24. Couple Therapy Hides or Exposes - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Conflict, Control, and Out of Control in Couples and Couple Therapy
Chapter 24: COUPLE THERAPY HIDES OR EXPOSES


Depending on the diagnostic skills of therapist and the degree of sociopathic charm, couple therapy environment potentially exposes the cover of the sociopath as a reasonable person.  For this reason, someone with antisocial personality disorder will prefer generally to avoid it.  The possibility is that the sociopath may poorly disguise his or her sociopathy in a couple therapy situation.  Facing an aggrieved partner who has finally come to the realization of the pattern of treatment, the sociopath may be challenged to give responses of convincing sincerity and depth.  The therapist who desires to be trusted and liked, and therefore not appropriately clinically cynical may however incorrectly perceive sincerity and depth.  The therapist may be swayed by the sociopath's explanations and diversions and question the credibility and mental or emotional stability of the partner.  If this happens, the partner who has entered couple therapy with the hope that an authoritative someone- the therapist will finally validate his or her experience will be massively disappointed... again.

The therapist often approaches therapy from a position of non-judgment in order to build rapport and join the existential world of clients.  In domestic violence, this approach has potential problems.  "A value free therapeutic stance is not possible or desirable for prevention work.  The battering literature suggests that a shift in values is necessary for perpetrators and victims of violence (Claes, Connolly, Daniel, & Engel, 1992).  For example, perpetrators need to move from entitlement to mutuality, from holding one's spouse/partner responsible for their acts/words to taking responsibility for one's own words and actions, from denying one's own regret and grief to owning feelings related to abuse.  Similar value shifts are encouraged when working with at-risk couples to begin shifting power imbalances and attaining lower levels of aggression" (Perez and Rasmussen, 1997, page 134).  While the therapist can assert such values, it is questionable that perpetrators can shift their values.  Entitlement to do as one chooses for personal gratification despite harm to others is completely egosyntonic for the sociopath.  Moving to mutuality is not part of the sociopath's process.  While the sociopath can possibly take responsibility for his or her behaviors or words, he or she resists taking any personal negative consequences for them.  Regret for another's distress, hurt, or injury is largely irrelevant unless personal threat or harm may follow.  The regret is based on whether the sociopathic action was effective in getting his or her wishes satisfied or whether or not he or she gets away with it without negative consequences.  Owning more vulnerable feelings based on intimacy needs are also irrelevant and the sociopath finds the idea of sharing power as an incredulous concept.  Keeping power and control- in fact, enhancing and increasing domination and manipulation is the goal of the sociopath.  A charming sociopath can fool the therapist who assumes a client desire for intimacy, connectiveness to feelings, reciprocal mutuality, and sharing.  The following is an excerpt about such a therapist.

"So why did I not recognise that particular psychopath, 'Dwayne'?  Like the abused women in my practice who are largely informed of 'reality' by their abusive partner, my contact with Dwayne was one-to-one, and I was drawn into his distorted view of his world without the external references that might have alerted me.  He seemed to me to be a recently separated person with all the emotional suffering and devastation that the sudden loss of partner brings.  That he was more disturbed than some was apparent in his increasing emotional and physical deterioration (crying, weight loss, claims of not sleeping, problems with concentration, suicidal ideation, and so on), and his unrelenting quest to get his wife back despite her contrary wishes.  The latter suggested a lack of self and an inability or unwillingness for self-reflection and responsibility regarding the breakdown of his relationship.  Nevertheless, he wove a tapestry of lies, and presented 'evidence', that persuaded me that his wife was seriously troubled and vulnerable and that he was genuinely concerned about her.  At worst I saw him as somewhat weak and dependent.  At the time I was dazzled by his obvious suffering, and oblivious to the lack of emotional depth in his story telling.  At no time did he express remorse for anything he might have done, or not done- a factor that should have alerted me to his psychopathy.  I was made aware of his strengths though by his clever use of a particular story (his grandiose self) that he shared with a degree of sincerity and modesty.  This suggests that, prior to our first appointment, Dwayne researched me on the Internet, which highlights the lengths an intelligent psychopath will go to in order to stage the effect he wants" (Wileman, 2008, page 115).

Couple therapy unlike individual therapy allows for the external references to give perspective on what occurs.  The therapist provides external examination for the couple- for the partner who is often submerged in the sociopathic rabbit hole.  The partner provides external experiences and feedback on the therapist-sociopath's interactions and relationships.  The therapist often wants to believe the client without considering the possibility of his or her story as a tapestry of lies.  The individual is often smooth, charming enough, and seemingly logical to surround otherwise alerting red flags with a compelling tale.  An adept sociopath can be sensitive and creative enough to sense the therapist's inclinations, including theoretical orientation to help the therapist see what the therapist wishes to see.  Dytch (2012) identified several common therapist misconceptions that compromise an accurate assessment of domestic violence.  They also offer input to some degree for identifying antisocial personality disorder.  Each assertion by the therapist creates potential for accurate assessment and effective treatment.

"The couple reports that they yell at each other, so they both contribute to the problem."  Loud arguments are indicative of anger and a crossing of a boundary of civil discourse and should therefore alert the therapist to the possibility of domestic violence.  Abusive relationships often involve angry behavior by both partners.  And, some go beyond mutual anger to include mutually abusive behavior as well.  While both partners may become abuse the intensity of violence and the degree of intimidation and fear created may be significantly higher for one partner.  In other words, while each partner is responsible for abusive or harmful behavior, one may be much more abusive than the other.

"I spoke to them about partner abuse and they deny it is going on."  The therapist should know that clients might minimize or deny problems, their frequency, and intensity.  It may be from fear of retaliation from the other partner or from shame or some combination of such emotions, cultural strictures, and manipulation.  Sometimes, an individual is so used to or inured to abuse that he or she does not identify it to him or herself.  He or she therefore can reveal to the therapist what he or she does not acknowledge to oneself.

"It is my policy never to meet individually with clients I see in couple therapy."  In domestic violence situation, honest revelations may not be possible with both partners in the room.  A direct inquiry about abusive occurrences can trap the victim in an untenable situation.  An honest answer revealing abuse may result in retaliation by the abuser.  Denying abuse precludes getting any help in ending the violence.  Seeing each partner individually may be critical to uncovering abuse.  Resistance on the part of the abuser to allow individual sessions for the partner may in itself be cause for suspicion of abuse- or at least of secrets being held.

"I have a 'no secrets' policy, so clients know that anything they share with me individually will be brought into the couples session."  This policy can be considered very appropriate for couple therapy based on the assumption that both partners have integrity about and are invested in the therapeutic process to improve the relationship.  Dytch believes "In my view, such a policy is designed to relieve the therapist's anxiety and hinders rather than helps the client.  As therapists, we often learn things we cannot or choose not to divulge.  Holding some information in confidence is a small price to pay if it allows us to leverage our clients into the right form of treatment."  This is a challenging situation where policies as boundaries are intended to facilitate a process of clinical integrity.  Policy in this case may need to defer to a higher value of client safety.

"Even if there is undiagnosed partner abuse, I'm helping them resolve the underlying relationship dynamic."  Dytch asserts, "By its very nature, abusive behavior prevents the resolution of other issues.  Abuse skews the relationship dynamic and leaves most of the power and control in one partner's hands."  Practically speaking undiagnosed partner abuse, as the underlying relationship dysfunction may never be addressed.  Unspoken and unacknowledged is the corruption of supposed mutuality and fairness by the punishment and intimidation of domestic violence.  Both partners unbeknownst to the therapist know that despite whatever communication skills are learned and contracts for behavior are made, when push comes to shove, the victim will be hit if he or she does not "let" the abuser prevail.  "I can teach them better communication skills until they trust me enough to disclose the issues they are withholding."  The abuser will learn skills and agree to the contracts in therapy knowing he or she will not follow through if he or she decides not to.  For example, "I statements" can easily be co-opted to abuse, manipulate, or intimidate.  The victim will also learn skills and agree to the contract but hesitantly and without confidence.  The victim knows that this portends to be another incident where the abuser can play reasonable and conciliatory and still do whatever the hell abusively he or she wishes at home.  Only the naive therapist thinks that therapy of this type has integrity... and he or she is wrong.

"I'm not taking a stand on the issue because I'm afraid the abusive partner will bolt from treatment."  This perspective and therapeutic choice is based on the assumption that having the couple in therapy is better than them not being in therapy.  However, being in the right type of treatment is more important than just any treatment. especially ineffective therapy.  In fact, keeping or allowing the couple to remain in couple therapy without integrity implies that the therapy will somehow be effective.  Worse, the so-called treatment allows the abuse to continue.  Nero the therapist fiddles while Rome is abused.  When the therapist takes a stand against domestic violence or abuse, the sociopath may run from therapy, but the other partner may have gotten something desperately needed.  One important benefit of stumbling upon a sociopath in couple therapy is how it affords the aware therapist becoming a professional and desperately needed witness for the non-sociopathic partner.  The therapist may be the first outside witness to see the abuse, or the first with authoritative credentials unlike family or friends, or the final needed witness to confirm the partner's experience.  The therapist may be in a position to provide critical validation, information, and lifesaving support to the vulnerable partner, in subsequent individual sessions after couple therapy has been appropriately terminated- or referral to such therapy.

CONTRA-INDICATIONS FOR COUPLE THERAPY
The sociopath's fundamental defects of empathy and sincerity, in the emotional hot seat of couples counseling, are at risk of being flagrantly unmasked.  This often happens sooner, typically in couple therapy than in individual therapy, where the sociopath, safe from the spontaneous challenges and disclosures of his abused partner, can more effectively misrepresent and deceive.  Since the need for domination is fundamental to the sociopath's needs, the partner revealing mistreatment or cruelty causes a sense of intolerable loss for the sociopath.  He or she cannot be the loser or have his or her deception exposed to others.  The power and control- that is, his or her exploitive advantage destabilizes.  This is unacceptable and cold calculating sociopathic rage is likely to direct retribution against the partner.  Couples therapy is contraindicated when a partner is a suspected sociopath for several reasons. Among them:

1) The therapist does not want to enable the belief (especially the non-sociopathic partner's belief) that a non-abusive honest relationship can possibly evolve with a sociopathic partner.

2) It is inherently humiliating for the non-sociopathic partner to make him or herself vulnerable to a partner whose only response to that vulnerability is exploitative.  The therapist does not want to collude in this process.

3) There is the risk that the sociopathic partner, who is probably blaming and possibly vengeful, will use the partner's complaints during the session as a basis, after the session, to punish him or her for having had the audacity to expose the sociopathic behavior.  This risk of abuse after therapy sessions is a dangerous dynamic.

The therapist must recognize these risks and take appropriate clinical measures, especially to ensure safely.  This may mean terminating couple therapy.  Couple therapy may be contraindicated when there is ongoing covert or overt domestic violence.  The risk of intensified violence is relevant when there is any abusive person in couple therapy- not just a sociopath.  Emotionally reactive abuse that can be triggered because of underlying attachment wounds and fears activated in the therapy.  Low self-esteem and habitual bullying tactics may become physically violent.  Culturally sanctioned inequities, domination, and control of the partner may intensify dangerously when resisted by a non-compliant and/or culturally mismatched partner.  Desperate reaction from severe dependency anxiety and become violent- particularly with men who deny their dependent feelings.  Borderline reactions because of hypersensitivity to betrayal, abandonment, or rejection actions can result in lashing out at the partner.  Narcissistic rage can be ignited for the narcissist because of his or her sense of entitlement that the partner is obligated to make him or her look and feel good not just at home, but perhaps especially to others such as the therapist.  The critical mass of accrued paranoid resentments may ignite with a dangerous violent eruption.  Substance abuse disinhibition or paranoia may release ore exacerbate other aggressive or abusive tendencies.  Organic psychosis or psychosis from extreme emotional or psychological distress can turn otherwise reasonable persons assaultive.

"To some commentators, the very idea of 'treating' a couple as a couple where domestic violence has occurred is controversial.  In an early article Bograd, for instance, argued that: 'The popular practice of conjoint therapy may be based on certain conventional beliefs or attitudes about women, marriage, and violence' (1984: 563).  Specifically, she maintained that couple therapy might implicitly 'perpetuate traditional sex roles' (1984, 565) because the woman was likely to be 'the most responsive' to the therapeutic experience.  Moreover, this reinforced 'the traditional notion that women are primarily responsible for the tranquility of the domestic environment' (1984: 565).  Some researchers have even reported that women experienced 'retaliatory assaults' (Adams, 1988: Mederos, 1999: 128) after couple therapy.  Within the North American context, these criticism have led not only to some services constructing a 'firewall' (Mederos, 1999: 134) against therapeutic interventions, but also to some states excluding 'marital counseling or family therapy as acceptable remedies for court-mandated offenders' (Merderos, 1999: 135)," (Rivett, 2001, page 397-98).

Rivett (2001, page 400-01) discussed how having a referring agency or organization including law enforcement or the court may form a third element in couple therapy when domestic violence is involved.  The third element in addition to the therapist and the couple can create a protective context for greater safety to the woman or children.  This depends in large part to whether the agency or organization is conscious of their vulnerability and do not duplicate patriarchal assumptions and excuse violence in the home.  Making the couple therapy centrally accountable to protect the abused partner is foundational for determining whether couple therapy is viable in domestic violence situations.  The therapist must not be distracted by other therapeutic goals and lose the first priority of safety.  Therapeutic or therapist ignorance and/or arrogance can place or keep the victim of domestic violence in great jeopardy.  It can result in not merely a clinical error but in fatality.

THE DANCING DOG
A common strategy in couple therapy especially from humanistic or a communications orientation is to promote empathy.  Getting each partner to recognize and accept the emotional experience of the other is expected to promote connection or re-connection.  With the individual with antisocial personality disorder this becomes akin to getting a dog to dance.  While the dog can go up on two legs and dance, the dance is unnatural and cannot be sustained.  The dancing dog always falls back onto four legs because it is totally and fundamentally, a canine animal… not even a bipedal beast.  The sociopath however is often much more than a dancing dog, who clearly remains a dog despite the prancing about.  The skillful sociopath is often much more like a well-programmed android who almost perfectly mimics a human being.  The sociopath can act like a caring person and act like he or she cares about the others feelings. He or she may recognize the other's feelings but in an analytical manner.  Comparable personal feelings are not activated.  "They seem completely unable to 'get into the skin' of others, except in a purely intellectual sense.  They are completely indifferent to the rights and suffering of family and strangers alike.  If they do maintain ties, it is only because they see family members as possessions" (Hare, 1994, page 58).

The relationship is not of mutuality but as superior to inferior… of user and the used.  The therapist who anticipates a capacity for empathy may be fooled by the sociopath's empathetic act.  While the sociopath can mimic generic personal development aspirations, he or she also is not motivated by the therapist or therapy's offer to facilitate individual growth.  "Psychopaths don't feel they have psychological or emotional problems, and they see no reason to change their behavior to conform with societal standards they do not agree with" (Hare, 1994, page 63).  An appeal to such standards is only relevant if they serve a personal gain in the moment.  The sociopath may appeal for example for the partner or the therapist's empathy about his or her (feigned) distress if that stops the partner following through with some consequence not to his or her liking.  The sociopath may invoke social boundaries about aggression or forgiveness if it curtails partner use or expression of anger in attempts to restructure the relationship.

Wileman (2008, page 116) describes the sociopathic façade of empathy when therapy attempts to prompt the partner to assert herself.  "As my work progresses, I assist the abused woman to anticipate her partner's reactions to her re-emerging sense of self, and she may practise relating to him differently and observing her effect on him.  The psychopathic person will notice such changes and increase his controlling tactics, which may take the form of seduction and, if he is highly intelligent, it will be superbly orchestrated.  If the couple is separated, he may text a teaser that lets her know she is on his mind but that he expects nothing, and simply wants her to move on and be happy.  She will be made to feel special.  To be valued at last and appreciated instead of being taken for granted or exploited is very enticing, and many women will believe him because it is what they want to hear.  As we discuss the difference between words and actions, his power over her fades away again" (Wileman, 2008, page 116).  If and as therapy facilitates growth and independence in the partner, the sociopath's power is diminished but his or her likelihood to manipulative and abuse increases.

Hare has specific recommendations for dealing with a sociopath.  The recommendations appear directed to the partner or associate of a sociopath, but are also relevant to the therapist.

Be aware of who the victim is.  Psychopaths often give the impression that it is they who are suffering and that the victims are to blame for their misery.  Don't waste your sympathy on them.

Recognize that you are not alone.  Most psychopaths have lots of victims.  It is certain that a psychopath who is causing you grief is also causing grief to others.

Be careful about power struggles.  Keep in mind that psychopaths have a strong need for psychological and physical control over others.  This doesn't mean that you shouldn't stand up for your rights, but it will probably be difficult to do so without risking serious emotional or physical trauma.

Set firm ground rules.  Although power struggles with a psychopath are risky, you may be able to set up some clear rules- both for yourself and for the psychopath- to make your life easier and begin the difficult transition from victim to a person looking out for yourself.

Don't expect dramatic changes.  To a large extent, the personality of psychopaths is "carved in stone."  There is little likelihood that anything you do will produce fundamental, sustained changes in how they see themselves or others.
C
ut your losses.  Most victims of psychopaths end up feeling confused and hopeless, and convinced that they are largely to blame for the problem.  The more you give in the more you will be taken advantage of by the psychopath's insatiable appetite for power and control.

Use support groups.  By the time your suspicions have lead you to seek a diagnosis, you already know that you're in for a very long and bumpy ride.  Make sure you have all the emotional support you can muster (Hare, 1994, page 61).

A skillful sociopath often attempts to seduce or charm the therapist.  He or she gets empathy from the therapist through convincing the therapist that the partner has been abused or exploited him or her.  The therapist is not alone as a potential victim or potential patsy.  The therapist may be coerced, punished, or intimidated in therapy, but also can be threatened and/or targeted with ethical complaints to professional associations and licensing agencies and lawsuits in the courts.  Setting firm boundaries in therapy should include the therapist being willing to terminate therapy if the sociopath is unable to function within appropriate guidelines.  The sociopath or other client who feels threatened may demand that his or her drinking or prior relationships not be talked about for example, or else he or she will leave therapy.  Determination of what can and should be addressed is a therapist's call and should not be given up to the discretion of or threat by a client.  The therapist should call the bluff or allow client termination to maintain therapeutic integrity.  While threatened, the sociopath often does not want to terminate therapy.  Or, cannot terminate or risk suffering the consequences that compelling original entry into therapy.  The therapist's willingness to terminate ineffective and inherently disingenuous therapy may be the only leverage to manage the sociopath since the therapy is either legally mandated or otherwise mandated with relationship termination to be occur.  The therapist who is unwilling to threaten- that is, clinically present or actually pull the trigger of termination is likely to be therapeutically co-opted and allow the therapy to lose clinical integrity.  The process of requiring certain therapeutic boundaries and pulling the termination trigger is for the therapist akin to Hare's recommendation for the partner to "cut your losses."

The therapist should also consider that harm reduction or small quantitative changes or functional boundaries might be the only realistic goals of therapy with a sociopath.  Inner psychic change, empathy, spiritual growth, and similar qualitative growth or change is unlikely or impossible.  The individual may continue with sociopathic thoughts, feelings, motivations, and impulses that are intractable.  All personality disorders including antisocial personality disorder are characterological and embedded in the individual.  The degree of sociopathy may be measured in the frequency and intensity of sociopathic behavior.  Thus, behavior change rather than internal change or growth should be the goal of therapy.  Inner changes may be difficult or impossible, while positive incremental behavioral changes may be the only realistic possibility.  Initial incremental changes may not be overtly positive actions but the reduction of overtly negative actions.  Not only is this type of change more plausible, but may be the goal of the partner.  The partner who is attached to the sociopath despite dysfunction, lack of mutuality and fulfillment, and abusive treatment may contrary to the therapist's or others' recommendations want to remain with the sociopath.  He or she may be satisfied with small changes in behavior.  And, the sociopath may be willing to make small concessions to maintain other benefits.

As disturbing as opting for minimal change may be to the therapist, this can be sufficient for the partner.  The therapist would have to choose to acquiesce to this choice or refuse to participate and terminate therapy.  The partner's right to self-determination should be honored if ethically possible.  The partner may decide behavior that the therapist considers abusive to be tolerable.  Unfortunately, determining what is too much abuse also makes abuse acceptable.  Practically speaking, for some partners some abuse is acceptable.  Despite a partner's tolerance or acceptance of some abuse, the therapist remains mandated to take actions to promote safety when behavior legally qualifies as domestic violence.  Lastly, the partner's sense of isolation accentuates the sociopath's abusive control.  Isolation, feeling alone, abandoned, and helpless are common experiences.  The therapist who is unfamiliar with or inexperienced working with a sociopath may begin to have similar feelings as the partner.  To deal with this, the therapist should seek professional support through consultation with a therapist with significant experience with this personality disorder.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
office: (510) 582-5788
fax: (510) 889-6553
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