Back to school…but is it time for a change?
Closet psychopaths often enter therapy with the express intention of psychologically tormenting the therapist; intent on complaining and pursuing compensation in court. Can therapists learn to spot clients with these tendencies and what can be done if one finds their way to your consulting room?
It is often assumed that people with psychopathic tendencies don’t seek professional help; their grandiose sense of self-importance, their lack of remorse or guilt and an inability to empathise, are generally seen as making them unlikely candidates for talking therapies. Or do they?… We have seen an increase in what can best be described as violent complaints against therapists, made by these sort of patients; the complainant seems determined to psychologically torture and ruin, at least professionally, their former therapist. There have been threats of physical violence and incidents of stalking and other harassment.
Based on her doctoral research, Kearns (2007; 2011) wrote about what Firman and Gila call ‘the Ahab complex’ which she related to the client who, due to the negative transference that can often result from real or perceived therapeutic failures or misattunement, will unconsciously and usually self-righteously seek to ‘destroy’ the therapist through making a complaint to their professional body. The clients whose complaints Kearns studied were seen to have been motivated by what Bollas (1987) called ‘loving hate”. Bollas used this term to describe how rage can be used to maintain an intimate connection with someone, while at the same time appearing to want to destroy that connection.
As a supervisor and consultant to colleagues who have had complaints made against them, Kearns became aware that in cases that don’t involve gross professional misconduct, complaints were usually made by clients who have left therapy in a state of dissatisfaction or of negative transference. Furthermore, although it is a notion unpopular in ‘humanistic’ circles, she came to believe that these are often clients who have, out of awareness, used their therapy not to move on but to enact revenge on figures from their past; to play out their unfinished business in the therapeutic encounter rather than to complete it.
Harris (1995) identified a trend in the US in the 1990s when he noticed that more and more complaints were being brought by former clients who were dissatisfied with the results of their treatment and believed that the therapist ‘mishandled’ their case (Harris 1995:249). Moreover he noticed that many of these types of complainants had formal diagnoses on the DSM Axis II and had been victims of serious trauma before coming into therapy, usually physical and sexual abuse.
Kearns (2007;2011) devised a research-based, diagnostic framework in order to help practitioners to identify clients who may potentially make a complaint [p. 48-51], highlighting the importance in the current climate for practitioners to learn to recognise these clients and to put facilitative contracts with the client and consultations with other professionals in place as soon as possible in the therapy. We want to stress that these types of complainants have very troubled and abusive histories and do not come into therapy with the conscious intention of attacking the therapist. However, the relational conditions of the therapy itself are likely to trigger off earlier relational states that cause the client to re-enact an earlier trauma by complaining about the therapist.
Through our experience of being part of a team defending practitioners of the psychological therapies against these violent complaints we have come to believe that it is possible that some of the complainants in these cases have entered therapy in order to torment the therapist and in the hope of being awarded compensation by their insurers. These people are what we call ‘closet psychopaths’.
 Axis II refers to Personality Disorders
A Case Study
The following case example is a work of fiction. Having said that, we are aware that there are undeniable similarities in human behaviour and experience so we want to make clear that anyone who thinks they recognise themselves in the story we have written is mistaken. We have deliberately written it to avoid the possibility of either the client or therapist being identified. We are reminded of Benjamin (1993) who, when writing about working with patients with certain passive-aggressive personality traits wrote, ‘I could give you examples, but I’m afraid to.’ In light of our concern for ourselves and others we have taken pains to show the flavour of a therapeutic relationship through inventing a story in order to illustrate and bring to life a certain phenomenon that we have seen emerging in clinical complaints.
Selena, an aspiring composer, sought therapy to help her with what she described in her assessment interview as ‘feeling blocked’. After several months of hearing about Selena’s increasing distress aroused by her apparent difficulty with staying focused on the task of composing, the therapist shared her thoughts about wondering if Selena suffered from ADHD. Selena seemed intrigued by that possibility and, not long after, began to report that she had always been an impulse buyer (a possible symptom of ADHD in adults that she could easily have picked up from a Google search).
This impulse buying soon became the focus of the therapy. The therapist recalls that her client’s entire presentation changed. Each week she would report more and more extravagant shopping sprees. The therapist became so concerned that she consulted with a psychiatrist colleague who suggested that the client might benefit from some form of stimulant medication. Reporting this back to the client had an extremely negative effect. The client was furious that her therapist discussed her with a psychiatrist. In hindsight we wonder if the client’s fury was not so much about being discussed with another professional but about being afraid of being found out.
After weeks of almost manic raging at the therapist Selena’s presentation changed again. She began to exhibit what is known as hyperfocus during her sessions. It can be said to be typical of adults with ADHD that they find it difficult to focus on things that are boring, whereas they often can exhibit an extreme ability to focus on things that they find stimulating. The focus can be so intense that they are able to ignore personal needs for sleep or food because they become so absorbed in the task. Selena’s enthusiasm for her newly-embraced diagnosis of ADHD was accompanied by an intense interest in aspects of her childhood. The therapist saw this as progress because, during the first six months of the treatment, Selena had been resistant to making links between the past and the present.
Now Selena wanted to almost meticulously and obsessively unpick the minutiae of her childhood experience. She would come to the session with a memory she wanted to explore and would want to explore it intensively. One such memory involved a family meal where she was admonished for fidgeting and playing with her food. She became intensely focused on the memory of the food – the grey colour of the meat, the horrible smell of cabbage, the peas that she would place on the perimeter of the plate, imagining they were Martians hunting food for the Earthlings they had captured.
Selena became so involved in remembering that she didn’t want the session to end, ignoring the therapist’s at first gentle reminders that the time was up. The therapist eventually became insistent that Selena needed to leave and handed her her coat and handbag. Selena began to scream. And scream. The therapist was in a bit of a bind as she had another client coming in 5 minutes. She had to think about how to gently eject Selena so that she could see her next client. She explained to Selena that someone was about to ring the doorbell but that she was willing to let Selena sit in her kitchen until she felt ready to drive home. From the kitchen there was a door to an alley and she told Selena she could leave by that route, rather than through the front door, which was adjacent to the consulting room. Selena calmed down and accepted her therapists’ offer to sit in the kitchen and left at some point during the next hour. This, and other choices made by the therapist when she felt caught in a bind, formed the basis of the client’s subsequent complaints.
Following this incident, the therapist’s supervision notes show that she was beginning to feel stalked. Selena had a rather distinctive car and the therapist kept seeing it parked in various places: her road, the car park at Sainsburys, in front of her church after the Sunday service. She remembered that when the client first came into therapy she thought she recognized her from somewhere but couldn’t place her. She let it go. Some years before the therapist had worked one day a week at an up-market health club. Her supervision notes she her discussing how, during one of Selena’s manic tirades she looked at the therapist and said, ‘Maybe I should re-join our gym.’
We will leave you to imagine the rest of this story and jump to the end, which is where we came in as solicitor and expert witness. The client made complaints to several professional bodies and the civil action that resulted from those complaints is ongoing. That isn’t strictly true, as this is a work of fiction, but the authors do know each other through working together on similar complaints.
What to do?
The term ‘psychopath’ usually conjures up an image of a serial killer, whereas the milder ‘sociopath’ may more redolent of con artists and other manipulators. Both of these terms suggest behaviour towards others that is either violent or violating.
Studies of full-blown psychopaths who have received group therapy in prison, found that they were more likely to re-offend and went about using the therapy to learn how to appear more empathic in order to get better at manipulating and deceiving others. What we call the ‘closet psychopath’ is not likely to commit a violent crime and end up in prison; they may well end up in a therapist’s waiting room though…
The following indicators of the potentially ‘violent’ complaint emerging from the therapy are adapted from the Interpersonal measure of Psychopathy (Kosson, D. S.) from an original scale developed by Kosson, Kirkhart, & Steuerwald (1993). We present them here so that professionals can be alert to the possibility that they might be working with a ‘closet psychopath’ and get the appropriate support.
What to do?
Anecdotally, we know from practitioners who have been pursued by closet psychopaths that their clients adjusted their symptoms and/or presenting problems according to the therapists’ clinical thinking. When working with a client who may fit the above descriptors, it may be advisable to keep your clinical thinking and theories about their history or diagnosis to yourself.
Tighten your boundaries, particularly around contact between sessions and self-disclosure. Keep careful, factual notes, particularly of your discussions with your supervisor.
These clients’ presentations appear to change over time and can be led by picking up subtle clues from the therapist’s facial expressions. One client said, ‘You think I’ve been sexually abused, don’t you?’, and soon developed horrific memories of having been abused, although she had come for help with a difficult work relationship. Over time the story of abuse became inconsistent and increasingly hard to believe. The therapist began to feel as though the client could read her mind. The client’s presentation became so complicated that the therapist was required to do a great deal of extra work, such as communicating with outside agencies, the GP and a psychiatrist. She soon felt overwhelmed and defeated. Onward referral did not solve the problem.
In fact, referring these clients to another therapist really is analogous to passing the proverbial hot potato: everybody gets burned. We know of a case where a complaint was made about the original therapist and the one to whom the troublesome client was referred. In our view, the fact that both of these complaints proceeded to adjudication is indicative of a flaw in the management of potentially vexatious complainants.
Press your professional organisations for support when you identify that you might be working with a ‘closet psychopath’. Current complaints procedures are in place to protect the public, not the therapist. We would like to see procedures put in place to support practitioners who are at risk of potentially vexatious clients before a complaint makes its way to one of the professional bodies or indeed the courts. We believe that a system that encourages practitioners to report, without prejudice, therapeutic relationships that are in danger of collapsing or that seem beyond their competence or comprehension could limit the number of complaints that get to the stage where lawyers and experts become involved.
This article has been written by Dr Anne Kearns, Psychotherapist and Julie Norris, Partner, Kingsley Napley LLP.
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