Firing a patient you’re scared of

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Oh but many people with ASPD really do lack the ability to empathize or ability to empathize to such a minimally low degree.

What you state above is true for many people in local environments that breed ASDP, but many of these people will become lost-causes if allowed be in these situations for too long.

Take a child, for example, out of a depraved and blighted environment and your examples work. Take an adult, say age 35, and interventions with the intent to help the person develop the ability to empathize, and modify behaviors, those things don't work as well. Possibly not at all. There may have been a time where interventions could've helped for this person.
 
If we call all human behavior that is undesirable or problematic a psychiatric disorder and claim we can help we’re kidding ourselves. Yet this is what we continue to do and do it more despite terrible results. No wonder people don’t like us.

I had a case of a "Schizoaffective," "Schizophrenia," "Bipolar Disorder" individual who only had ASPD. He was on my forensic unit. I had medical records when stacked literally over 5 feet high. I dug into all of the records, contacted all of the prior psychiatrists and psychologists whose names were on the charts, was able to get responsed from about 2/3ds of them and all of them admitted that they never saw the guy psychotic or manic but simply medicated him because of a prior diagnosis in his chart or for behavioral control but stated they continued the Axis I diagnosis that they even didn't believe in.

I took that same guy off all of his meds. He never was once manic or psychotic but regularly engaged in behaviors such as bullying, stealing other patient's food, etc.

A reality of our profession is we have several, from my experience the majority or close to it, even willing to diagnose and prescribe not even believing in the diagnosis and treatment they write on paper. Oh yeah of course I'll have times where I've diagnosed someone with Bipolar Disorder but later it turned out to be something else, or I wasn't 100% convinced but at the time had reasonable evidence to believe I may have been right, and was over 50% convinced (and when this happens I state so to the patient). I'm not talking about that. I'm talking about clinicians who didn't even believe the person had the diagnosis to over a 10% degree writing down a diagnosis and then giving out a treatment and then going on to the next patient without thinking they violated ethical or legal practice. I liken it to the over-prescription of opioids, sleep-meds, and benzos today.

And I've confronted some doctors about it and get responses of "James, psychiatry isn't a science it's an art," (and I almost entered the field of art, what they're doing isn't art, but more of a lame excuse to make out their quack practice into something that sounds nicer) or when asked why they did it give me a wink and a smile (which I don't find funny at all, if anything makes me want to slap the other doctor).
 
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I’m an attending. This patient is not “upsetting me” I’m scared. Talked to my manager and will not be seeing this patient. Nothing is worth putting myself at risk.
You should update your training status on your SDN profile, right now it says resident. It's a TOS issue to be sure that whatever you select is accurate. You can also opt not to include your training status.
 
Mentalization-based treatment - Wikipedia


That page doesn't talk about it specifically but it has been applied to ASPD with some success, as a failure to mentalize is common to BPD and ASPD.

It is probably not going to be helpful for the puppy-torturing kind of ASPD, the kind the PDDM would call sadistic personality disorder, but those folks are way less likely to be in your office in a non-forensic setting.
PDDM?
 
I assumed you didn’t work in and ED because of your profession which is true. Not sure why you need to caution me against assuming a neuropsychologist wouldn’t be doing emergency psych.

More about assuming that we do not work regularly with these patients.
 
More about assuming that we do not work regularly with these patients.
That’s not what I said or assumed. We all have a different breadth of experience that gives us different perspectives. I’ve always appreciated what your insights are in neuropsych working with all types of patients. Working as a psychiatrist in the ED making calls on admitting patients is an experience that is unique to psychiatrists that colors my feelings on this issue.
 
I questioned writing off an entire diagnosis of people as untreatable. Which is a terrible thing to say as a clinician. Not feeling competent or comfortable treating a certain disorder is one thing, you can simply find someone who is willing. That's part of being in a community, knowing where to refer rather than just throwing up your hands and telling patients to figure it out themselves.

It’s all settled then. You can find someone willing and able to treat OP’s patient.
 
Agree, I never questioned that. I questioned writing off an entire diagnosis of people as untreatable. Which is a terrible thing to say as a clinician. Not feeling competent or comfortable treating a certain disorder is one thing, you can simply find someone who is willing. That's part of being in a community, knowing where to refer rather than just throwing up your hands and telling patients to figure it out themselves.

I think many times telling patients to take care of it themselves is the most effective thing you can do. Psychiatry and psychology to some degree do a great job of removing agency from patients to solve their own problems. We remove or lessen the consequences of negative behaviors with labels, justification, medications and whatnot and create or worsen problems.
 
Hypothetical: You’re in outpatient pp as an attending doing medication management and brief therapy, how do you protect yourself? Do you guys carry guns? Tasers? Pepper spray? Or just hope you can hold off any type of assault?

When interviewing patients I was always taught to position myself nearest to the exit to avoid getting trapped.

Here we don't have an issue with patients running around with guns which makes things slightly safer, but when I was in the public service did a couple of mandatory self defence training courses over the years. Usually these emphasise maintaining a safe difference, avoiding confrontation and exiting the situation quickly, with other specifics like how to get out of hair grabs, choke holds, bear hugs etc. One stance I remember is the Philosopher's position, because it lets one quickly raise their arms to protect their head.

What? This doesn't make sense to me. Just because the patient came back multiple times doesn't mean that a panic button can't be used in the future. Likewise, just because a patient has never been violent in the past doesn't mean that a "bad situation" can't happen in the future. I never commented on the OP discharging the patient. I was simply commenting on the panic button issue. The OP initially said they didn't have them, which is absurd to me considering what we do. Now that we know they do have them, I'm left questioning how it's possible the OP didn't know when it's a key safety feature in the office, especially if you're going to see these types of personality disordered patients.

That's not the point of a panic button. If it was, they'd be visible to the patient. It's exactly the opposite.

And that is the point I am making - while it is a necessary safety measure, a panic button isn’t a deterrent to a potentially aggressive patient.

The point about the patient coming back means that the patient is already a known entity. Obviously a panic button can be used in future consultations, but I would see that as a complete failure of risk management. You have a patient that you already feel threatened by and know to be violent, but you keep seeing them, and it reaches a point where their behaviours escalate to the point where the OP needs to use a panic button then the opportunity to avoid this worst case scenario has been missed. It's not bloody rocket science.
 
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seriously do whatever you can to get rid of this patient

no one who is violent by choice is entitled to medical care from you
even those who are otherwise well-meaning and violent, they aren't entitled to what you cannot figure out a way to safely provide (if you can dart gun tranq them or someone wants to wrestle them down for a shot, great)

this gets into some of that stuff with good samaritan laws - if you find someone down and there is vomit or blood around their mouth, that is an infection risk to you, although not hugely so, you are NOT obligated to render mouth-to-mouth if you don't have one of those one way valve masks

by that same token, you are not obligated to give mouth-to-mouth at all, because there is a not inconsequential risk that they vomit, and where there is vomit, there is risk of blood, and where there is blood....

(nvm the guidelines for CPR in the community these days that says that breaths can be skipped in favour of compressions, that does not apply to those with CPR and ACLS training where it is acknowledged ventilation in addition to compressions is best, the presumption being that training will allow you to do both, breaths and compression. The main issue being do you provide breaths without equipment or not)

so, if it's considered ethical in those situations not to assist because of the risks of harm to you (I'm using an example where the need is extremely high, and the risk to you quite low, YET it is still ethical for you to not take that risk of harm to yourself)

I just can't even wrap my mind around rendering care to someone who likes to freak you out talking about being violent and having no remorse

many providers will put themselves in the paths of some of these harms, and I am a firm proponent of sacrifice in the physician, and even I would say that there are limits and it's OK for you to not be like those physicians

you don't have to be Mother Teresa or go tend to patients with ebola - more power to docs that do

TLDR
This guy is not entitled to medical care if he chooses to act in a way that makes his providers feel unsafe.
Our obligations to treat patients have limits. It is ethical for you to make choices that help you avoid becoming a patient yourself.
 
it seems to me, that main issue is how do you proceed

is there a way to safely communicate with the patient about his behaviour and continue the therapeutic relationship?
do you decide the risk to yourself is too great?

if the latter, then it seems to me, the question is, how do you safely terminate with a patient like this to try to minimize the risk of retaliation

that is what I'm curious to hear more on, since to me it seems that he's got to go

maybe this will play into a sense of control that he has, maybe it was his intention to get you to freak out and discontinue therapy, in which case I would say, fine, psycho, you win this round, provided it doesn't encourage him to escalate, which I'm wondering

OTOH, if that wasn't his intention, I kinda wonder if he'll figure it out if this happens or keeps happening to him, and maybe he changes his behaviour in the future

I'm a firm believer in people suffering natural consequences for their behaviour, even when it's with a mental health provider who wants to help you with your dysfunction

patients need to be able to express HI and the like to their providers, and how they feel about crimes or violence they've committed, but I think they need to learn how to communicate about that in a way that doesn't feel unsafe to someone. If not, he needs a different provider or to learn to communicate differently.
 
When interviewing patients I was always taught to position myself nearest to the exit to avoid getting trapped.

This can work at inpatient if you are standing and at a fair distance.

In outpatient seated, it is worthless. If an agitated patient decides to assault you, there is no way an average psychiatrist is escaping with just speed. The patient has the element of surprise and opening a door takes too much time.
 
This can work at inpatient if you are standing and at a fair distance.

In outpatient seated, it is worthless. If an agitated patient decides to assault you, there is no way an average psychiatrist is escaping with just speed. The patient has the element of surprise and opening a door takes too much time.
yes but maybe the sound of your unconscious body hitting the floor or door, closer to the entrance, gets more notice
 
And that is the point I am making - while it is a necessary safety measure, a panic button isn’t a deterrent to a potentially aggressive patient.

And your point is irrelevant to my point because I wasn't commenting on this particular patient. I was commenting with shock that the OP didn't have a panic button/didn't know there was a panic button.
 
It’s all settled then. You can find someone willing and able to treat OP’s patient.

Sure thing, if they are in my area, I have about a dozen people I could refer them to. That's part of our jobs in the MH field, knowing where to send patients to get help for various things, rather then leaving them out to dry.

I think many times telling patients to take care of it themselves is the most effective thing you can do. Psychiatry and psychology to some degree do a great job of removing agency from patients to solve their own problems. We remove or lessen the consequences of negative behaviors with labels, justification, medications and whatnot and create or worsen problems.

Sometimes, I definitely agree with you. But, sometimes, especially when a patient has a disorder which people refuse to treat, or refuse to acknowledge can be treated, some patients do not know where to look as they may have been repeatedly "fired" fro providers with little to no explanation. There is some lit on this in the ASPD field, that people are never referred to treatment in the first place because providers do not think it is treatable, and thus never try. We at least owe it to our patients to find out where they can seek help if we cannot help them for whatever reason.
 
Panic button is better than nothing. In my mind increases the likelihood that someone may find your body or figure out who did what to you, which has some utility in the grand scheme of things maybe.

Or get you help if the assault wasn't fatal and, in some cases, if you hit it during early escalation, people may get to you before there even is an assault.
 
Probably worth noting that firing an aggressive or antisocial patient isn’t without its own risks. While obviously completely different situation, reminds me of the recent workplace shooting.


“Illinois gunman Gary Martin brought a pistol to his termination meeting at the sprawling Henry Pratt Co. in Aurora. When he found out he'd been fired Friday, he started killing the people in the room, authorities said.”

https://www.google.com/amp/s/amp.cnn.com/cnn/2019/02/17/us/aurora-shooting-termination/index.html
 
Sure thing, if they are in my area, I have about a dozen people I could refer them to. That's part of our jobs in the MH field, knowing where to send patients to get help for various things, rather then leaving them out to dry.



Sometimes, I definitely agree with you. But, sometimes, especially when a patient has a disorder which people refuse to treat, or refuse to acknowledge can be treated, some patients do not know where to look as they may have been repeatedly "fired" fro providers with little to no explanation. There is some lit on this in the ASPD field, that people are never referred to treatment in the first place because providers do not think it is treatable, and thus never try. We at least owe it to our patients to find out where they can seek help if we cannot help them for whatever reason.
There is no one in my area or remotely close who will treat ASPD. I can imagine this is the care for 99% of my colleagues. There is no-one I can call and say, "I have a violent patient who is scaring me, will you treat them?" You can imagine the response. Also, I don't want to put anyone else at risk for someone who I believe is seeking primarily attention. Disclosing a disorder of ASPD to someone is risky, especially when the patient is invested in a different diagnosis, as it could result in retribution on the patient's part.
Seventy-five percent of people who I refer for psychological treatment of simple problems like panic attacks, anxiety or depression fail treatment. If we can't treat simple problems effectively how can we treat extremely complex problems?
Also from a legal perspective for our field, when we say we can treat someone and we fail we are now held accountable. This is why we need to be very careful when say as a field we can treat something. It seems the generalizability in mental health produces a huge gap between psychological RCTs and real world results. If we are treating someone for ASPD and they hurt someone else I guess our treatment failed and we are implicated due to our incompetence. This is extremely important to think about when discussing these issues.
 
Also from a legal perspective for our field, when we say we can treat someone and we fail we are now held accountable. This is why we need to be very careful when say as a field we can treat something. It seems the generalizability in mental health produces a huge gap between psychological RCTs and real world results. If we are treating someone for ASPD and they hurt someone else I guess our treatment failed and we are implicated due to our incompetence. This is extremely important to think about when discussing these issues.

I would review the laws and legal accountability because the above is not the case, so long as you're offering standard of care and the laws that are already on the books (Tarasoff, etc).
 
Presuming ASPD is the only diagnosis, and this is agreed upon by various/multiple providers-what is the treatment protocol? I’m not familiar with this area. What exactly are you “treating?”
Thanks.
 
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Maybe OP is only referring to pharmacological treatment? Because I agree ASPD is not best treated with meds.

Best practices would agree that ASPD itself is not managed well by meds. However, more individuals than not with ASPD have co-occurring disorders. Some of which may be treated by meds. Available evidence suggests treating of comorbid disorders is one way to actually attenuate some of the negative impacts of the ASPD. After that, refer out for behavioral management. the forensic division of your state psychological and psychiatric association is a great place to start to look for individuals who will treat these patients.
 
Presuming ASPD is the only diagnosis, and this is agreed upon by various/multiple providers-what is the treatment protocol? I’m not familiar with this area. What exactly are you “treating?”
Thanks.


http://www.kenniscentrumps.nl/sites...013_-_aspsmentalizing_framework_-_bateman.pdf

TL;DR for MBT for ASPD

Major targets are 1) Understanding of emotional cues in others, 2) Recognizing emotions in others, 3) Exploring patient's sensitivity to hierarchy and authority 4) Understanding of patient's deficits in mentalizing 5) Understanding of how threats to self lead to loss of mentalizing

Basic protocol is largely group therapy based with individual sessions occurring only monthly in order to process any problems encountered in group. Group focus exploits the fact that a) folks with ASPD are going to be a lot more influenced by people they see as peers and b) group will recreate a hierarchy that can then be therapeutically explored.

So pretty specialized but also not impossible or hopeless.

Slides for a talk Anthony Bateman gave on this: https://www.regionsjaelland.dk/sund...gementer/Documents/Slagelse ASPD Nov 2016.pdf

There is a big study underway in the UK correctional system looking at rolling out ASPD to probation services. Supposed to wrap up sometime next year.
 
Yup. Agree 100% with all of this
Best practices would agree that ASPD itself is not managed well by meds. However, more individuals than not with ASPD have co-occurring disorders. Some of which may be treated by meds. Available evidence suggests treating of comorbid disorders is one way to actually attenuate some of the negative impacts of the ASPD. After that, refer out for behavioral management. the forensic division of your state psychological and psychiatric association is a great place to start to look for individuals who will treat these patients.
 
http://www.kenniscentrumps.nl/sites...013_-_aspsmentalizing_framework_-_bateman.pdf

TL;DR for MBT for ASPD

Major targets are 1) Understanding of emotional cues in others, 2) Recognizing emotions in others, 3) Exploring patient's sensitivity to hierarchy and authority 4) Understanding of patient's deficits in mentalizing 5) Understanding of how threats to self lead to loss of mentalizing

Basic protocol is largely group therapy based with individual sessions occurring only monthly in order to process any problems encountered in group. Group focus exploits the fact that a) folks with ASPD are going to be a lot more influenced by people they see as peers and b) group will recreate a hierarchy that can then be therapeutically explored.

So pretty specialized but also not impossible or hopeless.
I would express some caution and look forward to seeing the results of the study. There is some potential for this to be disastrous. It not a particularly desireable goal to enhance the ability of potentially psychopathic individuals to understand emotional cues or recognize these in other individuals.

Some historical background is probably helpful. In the UK, there is a long tradition of treatment and rehabilitation of offenders. In fact, forensic psychotherapy is a subspecialty of psychiatry in which you can train. It focuses on the psychoanalytic treatment of violent and sexually violent offenders. Could you imagine such a thing in the US! These programs typically do not focus on treating dissocial individuals though and tend to select out individuals who make good analytic candidates.

In the US, treatment has been anthema since the 1970s when the conservative "law and order" turn that filled our prisons with black and brown bodies took hold and little emphasis on rehabilitation of offenders existed. We went from talk of prison abolition in the 1970s, the having the most incarcerated population in the world by the 1990s and the current backlash against prison overcrowding, the criminalization of the mentally ill, "the new jim crow" and the prison-industrial complex writ large.

Some of this however was due to a therapeutic nihilism that set in due to failed treatment programs in the 1960s and 70s. The most famous were the Oak Ridge Study in Canada which involved nudity, LSD, and treating schizophrenic and psychopathic individuals together. The psychopaths were released as cured, and had an increased risk of recividism following this particularly bizarre treatment. In the US, we had the Concord Prison Experiment, which used psilocybin-facilitated group psychotherapy under the direction of one Timothy Leary. The original study suggested a reduced recidivism in those so treated, but this was not found to the be case in follow up studies. psychedelic research would then fall out of favor for another 40 years. Failure of very specific types of intervention that would be considered highly unorthodox by today's standards became "treatment doesn't work." This is where the current nihilism for treating offenders has come from (and when we talk of ASPD, which is a specious construct in itself, we are chiefly talking about offenders who are convicted since this is the population who is studied and gets treatment).

In the US, there has been some interest in treatment of offenders more recently, and the more commonly used approaches are CBT focused at criminogenic thinking, mindfulness based approaches, and DBT which are used (if sparingly so) in certain correctional settings in the US. In the VA system I have seen MRT (moral reconation therapy) being used. elsewhere in the world cognitive analytic therapy has been used.

Personally, I would say that treatment of antisocials in private practice or community settings is a fool's errand, and once you get non-payment for your bills most therapists will learn the error of their ways. I did a psychologytoday search to find in my area the vast majority of psychologists listing "antisocial personality" as something they treat are the ones from the local diploma mill programs. OTOH, there may be mileage to treating these individuals in correctional settings, re-entry programs, and on probation, as part of a highly structured program that incentivizes participation and includes wraparound services to reduce recidivism.
 
I think risk assessments are also essential when treating this population. I'm not sure who is familiar with RNR (risk-needs-reaponsivity), but it provides an evidence-based framework for treating this population. Andrews and Bonta identified 8 criminogenic risk factors that are tied to recidivism; there is only one stable factor (criminal history), while the rest are dynamic. Through the use of their actuarial risk assessment tool, one can identify the high risk areas that need to be addressed in treatment. The responsivity piece refers, in part, to the dosage. Research has shown over-treating low-risk offenders can actually be harmful.
I would express some caution and look forward to seeing the results of the study. There is some potential for this to be disastrous. It not a particularly desireable goal to enhance the ability of potentially psychopathic individuals to understand emotional cues or recognize these in other individuals.

Some historical background is probably helpful. In the UK, there is a long tradition of treatment and rehabilitation of offenders. In fact, forensic psychotherapy is a subspecialty of psychiatry in which you can train. It focuses on the psychoanalytic treatment of violent and sexually violent offenders. Could you imagine such a thing in the US! These programs typically do not focus on treating dissocial individuals though and tend to select out individuals who make good analytic candidates.

In the US, treatment has been anthema since the 1970s when the conservative "law and order" turn that filled our prisons with black and brown bodies took hold and little emphasis on rehabilitation of offenders existed. We went from talk of prison abolition in the 1970s, the having the most incarcerated population in the world by the 1990s and the current backlash against prison overcrowding, the criminalization of the mentally ill, "the new jim crow" and the prison-industrial complex writ large.

Some of this however was due to a therapeutic nihilism that set in due to failed treatment programs in the 1960s and 70s. The most famous were the Oak Ridge Study in Canada which involved nudity, LSD, and treating schizophrenic and psychopathic individuals together. The psychopaths were released as cured, and had an increased risk of recividism following this particularly bizarre treatment. In the US, we had the Concord Prison Experiment, which used psilocybin-facilitated group psychotherapy under the direction of one Timothy Leary. The original study suggested a reduced recidivism in those so treated, but this was not found to the be case in follow up studies. psychedelic research would then fall out of favor for another 40 years. Failure of very specific types of intervention that would be considered highly unorthodox by today's standards became "treatment doesn't work." This is where the current nihilism for treating offenders has come from (and when we talk of ASPD, which is a specious construct in itself, we are chiefly talking about offenders who are convicted since this is the population who is studied and gets treatment).

In the US, there has been some interest in treatment of offenders more recently, and the more commonly used approaches are CBT focused at criminogenic thinking, mindfulness based approaches, and DBT which are used (if sparingly so) in certain correctional settings in the US. In the VA system I have seen MRT (moral reconation therapy) being used. elsewhere in the world cognitive analytic therapy has been used.

Personally, I would say that treatment of antisocials in private practice or community settings is a fool's errand, and once you get non-payment for your bills most therapists will learn the error of their ways. I did a psychologytoday search to find in my area the vast majority of psychologists listing "antisocial personality" as something they treat are the ones from the local diploma mill programs. OTOH, there may be mileage to treating these individuals in correctional settings, re-entry programs, and on probation, as part of a highly structured program that incentivizes participation and includes wraparound services to reduce recidivism.
 
I would express some caution and look forward to seeing the results of the study. There is some potential for this to be disastrous. It not a particularly desireable goal to enhance the ability of potentially psychopathic individuals to understand emotional cues or recognize these in other individuals.

Some historical background is probably helpful. In the UK, there is a long tradition of treatment and rehabilitation of offenders. In fact, forensic psychotherapy is a subspecialty of psychiatry in which you can train. It focuses on the psychoanalytic treatment of violent and sexually violent offenders. Could you imagine such a thing in the US! These programs typically do not focus on treating dissocial individuals though and tend to select out individuals who make good analytic candidates.

In the US, treatment has been anthema since the 1970s when the conservative "law and order" turn that filled our prisons with black and brown bodies took hold and little emphasis on rehabilitation of offenders existed. We went from talk of prison abolition in the 1970s, the having the most incarcerated population in the world by the 1990s and the current backlash against prison overcrowding, the criminalization of the mentally ill, "the new jim crow" and the prison-industrial complex writ large.

Some of this however was due to a therapeutic nihilism that set in due to failed treatment programs in the 1960s and 70s. The most famous were the Oak Ridge Study in Canada which involved nudity, LSD, and treating schizophrenic and psychopathic individuals together. The psychopaths were released as cured, and had an increased risk of recividism following this particularly bizarre treatment. In the US, we had the Concord Prison Experiment, which used psilocybin-facilitated group psychotherapy under the direction of one Timothy Leary. The original study suggested a reduced recidivism in those so treated, but this was not found to the be case in follow up studies. psychedelic research would then fall out of favor for another 40 years. Failure of very specific types of intervention that would be considered highly unorthodox by today's standards became "treatment doesn't work." This is where the current nihilism for treating offenders has come from (and when we talk of ASPD, which is a specious construct in itself, we are chiefly talking about offenders who are convicted since this is the population who is studied and gets treatment).

In the US, there has been some interest in treatment of offenders more recently, and the more commonly used approaches are CBT focused at criminogenic thinking, mindfulness based approaches, and DBT which are used (if sparingly so) in certain correctional settings in the US. In the VA system I have seen MRT (moral reconation therapy) being used. elsewhere in the world cognitive analytic therapy has been used.

Personally, I would say that treatment of antisocials in private practice or community settings is a fool's errand, and once you get non-payment for your bills most therapists will learn the error of their ways. I did a psychologytoday search to find in my area the vast majority of psychologists listing "antisocial personality" as something they treat are the ones from the local diploma mill programs. OTOH, there may be mileage to treating these individuals in correctional settings, re-entry programs, and on probation, as part of a highly structured program that incentivizes participation and includes wraparound services to reduce recidivism.

So much gold, thank you. I totally agree with ASPD being a problematic construct, not least because the criteria as written definitely bias it in terms of SES/race/cognitive ability due to disparities in the kinds of people who end up justice-involved and those who don't for similar behaviors.

I take your point about caution and the possible undesirability of teaching sociopaths how to read emotional cues better. I think you have to weigh this against the possibility that really internalizing the idea of other people having affective states might reduce aggression; my suspicion is that people whose diagnosis tends to wander between BPD and ASPD are especially likely to benefit, and the data to date suggest that may be true. On the other hand, there is probably a subpopulation so high on callous-unemotional traits (my guess would be also a lot more premeditated, dispassionate violence) that it will be another tool for predation. I have not done a lot of forensic work so I have only encountered people like this one or two times clinically but good God the experience of the interview stood out. I had a very strong countertransference fantasy that I had a lizard or spider wearing human skin staring at me rather than a person, as opposed to a more typical person who winds up with ASPD diagnosis, who I want to challenge to a fistfight in the parking lot.

I also take your point about general services not being a great place for these folks to end up and the need for contingency management like woah. I guess I feel like there is a difference between "I don't think I can treat this person" and "nobody can treat this person".
 
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Presuming ASPD is the only diagnosis, and this is agreed upon by various/multiple providers-what is the treatment protocol? I’m not familiar with this area. What exactly are you “treating?”
Thanks.
This is a quote from the article I referenced earlier. I'm not saying it's an answer to your question because I think this is very speculative and based on anecdotal experience, but I found it interesting that stimulants helped at least one doctor's child patients with callous behavior:

"Psychopaths not only fail to recognize distress in others, they may not feel it themselves. The best physiological indicator of which young people will become violent criminals as adults is a low resting heart rate, says Adrian Raine of the University of Pennsylvania. Longitudinal studies that followed thousands of men in Sweden, the U.K., and Brazil all point to this biological anomaly. “We think that low heart rate reflects a lack of fear, and a lack of fear could predispose someone to committing fearless criminal-violence acts,” Raine says. Or perhaps there is an “optimal level of physiological arousal,” and psychopathic people seek out stimulation to increase their heart rate to normal. “For some kids, one way of getting this arousal jag in life is by shoplifting, or joining a gang, or robbing a store, or getting into a fight.” Indeed, when Daniel Waschbusch, a clinical psychologist at Penn State Hershey Medical Center, gave the most severely callous and unemotional children he worked with a stimulative medication, their behavior improved."​
 
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