Introduction
Antisocial personality disorder (ASPD) is a Cluster B personality disorder associated with excessive deviant behavior. According to DSM-5-TR criteria, patients with ASPD must demonstrate three or more symptoms, including irritability, disregard for social rules, impulsivity, deceitfulness, a lack of responsibility/accountability for one’s actions, no remorse, and neglect of safety (Boland et al., 2022). Although the patient must be eighteen years or older to be diagnosed with ASPD, individuals should have a history of conduct disorder before age 15 (Boland et al., 2022). Finally, since people with ASPD typically feel no remorse, they are frequently uncooperative, manipulative, and might be hostile to psychotherapists. In summary, ASPD is a prevalent personality disorder that is challenging to diagnose and treat, and that is why it is critical to adjust and improve psychotherapy strategies continuously.
Therapeutic Approach and Modality
One of the novel treatments for treating ASPD is mentalization-based treatment (MBT), which utilizes group therapy as the primary modality. In general, MBT employs the concept of mentalizing – cognitive and emotional conceptualization of responses to stressors (Bateman, 2022). It helps struggling individuals understand the value of emotions (their own and others’), which, in turn, reduces the impact of cognitive-affective imbalances that lead to violence and irritability (Bateman, 2022). I selected this approach and modality in part because of its novelty and because other methods, including CBT, contingency management, and dialectical behavior therapy (DBT), have shown relatively limited effectiveness (Gibbon et al., 2020). On the other hand, while more research is preferable to establish group MBT as an effective evidence-based psychotherapy for ASPD, it is a highly promising methodology.
Therapeutic Relationship
While MBT has been used for many years, its group modality for treating ASPD is novel, and one of its focus points is the therapeutic relationship between the patient and others. As Flatten et al. (2024) explain, emphasis on balanced interpersonal relationships is critical in ASPD treatment because “Individuals with ASPD have a particular sensitivity to hierarchy and power.” Furthermore, patients are likely to perceive the psychotherapist as an authority, which is generally counterproductive precisely because this condition is associated with challenging authority and deviant behavior (Flatten et al., 2024). For this reason, group therapy is an appropriate modality that can help affected individuals discuss problems with other people of equal standing (Bateman, 2022; Flatten et al., 2024).
In this sense, it might be appropriate to begin with an individual introductory session to share the diagnosis and later transition the psychotherapy to a group setting. It is also plausible to integrate family members into the process to mitigate the patient’s resistance to therapy and mediate the therapeutic process (Flatten et al., 2024). Finally, sharing a diagnosis immediately in a group setting might be challenging precisely because of ASPD. For example, if the affected individual “receives” a diagnosis from a psychotherapist with other people watching, it is one of the most evident signs of obedience and imbalance of power, which are primary stressors that can result in violence (Flatten et al., 2024). Therefore, I think the gradual shift to group sessions is necessary to mitigate the sense of hierarchy and structure.
References
Bateman, A. W. (2022). Mentalizing and group psychotherapy: a novel treatment for antisocial personality disorder. American Journal of Psychotherapy, 75(1), 32-37.
Boland, R. & Verduin, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
Flaaten, E., Langfeldt, M., & Morken, K. T. (2024). Antisocial personality disorder and therapeutic pessimism – How can mentalization-based treatment contribute to an increased therapeutic optimism among health professionals? Frontiers in Psychology, 15.
Gibbon, S., Khalifa, N. R., Cheung, N. H., Völlm, B. A., & McCarthy, L. (2020). Psychological interventions for antisocial personality disorder. Cochrane Database of Systematic Reviews, 9.