Introjective identification therapy for patients with antisocial personality disorders: a theoretical outline.
Subject: Employee motivation (Health aspects)
Mental illness (Care and treatment)
Mental illness (Health aspects)
Publishing industry (Health aspects)
Children (Behavior)
Children (Health aspects)
Author: Martens, Willem
Pub Date: 12/22/2008
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2008 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Winter, 2008 Source Volume: 11 Source Issue: 4
Topic: Canadian Subject Form: Child behaviour Computer Subject: Publishing industry
Product: Product Code: 9911210 Motivational Techniques; 2700020 Publishing; 2700000 Printing & Publishing NAICS Code: 511 Publishing Industries SIC Code: 2711 Newspapers; 2721 Periodicals; 2731 Book publishing; 2741 Miscellaneous publishing
Organization: Organization: American Psychiatric Association
Accession Number: 192800780
Full Text: ABSTRACT

Treatment of persons with Antisocial Personality Disorder (ASPD) (American Psychiatric Association, 2000) is often challenging despite all the new treatment approaches, such as specific therapeutic programs For distinctive target populations and new developments in existing therapeutic traditions (Kahn, Oppenheimer, & Martens, 2007; Martens, 2001a, 2001b, 2002, 2003). The deep-rooted deviant behavioral and personality characteristics of those with ASPD are in severe cases very difficult to transform to less harmful and more socially desirable features and attitudes. I was inspired by two case studies of individuals with ASPD, illustrating the healing effects of positive identification (which will be presented later), and by the film Love and Death on Long Island, in which an author is intrigued by a young B-movie actor demonstrating a light and popular lifestyle and behavior complementary to that of the author's own. Because of this inspiration, I developed new theoretical building blocks for Introjective Identification Therapy (IIT), designed for antisocial personalities.

KEY WORDS: antisocial personality disorder, introjective identification therapy

TARGET AUDIENCE: mental health professionals, therapists, psychology

PROGRAM LEVEL: Basic

DISCLOSURE: The author has nothing to disclose.

PREREQUISITES: none

Definition of ASPD

The 4th edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV TR), presents features of Antisocial Personality Disorder (ASPD):

* A failure to conform to norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest

* A deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure

* An impulsivity or failure to plan ahead

* An irritability and aggressiveness, as indicated by repeated physical fights or assaults

* A reckless disregard for the safety of self or others

* A consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or to honor financial obligations

* A lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

Additionally, the individual must be at least 18 years of age, although there is evidence of DSM-IV Conduct Disorder before he or she is 15 years old. Antisocial behavior does not occur exclusively during the course of a schizophrenic or manic episode.

Established Methods of Treatment of ASPD and Success Rates

Studies into the treatment efficacy in adult psychopaths offer these findings:

* There is mixed evidence that therapeutic communities (TC) are effective in ASPD (Kahn et al., 2007; Martens, 2004b). Treatment of ASPD in therapeutic communities is problematic in terms of high rates of attrition, low levels of motivation, and increased reconviction (Kernberg, 1984, 1992; Martens, 1997), but in some cases it might be successful. The author suggests that differences in the a) personal schemes of treatment, b) treatment diversity, c) presence or absence of experimental attitudes of staff members, d) management, e) selection, and f) availability of high qualified and motivated therapists and staff members might be (partly) responsible for distinctions in treatment outcome between various studies.

* Psychotherapeutic (especially cognitive, behavioral, and psychodynamic psychotherapy) treatment could be effective in the long run (generally meaning at least 5 years of treatment) in some cases (depending on study populations, 5%-25% remission, and 10%-30% improvement rates), in so far that ASPD personality traits become less extreme (Kahn et al., 2007; Martens, 2004b). Psychoanalytical treatment might be effective, but no remission and improvement rates are available (Kernberg, 1984, 1992; Martens, 1997, 1999). Nevertheless, even those in remission seldom reject their egocentric attitudes; thus they continue to have interpersonal problems. Here again, differences in treatment-outcome studies may be explained by distinctions in personal schemes of treatment and the availability of highly qualified and motivated therapists, management, and selection.

* Short-term behavioral therapy and group psychotherapy do not seem to be effective in treating ASPD (Kahn et al., 2007; Martens, 2004).

* Because many antisocial traits such as aggression, impulsivity, sensation seeking, incapacity to learn from experiences, and lack of social-emotional and moral capacities are neurobiologically determined (Martens, 2005b), it may be possible to diminish these traits with the help of psychopharmacological treatment (Martens, 2002), neurofeedback treatment (Martens, 2002), and psychosocial guidance in combination with psychotherapy (Martens, 1997, 2002).

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Definition of Projection, Introjection, and Introjective Identification

Projection is the initial phase of introjection--its condition of possibility. Projection can be defined as the perceptual process that tests and evaluates the object in terms of acceptability to self. It is the insertion of self into the object by the subject with the immediate and mostly unconscious purpose of assessing the object either as nourishing or toxic (Malancharuvil, 2004).

Kernberg (1976) provided a definition: "[Introjection] is the reproduction and fixation of an interaction with the environment by means of an organized cluster of memory traces implying at least three components: (a) the image of an object, (b) the image of the self in interaction with the object, and (c) the affective coloring of both the object-image and the self-image."

Introjective Identification (II) occurs when there is a process of introjection (inclusion, incorporation) and when an identification with what is introjected is added to this. Different writers, particularly those of the Kleinian school (Klein, 1950; Segal, 1964), refer to the introjection of the object into the ego and to the subsequent identification of the ego with this object, when they discuss introjective identification. Adroer (1998) suggests, however, that II can also occur in the self, although it is outside the ego (in pathological states).

Lacan's View On Imaginary Identification and Significance Of Language

Lacan's conclusions are based on psychodynamic observations and research. In his essay on the Mirror Stage, Lacan (1977) describes how the infant forms an illusion of an ego, of a unified, conscious self, identified by the word I. To Lacan, ego (self, or Identity) is always on some level a fantasy, an identification with an external image, and not an internal sense of a separate whole identity. Rather, self is other, in Lacan's view; the idea of the self, that inner being we designate by I, is based on an image, an other. The concept of self relies on one's (mis-) identification with this image of an other (Lacan, 1963, 1977, 1981).

Central to the conception of the human, in Lacan, is the notion that the unconscious, which governs all factors of human existence, is structured like a language. He bases this on Freud's account of the two main mechanisms of unconscious processes: condensation and displacement. Both are essentially linguistic phenomena, where meaning is either condensed (in metaphor) or displaced (in metonymy) (Lacan, 1963, 1977, 1981). The elements in the unconscious--wishes, desires, and images--all form signifiers usually expressed in verbal terms, and these signifiers form a signifying chain--one signifier has meaning only because it is not some other signifier. Lacan, on the other hand, says that the process of becoming an adult, a self, is the process of trying to fix, to stabilize, or to stop the chain of signifiers so that stable meaning--including the meaning of I--becomes possible (Lacan, 1963, 1977, 1981). As a consequence, therapeutic observation and correction of language use might play a significant role in introjective identification therapy.

What is Introjective Identification Therapy?

Introjective Identification Therapy is intended to be an adjunct to current therapeutic strategies rather than a substitute. Introjective Identification Therapy is a therapeutic approach mainly focused on systematic and strategic increase of socially desirable character traits, attitudes, or behaviors of patients with ASPD by means of positive identification with a person or image. It could be a real or fictional character from movies, books, politics, religion, culture, etc. who demonstrates features that are considered ideal for achievement (this will be referred to as an idealized person) by the patient, and are complementary and a valuable addition to the features of the patient. Subsequently, the patient would learn to let flourish and maturate the new revealed parts of his or her self (by means of conscious utilization and training of these abilities and characteristics) in such way that it becomes a substantial and active dimension. The ideal transformation process can be considered a discovery of the hidden sources and components of self, rather than the "blind" inclusion of characteristics of a stranger. The correction of self-concept, increase of self-knowledge and self-esteem/respect, growth of social-emotional and moral capacities, spiritual activities, gradual increase of responsibilities, and training of pro-social coping skills might be significant additional issues in this approach (and/or other therapeutic approaches that could be combined with IIT), because these are significant correlates of improvement and remission in persons with ASPD (Black, Baumgard, & Bell, 1997; Martens, 1997; Robins, 1966).

Preparation of Patients

Therapists should prepare motivated patients for this new therapeutic approach by teaching them the following:

* the correct and adequate utilization of identification (using test cases, for example)

* effective patient-therapist cooperation and adequate responses to therapeutic guidance during identification activities

* replacement/empathic skills

* pro-social coping strategies so patients can handle difficulties that arise as a consequence of their attitude change (acceptance problems with their environment, peers, friends, and partner)

The therapist should inform the patient adequately and completely (discussion of risks, possibilities, and rules) in order to create realistic expectations and an efficient therapeutic attitude.

Therapeutic Steps and Strategy

Recognition of undesirable traits. By means of intensive and careful self-investigation, the patient should select his or her traits and attitudes that are undesirable and should be rejected. It might be useful to evaluate past efforts to change attitude or behavior (and to diminish these undesirable features). What can the patient learn from these attempts? The second step in the therapeutic process is to find an appropriate idealized person (some individuals cherish several) who demonstrates characteristics that might be suitable for addition to the traits or attitudes of the patient and as a substitute for the rejected features.

Idealized person. Patients must learn to collect information regarding the idealized person, and they must do some homework in order to become motivated in a realistic and effective way. They should be stimulated to discuss their observations and visions with respect of the idealized person in a profound and nuanced manner with their therapist. However, the therapist must be very alert to a patient's attraction to harmful features of the idealized object, and the therapist should discuss these harmful influences with the patient in a very early stage. It should also be discussed why the idealized person is a special person and which features could be regarded as ideal for the patient. Therapists and patients should also discuss whether successful identification is a realistic goal. Only realistic goal setting and a realistic concept of examples are useful and harmless. When these matters are investigated and the results are positive, the main therapeutic process can begin.

The patient must learn to discover, in a systematic and profound manner, the internal (emotions, ideas, drives, and attitude) and external (expectations and reactions from the outside world) life of the idealized person. Pro-social role models, ideas, emotions, and behaviors/attitudes of other persons play a major role in the transformation process because successful social-emotional and cognitive interactions with the external world might have a corrective (utilization of relevant feedback from other people), refreshing (bringing new views and perspectives into our life), and creative influence (increased self-investigation and examination of alternative possibilities for attitude and behavior, discovering our own hidden talents and capacities). But, in Introjective Identification Therapy, it is a necessity to optimize and watch this process of receiving influences carefully and continuously in order to avoid harmful influences and to intervene when avoidance is not possible. Harmful influences are possible as a result of over-idealization and wrong interpretation of the traits and attitudes of the idealized person by the patient. The therapist must also be watchful for the impact of undesirable traits (that should be excluded from the therapeutic process) on the patient by means of intensive therapeutic process control (assessment and continual monitoring of vulnerable points in the therapeutic process and attitude of the patient).

Imitation and creative play. Thoughtful social information processing and social comparison activities (what are the differences between and similarities of the idealized person and other persons) in combination with empathic and cognitive investigation in the external and internal world of the idealized individual must lead to an establishment of a stable and realistic internal representation of the idealized figure. Intense connectedness and interactions with this representation of the idealized figure is required to borrow his or her desired characteristics and attitude (by means of observation, comparison, self-perception/reflection, and imitation).

In fact, students of old masters such as Rembrandt and Bach learned first to copy (imitate) the work of their teacher in order to observe the precise technique of art and find out how it works. After that, the student might be better able to develop his or her own style. By means of imitation, the patient might discover the rudimentary parts of him or herself that correspond with the desired features and/or attitude of the idealized person.

The patient can wake up these rudimentary capacities in his or herself and let them grow and maturate so that they become a substantial and active part of his or her self. The characteristics of the idealized person that were studied and imitated might be gradually adapted (when therapeutic guidance is adequate) and transformed from incorporated parts (representations of the idealized person) into the patient's authentic structure and the "substance" of the patient's character and core of self.

The therapist must stimulate the patient's ability to creative imitation (play with the internal representations of the idealized person and adopt it in a genuine way), while blind imitation should be discouraged. Our intrapsychic world is able to use creatively prepared external influences (also as a consequence of imitation, social comparison, impressive external information and events, social support, and positive attention) to create a new intrapsychic balance, specific self-recovering activities, and a change of character or attitude (this happens even in patients with antisocial and psychopathic personality disorders; see Martens, 1997). I agree with Adroer (1998) and Grotstein (1983), who suggested that, "what one internalized is not so much the object and its functions, as one's experience with the object."

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Language. The therapist and patients should watch language use during the motivation phase (patients' expression of desires, needs, and goals), during the selection of the idealized subject for introjective identification, and during the process of IIT itself, because it will contain significant unconscious information. Furthermore, emphasis on therapeutic correction of language use and exact grammatical formulation in the therapeutic process is important because these careful linguistic activities should provide an exact line-up and structure (framework) for mental and emotional forces or activities that are required for introjective identification and the transformation process (for more details see Lacan, 1981).

Coping with relapse or crisis. Finally, the patient and therapist should evaluate the transformation process to provide useful information for coping with relapse or crisis in the future. The patients must find out what the learning moments and conditions are that correlate with positive experiences in finding solutions for problems and how he or she can use this information adequately for prevention or intervention with problems in the future.

Aspects of Therapist-Patient Relationship

In therapy, the therapist becomes a new object in the client's life, thus activating the dynamic of transference (Van Beekum, 2005). I agree with Scharff's (1992) view that the power of therapeutic action derives from the mental mechanisms of projective and introjective identification (Scharff, 1992). This is especially the case in Introjective Identification Therapy. Eshel's (2004) experiences and observations indicate that the crucial step at the heart of the process, between projective identification at its onset and the patient's introjective identification later on, is the analyst's experience of being-in-identification with the patient's projected, threatening, and painful experiences.

The analyst actually lets the patient's experiences in and processes them within his or her own emotional experience. This is referred to as I-dentification (see Lacan), experiencing vicarious experience and the ensuing possibility of being. Containing thus evolves through the patient and analyst's converging, deep interconnectedness and interpenetrating impact on each other, forming a conjoint, living, therapeutic entity in which the analyst's psyche is used as an area of experiencing and transformation for the patient's expelled, unbearable experiences (Eshel, 2004). The author also suggests that the identificatory, an in-depth understanding of the patient, is achieved by the analyst's staying as connected as possible to the patient's emotional experience.

The therapist's self is the therapeutic instrument, and the therapist must provide a holding environment: a therapeutic space free of impulsivity, narcissistic concerns, and retaliation (Scharff, 1992). Scharff's technique of listening to the unconscious communication coming from the patient in words, silence, gestures, and in feelings evoked in us is suitable for Introjective Identification Therapy. Furthermore, the therapist must follow the affect, analyze dreams and fantasies, and point out the compulsive repetition of unhealthy behavior due to unresolved conflict.

These therapeutic issues of the therapist-patient relationship require attention:

* Therapeutic increase of faith (antisocial personalities have problems with trusting others). Many current therapeutic approaches include strategies for stimulation of the patient's faith in the therapist.

* Enhancement of reliability in therapeutic relationships (deception and unreliability are diagnostic features of Antisocial Personality Disorder) by means of clear agreement and strict rules (that include consequences of unreliable behavior).

* Decrease of antisocial characteristics such as impulsivity, recklessness, and sensation seeking (which are frequently neurobiological determined, see Martens, 2005b) by means of adequate multidisciplinary treatment (combination of psychotherapeutic, neurological treatment, and psychosocial guidance, see Martens, 2002).

* Influences of frequent co-morbid disorders in antisocial persons such as substance abuse disorders and other personality disorders must be considered.

* Therapeutic use of humor might have a positive and healing effect on the therapist-patient relationship and therapeutic process (see Martens, 2004a).

Case Report 1

Mr. X had murdered his wife and several of her lovers in a very brutal way during an outburst of extreme jealousy and related rage. He was sentenced to a forensic psychiatric treatment, because he was found not guilty by reason of insanity. He was diagnosed according to the DSM-II (American Psychiatric Association, 1968) as suffering from Antisocial Personality Disorder. He demonstrated severe impulsive, aggressive, reckless, and callous traits, serious social-emotional and moral incapacities, and a long-lasting alcohol problem. He was frequently in trouble with the law as a consequence of fights and reckless driving. Mr. X was 33 years old and of average intelligence. He liked social contacts but in a less subtle, empathic, and a rather indifferent way. At many times he demonstrated unpredictable and aggressive behaviors.

Mr. X grew up in a poor neighborhood. Both his parents had criminal and antisocial traits and had heavily abused alcohol. They had six children who were often neglected. Mr. X finished technical school and worked for 12 years as a car mechanic. He was only interested in boxing and car racing. He became a member of a street gang when he was 13 years old and, under the influence of other gang members, he began participating in criminal activities such as burglary, robbery, and physical assaults; however, he was only arrested for fights.

In the forensic hospital, he was confronted on his ward by patients with different backgrounds (milieu, education, attitudes, and interests). It was remarkable that he became a close friend of Mr. Y, who was a hippie. The court sentenced Mr. Y to forced treatment because he had killed his wife before attempting suicide, hoping to die with her. Mr. X was intrigued by Mr. Y because of his stories (he traveled around the world) and his wisdom (he had read many books of Herman Hesse, Buddha, and so on). These two men spent much time together. Mr. X was very much impressed by and under the influence of Mr. Y's attitude. He was relaxed and cultivated; he coped with problems by means of subtle and constructive humor, and he was a good thinker. Mr. X changed his behavior and attitude gradually. His brutal and rough behavior diminished, and he made serious attempts to behave (control his irritating, impulsive, and aggressive impulses) and think in a civilized manner. He practiced gentle behavior because he observed the positive effects of Mr. Y's behavior (everybody liked Mr. Y and gave him positive attention) and experienced satisfaction as a consequence of his new attitude. In the beginning he avoided stressful and aggression-provoking situations. Gradually, he tried (sometimes with help of Mr. Y) to cope with stressful and frustrating situations in a socially desirable manner. For example, he tried more and more to express his irritation and aggression precisely and structured in words and adequate emotions, rather than in an explosive way.

After a year of friendship, Mr. Y committed suicide. Mr. X became very depressed as a consequence of the death of his friend. It was remarkable that he was able to use Mr. Y's example in an adequate and structural way after Mr. Y's death. Mr. X's psychotherapist encouraged him to optimally use the positive impact of Mr. Y's features and attitude and to also work it out in psychotherapeutic sessions. Mr. Y was the mirror in which Mr. X saw his own limitation. In this way he became motivated to lastingly change his behavior and attitude, while he borrowed and experimented with the characteristics of Mr. Y. Aggressive impulses were transformed in a creative basis that was required for stable, gentle behavior. When he was irritated or provoked by a fellow patient, he realized more and more that subtle reactions were much more effective and satisfying than brutal ones. Furthermore, this new attitude also increased his self-esteem and cognitive and social-emotional capacities.

Mr. X found the support of the psychotherapist a great help in his battle to become a more desirable person, and after 3 years of intense psychodynamic psychotherapy he was ready to finish forensic psychiatric treatment. He demonstrated an impressive growth of self-knowledge, social-emotional, and moral capacities, and he discovered the soft, subtle, and mild side of himself. Mr. X has been free for 24 years and has never re-offended. He has been happily married for many years.

Case Report 2

Mr. A was sentenced to prison because of criminally fraudulent activities such as deceitful bank transactions and forgery. He suffered from DSM-III Antisocial Personality Disorder, neurobiological determined impulsivity, and social-emotional incapacities, which might be related to long-lasting aversive experiences and injuries (head injuries and emotional trauma) as a soldier in battle situations during World War II in Korea and Algeria. As a veteran, he was unable to adjust socially, adhere to a normal daily routine (he found life in normal society boring), hold a job, and form relationships. As a result of his civilian and enlisted duties related to the outbreak of World War II, he was unable to finish grammar school. He was frustrated because the only jobs available to him were far below his capacities, because he had been unable to complete his education. Furthermore, he had continuing financial problems because he was incapable of controlling his expenses adequately. He began participating in fraudulent activities as a consequence of his thrill-seeking tendencies, lack of impulse control, lack of fear, recklessness, and intense need to impress other people by means of expensive clothes, cars, and so on. While in prison, he responded to a relationship announcement and began corresponding with an intelligent and wealthy female psychotherapist. They became good friends and lovers, and they married in prison. Mr. A was allowed (as a result of good behavior) to spend the weekends in the nice country house of his wife. Through his wife he came in contact with well-educated people who had a positive impact on his development, and in this setting his sense of authenticity could flourish. He discovered new dimensions of his self. He learned very quickly to discuss topics with his wife and her guests on their level, and he incorporated elements of their habits, gestures, and erudite lifestyles that were attractive and appropriate to him. His wife guided him through this process. He distanced himself more and more from his old attitude. He was soon motivated to finish grammar school, and he then graduated with honors from a university with a law degree. Mr. A became a very talented lawyer and also became very famous as an attorney of prominent white-collar criminal offenders.

Effective Components of Introjective Identification Therapy

The effective components of Introjective Identification are as follows: self-investigation and an increase of self-knowledge; social comparison and correction of self-concept and self; profound cognitive and empathic examination of another human being; conscious rejection of undesirable features; constructive self-enhancement activities; an increase of authenticity, well-being, and happiness as a consequence of self-chosen and self-realized positive change; and an increase of self-esteem and self-respect. Imaginary evaluation, connectedness, and interactions with the idealized person are essential parts of Introjective Identification Therapy, because these are the only ways to examine the internal world of, and to create a bond with, the idealized person. In addition, this might bring the idealized individual to life in the patient's fantasy and own internal world.

Discussion

Identification process is necessary for preparation for many significant human activities such as attachment, empathy, social-emotional and moral development, and social interactions and adjustment. Introjective Identification Therapy is intended as an additional component that could be used in combination with other psychotherapeutic, neurologic, and psychosocial treatment methods and psychological training programs. The correction of self-concept, the stimulation of increased self-knowledge and self-esteem/ respect, the growth of social-emotional and moral capacities and of spiritual activities, the gradual increase of responsibilities, and the training of pro-social coping skills might be significant and indispensable additional issues that should be realized in this approach and other therapeutic approaches that are combined with IIT. These are significant correlates of improvement and remission in persons with Antisocial Personality Disorder (Black et al., 1995; Martens, 1997; Robins, 1966).

It is also important to investigate how Introjective Identification Therapy can be combined in an effective way with other therapeutic approaches, and which combinations of approaches are most suitable in distinctive situations (dependent upon co-morbidity, etiological factors, and so on). The author believes that all kinds of psychotherapies can be paired with Introjective Identification Therapy. The combination can be realized by means of inclusion of IIT as an extra module in an existing therapeutic method, and the therapist can decide on basis of motivation of the patient, the nature of the patient's suffering, and his or her etiology and therapeutic progress if, when, and how the IIT-module can be used. When Positive Identification Therapy as a separated discipline is combined with other therapies, it requires the cooperation of two or more therapists who will discuss at which stage of the main therapy it might be effective to begin and terminate Introjective Identification Therapy. In fact, different cooperation techniques have developed over the years in other treatment programs, and special training programs exist to teach these techniques. These techniques can be employed in the context of uniting of IIT with other therapies (see Henggeler, Schoenwald, Borduin, Rowlan, & Cunningham, 1998).

It is time to initiate empirical studies to test current theoretical explanations. Cultural, religious, genetic, and neurobiological correlates of the identification process are also not yet studied. Cultural and religious values, cultural and religious institutions, and culture itself is interwoven with our life, and cultural context plays an important role in the development of individual social and behavioral characteristics and peer relationships. Specifically, cultural and religious norms and values may serve as a basis for the interpretation of particular behaviors (aggression, sociability) and for the judgment about the appropriateness of these behaviors (Martens, 2005b). The consequence is that our identification processes in an indirect manner might be determined by cultural and religious influences. However, some personality traits (impulsivity, criminality, aggression or hostility, lack of empathy, and lack of social adjustment or understanding), tendencies, social-emotional and moral (dys)functions, and social perception/interaction capacities have significant neurobiological and genetic correlates and might also have indirect impacts on our identification processes. These cultural, religious, genetic, and neurobiological correlates of the identification process should be examined profoundly, because increasing our knowledge about these influences can be used for more adequate treatment and assessment programs and explanation models.

POST CE TEST QUESTIONS

1. Which of the current treatment approaches are most effective for persons with Antisocial Personality Disorder?

a) cognitive behavior therapy

b) psychodynamic therapy

c) therapeutic community treatment

d) combination of psychopharmacological, neurofeedback, psychotherapeutic treatment, and psychosocial guidance

2. True or false: Lacan introduced the significant concept of self that relies on one's (mis-) identification with the image of another.

a) True

b) False

3. True or false: According to Kernberg's theories of introjection, images are so important because it is necessary to realize the interaction with the outside world.

a) True

b) False

4. Introjective Identification Therapy is a therapeutic approach that is mainly focused on systematic and strategic:

a) increase of socially desirable character

b) decrease of criminal tendencies

c) increase of capacities of social interaction

5. Psychotic and traumatic patients should be excluded from IIT because lack of reality testing and lack of tranquility will lead to:

a) lack of therapeutic motivation

b) self-destructive intentions

c) complication and interference with therapeutic process

6. True or false: Therapeutic correction of language use and exact grammatical formulation in the therapeutic process of IIT especially is important because these careful linguistic activities should provide an exact line-up and structure for mental and emotional forces/activities that are required for introjective identification and the transformation process.

a) True

b) False

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Selection of Patients for Introjective Identification Theory

Adequate motivation; a minimum of intelligence and cognitive abilities; sufficient character strength and flexibility (is necessary to include representations of the idealized persons in his/ her own character without losing his/her own authentic core cohesion; capability to (or able to learn how) cooperate with the therapist; patient must demonstrate deviant characteristic that could be improved by IIT (for instance, persons who developed a personality disorder as a consequence of aversive environmental and psychosocial influences of parents, peers, and neighborhood).

Severe traumatic experiences that are linked to antisocial personality disorder (see Martens, 2005a) and patients with co-morbid psychotic disorders and bipolar disorders should be excluded from Introjective Identification Therapy because these patients demonstrate a lack of reality testing (psychotic and bipolar patients) and lack of internal/external tranquility, too much confusion that might complicate or interfere with Introjective Identification Therapy.

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Willem Martens, MD, PhD, is chair of the W. Kahn Institute of Theoretical Psychiatry and Neuroscience and is the advisor of psychiatry for the European Commission (Leonardo da Vinci) and Ministry of Education, Culture, and Science of the Netherlands. He is also a member of the Royal College of Psychiatrists--Philosophy Interest Group, UK.
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