What kind of psychotherapy would be helpful to a sociopath?

February 29, 2016 9:42 PM

Not to change them or help the people around them that are affected by them. I mean, what sort of therapy might actually help them to live a happier life, accept the unchangeable things that drive them into spirals of anger, and smooth out the cycle of exploding their life every three years or so?

This is about someone I have loved dearly for a very long time and know well. I'm really not interested in discussion over whether or not she or others like her are good or bad or whether they can be changed, what's good for people around her, whether I'm really sure she is a sociopath, etc.

She is a self-aware and highly intelligent sociopath, mid 30s, and is incredibly frustrated with her inability to connect with people emotionally and have mutually fulfilling two-way friendships and relationships. She has struggled with depression, bouts of overwhelming anger at the world, and likely PTSD.

She seems to be getting worse lately (more anger, more risky behavior, disconnecting from people close to her) and I'm really worried about her. She wants to talk to a therapist who understands what's going on with her, but, honestly, I think she has run circles around other therapists and hasn't found them useful.

She's very introspective, never stops thinking about this stuff, and doesn't want to spend three visits just to have therapist tell her things about herself she already knows. In describing experiences and feelings, she gets caught up in narrative and in creating the most beautiful story, like the perfection of the narrative with its high contrast and sharp emotional edges is more important and valuable than what is actually true or authentic. So much so that she's not always able to separate what is actually true from what makes the narrative work. I worry that without trying or meaning to, she could also lead a therapist into believing something that wasn't at all helpful to her, and/or to reach the same conclusion she had.

Is there a particular psychotherapeutic discipline or approach that is better suited to her unique personality? Has anyone with similar personal experience found anything (therapy or otherwise) that was helpful?

I would love any ideas or guidance, oh hive mind, and I would even more so appreciate answers from personal experience.

posted by anonymous to Health & Fitness (7 answers total)

we have several clients like this at my job. her situation is complex. if i was working with her i would probably recommend the following.

-first treat the PTSD and the depression with meds, allow a few months for adjustments
use of anti-anxiety drugs can be helpful to avoid tantrums, unless she has a history of substance abuse then try one that is not habit forming.
if she has PTSD symptoms that are notable like disassociation or panic attacks (or if she has physical ptsd symptoms that are affecting her physical health & quality of life) those need to be addressed somehow before a therapist can really start working with her in a productive way.

if you refer her to a therapist that does cognitive behavioral therapy, maybe have her go into session 1 saying, i have a personality disorder and my goal is to form and maintain better quality relationships with others, or my goal is to prevent outbursts of explosive anger, etc. then, only do CBT work. exercises. worksheets. minimize the time spent telling the therapist stories, and focus on applying techniques so she can do it on her own, out of session.

her use of CBT (or dialectical behavioral therapy) will probably always focus on what the outcome is or her, since she may very well be incapable of feeling guilt about how her choices & actions affect others.

if she is emotionally sensitive to change talk (there is a lot of change talk in CBT) and that provokes this sort of "performing for the therapist" reaction then a DBT focused therapist might work better. she should ask any potential therapist if they have experience dealing with personality disorders, ptsd, or criminal populations (because - high incidence of personality disorders and specifically antisocial personality disorder there, as well as ptsd)
posted by zdravo at 11:28 PM on February 29, 2016 [6 favorites]

I would suggest therapy - specifically CBT or DBT group therapy. But it is HARD. I mean, even if you're motivated, therapy is difficult and sometimes a huge slog. She would have to allow herself to be vulnerable around other "patients" for whom she may have distain (or feel she has nothing in common with). For her to have any benefits from it, she would have to commit to therapy which includes accepting the risk that it will be difficult and it may not solve *everything.*
posted by Dressed to Kill at 5:24 AM on March 1, 2016 [1 favorite]

I was wondering about group therapy too. (Not a support group, but group therapy specifically.) The way to learn to have real two-way relationships is to practice having them. And individual therapy probably isn't the right place for that, since your relationship with your therapist is necessarily asymmetrical.
posted by nebulawindphone at 7:24 AM on March 1, 2016

Sociopathy and PTSD can look alot alike sometimes.

Honestly, a therapist who is well experienced in working with the type of trauma she's experienced would be really really useful.

Trauma therapy is for the long haul. Ay this point she likely needs to commit to the same person for at least 1 year. She may want to have someone a little more assertive than she has had in the past, especially if it is difficult for her to move past defence mechinisms to what is actually going on with those feelings.

I do get caught up in my narrative over my feelings, and I have a really hard time identifing and staying with those feelings to make changes. It happens and it happens slowly. The narrative serves a point, because in some ways I allow others reactions to be a substitute for my feelings.
posted by AlexiaSky at 8:47 AM on March 1, 2016

I worry that without trying or meaning to, she could also lead a therapist into believing something that wasn't at all helpful to her, and/or to reach the same conclusion she had.

A therapist skilled in treating personality disorders will not fall for the lie that she's unconsciously spinning for herself. A good one, anyway.
posted by serenity soonish at 9:18 AM on March 1, 2016

Sociopathy is neurological, it is not a personality disorder.

Finding a good therapist with useful experience in this area is difficult. Schema therapy can be helpful.

Unfortunately the psychological profession in general hasn't caught up with the science, and even the science still has a long way to go. Unless you're very lucky, talking to a therapist about sociopathy in 2016 will be simlar to talking to a therapist about homosexuality or autism in the 1950's.
posted by HiroProtagonist at 4:54 PM on March 1, 2016

You say " I'm really not interested in discussion over ... whether I'm really sure she is a sociopath ...She is ... incredibly frustrated with her inability to connect with people emotionally and have mutually fulfilling two-way friendships and relationships."

That's kind of a textbook definition of "not a sociopath", so answering your question is very difficult.

I am trained as a clinical psychologist and I did some training in DBT therapy so I have some specialist knowledge here, and to me your description sounds much more like Borderline Personality Disorder. Both ASPD (anti-social personality disorder) and BPD (Borderline Personality Disorder) are terribly stigmatizing diagnoses, and many therapists will refuse to work with people carrying either diagnosis. Correcting such a mis-diagnosis is really important if that's what's going on.

That being said, assuming for sake of argument that she is a sociopath, there are some very interesting experiments in which people tried a talking cure with the addition of psychedelic drugs! which is all detailed in Jon Ronson's The Psychopath Test. TLDR: some evidence that talk therapy makes psychopaths/sociopaths (the terms are somewhat interchangeable) into better psychopaths, more able to fool their victims.
posted by soylent00FF00 at 5:17 PM on March 1, 2016 [1 favorite]