Thursday, January 22, 2009

Antisocial Personality

Many people use the term "antisocial" in daily language to describe a feeling of not wanting to socialize, or of reclusiveness.

In DSM terminology, "antisocial personality" refers basically to a history of criminal behaviour.
So it is important to clarify what is meant by "antisocial" if it comes up in conversation.

I suppose, like all other judgmental categories characteristic of the DSM, one ought to question carefully what is considered "criminal", and whether this assessment is a product of cultural bias, prejudice, etc.

For example, a protestor advocating for civil rights in some tyrannical regime might be arrested
and labeled a criminal by some, a hero by others. These assessments might also change with the passage of time--the next generation might view the same events quite differently than we do today.

A soldier who has killed dozens of people in a battle might be considered a hero by some, a criminal by others. Depends on whose side you're on, I guess. And it depends upon one's sense of morality or fairness, regardless of whether you're on a "side" or not.

However, I do believe that there are types of behaviour, present in any population (whether the population is at peace, in a war, in states of wealth or poverty, etc.), which could be considered "antisocial".

The main "antisocial" problem in an individual that concerns me is a history of recurrent cruel or violent behaviour towards other people.

There are many other types of criminal behaviour, involving stealing, fraud, dealing drugs, etc.

And there are types of behaviour that are not "against the law", but which often accompany other antisocial problems. For example, a pattern of lying frequently in order to attain social or material goals. Or, simply, acting with no regard for, or understanding of, another person's feelings or well-being.

Once again, I suppose these phenomena need to be considered in a cultural context. If a person is lying, stealing, or engaging in forgery in order to help a persecuted person escape from a tyrannical regime, then such acts could be considered among the highest forms of altruistic heroism. Yet, for some individuals, such behaviours have been part of a daily pattern, independent of other circumstances, ever since early or middle childhood.

Another so-called antisocial trait would be a recurrent failure to take responsibility, to feel or express remorse, for actions that have caused harm to others.

Often times, antisocial behaviour has developed in childhood, and persisted through adult life. An important contributing cause is a childhood environment in which there is a lot of antisocial behaviour in the home and in the community. A history of trauma, neglect, or abuse can be risk factors. There are genetic predispositions, probably best understood by indirect influences, such as inherited tendencies towards aggressiveness, irritability, impulsiveness, difficulties perceiving or being moved by others' emotional states, etc.

Here's a reference:

Antisocial behaviour has a strong subcultural influence as well, for various reasons. First of all, if a person is aggressive, they are more likely to associate with other aggressive people. In this way, violence may become more of a norm within this subculture, or even a quality to emulate or to boast about, leading to some elevation of social status within the group.

The criminal justice system deals with a lot of antisocial behaviour through the prisons. While sending a violent person to prison may protect society during the prison term, it exposes that violent person to a subcultural milieu in which all of his (or her) neighbours have also committed criminal offenses. This may perpetuate that person's "antisociality".

In psychiatric practice, I find that antisocial behaviour is very difficult to address. The main issue for me is my own feeling of safety--if the therapist does not feel safe with someone, I don't think therapy is possible.

So, I think safety is an essential prerequisite for any sort of therapy. Court-mandated therapy in a safe setting (such as a prison) may well lead to improvements in symptoms for many people with antisocial behaviour (e.g. learning about anger management, treating irritable depression, etc.). However I think that externally-mandated therapy is always likely to be very limited.

Another big problem with so-called "antisocial personality" is that this style may be what is called "ego-syntonic". That is, the individual may have no wish to "change", or have no true perception that there is any sort of "problem" with them. They may attribute their episodes of violence, etc. or their prison terms, to other people having crossed them the wrong way, or to the bad luck of having been caught. Or they may simply engage in various apparently positive social tasks motivated only by a sense of immediate material gain (e.g. they may be friendly or charming with someone only to be able to build enough trust to rob them, or sleep with them later, etc.). For ego-syntonic problems of this type, I do not think psychotherapy can be effective at all. It may in fact be just one more game that the person plays, in this case with the therapist.

There was a movie a few years ago called The Corporation (written by BC law professor Joel Bakan) which argues that corporations (big business enterprises) in our society function as antisocial individuals (the law actually considers them "persons"), and that our current system of laws actually encourages or even mandates this as a norm. A core part of this argument was based on the fact that a corporation's primary motive is maximizing profit; well-being, empathy, ecological stewardship, etc. may well be considered, but only as instruments to maximize profit, not as primary motives. This is similar to understanding the behaviour of a person with "antisocial personality" as being motivated primarily by the plan of immediate individual gain. (incidentally, I found this movie to be good, and I agree with many of its ideas, but it would have been much more effective and convincing for more people had it presented its case in a more balanced manner -- it comes off as politically very left-wing partisan, somewhat dogmatic, presents only one side of various issues, and therefore will immediately alienate and disengage others with different political views, who are likely to reflexively dismiss it, rather than accept its ideas or engage in a productive dialog).

Getting back to so-called antisocial personality, I think that if therapy is to help at all, it would have to require, first, that the therapist feels safe, and second, that the person truly wishes to work, on some level, on building a sense of care, love, and altruism for others. Otherwise therapy might be quite limited, for example to offering some help reducing subjectively bothersome irritability (help which would hopefully reduce future episodes of violence, etc.).

In terms of medical records, I do think that noting a history of antisocial behaviour is relevant, for safety reasons. Persons with a history of recurrent violence, sexual assault, stealing, etc. may pose a risk to fellow patients or staff during a hospital stay.

The other means of dealing with antisocial personality involve structures other than psychiatry. The criminal justice system is currently the main other structure. I feel that reform of the prison system could be a powerful change, since I think it is harmful for dangerous individuals to be locked up among a group of other dangerous individuals, then released again into society.

I wonder if modern technology could be one example of a practical solution for some cases: for example, if a violent person such as an assaultive husband or sexual offender, is given a restraining order forbidding access to his wife, family, or ex-girlfriend, it may be much safer for society, and especially for the wife, family, ex, etc. if the offender has some kind of electronic monitoring (using GPS technology, for example) which would immediately alert the family and the police if the offender were to violate the conditions of the restraining order (e.g. by approaching within a 1 km radius). It would permit the victims to feel safe, while doing least harm to the offender (by not exposing him to the negative environment of prison). Such a strategy could be much more effective than sending the offender to prison, since everyone would be right back to square one--or worse-- the moment after the prison term ended. I think of how many tragic episodes of violence (numerous such examples from local media alone in the past few years) could have been prevented if such a system were in place.

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