Topic: Clinical Approaches with Forensic Clients

Working with Antisocial Presentations

Forensic AOD clients often display antisocial traits and behaviours (e.g. Regier et al, 1990) which can present specific challenges in working with this client group.

Common Antisocial Traits

In your work with antisocial clients there are a range of traits – including thoughts, feelings and behaviours – which contribute to the challenges of working with these individuals, and which can have a significant impact on the clinician working with them. Some common characteristics which you may observe in these clients include:

• Impulsivity
• Exploitative, manipulative behaviours & taking advantage of others
• Dislike for others
• Callous attitudes & lack of empathy
• Criminal activity & reckless disregard for others
• Presenting as cocky, grandiose and highly confident
• Frequent boundary breaches
• Sense of entitlement (look after number 1)
• Black and white thinking patterns
• Entrenched attitudes, resistant to change
• Operate under a different ‘moral code’ & a disregard for societal laws
• Don’t take responsibility for own actions
• Charming
• Unlikely to stay in a prolonged monogamous relationship
• Change jobs frequently or prolonged absences from work if a long-term job
• Victim blaming
• Presents as having a lack of emotion
• Decreased tolerance for boredom/ looking for outside stimulation
• Financially irresponsible
• Increased likelihood of suicide/suicide ideation

Antisocial Personality Disorder

A personality disorder exists where personality patterns differ markedly from cultural norms and are long-standing, inflexible and pervasive. Where a person displays many of the above antisocial characteristics, they may meet the criteria for Antisocial Personality Disorder (APD), which is broadly characterised by:

• Significant impairments in personality, for self-functioning (e.g., identity and/or self-direction) and interpersonal functioning (e.g., empathy and/or intimacy).
• Pathological personality traits in regard to antagonism (e.g., manipulativeness, deceitfulness, callousness and hostility), and disinhibition (e.g., irresponsibility, impulsivity and risk taking). (See DSM-5 for full criteria)

Rates of APD in forensic clients are much greater than in the general population. As such, it is highly likely that you will regularly treat clients who meet the criteria for APD.

Be aware however that there is some disagreement in the literature about what factors constitute a personality disorder, and whether “personality disorders” should be conceived as a continuum of trait severity rather than a categorical classification, and that they may not remain stable over time. As such be cautious about using this term with clients, and if they do say they have a Personality Disorder, encourage them to be flexible in their thinking about it, to avoid a labelling mindset.

If you are concerned that a client’s antisocial tendencies may constitute a personality disorder, you may consider referring them to a forensic psychologist to conduct a thorough personality assessment.

Antisocial Personality Disorder and Substance Use Disorder

Where a client has been diagnosed with both APD and Substance Use Disorder, the following complications are generally present:

• Substance use commenced younger
• More SUD-related problems present (e.g. significantly more problematic family and interpersonal relationships, legal problems, psychological and financial problems)
• Dependence occurred more rapidly
• Addiction is more severe
• Social, legal and physical harms are more significant
• Psychiatric comorbidity is present in higher rates
• Much more likely to be at risk of suicide

Challenges of working with antisocial clients

Common features that make antisocial clients difficult to treat include:

1. Some clients may perceive that there is nothing wrong with their personality or functioning.
2. Their behaviour and attitudes are often threatening to others. Although these clients may feel they are in emotional pain, it is common to find they cause others a great deal of hardship as well.
3. These clients can be highly resistant to change. Although they may enter treatment hoping to obtain some relief from their psychological difficulties, they often do not wish to address their own shortcomings, nor do they wish to alter maladaptive behaviour or attitudes.
4. Such clients have difficulty imagining being any other way. When health or corrective services clinicians try to elicit their cooperation in making changes in life, the clients often reply by saying they cannot change. For these clients, their difficulties are often synonymous with their identities.

Additionally, antisocial clients sometimes manipulate in order to get their needs/wants met. This can be particularly problematic during assessment if it is not recognised. Manipulation may occur by:

• Malingering (e.g., pretending to have psychosis to avoid culpability)
• Faking good/bad (e.g., denying current substance use in order to avoid being recommended for treatment, OR exaggerating/feigning symptoms to seek medications)
• Minimising
• Use of charm to manipulate (“He was such a nice guy!”)

Finally, antisocial clients also may be more adept at breaching boundaries than clinicians may be at managing them. Some clients may take pleasure in placing clinicians in vulnerable or uncomfortable situations, or in forcing clinicians to violate their own rules.

Tips for working with antisocial clients

Antisocial clients, more than most, will invite us to respond in a way that doesn’t feel authentic to us, to respond more harshly or more passively than we might normally. It requires effort to maintain our “normal” stance but doing so provides the client an experience of consistency and boundaries, which can assist in client containment.

Working with an approach that is too firm may invite a power struggle, disrespectful treatment, and is not likely to work. Often this approach leads antisocial clients to feel they need to reassert their autonomy. They may perceive your firmness as hostile, and in turn escalate.

Being too permissive with antisocial clients increases the risk of violated boundaries. It is vital to set firm boundaries with someone whose own boundaries are poor. It increases the risk of colluding, being seduced into meeting client’s non-therapeutic agenda, ‘rescuing’, and being taken advantage of. Furthermore, this approach makes it less likely to earn client’s respect, does not provide the structured environment necessary for treatment, reinforces entitlement and victim mentality, and does not allow use of consequences as a motivator for change.

Some helpful tips for working with this client group include:

• Clearly articulate the behavioural expectations and ensure that you are consistent in the implementation of immediate consequences where these expectations are breached;
• Remember you may have more investment in the engagement process than the client;
• Maintain a focus on behaviours rather than personality, on shared goals and on agreed strategies;
• Monitor your own responses – e.g. rage, disgust, fascination
• Be careful to avoid mirroring client hostility, indifference or deceit
• Link goals to their own longer-term interest to enhance motivation – g. focus on “how will this change benefit you”
• Seek to avoid disruption of care by careful treatment planning & communicate openly with the client about treatment planning (helps to minimise manipulation)
• If possible, maintain same clinician for an antisocial client
• Encourage the client to be actively involved in therapy to reduce risk of treatment withdrawal
• Be aware of comorbid presentation and ensure the client is also receiving treatment for those problems
• Review treatment progress regularly with the client
• Seek regular supervision and reflective practice as working with these presentations can be particularly challenging for clinicians.

Many of the above strategies are probably common to your work with all clients – but they are particularly important with antisocial presentations.

References:

Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd, L. L., & Goodwin, F. K. (1990). Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) study. Jama, 264(19), 2511-2518.