The Mark of Cain by Meloy J. Reid

Author:Meloy, J. Reid.
Language: eng
Format: epub
ISBN: 978-1-134-90237-8
Publisher: Taylor & Francis (CAM)

Section II

Treatment, Risk Management, and Psychodiagnosis

13

Introduction to Section II

J. Reid Meloy

Psychoanalysts tend to make their diagnostic formulations by beginning treatment. The interaction between themselves and their patients, principally through transference and countertransference, provides them with a sense of the patients’ personality organization and their amenability to treatment. This reversal of the medical model—which calls for diagnosis first, treatment second—also captures the evolutionary history of our understanding of psychopaths. Psychoanalysts have studied the psychic architecture of psychopaths during the past century by continuous interaction with them through treatment efforts. Relatively recently we have begun to make diagnostic formulations, both clinical and empirical, to spell out similarities and differences when such patients are compared to various other groups of narcissistic individuals.

The four treatment papers in this section—incisive works by August Aichhorn (chapter 15), John Lion (chapter 18), Neville Symington (chapter 19), and Larry Strasburger (chapter 20)—are the best offerings among the very few analytic treatment papers on psychopathy that exist. As one would expect, rather than focusing on technique, these papers offer a psychoanalytic way of knowing the psychopath—through the countertransference, or internal reactions of the analyst. The absence of papers on technique is easily explained: there is no clinical or empirical evidence that psychopaths will benefit from any form of psychodynamic therapy, including the expressive or supportive psychotherapies, psychoanalysis, or various psychodynamically oriented group psychotherapies (Meloy, 2001).

Why would we, then, pay attention to countertransference in reaction to an untreatable patient? Precisely because psychopathy is not just present or absent, black or white, but varies in degree from one patient to another. Countertransference, along with objective measures such as psychological tests, becomes our barometer for gauging the severity of psychopathy and therefore the treatability of any one patient. The lesser the psychopathy (imagine, if you will, a mild form of diabetes), the more effective the treatment and the better the prognosis.

TRANSFERENCE

Psychopathic patients, true to their core narcissistic personality traits, will emotionally seek to establish one of four transference positions with their analysts. In Kohut’s (1971) terms, a psychopathic patient will seek to idealize (I want to worship), to mirror (I want to be worshiped), to twin (I want to imitate), or to merge (I want to control). What differentiates the psychopathic transference from that of other narcissistic patients, however, is the behavioral, rather than the fantasized or verbalized, expression of these transference positions and the relatively rapid emergence of the most developmentally primitive of the four: the need and desire to control the analyst. This transference will be experienced by the analyst as the discomfort of “being under his thumb” or as a compelling need to “walk on eggshells” to avoid what is catastrophically imagined as rageful, explosive, and potentially violent affect (perhaps a complementary and fearful identification with how the psychopath felt as a child; see Racker, 1968).

Other predictable resistances in the psychopathically disturbed patient include manipulative cycling, deceptive practices, malignant pseudoidentification, and sadistic control.

Manipulative cycling was first identified by Bursten (chapter 17) and is a cognitive-behavioral sequence that is highly

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