A Lesson In Dealing With Anti-Social Personalities

He really looked down on his luck, as do most people who came into this particular urban mental health clinic. He was receiving drug samples from a nurse practitioner somewhere in the system; drugs too expensive to continue getting samples to give him. Drug companies stop giving out samples of drugs when it is no longer financially appropriate to do so, when it becomes an "old" drug, presumably used enough that the extra "boost" of sales from sampling is not necessary. In my mind, I was already planning how I could keep him well by making a switch for the long term, since he was unlikely to be insured by even programs for the indigent very quickly.

His ragged clothes had obviously come from a clothes bank. I knew I could get him enough samples of drugs to keep him stable for at least a week or so. I expressed basic worries; asked him if he was safe where he was living. He said "no," he felt threatened. It was unclear if he was physically threatened, but he certainlly did not feel secure. I knew he had been less than three weeks out of jail and he was staying with "friends."

I tried to get a history, but he spoke few words and spoke them softly. He did admit to a string of drug offenses and then parole violations. I probably should have been suspicious when he told me in more detail about his family's drug history and drug offenses, before I was able to get him to tell me about his own. It did indeed sound like anyone who had grown up in that sort of a family did not have much of a chance. He was approaching middle age, maybe a little old to be talking about his parents. Well, thought I, at least he felt some shame. And he said he was clean, now.

I asked about food. He certainly could not remember his last meal. I am not supposed to give out food, even though sometimes people who wandered through this agency would eat my lunch if I left it on the desk, so I usually placed it where they couldn't see or eat it. I did talk to one of the counselors and I established a "pantry drawer" with some nutritional food bars and some Ensure -- maybe not the tastiest thing in the world, they tell me, but it is a milk-shake like entity that will keep up basic nutrition.

My patient refused all of my emergency provisions.

I went to check with the social work type counselor person (non credentialed, of course, to keep the budget down) about options for lodging this man. After all, what good would the overpriced prescription drugs I would be able to get into his gullet possibly do if there was no basic physical safety or well-being?

The social work-type counselor person for this patient was much younger than me and I don't think he had much in the way of degrees. But he could not repress a smile on this one. My patient was in a situation where he was perfectly safe and was eating just fine, and would have to cough up some money, which he could get almost immediately from a short term job he had already been offered and accepted. Then, he would get better lodging. In other words, I had been lied to. I had been had.

It was not the first time. I found out early in my training I was fairly susceptible to this sort of thing. I have known some psychiatrist and therapist types, often in military settings, who tended to make errors in the other direction, doubting people who later were proved to be worthy of things they asked for. I made a decision early on that if I had to make mistakes sometimes, and we all have to make mistakes sometimes, I would rather make this kind of mistake than to be too harsh when harshness was not warranted. After all, the only thing lost on this case was my pride in my abilities, an entity which is, at its best, very fragile indeed.

The patient hung his head when I sent him back to his counselor. I knew angry confrontation would not help any. I wondered if he had been a good enough liar to survive without getting beat up excessively in jail. I met some of the greatest liars of all time when I worked as a psychiatrist in such a setting.

You would think that psychiatry had a nice set of rules to tell when people are lying, but it does not. When people lie chronically and habitually without remorse, they are known as "sociopaths" or in more modern terminology, "antisocial personality disorders." Medication is not helpful here. There is an old joke among psychopharmacologists. "Someone invented a pill for antisocial personality disorder. There is only one problem. Nobody wants to take it." The reference here is to the fact that nobody who has this disorder wants to admit they have anything wrong with them. They take responsibility for nothing. They seem to have no guilt, classically no "remorse" for whatever they have done. Therapy may work, but I have not seen any figures suggesting it does so more than half the time. Jail, which means dealing with the consequences of their actions, may work at about the same rate. I said "may," because I have not seen much work.

Once, long before I worked in the prison system, our family rabbi of blessed memory, who did prison visits to see those rare inmates who said they were Jewish, took my mother with him to do some visiting. My mother called me not long after, profoundly moved, to tell me about all of the nice Jewish boys who were in prison because, as they had told her, they simply had been unable to afford good enough lawyers at the time. They were all really innocent, my mother of blessed memory told me, and they were wrongfully imprisoned, and it was horrible. I remember thinking these antisocial personalities were quite good at what they did. Efforts to explain the situation to my mother were of no avail. She could not believe that the nice Jewish boys she had met with the rabbi could be lying, no matter what I told her.

Some of the character traits required to maintain a personality of this sort may be genetic. I remember reading about a series of folks, charted over generations, where male antisocial personalities marry depressed females, for several generations. Genetic engineering, when possible, is unlikely to fare any better than the imagined "antisocial" pill. Who would admit they needed it?

"Pollyanna" (me) has been dealing with this one for years. I have seen some glimmers of hope, and restrained my cynicism long enough to try to help. The glimmers seem to have something to do with community support. Often it is the religious community, especially in prison. I think this is quite simply because it is one of very few things available to help a prisoner actually feel good.

As for the durability of these changes, I have no data. I only know what I told prisoners for years, I do not believe in bad people, only good people who do bad things. After all, I am only a psychiatrist, shlogging through life on the front lines. But this I do know. Somebody seems to get better sometimes, and I have not been impressed by those who say they have answers. So if it is the 30th chance or the 50th hour of treatment, I guess I will be the one there trying to give it, even if the counselor represses a smile. If you don't know which attempt will work, or if any will work, to me that is not a reason to stop trying.