Psychiatry & Psychotherapy Podcast - Interview on Psychopathy with Expert Carl Bruce Gacono, Ph.D., ABAP

Episode Date: May 20, 2021

In this episode, I interviewed Carl B. Gacono, PhD, who is an expert in the areas of criminal psychopathology, behavior, and treatment. We dive into understanding and acknowledging the distinct differences between psychopathic and non-psychopathic patients and how their assessment with the PCL-R and Rorschach aid in their management and treatment. We also discuss how understanding transference and countertransference is essential when interacting with these difficult patients. Link to Blog. Link to Resource Library. 

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast. Go to Psychiatrypodcast.com. Sign up, sign in, take the test, and the certification is emailed to you in seconds. In this episode with Carl Gekono, PhD and forensic expert, he is both a researcher and a clinician, someone who has worked over 20 years in prisons and now in private practice.

We will be going through psychopathy and criminal offenders. We'll be talking about antisocial personality disorder, psychopathy, the Rochark. He is an expert with over 50 publications, including books like, female offenders and the Rochark Assessment of Aggressive and Psychopathic personalities, the clinical and forensic assessment of psychopathy. And to sort of introduce this episode, I was thinking about empathy. And if you remember from my Therapeutic Alliance episode on empathy, I talk about how there's different levels of empathy.

There's empathy for the moment-to-moment emotion that's flashed on the face, the sentence, the context, the short context, the paragraph. and then the book, the overall arc of someone's life. And something that we talk about in this episode is that with someone who is psychopathic, narcissistic, someone who has raped people, murdered people, has a lifelong trajectory of manipulating and hurting people, these people think very differently than the kind, empathic, warm therapist that listens to my show. And yet we often take care of people who have been harmed in some way by one of these types of people.

And when we're talking with someone who's more psychopathic, narcissistically oriented, we can project our own thoughts, our own ways of thinking about reality, maybe that most people tend to be good, most people tend to do good. we can project some of these thoughts onto these people while they're projecting their own thoughts onto us that we would maybe enjoy their suffering. You see, they're projecting that image that they have internally onto us. And I was thinking about this and thinking about empathy and how sometimes it's hard to understand this stuff. And so I think it's good to kind of go into it in more depth. You may not know, but I spent three and a half years in a juvenile hall on the

weekends during medical school. I would go in every Sunday and I would talk to the inmates there, female and male, and I would run groups, actually. I enjoyed it. It was a passion of mine. And connecting with these people and sort of in a different way, right? You're connecting in a different way. Empathy is actually seeing how differently they view reality. So I'm going to tell you a little bit about psychopathy in this intro to kind of summarize it to get us going for this episode. Psychopaths thrive in situations where there is chaos because they can fly under the radar as people focused elsewhere. They can apply to societal settings, work settings, and even personal situations where individuals are vulnerable for any number of reasons.

If you look deeper, you discover inconsistencies in their lives. Investigate their references, and you will find many aspects of their history are fabricated. There will be gaps in their history. Find the right person to interview, and you will discover a trail of interpersonal problems that reflect their exploitation of others. It is important not to ignore their inconsistencies, their lapses of personal problems. their lapses of personal empathy. The fact that you have never met their family,

their strange behavior in situations where empathy is common sense to responsible people. Rather, these situations, as the tip of the iceberg, relate to their personality deficits. Do not accept their excuses or give them the benefit of the doubt. Trust your gut when things seem not quite right.

If not, you will leave yourself vulnerable to exploitation. This can be difficult as most people view others through their biases and tend to see others is basically good with good intentions. To these psychopathic individuals, kindness is weakness. Male psychopaths in general tend to be malignant narcissists, meaning that they use devaluation, manipulation, and use others to boister their own self-esteem. They're detached and have a heightened self-focus that leads them to lack attachment. They are loners by choice on the Rochecks. They tend to be higher in measures of self-focus, lack of attachment, lack of anxiety, poor interpersonal relationships that are infused with aggression and primitive defenses. There are a lot of comments in the previous episode on female psychopathy.

I re-listen to it, and I don't, I myself had some internal critiques. you know, maybe I need to be a little bit more forthright when I disagree with someone in the moment. I'm learning. So be patient with me as an interviewer. And I'm going to ask some of the questions that you guys asked to Carl in this episode. I am not an expert in this. And so it's important to bring someone on who is an expert and to learn from them and to see what we can glean from their practice and understanding of things. Hopefully this will be a helpful episode to you. as a clinician and understanding and having more empathy for someone of a very different personality type than yourself. Before we start, one more story. I had a interaction with someone in my past

who we called Sub-6. He was on my rowing team, and he had lied about his rowing time to get into college. He had a wake of destruction behind him in his interpersonal relationships that I saw for time. And it kind of culminated my last interaction with him when he was recently broken up with a girl and he was going to go to her parents and explain that she was potentially using drugs and all this other stuff. He was basically going to express his concern his, you know, desire for her to do better, right? But the other thing is, is I knew this situation. I knew him, and I knew that he didn't really know that she was using drugs. And so I confronted him. I said, Bob, I think this is BS. You're hurting her by torturing her parents. You're driving a

wedge between her and her parents because you're upset that she broke up with you. And he looks at me and kind of laughs. And he says, yeah, I'm still probably going to do it. And it's just this image of someone who is sort of trying to puff up his own image, right, in his own mind. But at the same time, not really caring that he hurts other people, does damage that might last for years. So I'm sure we all have stories like this, stories of people who are more psychopathically oriented. Hopefully, you don't have too many. but if you do, it's something to obviously work through in therapy.

And part of the therapy that I've found with the clients that I see who have interacted with someone who is psychopathic, a Machiavellian narcissistic, is that they're trying to grapple with, how are people like this? How are people so different than themselves? This is a small population, but it's a population that does a lot of destruction. So I hope you enjoy this episode. Here we go. All right, welcome back to the podcast. I am here today with Carl Giacono. He is the author of several books largely on psychopathy, on the assessment of psychopathy at a very detailed level.

He's written, gosh, it looked like over 50 articles, 50 peer-reviewed articles on the topic. So it's a great pleasure to meet you. And after reading your bio and, you know, in the introduction of one of your books on psychopathy, I think we have some things in common. You were a wrestler, you did martial arts, and you were telling me that you didn't know that you had asthma when you were wrestling. That sounds really painful.

Oh, David, in those days, you know, everything, they gave you a big penicillin pill, and that's what they gave you for everything. So asthma would turn into kind of lung problems and bronchitis. And yeah, I didn't realize I had asthma, and I was wrestling. So I was naturally pretty gifted, but can you imagine being in the third quarter and you can't breathe? That's torture.

Torture. And they needed some years of martial arts. I was reading. And what fascinated me was that you said you went like three hours a day, six days a week or something for a period of time? Yeah, it was seven days a week. It was the old school kind of thing out in California where I did it in Salinas, California. And I really had not much else to do because I, left the East Coast to go to California and I ran out of money in Salinas and got a job as a

carpenter in a greenhouse. I lived with five guys that couldn't speak English. Basically, I was the only white guy working at the place and the only guy in the studio. Everyone else talked Spanish. So I learned enough to pick up and communicate, but it was old school. You know, you went outside and your bare feet. You did a lot of running. We'd go out and run up and down hills and mountains and Salinas. I mean, it was the only way to train. Yeah. Yeah, I grew up in Cooper Tina and pretty close there, and then I lived in Morgan Hill for a time. Okay. So I know that area. I've been there. One of the things I was thinking about was, as we start here, kind of like just giving my audience an idea of what we're going to talk about. We're going to be talking about psychopathy.

We're going to be talking specifically about the Roershack. I hope I'm pronouncing that right. Yeah, that's good. Rochequer, which, you know, a lot of people who commented on the last episode I did on psychopathy on this book, Understanding Female Offenders, which you were a part of, you were one of the authors that wasn't on the prior episode. A lot of the people said, oh, I didn't know that that was really a thing anymore, that that was valid or that that was still paid attention to. But it sounds like it from your work and from the stuff that I've read, that it's a valid measure. it just isn't it's it's hard to understand it seems and it's like it's it's not intuitive it's not something very simple you have to you have to get your mind around it and the meanings of it yes well you know david um when we're ready to get into that if you want me to start now um but i'll make a

general comment and just let me know um you're exactly right all those points you made about it it's a test that requires a lot of mastery to be able to use it successfully and it's often lacking in people that are teaching it. And there's also a tendency in academic settings to devalue instruments such as this that they don't understand. And many of the critics that come out of those situations in the academic settings that do that are really not people that actually work with people. They're not psychologists that every day work with folks. Plus, I find with the Rorschach, I can explain it in ways that make it simple that you can understand kind of how it works. when you're ready for that. But I think we need to be comforted by Carl Rogers in today's

podcast because it's a rather ambitious agenda. And I think Carl Rogers was asked, well, what do you accomplish in a 50-minute session? And he said 50 minutes were. So I'll let you guide me as to what you want to talk about and where you want to start. Yeah. Yeah. Well, I think just to give people an idea of your career, because I think all too often we hear, from people who have very little experience with the population that they're talking about. You know, you may get a lecture from someone and they've spent at some time reading books or reading articles. And the thing that I really like to do on this podcast is to bring people on who otherwise wouldn't have a platform. Like, they're not, you're not known as like a famous

person in the sense of like, you're famous probably in the community of people who know about psychopathy, who want to know about the Roershark, but you're not like someone who, by and large, you know, like, is going to, has written popular books that has maybe little scientific backing. Does that make sense? Boy, David, it more than makes sense. You know, one of the things my generation didn't have this type social media. And a lot of the things that confuse clinicians, clinicians read articles and things in order to guide their clinical practice is all the confusing results that come out of it and

things that don't make sense. And a lot of this stems from academic settings where people kind of are theorizing and doing things from the perspective of looking through a telescope. Many of them have never worked with the populations or actually interact with these people. So a lot of the research findings are kind of invalid and misleading. And one of the things with both Ted and Jason and I were scientists practitioners. It's an old tradition where we have done the clinical work. We work in these settings, plus we test our theories and hypothesis by rigorous methods. So we bring an added piece to what we talk about that makes sense to clinicians is generally much more useful.

It's like most of us at some point when we went through graduate training had that professor that was actually practicing in their area and would come in, and we know that their talks were much more enlivened and meaningful. So, I mean, you're hitting major points that are important. And I think with Jason, Ted and I, our commitment is to get this out. And in a way, the social media is leveling the feel. Whereas if the only thing in journals tends to be controlled by people who have limited perspectives, then that's all you get to see.

But shows like this and talking about it, we can get information to clinicians that's actually helpful and not only sorting out and understanding the research, but guiding their practice. So, I mean, you know, you've hit it right the nail on the head. Yep. Yep. And so, like, just to give the audience an idea, how many psychopathy checklists do you think you've done on actual people? Oh, my lord. Well, first of all, I worked 20 years in jails and prisons, and it's included jail settings. I was the assessment center director at Tascadero State Hospital in California, which is the country's largest maximum security forensic hospital. my one job during a period of time is the assessment director is I assessed all the malingers, the suspected psychopaths, the sexual homicide perpetrators, and pretty much the cream of the crop.

And you learn much more by doing that. So to answer the questions between, I kind of talk in terms of between Jason Ted and I, I combine our clinical experiences because we work so closely together. Probably we've interviewed assessed and worked with thousands of inmates. we probably at least assessed maybe about 150. Well, no, Jason has 100 and something, probably about 300 bona fide psychopaths that score high on the PCR. And then at one time at the Tascadillo State Hospital, I was doing three PCR assessments per day. So, I mean, you learn a lot by not only the clinical experience, but approaching it through theory and then applying research methods to actually what you're finding.

this is what I always say to clinicians don't devalue their clinical intuition, but also don't be biased. Read the theory, subject your observations to kind of rigorous methods. Because the first step of the scientific method is observation. This is often lacking the things that come out of academic settings. Think about it. Geologists go chip away at rocks. Marine biologists go swim with the sharks. anthropologists, they go to digs or they go live with the guerrillas.

Our profession is the only one that people offer opinions about things based on their understanding of reading things and often illusionary correlations, and then their opinions are valued. I mean, this is where programs like you and the social media can eventually level the playing field and get our field back more to a science than a pseudoscience. Yep. Yep. And so with that kind of introduction, okay, what is psychopathy just to kind of review? And specifically, one of the questions that was asked is, like, what would the average person look for if this person was not in jail?

Like if this person was just someone they were interacting with in the general population, like what would be some of the tells or what would be some of the sort of red flags? let's say someone was dating someone and they were like, am I dating a psychopath? Well, if you are, change your address, move, get a PO box and kind of get out of there. But anyway, now to answer the question, seriously, psychopathy comes from a tradition in psychiatry and traditional research that went back to anywhere from CREPLIN to Partridge through Cleckley to be measured and assessed by Robert Hare in his work with the PCR. are. It's a very traditional conceptualization that contains generally antisocial and irresponsible

behaviors as well as characterological traits of kind of severe narcissism. The antisocial personality disorder, and this is a way to understand it by contrast, stems from the word sociopath that was in the first DSM, and it's mainly relied on behavioral criteria. It's a much more heterogeneous group. When you go to any prison setting, probably about 75% of the inmates meet antisocial personality disorder. Only about 25% would be seen as psychopaths. And let me give you an example at two folks that meet the criteria for antisocial personality to show you the differences. One guy's a sexual homicide perpetrator. He comes into the interview with me. He shakes my hand, and he says, Carl, you can call me Don. Now, remember, he doesn't know me. I'm coming in as a professional,

but right away we're on an informal basis. He sits his rear end down in the chair and props his feet up on the table. Another guy comes in, and this is a guy that meets antisocial criteria, but he's also an avoidant personality disorder. I'm assessing him because he's sexually attracted to automobiles, and the psychiatrist doesn't know how to explain his behavior. This guy comes in, he doesn't make eye contact. He's anxious. You know, he's very self-effacing and, you know, polite. he's actually a very attractive, you know, young guy,

but they both meet the behavioral criteria for antisocial personality disorder. Number one, Mr. Brandios and psychopathic, he scores about 34 on the hair psychopathy checklist. The second guy scores about 20. So see, within antisocial, it's such a heterogeneous group. Psychopathy has the two factors. both the characterological traits and also the behavioral traits. If you are a psychopath, you're likely to meet the criteria for antisocial disorder. If you are antisocial, you're not likely to be a psychopath.

Hence it becomes a trick question if you ask me are antisocial personality disorder is treatable. Well, if it's such a heterogeneous group, obviously some of them must be. So you look at the base rates are quite different. And then you look at another factor. When we score people on the PCR and we look at these high scores above 30, behaviorally, they're different than low scores. They get into trouble more often. They have more instances of violent reoffense. They reoffend on parole more often.

They fail treatment. So see, we get the behavioral validity that these high scores are different. So psychopathy is more of a clinical, psychiatric, a long-term kind of tradition. with an evolution where sociopathy and antisocial personality belong with the DSM and they're based on a social deviancy model. They overlap their cousins, but they're different animals. Okay. Yeah. So it seems like with psychopathy, one of the characteristics is this like callous, remorseless use of others. Yeah. And I'm wondering if that person were in the general population, not maybe getting caught for crimes or not committing crimes,

what types of things would you notice about them or like what types of behaviors would they be doing that might be those red flags of like, okay, maybe I'll create some distance from this person psychologically or interpersonally. This is a good question. And let me address that in one minute with kind of leading into it. There's a guy named Paul Babiak that walked right up

called snakes in suits. He's an I-O psychologist that talks about psychopaths and industrial settings. And I want to point out that in those settings, when he's used the PCR, the people that are problematic are very high on the PCR. People that are psychopathic do well in situations where there's chaos and they kind of get through the cracks. If you look at psychopaths historically in those kind of settings and context, it's likely that somehow did things throughout their life, but they didn't get caught for it, like your point. Maybe they had a little better ego functioning and they were able to slide or get bailed out. But there is no successful psychopath in the sense that if you look at their interpersonal relationships and their behaviors, it's just a matter of time when they get

caught. Now, your other question, you're really to answer that question. You want to look for things related to in non-patients, both narcissism and psychopathy. People that are highly narcissistic are problematic interpersonally. But with psychopaths, let's say you are concerned about who you're hiring. Well, always double-check all their references. Look at their Vitas. How many times do they fudge vitas or embellish them? And how many times do people not follow up on that? If you're in a relationship with someone that, you know, you don't meet their family. They never talk about their history. I mean, things like that. There's a lot of things that seem to be hidden and kind of, you know, if they occasionally have temper in this, but you ignore it out of hysteria thinking,

oh, well, you know, this is just an isolated thing. Basically, you look for inconsistencies in people, and particularly with these kind of syndromes and disorder. Do they do that odd thing? They don't show up at the hospital when the person's sick or something about that. They don't really talk about their families in the past. You know, those little clues. See, as people in the real world, we kind of focus a lot on repression and denial and give folks the benefit of the doubt. Someone doing assessment like myself, you look for inconsistencies in people that don't add up and don't make sense. So, you know, if they're not talking about their history, if you don't have documented history if you find inconsistencies and lies and then, you know, they make excuses

for it quickly. But if you're ignoring that, it's like an extremism. One case, but the woman was kidnapped by this guy and raped and ended up marrying him. She made a comment during the interview, well, you know, after the third day or a week of this, I kind of thought something may be wrong. One thing when you're approaching psychopathy, you don't want to be like Blanche de Bois. I put my faith in the kindness of strangers. This is kind of an hysterical assumption.

It's the same way when you interview people, always read their histories. Don't go in blind because you don't want to be biased. Yeah, you know, it's interesting. One of the pushbacks from episode one was someone said, I can't believe that you're making a diagnosis from a history review. And I think that, like, most of my episodes and most of my episodes and most of to my audience, it's very geared towards treating the individual, you know. Yes. And there's building the therapeutic alliance with the individual that comes in the door, giving empathy.

And I think that there's something about psychologists or just healers in general where we want to give people the benefit of the doubt. And I think we want, we want to believe people. We want to help them. We want, we want to be caring and compassionate. And a couple people pushed back on that first episode because of how, you know, you know, you know, you know, you know, You know, in the psychopathy checklist, it was described that we would, you guys would allow them to give their full history the way that they would report it. And then at the end, kind of this, I got you moment. Like, this is what you're, this is what the file says about you. So you're lying to me.

And kind of pushing up against them. It seemed, I think it seemed, and I'm wondering if you can like talk about that in a sense that would make sense to my audience. Yeah. Not just a forensic person coming in. Oh, it's such a complex question, but let me try to address some of the components, David. It's a good one. First of all, when we're doing treating versus assessment, there are different roles. Someone that's a treater should not testify about forensic issues in court. Somebody who does an assessment is supposed to be unbiased to make sense of the issues related to a forensic issue. They're supposed to be neutral and not an advocate. Yes, I'm also a clinician. I've worked with clients. I become their advocates as well. But I don't do that in my role as an aviates. So first of all, it's important to separate that out. Second of all, psychopathy is not a diagnosis. So we're not rendering a diagnosis. Second, third of all, psychopathy was originally developed and used as a research tool for separating people out within the antisocial populations. In other words, are there subgroups? Is there a particular group that's problematic? And when identified, then you can pay more attention to those to keep a smoothing, running institution.

So it was basically a research device that had clinical applications. Remember, psychopathy is not a diagnosis. It's not in the DSM3. The equivalent to psychopathy in the DSM3 might be diagnosing an antisocial personality disorder with a concurrent narcissistic personality disorder. So we don't want to get locked into false things as a way of kind of building up cases about it. But what was the other part of the question? Oh, okay.

So it's not a diagnosis in the way that, like, this isn't something that psychiatrists diagnose and treat. This is something that forensic evaluators may assess. As part of a referral question. As part of a referral question. Yeah. In other words, if the question is, is this person violent in what situation and describe the violence? Psychopathy is one aspect of looking at, say, affect a predatory violence. and understanding the context of the person's behavior.

A legitimate referral question is never to say, is this person a psychopath or not? So the question that is posed to you is, is this person a danger to society? Are they going to go out and reoffend? Are they going to go out and rape more people, kill more people? And so I think with that mindset of like, this is, can the psychopathy checklist predict

that people will be more violent and that people will sexually offend more people. You know, has it been a valid predictor of that? See, what you can say, when you understand prediction, prediction is variables of a personality within a context. So let me give you this example. Here's a guy I look at and evaluate, and every time he's done an assault, which is why he gets into prison and jail all the time, he's been drunk and in a bar. So I do an assessment of him and includes the PCLR. He's non-psychopathic. But he scores on a lot of the items that highlight his impulsivity and irresponsibility and just, you know, being a borderline kind of mess.

So what I can say is that if this person is drinking and if this person is back in bars in certain situations, I won't say he's not psychopathic, but the psychopathy would not be the issue. but he's likely to reoffend. So then from a treatment perspective, I can say, well, let's treat the substance abuse and let's treat the other kinds of issues. See, there's static and changeable factors in risk prediction. So no, you do not use the PCR to say somebody will do something. You can use the PCR to conceptually understand that they're in a higher risk group and that this kind of psychopathy traits and characteristics is another vulnerability

to reoffending in certain areas. But the research does show that people that are high on the scale are more likely to do certain things. Now, you also have to understand that with sex offenders, child molesters, many of them tend not to be psychopathic. It tends to correlate more of those kind of traits with rapists. So see, it becomes a complex issue. Nobody uses one thing in psych, well, they shouldn't competently.

We use multi-methodes in assessing and answering questions. Yeah, okay. So one of the things that I've heard from one of my other mentors, Dr. Cummings, is that a quick way to assess for psychopathy is to look for that history of violent, predatory aggression. Is that something that you would agree with? I would say there is no quick way to look for it because psychopathy is the culmination of traits and the whole is greater than the sum of the parts. predatory aggression is one thing that would be a red flag that perhaps I would want to assess psychopathy. But it's kind of like sadism and sexual sadism.

It tends to be correlating with psychopathy, but I've evaluated people that are sadists that are non-psychopathic. So see, we have to, these things become more complex and have to be ferreted out related to that. So, yes, predatory aggression, well, that would be one thing that would say, hey, that's a red flag. I want to look at this further. But violence and aggression come in many forms. And you have schizophrenic patients that are doing things out of delusions, being overwhelmed with affect, psychosis. You have people that do things out of impulse things related to emotional discontrol versus, like you said, the point you brought up with the predatory aggression, which is planned and purposeful,

that is more common in people that have psychopathic traits and or psychopathic, predatory behavior. What about there was this idea that people who are more psychopathic? They want to win every short-term game. They're not thinking of the long game of life, right? Like, oh, you know, what's going to bring meaning happiness, developing a family? obviously these things take a lot, a lot of effort over an extended period of time. So they're more thinking of like that short win, you know, is that, would you use that to describe a psychopath, someone who always tries to win everything, even at the cost of relationships?

Well, you know, David, these are good points. See, one item or one behavior in itself, I don't think a psychopathy. Let's look at a schizophrenic patient that, you know, is a mess. He or she has no long-term plans, they're disorganized and all that stuff. That idea is not necessarily psychopathic. Although if you look at psychopaths, they're often unrealistic about their long-term plans. For example, in interviewing a guy that was psychopathic and asking about, you know, what are you going to do when you get out of here, this kind of thing? He said, well, Doc, I'm going to be a corporate lawyer. And this guy had never completed a GED, and he's never been out of the institution for more than a year in his adult life.

He's a gang member. He comes in with the tattoos, and he's malingered to get into the state hospital. So, of course, a lot of times in interviews, I take some leeway. I had to chuckle about that. I really couldn't control myself. I said, well, you know, you kind of have some traits of a lot of the attorneys, I know. And at first, he kind of got defensive. What do you mean by that?

Then we talked about it. He started laughing and we laughed together. So, yeah, they often have unrealistic plans that are grandiose or plans that aren't well thought out. For example, when you interview about that item, you know, oh, when I get out, I'm going to treatment, I do this and that, I'm going to this type school. And then you ask them the details. Well, where do you plan on living? Okay, is a school like that? Does it exist in that area?

And they haven't checked anything out. Don't have the details. These were just all kind of things they thought up in their head. Okay. So let's talk about, is it true? treatable. Is psychopathy treatable? And like, there was one point in your book on psychopathy where you said a lot of the treatments that we use in outpatient settings, supportive therapy, listening to people, didn't seem to work with this population. There was a question from the audience

as well, my audience, about psychopathic females. We didn't get into it. Obviously, it was just one episode. But shortly, like, how do you make the assessment of treatability? when it comes to psychopathy? Let's kind of address the first part of that question about the treatability. First of all, you have to separate the psychopathy from the antisocial, because the antisocial personality is so heterogeneous that, of course, many people are treatable. Psychopathy, and whether it's treatable or not, you also have to look at the item analysis and kind of what items they score on.

You know, is this person primarily an irresponsible kind of impulsy, borderline sort of guy that uses too much drugs, and he just happens to get around 30 on the score of the PCLR, or is this a guy that has twos on all the character logical and narcissistic traits? So we have to start out with that. Then second of all, the types of treatment, well, remember. Wait, slow down. So the borderline would be more treatable, you would say, than the narcissist in that case? Well, certainly it would dictate or give you guidelines for what kind of approaches you would want to use. All the cognitive behavioral kind of things, impulse control work, stress management techniques, criminal thinking, anger management, you know, it might suggest that there's some things you could be intervened.

But now that you ask me a specific question, we have to define the difference between management and treatment. See, management that caused a person to kind of perhaps gain better controls over some behavior versus treatment, really changing the personality structure and the traditional with ways we think about treatment are two different things. Some folks we can manage and help modify their behavior, but I don't know if really the treatability occurs. What happens in the longitudinal data with psychopathy is they find that as you get older, if you have these patterns, some of the factor two items tend to lower, meaning you get older and you burn out on some of the behavior and getting into trouble. But the narcissism tends to remain. And that's why with

psychopaths, the violence potential stays high even into older ages, because as long as you're narcissistic and think the world owes you all this stuff, you're going to be kind of frustrated and grandiose and pissed off at people and things when they don't work out. So we have to separate treatment from management. And then you move into the idea of what kind of treatments make more sense. Well, we look at Glacters reality therapy, we look at cognitive behavioral work, we look at the work of Yackelson and Saminaap, and then on the criminal personality and working with criminal thinking. But we always keep in mind Yackelson and Saminau and what they talk about, how things to criminals and the words they use mean something different than it does to us. See, these folks interpret

kindness as weakness. So if you come across loving and caring and intellectually can't keep up with them and your interventions show that you're naive and gullible, they devalue. you. Think about it. If you're an antisocial or psychopathic individual and you've been abused and misused by the system and beat as a child or whatever occurs, are you going to trust adult figures and authority figures? And are you particularly going to trust naive adult figures? So you come in with all that kind of traditional therapeutic stuff and an approach to these people and they disrespect you and they devalue you and they kind of say the right things, but they're not doing anything. Let me give you an example of a criminal thinking group I did at the hospital.

It was all cyclopaths. And somehow the power went off for something. So my buddy and I co-leading the group, I said to him, look, this is a criminal thinking group. Why don't we take some time to look and see what these people are thinking? Hey, John, what do you think? He says, well, Doc, I remember being in your office the other day, and I wondered if some of your drawers were open. If there's anything in there, I may want to steal. Oh, that's helpful. Thanks for sharing. Now, let's move on to Steve. Steve, what are you thinking about. Well, Doc, I wondered if the back door here is unlocked, because I wonder how long it would take to get out the door and up over the roof and escape from the institution. Oh, once again, a great contribution to the group. Thanks for being honest. And you go down the line.

But these people tell therapists what they want to hear. And if you're naive and gullible and your counter transference feeds into their victim stance, the way they present data about how they've been abused and stuff, you're going to lose in treatment and not accomplish anything. And I'll give you two more examples about it. Here's a guy in an adolescent group that they're doing. This was a probation camp I did in San Diego and organized. And the guy is in there and they're working from a traditional family therapy model. And this guy after one of the groups, he's a psychopathic adolescent.

He beats his father up in a parking lot. With these kind of individuals, the critical. Criminal thinking, psychodynamically, you're confronting the defenses and the structure. You can actually gain their respect. It's like Iguis Alcorn talked about in wayward youth. They can develop an idolized transference to people that show them they have something to offer. So a criminal comes in and gives me the story about, well, you know, Doc, here's why I got in trouble. I did the crimes because I was trying to get money because my family didn't have any food.

I say, okay, well, you know, that sounds reasonable. Let's break that down. Now, isn't it true at your job? First of all, you were using drugs during the job, and the money you got from the job you were spending on drugs. Oh, well, oh, yeah, yeah, yeah, okay, Doc. You know, isn't it true that you were going in late to work because you thought that everyone at work were square and you thought the job was beneath you? Oh, yeah, yeah, yeah. Now, isn't it also true that when you went to the job, you eventually got fired?

Oh, well, I left the job out of a mutual disagreement. No, isn't it true that you got fired because you were going in late and your attitude was poor? So see, the offender, the criminal, the antisocial, will present this plausible sounding argument that when you look at the details, it's not plausible. In reality, the guy wasn't doing the crime to kind of get money for his family. he set up a scenario where you're spending money on drugs and got fired from the job, but he deflects responsibility in that pattern of behavior. Do you think that they're telling you that because it's a social sort of like,

okay, it makes them more likable or because they really believe it at the time? This is a difference between men and women. I think Jason talked a little bit about that. In the females, we found clearly in the research that they are doing it because they need others to mirror back to them that they're okay and not damaged, and they also use others to help them regulate their emotional states. With the male psychopath, they're telling you this because sometimes they like hearing themselves talk, and they're just BSing, and not that they believe it. Let me give you an example. Here's a psychopaths we interviewed, and he went on and

about how many people he killed in Vietnam, cut off the ears, took him home, this and that, About halfway through this long dissertation, I turned to his treating therapist that's sitting there during the evaluation, says, is this guy ever been in the service? Because I'm asking him questions about hollow points and weapons, and he has no knowledge of it. And I say, has he ever been not been in the service? The treating psychologist says, no, he's never been in the military. And I look at the guy and the guy doesn't even do anything except shrug, laugh, and then goes on talking about more BS. So see, they'll lie for the sake of putting one over on you, you know, in order to make themselves feel good, but they'll lie just for the sake of lying. Are you naive and gullible? It's a form of entertainment at times.

So no, I don't think they believe it as much as it's part of their narcissism and the cognitive style that supports their psychodynamics. Okay. Because sometimes it's like with someone who's narcissistic, they have this sort of idealized version of themselves that they seem to be trying to really protect at all costs. And they get the most furious when this sort of idealized persona is confronted. Like you are not really who you think you are or I've projected you are. But it seems like what you were describing was a little bit different than that. It's like they almost like don't, they're very, they don't even care when you point out that they're not telling the truth.

It can be both, David. You're right on with that. All these things that they do are related to maintaining their personality structure and dynamics and bolstering their grandiosity. So, no, you're right. You can hit moments with these people if you confront the grandiosity and the defenses that, yes, they will react with anger and so forth. So, no, you're right on target. But you also get this thing I say that a lot of times with lying, they're just doing it because they're just talking. They're making it up as they go along.

Well, so like another one of the emails I got about this, so you can see I got a lot of emails. Yeah. Was that someone was like, well, isn't this all trauma related? And if we just did enough EMDR, if we just did enough trauma work, you know, wouldn't this resolve 95% of their issues? And they would just be good citizens now, not killing people or raping people. Well, it's a good question. It's kind of like the PTSD is. now an excuse for gender-wise with women for borderline personality disorder and every disorder.

The problem with this thinking is when you gloss the diagnosis and actually what's happening, you don't get appropriate treatment. I give you examples, examples of that. But now to answer the question more specifically, the people that often make these statements don't understand how character pathology develops and what character pathology is. I've worked on inpatient units with conduct disorder with kids, with adolescents. I've seen the development of trends and how these things develop and evolve. So no, trauma actually impacts certain things in personality development. But once you have this personality development for 20 years and you idealize and devalue, the issue is the character disorder. It's not so much the trauma.

In fact, in many of the males that we work with, the trauma gets addressed, but that's way down the line in the treatment after they've gained control over their behavior. and have some more ego skills to deal with. So, yeah, it's, the issue is really the chronic character pathology and the ingrained amount of the pathology that's developed. And if you don't deal with that first, it's harder to deal with those other issues. And you know what? It's like going to AA.

If you can stop drinking, for some people, that's enough. You know, other people can go to AA and not only benefit from that, but then they can also deal with deeper personality work. But this is an individual case-by-case thing. But no, the idea of just treating trauma in these folks, it's kind of like, you know, here's a psychopath that you talk about his treatment. Well, what have your benefit? How are you doing?

Well, I learned the math tables. Now, this guy gets out. He goes to a job, and within a couple days, he's been in a fight with the boss because he has problems with authority. The issue is the fight with the boss and the authority issues. While learning the math tables is important. And if you don't alter and manage and modify the character pathology, they're not going to have much of a chance. So diluting it with the idea of the trauma misleads kind of being able to help these people.

Okay. Now my, there was another person who said, isn't this all attachment related, you know, and you just talked about their problems with authority, you know, is the problems with authority just because they had horrible, horrible parents growing up. They grew up in an incredibly chaotic environment, and because of that, they had no mentors that they could, like, trust and gain an attachment with. And so now they're probably more of the disorganized or anxious or avoidant insecure attachment styles. What would you say to that? I would say that's another political trend that's come in to supersede everything that doesn't capture the picture. Here's what you find in actually the histories of many of the psychopaths. There was often figures an uncle, a priest, somebody in their life that they could have looked up to and they could have went along with, but they chose not to.

Instead, they went with the people that were doing the illegal and exciting and those kind of things. If there were an uncle that, you know, tried to reach out to them, they stole their stamp collection. So, no, it's attachment is one dimension of problems in psychopathy, but focusing on one dimension or trait and ignoring the whole is missing. the boat completely. So no, that isn't the answer. Often these people have, here's what I often say to the adolescents in the groups. Now look, first of all, I haven't put up on the board, I say, tell me how you're different than the kids that go to school and they, you know, play sports and get A's and B's. And this is a way of getting out to criminal thinking. And they'll begin by listing and saying, well, you know what, we like to do exciting things. You know what? We don't like to follow the

rules. You know what? And they'll list all the things that describe their personality. And then once I've formed a relationship, you form relationship with these people by showing them that you understand who they are. If you can't do that, they're always kind of laughing at a lot of your techniques and kind of things that you bring in that aren't consistent with who they are. But if you can demonstrate that you really understand their personality, you begin to form links for working with them. So the other question I asked them, now, look, your parents took you to three different schools because you got into trouble. Oh, yeah, the other thing they put on the list is we tend to blame others for our problems. So you say to them then, and this is the adolescent groups in the introductory phases, well, isn't it true that you guys,

how long did it take at that second school before you found all the people that were using drugs and selling drugs? And then they begin to laugh. They know they can't fool you, and they know they're giving you BS. And then I joke with them, of course. You know, I say, yeah, I bet you you pick these people out on the way to the principal's office. You saw the ones standing over there. They do exciting things in part because of the proneness to boredom. And their disregard for rules kind of sets them up for these behaviors.

So see, it's like everything in our field, David. If we don't accurately assess and understand who we're doing with, we can't be helpful. With these adolescents when I was in San Diego, I used to work with. them and we did a modified group therapy based on Yackelson and Saminau's work with the criminal personality. And then we did family therapy, individual family therapy, also including those techniques rather than traditional family therapy. I had these kids showing gains at the probation camps. And one kid even got back to me, he went to a standard therapist who started with all the kind of going with the victim stance and the trauma and all that. And he looked at the therapist

and said, I want to go work with Dr. Carl, not these be kind of approaches. So they devalue these things that as middle class, upper class, educated therapists, we're laying our own projections of how people functioning onto them, rather than doing what Carl Rogers said was entering their world and understanding it from their perspective. Yeah. And I think that's hard. I think that's hard because most therapists have that.

a very different set of issues. They have more of the anxiety, they have more of the fear. I had one person send me a message like commenting on how maybe they just have a lot of fear and that fear is leading them. And I'm like, no, actually, they don't have a lot of fear. That's like part of how their brain is wired. Their amygdala lights up less, right? See, I have the anxiety. Yeah, I have the anxiety and fears of all neurotic. people. I go to Woody Allen movies and cry. But the bottom line is during a supervision session during my master's degree, where I was trained in Nigerian therapy and marriage and family therapy, my supervisor is looking at the interview this offender. And I'm doing all the reflections

and all those things very nicely. My supervisor looks at me and says, Carl, you're doing a good job in there, but is this what that person needs? You know, what you're talking about also is that you actually have found a way to be more empathic towards them. It's just you're thinking, you are now understanding that this person has a mind very different than your own, but you understand their mind because you've met so many and you've done this deep, deep work. It's like, the way that I see this is that when I work with somatic patients, I can see that they're talking about their pain and, you know, this pain is something they experience.

But I can also see flashes on their face of anger and I can hear areas in their life where they're not standing up for themselves. And so I can see the anger. I can hear the places they're not standing up for themselves. They don't have boundaries. They don't have a voice. But they're completely initially disconnected from their anger. I've actually seen this in a lot of therapists as well. It's like they've so learned how to embody this benevolent empathic stance that their anger is very distant from them. And because of it, they notice psychopathic, narcissistic people in their, maybe their bosses who are creating programs that are totally dysfunctional for the actual caring for of people. And so some of the work that I do in my coaching is I work with these people on

gaining a voice, finding that anger, finding that part of them, the fighter in them, right? To protect not just themselves, right? Because often they're not thinking of themselves, but to protect the patience. Just yesterday I had this conversation with someone and it was like, okay, you have the moral high ground here against these people because you want the best for the patience. you know and everything that these other people are doing are going to make patient care worse you know then i don't know no you've got it see it's it's it's the basic principle is it's not the way we view the world that's important working with a client empathy means different things to different people and with an antisocial population that tends to be somewhat paranoid and mistrusting

if you appear weak and naive and gullible they cannot form trustee. you and you can't get their respect in order to work with them. So yeah, it's, it's, it's, you said it perfectly, David. It's really common sense, but it's hard for people to do. I remember going to an analytic conference where this case was being presented. Once again, this therapist had the blocks of their own anger. It was obviously the patient that they were talking about was angry and acting it out, but they didn't see it. People with narcissistic traits that don't understand their own personality when they go to score the PCR, they often, and lower the scores because they can't see the traits in the other person that they deny in

themselves. So yeah, you know, I went through about five, six years of four or five times a week psychodynamic therapy and plus my training and then working with children and seeing the defenses, this helps you to be objective and open to these things. I'm not the same with a neurotic client working in therapy that I would be with one who has these issues. With personality disorder, clients in the institutional setting, whenever they make a request, the first thing I think is, why are they asking me this now? What is this about? I don't analyze every schizophrenic patient that, you know, there but the grace of God and some poor genetics, that could be me. But you have to adjust. You cannot take one template for viewing people and apply it to everyone. Yeah. And that's why

I think this conversation is so important is because we want, we want to see reality more clearly. We want to see what's going on more clearly. And we want to kind of subject our own biases to the data. Okay, so we have the psychopathy checklist. And then you add it on top of that, the roar. The roar shark. And so what, what did you, tell me a little bit about the roar shark. What does it measure? How does it measure personality? How does it differ from self-report measures? Excellent. You know, what's interesting about both the PCLR and Rorschach, they were not designed to be an applied instrument. You know, Herman Rorschach refers to the Rorschach as an experiment. So neither of the PCLR or Rorschach were designed for the uses they are, even though because they're so powerful, they're very good at what they're purported to do. The Roershock test is a performance-based instrument, which means you get a sense of from it of correlates to how a person functions in the world and how they react and do certain things.

Now, here's the thing for you. I drop you on a desert island. I give you a week to get off it. There you go. Where do you start? And I'm talking about you, not a generic you. Okay. I'm going to start trying to get some trees, trying to build a shelter.

you know is there a hole I can sleep in at night is there water supply um with the trees I'm going to think you know how can I get these things to float how do I get these things to connect together how do I build a raft food is there just bugs am I just eating am I just going to be eating bugs is there something I could do to spear fish trap fish net fish yeah go ahead see this is beautiful don't you think everything you just says tells us about how you approach your daily life and interact into other situations, that way that you approach solving that problem? See, another person raises their hand and yells and that panics or yells fire in the movie theater. But think about what you just said.

One of the things the Rorschach measures is a person's style in how they interact and how they solve problems. So it's the idea that when you discover this on the Rorschach, couldn't there be some links to how this works in the person's everyday life and other situations? Now, I want to kind of go step at a time with this. So you did this. But differing from the island scene, which is a performance-based measure, if it's a test of you and an experiment, the Roershock is carefully standardized, it's reliable, and it's valid. This means it's given in a controlled way every time it's administered.

it means that when it's scored, two people will agree upon the same scoring. And validity means that the variables and things that are scored and look at have been proven and subjected to experimental rigorous measures. For example, if we're looking at a measure for anxiety on the Roorshock, obviously that was tested on anxious people and people who might be anxious in a certain situation. So people that do those kind of things or fit those categories would tend to score higher or produce this variable. So there's a whole scientific backdrop to the Roershock, and it's never assessed based on what's a frog, it's a bat, you know, the common perception of it is just not accurate. But before I break down the Roershock mystery, I want to give two points.

All Roershock variables are scored and have been researched early to determine. just what they mean. The second thing is the Roershack requires a huge investment in time experience and supervision to master. The danger as I go over this and make it simple will be kind of like Watson and Holmes, where Holmes comes up with this kind of deduction and Watson. So what happened? You know, what's going on?

And home breaks it down in a logical manner and says elementary Watson. And then, of course, with Basil Rathbone and in that one, Watson always then kind of You know, this was classic, not of Sherlock Holmes, but of the interaction. Oh, well, that was easy. Why couldn't anyone do it? So the Roershawk is like that. Or another way of thinking about it is when you consider Michael Angelo in his quote, if people knew how hard I had to work to gain my mastery, it would seem so wonderful.

So I'm going to make it simple, but it's very much more complex. Let me start out with the Rooshock has the 10 Blots. it's set up to be an ambiguous situation so that we can really see how a person kind of either plays or responds to an unstructured stimuli. So you basically go through the cards and you start with the first one

and you say, what might this be? Can you see this card number one, David? Yep. Tell me what it might be. I see two angels, their heads in the middle, maybe their hands, maybe the angels are kissing. That's okay, don't worry about it. I'm not going to analyze your response.

I want you to. I want you to. Yeah, I could also see, oh gosh, the big figure could look like something like a wolf. Okay. Yeah, the big image. I'll put this on my Instagram for you guys to take a look at this. You guys can do it yourself. Okay. Now let me ask you a question about those two responses.

Did you integrate everything that you saw in the blot? Probably not. But I told you what came to my mind first. Yes. And I was trying not to filter it. There was part of me that wanted to filter it. You could have filtered it. It doesn't matter.

But anyway, you start with the blot is you look at the person and remember, you look at patterns. You don't look at one response. So let's say that at least on one of those response, probably if it was a wolf's face or something, you use the whole card. So does it make sense? And this is the face validity of the test, which means what's common sense. And it doesn't attract from all the experiments behind it, the statistical prowess and strength. But here's the common sense. If a person produces a lot of Ws, why are they doing that?

Are they the type of person that tends to integrate all the information when they make a decision? Wait, W is I don't know what you're talking about. Oh, good point. Thank you. W would be the whole. So the person that uses the hole all the time or most of the time, are they the type of person that tends to want to take in all the data before they make a situation? In the case of a psychopath using a lot of these holes or total amount of the blot,

why are they doing that? Are they scanning, looking for people to prey upon? Are they scanning, looking for predators that may pray upon them? So it's the idea of the choice of the location. It tells us something about your cognitive process and problem solving and how you approach a situation. Now let's look at something else, what's called a D response. This is a common detail. One looks at instead of looking at the hole, they break it down into details.

And a lot of their responses are common details. Is this a person who tends to be somewhat pragmatic, pragmatic, goes through life, focusing on the details, taking care of business, one at a time. See, it's really a performance-based test that it's kind of assessing things about on the test and relating it to what could be representative to that in your everyday life. Let's look at someone that produces unusual details, tiny things. Are these paranoid people that kind of focus on details and they lose the forest for the trees when they're problem-solving? Or are these people that are compulsive and want to look at all the details, so as they don't miss anything and make a mistake,

you find the answers to those kind of clinical questions in the history and with the rest of the Rorschach. But it's how you approach it. Let's look at one other thing related to the Rorschach, and let's look at the use of color. So let's say your response is on the Rorschach have to do a lot with color and seeing color on the blots. And the blot I showed you didn't have any color.

You actually added some perhaps human movement which is another thing we look at, is movement on the car. So color. Think about color and just the common sense of color related to emotions. How many times have you heard

you're green with envy? You saw red. Man, I'm feeling blue today. So see, there's a long tradition of more common sense that associates colors with different affective states. So what the Rorschach does

is score for color responses and how it's used. and then with the coding and such, it can relate certain types of responses to say, those found in depressive, those found in manic people, how is color used as far as impulsivity? Psychopaths and antisocials produce a lot of what's called pure C.

You know, what makes it look like a runny mess? Well, it's the color versus a color response that it's two bears and they're in a circus performing, and I see a little bit of red on the bow they're wearing. You notice there's a continuum of there of the color being used as an adjunct to the form versus just it's a mess and I just see the color. Well, ironically, the research shows that people that produce a lot of that disorganized color

tend to be more prone to acting impulsively. See, this isn't me just saying that. That's what the research shows. So what you do when scoring the roar shot, you score all these. things that come up with indices and ratios. And then you compare these to nonpatient groups, depressive groups, schizophrenic groups. You're looking at thought disorder and thinking disturbance. How well did the person's response meet what you'd expect to find in a thousand people? Was the accuracy of their response compared to what you see in a thousand people completely

divergent. Is this person making unusual combinations on the Roershock? It's two ants attacking a submarine. Well, these responses tell us something about the way the person functions in the world and the kind of issues they're having. So one thing that they brought up in the last episode that was just, it's still like mind-blowing to me is that psychopaths have lower texture. They don't see fluffy.

They don't see the texture. in these pictures, whereas the female psychopaths had higher number of texture, and they commented that the texture had to do with the attachments and the depth of the attachments. It more has to do, David, with affectional relatedness. See, the females do have more of this kind of thing, but if you look at their impairments in object relations, their poor judgment, their aggression, obviously it's not a healthy attachment or it's not a healthy kind of affectional relatedness. Yes, but the male cyclopass tend not to produce that at all as representative of their detachment. If you get borderline patients,

sometimes they'll have multiple indices of this suggesting their neediness and their over-affactivity and their poor boundaries and just their clingingness. So they also have done interesting studies in couples with that texture response where if you got couples that, have no texture, either of them, they can tend to get along. It's like that Woody Allen movie. Remember, it's in Annie Hall and he's walking along and says, well, you people look like you're doing fine and you look like you're getting along. And they say, how do you manage that? Because he's interested relationships. And the couple says, we're both shallow and superficial, so we get along very well. See, if you have one couple that has three textures and that person that's detached,

you're going to have a problem. If you have both people that are similar as far as most dimensions, it's going to reduce conflict. So, yeah, the texture response is related to affectional relatedness, but not so much specifically to healthy attachment. A lot of other factors have to be determined. Okay. Okay, so break down what you found, like, how does a psychopath score differently on this test? Okay. With the male psychopath and female psychopaths is different, as I think Jason and Ted alluded to. With the male psychopath, they tend to fall along a spectrum of being kind of this malignant, aggressive, kind of narcissistic position where they're grandiose is supported by a lot of things, including devaluing others. Okay. So slow down here. So how do you, how does what kind of responses on this make you think that the person's narcissistic or that they want to devalue others?

Okay. Now remember, you'd want to look at the whole protocol. There's actually a scoring system for primitive defenses that can be used in the Roar Shock. This is an adjunct to standard scoring, but you can score defenses such as projective identification, projection, idealization. Let me give you an example of projective identification, because this is a cool one. You look at a card and you see an angry, an angry monster. Well, guess what? These are inkblots. There ain't no angry. angry monster there, but the emotion is being projected onto the card. Perhaps this person has anger inside themselves, perhaps it relates to depression, whatever, but they're putting that onto the blot. Guess what? There's no movement. The blots aren't moving. So when a person sees movement, that's also an aspect of something happening inside themselves. But now let's differentiate this between projective identification and pure projective. Projective identification, we look at that same card and we see a monster, it's angry, but the monster has a club and it's coming after me. You see the difference from an analytic perspective. Not only is the material put out there

onto the block, but it's returning. It's part of a projective identification cycle. Listeners that don't understand projective identification, let me give another example, and I'll get right back to the rush. Here's a psychopath that I'm about to put in room seclusion in the hospital setting. Of course, it's not me alone. It's about six other guys. eyes. I say, well, you know, Travis, you've done this and this again, it's time to go in room seclusion. He looks at me and says, Doc, because, you know, we have a relationship for whatever relationship you can have with a psychopath. They tended to respect me because I did understand how they were thinking. And he says, you enjoy this, don't you? Well, what he's doing there is he's projecting

his sadism on to me and expecting me to react to projective identification in a sadistic manner. So I could say to him, well, you know what? You're a no good son of a bitch and I'm angry and I could go off inappropriately, but instead what I say to him, well, Travis, you know, actually, I don't really enjoy this. This takes a lot of time and energy away from the work I have to do with other patients. But given your personality style and my work with you, the only thing I really have to offer you is teaching you ways to control and manage your anger better. At this point, Travis scratches his head and walks away. What did I do? I interrupted the projective identification cycle by not behaving in a way he expected. When you get good at treatment, you do these things naturally,

but it's why you have to understand the psychodynamics, even if you're doing the cognitive work. Another situation, he says to me, well, Doc, you'd like to be there when I get to the gas chamber, wouldn't you, and watch it? And he smiles. Once again, he's suggesting that I'm sadistic, and he's projecting the sadism on to me. But what I say to him, you know what, Travis, I might like to be there, but I'd actually be quite safe. that you chose to waste your life in such a worthless and irresponsible manner. I'd be sad about that as I would for any waste of a life. See, once again, he scratches his head and puzzled because I'm not feeding into the dynamics. What I'm doing is confronting the defense as a la Kernberg, but on a cognitive

level. So that kind of projection and projective identification is scored on the Roarshock and comes up so you can actually see the defenses. Do you think that's a little bit of a jab at him, though? I mean, like, is that jab helpful? By the way, for my listeners, I do see your sadness on your face. You flashed a micro-expression of sadness. So I think you're congruently are sad. So you're in touch with your true emotional expression. But the question I have is, like, that you wasted your life. I mean, is he only going to the gas chamber if he commits another crime, or if he does something, or if he doesn't change his life? He's not really going to the gas chamber. That's hypothetical.

But his whole life at age 40 something has been irresponsible and taking advantage of other people and so forth. So yes, you hit a good point. You can't make interventions like that that are really confronting the underlying defenses of projective identification if you don't believe it and you're not congruent. When I make an intervention like that, I am very sad because it is sad. The same way if you're interacting with a borderline patient and they look at you with, with that expression, knowing that they misinterpreted something you say. And you say to them, I wonder if something I said bothered you or you saw it in a certain way. And then they reveal this distorted thing about their interpretation of your interaction.

And then what you say to them is, you know what, I really didn't have those thoughts at all. But I wonder if sometimes you have those thoughts about yourself. See, this is confronting the defenses in the individual. Yeah, usually, I mean, the way that I've, I think I would say it a little bit different, I would start with, you know, I could see it would be really distressing that you would think that I would be thinking of you so critically. Okay. I would start with that. And then I would say something like, I'm wondering if you believe that that's what I was thinking 100%, or if you question that maybe I might be thinking something different. to gauge the reality or, you know, are they in sort of a psychic equivalence mode? Are they sort of 100% stuck in this narrative that they have of what they think you that you've been thinking?

Yes. Well, see, that's reasonable as well. I go by Kernberg's idea that with borderlines, we confront the defenses with narcissists, we interpret. You know, not 100%, but as a general rule. So what my attempt with this lady was to kind of help her kind of be better organized. It's like borderlines don't do well with the lack of structure. My intervention is attempt to structure things and break up that projective kind of identification cycle, which causes them to be disorganized. You know, I'm sure in consultations, you've had many people that have talked to you about people they get into treatment that ended up being borderline and under standard techniques and, for,

structure they decompensated during the treatment. So any intervention that really helps them structure their world and be integrated. And for me, the intervention with this particular person helped them kind of be more focused and integrated rather than I'm disorganized. Yeah, you know, I mean, transfer's focused therapy, it's well researched. I think you're leaning to that. I was leaning a little bit more into mentalization. I think both of them work.

Both of them are evidence-based for borderline persuasion. order. I think that what I've noticed, though, about some, sometimes when looking at some of these people talk about transferment-focused therapy is that it can be a little bit adversarial, and I think they could stir up the emotion just by how they interact with the person. So then it's like they're stirring up the anger, and then they interpret the anger as coming as like a transference, you know, where it's like, really they just stirred up the anger because of how they sort of prickled the person's defenses. Yeah, these things require such a sophistication of training and intervention and timing.

You know, one thing's I've never done with clients, even the inmates, I don't yell at them, I don't raise my voice. I don't really get angry unless it's something that one schizophrenic guy that was delusional. It was useful to express, you know, you really need to do this or that because I'm really the only guy in here that's in your corner. as a way of kind of helping them stabilize. But I don't believe in those kind of confrontation as far as anger and that. I define confrontation as pointing out inconsistencies. It can be very, very powerful to say, well, you know, you said this, but you did this.

What do you make of that? That's a confrontation. Right. So not the, you know, yeah, I don't. Ted's, as an example he gave in the last thing, We're kind of how he does that confrontation during the interview with the PCLR. Right. I don't need to do that or don't use that technique.

I start my interviews with, look, the records say this about you. You know, records don't always tell the whole story. Why don't you tell me more because I'd like to hear your side of the story. And then my confrontations are pointing out the inconsistencies. You know, well, you said this and then you did this. What do you make of that? See, that's a confrontation because it's geared to his point. I don't get most of the people that I work with,

even that guy, the example earlier, the long, realistic goat, we end up laughing about it. Here's a guy I'm working with in treatment, and he comes in and he's about to get kicked out because it's like his third dirty UA. And he says to me, well, Doc, they held me down in the bathroom and they blew pot smoke into my mouth. Well, I break out laughing, he breaks out laugh,

and he knows he's full of crap. But see, most of the people I work with, it's been more like that. But you have to be able to confront and set the tone that they know you know what's going on and have something to offer because that intrigues them. Yeah. Yeah. That's confrontation. Yeah.

Your sophistication and being able to outthink them and point that stuff out. Right. Yeah. I think there's probably some level of narcissism, psychopathy in which they would never seek treatment. or it's almost like they would just, they're never going to see you as an outpatient, right? But there's some that have varying degrees of narcissism that want help, that want to sort of overcome these hurdles,

interpersonal hurdles, the pain points. And it seems like those people respect authority, they respect sort of the intellectual chess that you can play, if you can see them clearly, if you can see through some of the facade, odd, right, that they project. It's almost like they gravitate towards that. They need that.

It's almost like they want that, especially if you don't shame them in the midst of it. It's like, hey, like, you know, we're going to work on this, but this is what I'm noticing, right? I don't know if you have any thoughts on that. Well, yes, you know, David, it's, it's in a way it's kind of a, it's important to conceptualize the issue. Obviously, on any assessment instruments of standard error measure. So you score 27, is that really a 27 or is it 25 or is it really a 30? So when you look at psychopathy, some of that can be looked at from the perspective of what items an individual elevates on. And so it always depends on kind of the person I think you're working with is people are individuals.

We apply group data to group data, but when it comes to the individual, we look for their nuances and their uniqueness and their differences. So, you know, what you said, I think it often depends on the context. Here's a guy that's 34 on the PCR. He's a psychopath. I'm interviewing him, and he happens to be in shackles because he was in room seclusion. We're doing an assault. He's adopted, so you don't have a lot about the early history, but he raped his adopted mother when he was 14. He's real violent. He's predatory and so forth. But we get through the interview of which he can tell that I kind of understand some things. And I think in a moment of sincerity, says to me, well, Doc, can anything be done about this? So in that moment, he's sincere, but like a regular neurotic and a person that doesn't have this kind of character logical impairment, the sincerity tends to be consistent and over time and not occasionally coming out. You know, the criminal thinks in this way, I'm a good person because I go to church on Sunday and they ignore the fact they beat their wife every day in between.

So they're able to compartmentalize, rationalize, and maintain images of themselves about that kind of stuff. So I think when we think about interventions, we always have to consider the personality style and who we're dealing with. Is it a neurotic person? Is it a regular personality disorder that may not have these kind of issues? Is it a bona fide psychopath? Is it really just a plain narcissistic disorder that also has some capacity for attachment and softer feelings and so forth? forth. These questions really are answered best on an individual basis rather than a global swipe. Yeah. So, okay, a lot of different things floating around in my mind that we could go to.

But I want to just make sure that we hit at least what you wanted to get through on your findings with the Roar, Roe Shock. Yeah, in general, what we find with the Roar Shock. And remember, any study like this when you're looking at people above 30 on the psychopathy checklist, inherently all categories are dimensional. I mean, apples have come in all kinds of color. Apple and an orange can be round, but they're obviously, when you look at the sum of the parts, it's quite different. So when you look at psychopathy and I tell you some of these things,

we may be talking about one subtype within the high range. So what we find with the males is support for the idea of a very malignant narcissistic, whose devaluation, manipulation, and use of others is a way of bolstering their self-esteem, and they tend to be detached. They tend to be involved in more stranger kind of victimization and violence, and tend to be loners by choice and so forth. And on the Roershock, we find things like elevations and indices that have to do with self-focused, the lack of attachment, the lack of anxiety, poor interpersonal relationships that are

infused with aggression, primitive defenses, and so forth. The females look somewhat different. They tend to have much more affect. And this is the spectrum of the antisocial women and the psychopathic women. They have more affect than the males. They don't seem to have the grandiosity that bolsters their self-esteem. Rather than many of the indices on the Rochechak indicate a kind of hysterical or malignant hysterical kind of presentation. Yeah, what kind of things when you say hysterical? Like, what kind of things are you seeing that make you think hysterical? Defenses such as denial, polyanish denial, indices that have to do with kind of rapid discharge of thought into emotion, like impressionistic responses. And I'll give you an example.

It looks like, it looks like rain. It looks like snow. It looks like depression. Also, a lot of abstractions, which would be things like it, it could be a sign of this or a sign of that. So what you see is indices that have to do with that kind of polyanishness, denial, affect that quickly is split off from the personality, and then a style of speech, you know, like David Shapiro's work on impulsive styles and styles, a style of speech that's lacking in detail. So we find that with the women more so than the men. Okay. And so you have that hysterical piece and histrionic, did you say, or not histrionic? Yes. In the book on the understanding female offenders, we do an extensive lit review on this.

I may be confusing and mixing metaphors, but I'm talking about the hysteric as the cognitive style and defensive, the object relationship. that you find in people that are like this. The classic statement is from Blanche Duvue in the streetcar named desire, where I put my kindness in, I put my faith in the kindness of strangers. It's like that kind of denial of things and an impressionistic approach where you're not focusing on details and problem solving. Hysterics are really set up not to look at details and look at things that are painful. A lot of their systems that operate in their personality, including the somatization, is kind of a way of avoiding affect and dealing with affect.

With an hysteric, it's never really successful to kind of say to them directly and blankly, well, this means this. And pointing the two pieces together because this may be too challenging to their personality maker. You know, you remember Jason and Ted talked about that when they interview these women, a mirror. supportive, you know, this kind of thing works much better in the interview and getting information than confrontation. Yeah. So, okay, so I think I'm grasping it a little bit more. I'm still a little bit confused about this idea of hysteric and psychopath together. So it seems like they're not really, and you said Pollyanna. So they're just, it's kind of a denial of the bad with this sort of positive outlook. Yeah, and a fragilness to it. In the interviews, they often incorporate the, with our female colleagues that do the

interviews say that the women often try to befriend them. With the males, they often try to seduce them. But they come across as someone looking for help and needing help. What they do dynamically during the interview is they incorporate the examiner into doing two things, mirroring that they're okay people, saying to them, well, you know, that was bad, boy, you really had it hard, you're really a good. good mother, you try so hard, and helping to regulate emotions that are overwhelming. You know, here's an example of a, she was a serial killer, but she was also a psychopath

that we interviewed years ago in a correctional setting. During the Roar Shock, she sees a response she doesn't like and she dramatically slams the card down on the table. Or during the interview, one of my co-interviewers, Dr. Reed-Malloy, he withdrew attention from her and she really reacted with anger and sarcasm and such to that withdrawal of attention. The male psychopath's grandiosity seems to be much better functioning at their self-soothing. They kind of can look in the mirror and they have an idealized version of what they see that's unrealistic. The female psychopath looks in the mirror and she sees a Picasso like distorted image of who

she is. There's a basic sense of being in touch with feeling damaged. So the hysteria really has to describe a personality style that helps to regulate emotions, regulate and bolster self-esteem, and they don't appear to have the grandiosity in the same way as the males. Okay. I imagine someone at this point is saying, like, you know, don't we all have this sort of, well, okay, with what you said, they want to be mirrored, they want to be seen as okay. Don't we all want to be like seen as okay?

Don't we all want to feel okay about ourselves? Don't feel too bad. You know, I mean, so it seems to me that someone would just listen to that and be like, you know, of course, everyone wants to feel a lack of shame about things. And if there's things that are more revealing in a negative light about us, it's like, of course we don't want those things put out in the open. and it's almost like really hard to say some of those things out loud, you know? Like, don't we all have those things?

And if it's just their stuff that's out there in the open, isn't that just why they would feel so much shame or why they would want to make sense of what pain they're going through, you know, why they've been using drugs? This is a good question. David, I want to answer it in three ways. One is we're not all personality disorders, so we don't want to do that. Two, we don't rearrange our entire life around maintaining an image that doesn't exist and go to all sorts of behaviors, including hurting others and physically doing things against others in order to maintain that image. And three, the good example is, have you seen the movie Platoon in the old days?

Yeah, I don't remember it very well, but go ahead. Well, there was two sergeants that epitomize the idea what happens in a difficult context. One was Beringer, Tom Beringer's role, who was a bona fide. psychopath in the military. The other was William Defoe, who maintained compassion and sensitivity and adapted the best he could to the situation. And it's a beautiful portrayal of that kind of issue. What do we do if we're in a similar context? Is everyone capable of doing the same things? And that particular movie, Platoon, if you contrast William Defoe with Tom Berringer, kind of answers that question in a way that even I can't do as well. But when we ask the question about,

don't we all do this and this? What it's ignoring and denying is the fact that how we look at normal behavior in non-personality disorder people versus having to view the context of someone that has these severe issues and how they see the world. The things I'm talking about with the hysteria narcissism, I'm not applying this to the non-clinical normal population. I'm applying these things to what we find in a clinical population.

that they have extensions to the non-clinical population? I'm not sure. We don't comment on that. That's going beyond our data. But you have to look at the context of the behavior. It's like I remember in graduate school, the example they did. You see this person running down the street naked. What do you think?

How do you assess that? Some people are jumping to conclusions. Well, the person's crazy, this and that. And then my instructor adds, what if you find out they were taking a shower and their house just blew up, and they had to get out of the house so they didn't have clothes on. See, we can't ignore the personality structure when asking the questions. It's just like with a schizophrenic patient that, you know, many of them I became very affectionately connected to. You know, my counter transference is, you know, this could be me with difference in genetics or difference in environment and so forth.

You know, they would say, hey, is Dr. Carl want to see me today? They formed relationships within their psychosis. My treatment plans with them is if I could make my interaction with them, give them a human connection, and make them have some human connection on that particular day and maybe over a week's time, I've accomplished a major thing in that person's life. This is different than interacting with personality disorders, where either intracychically or behaviorally, whenever they make a request, they're asking for something. So when you deal with this level of personality,

you want to avoid sharing certain things, you really have to watch the limits, and you always ask yourself before you respond, why are they asking me this now? Did they just ask this question to another staff and they've come to me now to split staff, or what's going on? The questions and answers are different

depending on the personality style and organization of who we're interacting with. It's just like I'm sure in your own treatment. If you have a neurotic client that has anxiety, and so forth, and you're working with them, they may have to resolve some things. Maybe they have a trauma or some guilt that by reliving it and talking about it, it causes relief. With the character pathologies, that is not enough. This is an ingrained style of personality that functions differently inside. For instance, you and I feel remorse and guilt. These people

may not know how to experience that. Dynamically, they may not have the ability to mourn a loss. when we look at ourselves, we have bad days and we think, oh, geez, through our will be better. Sometimes when these people get into these states, because of the splitting, it's black and white, and they don't have the capacity to maintain those two images at the same time. So every question has to be couched regarding treatment or assessment. We can't say, well, isn't everybody like that? Or wouldn't we do that too without saying, well, and my personality, disorder, that I also do these things to those people.

Have I been in trouble with the law already based on a need to seek, thrill-seeking behavior? So we can't lay our perceptions onto people without considering, you know, how they're organized personality-wise. Yeah. Okay. Very good. Hey, we've got to wrap this up. This was a pleasure.

I could see us doing a part two, even just to kind of dig into these things. that you've been learning and your approaches, I think, I think our fan, the people listening to this would probably enjoy more on narcissism. I know there's been a couple of requests for that. Well, it's fun, David. We're really commitment to try to get things out there that help clarify things and give clinicians things to think about that can actually guide their work. Yeah, and so if you were to summarize, like, what that, what the final pearl would be or what the thing you would want them to leave this conversation with, what would you, how would you summarize, kind of like what you would most want them to understand?

Maybe about three things. One is clinicians and people working. Don't let people talk them out at the clinical observations and intuitions. Consider learning more about pursuing ways of testing those kinds of things. Consider a lot of the research that's published is biased. It may not be the end in sight. And I don't know if I kind of have another one, but certainly the encouragement to continue the work,

in the expiration and working with these difficult kind of folks. Very good. Very good. What's been a pleasure? I think you have just a lot of wisdom, practical wisdom, being in the trenches, and then also just digging into the research. And so I think that this has been a great conversation. I appreciate it.

Well, thanks for having me on. I really appreciate it as well. Well, hey, I appreciate it. We'll be corresponding by email. And we'll leave it there for today. Okay, David. Have a good day. Thank you.

I hope that you enjoyed this episode with Carl Kekano. And I hope that you go check out the blog, the write-up that we did together with an amazing pre-med student, Ellie McDaniel. I hope that you think about what might this look like in your practice, in your life, you know, maybe. as we have talked about this, it stirred up some past interactions you've had with people where you were like, you know, I don't really know what was going on with that person, but maybe it makes a little bit more sense if I think about them in a different way, rather than the way that I think about myself. I hope that we could have more empathy for people,

even if that empathy is seeing the world from their viewpoint, a viewpoint which may be very different from ourselves. And so I hope that you were able to take something away from this episode and be challenged. And if you have any other questions, I will be sure to write them down for future episodes. Thank you.