who completed a CAT with a forensic patient, detained in a unit for those with dangerous and severe personality disorder (DSPD). Within this case study states identified included: “Mr Untouchable”, who was “powerful, devious, toying, callous, feeling destructive” and trusted no-one, and employed to protect against the more vulnerable aspects of himself described as “Mr Vulnerable” (e.g. submissive, doormat, deprived) and “Invisible Man” (lonely, shut off, hidden) states. Interestingly the “normal” state, which the patient described as “comfortable”, “controlled” and “okay”, was on further exploration more indicative of an overly controlled state.
Given that individuals that meet criteria for ASPD, are also likely to have experienced childhood experiences of abuse and neglect (Luntz and Widom, 1994; Bierer et al, 2004) it is possible to map RRPs associated with early traumatic relationships. Based on our clinical experience of working with these men, common internalized childhood experiences were: feeling weak, vulnerable, used and abused, dismissed and neglected. Dreaded positions which clients sought to escape from through enacting the top pole of the RR, i.e. the perpetrator role, and/or through use of substances. These procedural enactments will be explored in more depth within a subsequent paper.
A proposed ASPD framework for Cognitive Analytic Therapists : Key Reciprocal Roles
To develop a CAT model of ASPD we looked at the differences and similarities between ASPD, Psychopathy & NPD and wondered whether people with ASPD presentations tended to be placed in in prison and people with NPD presentations in secure hospitals. We thought it was important to make this distinction as it can be difficult to understand why some offenders with similar presentations can be housed in different settings, and subsequently receive care from within a health or criminal justice setting.
For the different diagnostic criteria for these personality presentations we observed a significant overlap in the content of some of the RRs that were identified for each of the presentations. For example, Attacking to Attacked, Dismissing to Dismissed and Controlling to Controlled RRs are present in ASPD and NPD, regardless of levels of psychopathy, whereas manipulating to manipulated forms of control are more present in high psychopathy presentations compared to the less intense ‘Using’ form of control enacted by the men on the lower end of the psychopathy continuum. With ‘using’ there is a sense of being treated as an object in an indifferent way by the other in order to get their needs met rather than feeling ‘manipulated’ which feels far more personal and invasive.
The authors developed a four-quadrant model to better capture the more distinct aspects of the different personality presentations and also their commonalities and overlap along two continuums. See Figure 1: The vertical axis tracks level of psychopathy.
From our experience men with high psychopathy and NPD were more likely to be High Secure, Category A (those deemed at risk to the public and have the means to escape) patients who may have committed offences such as murder, whilst, NPD and low psychopathy may be white collar criminals with glib, superficial charm. High psychopathy and ASPD may be associated with the violent and high risk offending prisoners who are ‘model prisoners’ but their risks are hidden and not addressed/detected during their sentence. These men in prison may be given trusted jobs such as wing cleaners but use these roles to engage in activities such as intimidation of other prisoners and distribution of illicit substances. ASPD and low psychopathy could apply to the violent and impulsive men who can often be placed in segregation units as their behaviour is overt but difficult to manage. They may have been convicted of offences such as actual bodily harm (ABH), grievous bodily harm (GBH) and acquisitive crimes. Awareness of the range of reciprocal roles enacted could also inform understanding of offence paralleling behaviour, i.e. enactments of RRs involved in the commission of the offence, re-occurring in relation to peers and staff within the prison setting, and inform assessment of current and future risk.
Within our clinical work, we have experienced and observed key reciprocal role themes identified in therapy with those presenting with anti-social traits. These were dismissing-dismissed, disrespecting-disrespected, protecting-protected, using-used, controlling-controlled, contemptuous-contemptible, admiring-admired, seducing-seduced, humiliating-humiliated, destroying-destroyed. It was hypothesised that violating-violated may be the RR most indicative of psychopathy. This could often feel more like projective identification rather than just transference or counter transference, where feelings that cannot be consciously accessed are projected or forced into another person in order to evoke the feelings projected. This can feel overwhelming for the recipient. In one author’s personal experience, it is the presentation of victimhood mentality and a strong sense of entitlement and/or extreme oppositional behaviour that can be the biggest barriers to empathy.
Another proposition was whether the men represented in all four quadrants had the same overarching RRs for example controlling-controlled, abusive/attacking-hurt/attacked, but different procedural expressions of these RRs, with differing aims, intentions and assumptions resulting in different expressions of antisocial and violent behaviour along a continuum of chaotic and impulsive behaviours through to more conscious, and premeditated instrumental violence (See Figure 1). These are areas the authors will develop within a future article.
Using the model suggested in this article the authors will now present a fictional case based on a composite of real cases to consider an initial formulation of an individual who meets the diagnostic criteria for ASPD.
James is a 35 year old male in prison for murder. He experienced a difficult childhood. His father was physically violent towards him and his mother. His father’s violent behaviour was unpredictable and worse when he was intoxicated with alcohol. He recalled as a child often being berated by his mother in front of his friends. He was also bullied at school, and told by his father that he was “weak” for being attacked. During adolescence James started to become aggressive and found that others did not hurt or harm him after this; he received praise from his father for attacking other children at school. As James grew older he started to use cannabis and alcohol, which he stated made him feel relaxed. He came into contact with the Criminal Justice System due to crimes committed to fund his use of cannabis, and as a consequence of damage to property whilst under the influence of alcohol. James described how drinking alcohol made him feel “invincible”, “powerful” and “in control”. He quickly became angry when others disagreed with him, and responded with violence, which resulted in prison sentences from the age of eighteen.
James’ intimate relationships often existed in the brief periods between prison sentences. Although possessive of his partners, James eschewed intimacy, concerned that he would become violent towards them and he feared being humiliated through their assumed infidelity. To avoid this latter outcome James sabotaged relationships by being unfaithful first, which inevitably resulted in pushing his partners away. His index offence occurred during a night out socialising with friends and his partner at the time. James was heavily intoxicated and angrily accused his partner of flirting with a stranger who had looked at her. James argued with the man whom he felt had mocked him, the victim then laughed at James, who immediately responded by violently kicking him in the head to the extent that he later died from his injuries. When the victim had laughed at James and flirted with his girlfriend, James had felt humiliated and weak. To manage these feelings and to get out of what he later described as his ‘dreaded place’ James adopted an attacking and destroying role, a position that ultimately led him to be sentenced to 12 years in prison for murder.
In prison, James viewed others as weak and was easily frustrated by them. Others experienced him as a bully because of his physical stature, which he used to intimidate them, and became physically violent if he believed he was being “disrespected”. Whilst in prison, James also intimidated staff, for example becoming verbally aggressive when they did not comply with his day-to-day requests, which led some staff to cope with the anxiety and fear they felt, by trying to avoid him. Throughout his sentence, James was moved from prison to prison within segregation units as a consequence of his violence. He had not engaged with his sentence plan, as he did not want to talk about his offence and his violence, stating that engagement would not be authentic as he “would just be saying what he learns from offending behaviour courses”. For him, going on courses would be to just “tick a box”, and believed that group facilitators would write negative comments about him if he challenged them; as well as not wanting to talk about his crime in front of others as they could “use it against him”.
The reciprocal role James enacted as perpetrator within his index offence was him as attacking/destroying in relation to an attacked/destroyed victim; an extreme version of the bullying-intimidated RR witnessed by peers and staff in prison. During his index offence he rapidly switched to this self-state as a way of defending himself from the intolerable position of being dismissed through being publically mocked and laughed at (dismissing/mocking-dismissed/humiliated/weak), a place that painfully resonated with his history of being mocked and bullied, whilst experiencing rejection and further humiliation from those whom were supposed to care for him. Using the quadrant model depicted in Figure 1, we can start to think about James within the ASPD quadrant, with low psychopathy, evidenced by his more impulsive use of violence when perceiving himself as being disrespected and rubbished. The overarching RRs within the centre of diagram of dismissing-dismissed, and attacking-attacked are enacted by James in a more spontaneous and overtly oppositional way in relation to engagement with therapeutic programmes, or staff when his needs are not immediately met, and with his peers as a way of protecting himself from showing vulnerability associated with being attacked, mocked or rejected. This can help staff to anticipate what RRs might be enacted with them, and act as a barrier to engagement and maintain his risk to others.
We hope this paper will act as a springboard to invite interested colleagues to join us in a wider dialogue to continue to shape and develop our CAT understanding of ASPD including: a description of the procedural learning internalised from damaging traumatic early experiences, and the interpersonal and intrapersonal procedures developed to survive but which continue to be re-enacted within the men’s current relationships; the need for the prison service to address developmental factors as well as offence focused work and to acknowledge the role of the wider prison system and the reciprocal roles re-enacted at this organisational level, which also impacts on a client’s ability to engage with staff in therapeutic interventions.
It is hoped this will provide a useful framework for practitioners to facilitate and incorporate a wider understanding of the damaging presentations that men with ASPD present, and scaffold them in their work with clients and we would welcome feedback on your experiences of working with this client group and whether they fit with this model. We hope to continue this dialogue with you in person at the ACAT conference in Nottingham, this September.
Dr Kerry Manson is a CAT Practitioner and Supervisor in independent practice. Previously she worked as a Consultant Clinical Psychologist managing a therapy service and delivering CAT in a prison setting. She has also worked in a Personality Disorder Unit based within a prison.
Dr Sunil Lad is a Counselling Psychologist, he works in a number of prison mental health teams and Community Offender Health Services within Northamptonshire Healthcare Foundation Trust, and is ACAT accredited in CAT skills.
Dr Marisol Cavieres is a CAT practitioner, supervisor and trainer in independent practice. Previously she worked as a consultant clinical psychologist within a community forensic team in Auckland, New Zealand, and has had various posts within adult mental health specialty in North West England and New Zealand.
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