Antisocial personality disorder in group therapy, kindling pro-sociality and mentalizing

Abstract

Patients with antisocial personality disorder (ASPD) are known for being difficult to treat. Treatment for ASPD is debated and lacking evidence. Among several reasons for treatment difficulties concerning ASPD, negative countertransference in health personnel is one central topic. Mentalization based treatment (MBT) is a reasonable candidate treatment for ASPD. From an ongoing pilot-study on MBT with substance using ASPD patients, we explore therapist experiences. Four experienced MBT therapists together with the principal investigator performed a focus group together. The therapists were themselves involved in performing this study and analyses are made as an autoethnographic study, with thematic analyses as methodological approach. As this study involved a qualitative investigation of own practice, reflexivity of the processes was performed. The aim was to explore in depth: therapist experiences and therapist wellbeing in MBT-ASPD. We found four main themes on therapist experiences. 1) gaining safety by getting to know them better, 2) gaining cooperation through clear boundaries and a non-judgmental stance, 3) shifting inner boundaries and 4) timing interventions in a high-speed culture. These four themes point to different therapist experiences one can have in MBT-ASPD. Our findings resonate well with the clinical literature on ASPD, the findings imply that clinical teams should have a focus on therapist countertransference and burnout, ensure that therapists uphold boundaries and open-mindedness in treatment of ASPD and that therapists experience vitalizing feelings in this line of work.

Establishing an optimal working relationship with patients with an antisocial personality disorder. Aspects and processes in the therapeutic alliance

“…A direct approach is also important, including setting clear boundaries while still maintaining respect and honouring the patient's autonomy. The significance of firmness in setting boundaries was also highlighted in recent studies by Morken et al (2022) and Seaward et al (2021). Van den Bosch et al (2018) similarly recommended a 'firm but kind' attitude.…”

“…These factors have been found to be important in studies involving patients with anxiety disorders, depression with comorbid alcohol use problems, and personality disorders (Bender, 2005; Knock et al, 2021; Luong et al, 2020). On the other hand, other factors, such as clarity, transparency and trustworthiness, appear to be more specific to personality disorders in the dramatic or erratic cluster and of particular importance for patients with ASPD (Bender, 2005; Morken et al, 2022). These aspects were described in the subtheme genuine involvement , emphasizing the value of establishing genuine contact through curiosity, understanding, transparency and trustworthiness.…”

“…On the one hand, the therapist must be sensitive to the need for respect and autonomy and the fragility of trust; on the other hand, the patient needs a therapist who can provide structure and set boundaries. This approach demands flexibility from the therapist, who must adopt a collaborative attitude and focus on the patient's needs while also standing firm when boundaries are tested or violated (Morken et al, 2022; Van den Bosch et al, 2018).…”

“…Therefore, therapists need to exhibit outward attention and invest effort in making connections. On the other hand, therapists also require a highly developed reflective capacity, including a strong sense of self and awareness of personal boundaries, which has been consistently identified as crucial for working with patients with ASPD (Morken et al, 2022; Van den Bosch et al, 2018). This reflective capacity helps therapists navigate the complexities of the therapeutic relationship.…”

“…However, research that specifically focusses on patients with ASPD is scarce. Recently, Morken et al (2022) employed an autoethnographic qualitative study of mentalization-based group treatment for patients with ASPD. Based on their own experience, they concluded that a direct approach with clarity about boundaries and structure was essential, alongside an open-minded, non-judgmental attitude that respects the patient's autonomy.…”