Treatment as an alternative to prison is attractive not only to our clients, but also to our programs, our politicians, and our taxpayers. As more and more people are being sent to rehab rather than prison, addiction treatment providers face new challenges. Our traditional substance use treatment tools are proving to be less effective in dealing with clients’ antisocial characteristics.
Treatment providers have spent many years developing successful programs to deal with substance abuse, but many of our tools are not as useful in dealing with “criminal thinking,” or the DSM’s “antisocial personality disorder.” For example, cognitive-behavioral therapy (CBT) can be highly effective for substance abuse clients who are committed to a goal of abstinence. Counselor and client work together to identify and change unhelpful thoughts and patterns of behavior. But CBT has no chance of succeeding with clients who won’t tell you what they’re really thinking.
So programs need to identify clients with the heaviest antisocial characteristics and use different tools—or maybe even create a separate track for them. Those who are diagnosed with full-blown antisocial personality disorder can be very disruptive of treatment, and it might be best to deal with them in a totally separate program in a different location.
Let’s consider what individuals with substance use issues and those with antisocial personality disorder have in common. Both groups are often highly intelligent and can make a very good first impression. Neither group is very good at dealing with frustration, and both continue making the same choices despite not getting the intended results. Sadly, premature death is associated with both groups.
But those diagnosed with substance abuse and those with antisocial personality disorder differ in at least four important ways:
1)The pattern of substance abuse often reveals a lot about which diagnosis applies. Those with a primary diagnosis of antisocial personality disorder are usually chronic abusers, but not addicts. They usually don’t use over a period of years on a daily basis. That’s why it might be easier for them in the early days of treatment to go without using.
2)The pattern of relationships with other people is also very different. Those with antisocial personality disorder don’t usually experience the anxiety that our more traditional clients do—they lack the capacity for truly intimate human relationships. They have few or no long-term relationships, because they manipulate and exploit others without remorse. On the other hand, the use of substances causes many conflicts in the interpersonal relationships of those with addiction problems. Addicts do have the ability to maintain long-term relationships, and they care—maybe too much—about what other people think of them.
3) Differences in the thoughts of the two groups are the most reliable indicator, but also the hardest to ascertain accurately. Thought patterns of our traditional clients reflect worthlessness, shame, guilt, self-doubt, fear and hurt. Thought patterns of the antisocial personality disorder client are more narcissistic, with no sense of responsibility for consequences. There are often violent and even murderous thoughts.
4) Finally, there are differences in emotional makeup. Those with antisocial personality disorder don’t experience empathy, love, fear, anxiety, depression, or remorse as the rest of the population does. On the other hand, many of our traditional substance use clients turned to drugs, in part, to relieve the intensity of the emotions they were feeling.
Because of the many common characteristics, and because both populations often share misinformation, it’s easy to confuse those with substance use disorders with those with antisocial personality disorder. Programs need to make differential assessments, and design different types of treatment plans. Antisocial characteristics need to be addressed regardless of whether a substance abuse client qualifies for the antisocial personality disorder diagnosis. More accurate assessments also will facilitate optimal decisions on which clients to maintain and which clients to refer.
It is important that we avoid, for our criminal justice clients with antisocial characteristics, the same situation that used to exist for addicts: lack of treatment options due to a belief that the population is impossible to work with and beyond hope.
It is not realistic to expect that serious substance abuse or antisocial problems will get better without intervention. Both groups need us to work hard to motivate them to enter, participate and stay in long-term treatment. Antisocial personality disorder clients, especially, are not internally motivated to stay in treatment.
The most promising approaches to ASPD clients include the following components:
Detox and sustained abstinence. Usually only possible in a strictly controlled setting, this is the first ingredient of success. A sustained abstinence in a strictly controlled setting is necessary for the development of a commitment to lifelong abstinence. The connection between relapse to drugs/alcohol and relapse to antisocial behavior is too close to consider controlled use of substances.