Shirah Vollmer MD

The Musings of Dr. Vollmer


Posted by Dr. Vollmer on August 29, 2013


George Vaillant MD, a Harvard Psychiatry professor, a hero of mine for many years, wrote an article, published in 1975, entitled “Sociopathy as a Human Process.” I have read and studied this article numerous times, but now, as I review for a Journal Club with my Psychiatry Residents tomorrow, I am touched by this article, yet again. Like watching a movie for the fifth time, or listening to a podcast for the second or third time, I am always stunned by what I missed in the first few exposures. The repetition brings new understanding; the hallmark of a good piece. For example, he says “in an outpatient setting the management of these disorders produces therapeutic frustration.” Somehow I did not catch the phrase “therapeutic frustration” but the two words together capture the energy put into a treatment relationship which hits up against apparent walls. Dr. Vaillant helps us to understand that these walls are not a result of the hopelessness of these patients who appear not to have a moral compass, but that these walls are a function of the deeply traumatic experiences of these patients, leading them to need a more intensive intervention than outpatient psychotherapy can provide. In essence, the tool is limited, not the patient. That’s brilliant. It is easy to ┬álapse into thinking that if I could just listen harder, and more thoughtfully, then I could be helpful, but in point of fact, there are patients who require a more comprehensive treatment program, in that their reluctance to outpatient treatment does not mean that they could not benefit from a therapeutic residential environment. On the one hand this is obvious, but on the other hand, the default assumption is that resistance to outpatient treatment would mean even more resistance to residential treatment. Dr. Vaillant reminds us that if we could provide a benevolent cage for sociopathic individuals, then we could help them learn from their peers about how to grow in the world, with empathy, motivation and a moral compass. His theory is that these patients lacked the family structure which helped them learn delayed gratification, and as such, they never learned to tolerate the anxiety of waiting their turn, or allowing others their point of view. Only a group environment, in which the patient has to get along with their peers will begin to help them to relate, and hence care, about their fellowship. This is brilliant again. Psychotherapy is the wrong tool. Group living, not prison, is the right tool. I do not know where one can find residential treatment for adults where the focus is on forming a functional group, but it strikes me like it is like a wilderness program, where all participants have to chip in, to survive in the woods. This would be a relatively low-cost intervention with a high yield-keeping them out of prison. The point for my residents-sometimes you have to read the old literature to know what to do in the future! Again, an obvious point that is often forgotten.

7 Responses to “Sociopathy”

  1. Shelly said

    Two things about this piece strike me: First, the fact that while you and Dr. Vaillant embrace residential treatment as something that people would want and would voluntarily go there as a means to grow and learn. While you have almost 30 years of experience as a top-notch psychiatrist and you of course realize how stigmatizing and traumatizing mental illness is on patients and their families, being in a mental hospital or wing either by choice or by force is probably the last thing a patient or their family wants. Once they are discharged and they continue in an outpatient setting, there is a sense of “almost freedom.” However the stigma still exists and there is still the humiliation and embarrassment that goes along with it. And it is this stigma that can ruin lives. The second thing that this piece strikes in me is that how you have hope that a sociopath can be taught to get along with other mentally-ill patients, and keep them out of prison. Do you really think that can be taught? As a psychiatrist and not a forensic psychologist (sorry), perhaps you will be fooled into thinking that the sociopath has been cured and can be freed into society to kill again? The best and safest place for a sociopath is behind bars. He or she can receive all their treatment there, where he won’t harm anybody ever again.

    • In this imaginary world of ideal treatment, the sociopath would be sent to an “Outward Bound” kind of program where the challenge is to learn to live communally. Again, using our imagination, this would not be a stigmatizing experience, but rather a “boot camp,” of sorts. I know this does not exist, but we have to imagine the ideal treatment modality and then try to fit it into some realistic parameters. Yes, now there is a stigma, but part of this imaginary world is getting rid of the stigma by demonstrating that these individuals lost their way, but that they can find their way again.
      Clearly, the criminal justice system is an important aspect of a safe society. Having said that, there are those who stray from the law, but who have not caused bodily harm, who might be transformed by a communal living intervention. This imaginary world imagines that criminal behavior can be prevented by targeting the appropriate individuals for this intervention. Thanks.

  2. Ashana M said

    I suspect the idea that adult sociopaths can be healed to the point of rejoining society as functional members is a fantasy that allows us to continue to believe in the inherent goodness of human beings. It is there because it serves us, not because it is true.

    • It is sometimes true, and that gives us hope, but as you say, for many, it is not true, which leads to despair. Thanks.

      • Ashana M said

        Why despair?

        • The despair that many people who harm others can not pivot towards a productive, and not destructive, lifestyle.

          • Ashana M said

            It seems fairly evident that some people can’t. I still don’t understand why this would lead to despair. When you give up unproductive approaches, the way is opened up to try something better. Reality seems like a reason to hope, rather than despair. The despair to me is that we stay locked in ways of thinking and acting that haven’t worked in the past, don’t work now, and give no indication of working in the future. Our inability (and unwillingness) to help ourselves really is cause for despair.

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