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 lapse 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.