Sorgabberleythe Impact of Medicalization on Individuals

Home , Mad in America, Medicalization, The Protest Psychosis

A Thesis

entitled

The Impact of Medicalization on Individuals Labeled with Antisocial Personality

Disorder

Abberley E. Sorg

Submitted to the Graduate Faculty as partial fulfillment of the requirements for the

Master of Arts Degree in Sociology

______Patricia Case PhD, Committee Chair

______Barbara Coventry PhD, Committee Member

______Dwight Haase PhD, Committee Member

______Cyndee Gruden, PhD College of Graduate Studies

The University of Toledo

August 2019

This work is licensed under a Creative Commons Attribution-NonCommercial- NoDerivatives 4.0 International License. https://creativecommons.org/licenses/by-nc- nd/4.0/

An Abstract of

The Impact of Medicalization on Individuals Labeled with Antisocial Personality Disorder

Abberley E. Sorg

Submitted to the Graduate Faculty as partial fulfillment of the requirements for the Master of Arts Degree in Sociology

The University of Toledo August 2019

Though the literature surrounding antisocial personality disorder (and the associated label, psychopathy) is vast, there remains an almost total absence of the voices of people who have been assigned this label from the discussion. ASPD differs from the majority of medicalized diagnostic labels, in that patients who have been given this label are frequently framed as untreatable. The clinical pessimism surrounding this label has led some researchers to argue that the purpose of the ASPD label is not to provide patients with access to appropriate care, but rather to exclude them from treatment by flagging them as lost causes in their medical records. Utilizing a qualitative analysis of online posts written by individuals diagnosed with ASPD, this project seeks to provide a new perspective on the debate surrounding ASPD and medicalization - that of the patient diagnosed as antisocial. I explore how these patients engage with the medicalization of their social and emotional problems, their experiences with mental health service providers, and their critiques of how ASPD is viewed by those who have not been labeled with this disorder. I seek to understand if these individuals accept the clinical pessimism

iii associated with the medicalization of their problems, if they desire changes to how ASPD is viewed clinically, or if they reject ASPD as a flawed construct.

iv Table of Contents

Abstract iii

Table of Contents v

I. ASPD and Medicalization: The Problem 1

A. Research Questions 3

B. Theoretical Approach 4

C. Conclusion 7

II. Literature Review 9

A. Medicalization and the Creation of ASPD 10

B. Three Orientations Towards Patients Labeled as Antisocial 19

C. Approach One: Clinically Pessimistic Medicalization 20

D. Approach Two: Reformist Medicalization 23

E. Approach Three: Demedicalization 32

F. Critique of the Literature 37

G. Conclusion 44

III. Methodology and Data Collection 46

A. Data Collection 47

B. About This Sample 49

C. Further Sample Demographics 51

D. Conclusion 54

IV. Analysis and Discussion 56

A. An Antisocial Identity in Online Spaces 60

B. Antisocial Social Etiquette: Rules of Social Engagement within

v “ASPD Tumblr” 63

C. “Poserpaths” VS “Actual Antisocials:” The Boundaries of

“Antisocial Tumblr” 68

D. Medicalization and an Antisocial Identity 72

E. ASPD and Abuse: Experiences Prior to Diagnosis 79

F. After Diagnosis: The Effects of Being Labeled with ASPD on

Access to Mental Health Services 85

G. “Is ASPD Even a Real Disorder?”: Critiques of the ASPD

Construct 88

H. Conclusion 92

V. Conclusion: The Failures of “Fear-based Discourse” 93

A. Limitations of this Study 94

B. Directions for Future Research 95

C. Concluding Remarks 97

References 99

vi Chapter One

The Problem

1988; Gunn 1998; Bernstein 2015). This has led some to advocate for major reforms to how ASPD is approached by metal health service providers (Bernstein 2015). Others advocate for a kind of demedicalization, the retirement of the antisocial label in exchange for a new approach to patients with behavioral and emotional problems. Whether mental health service providers and researchers continue to approach ASPD through a lens of clinically pessimistic medicalization, reformist medicalization, or demedicalization, the outcome of this debate will have major impacts on those diagnosed with ASPD, and yet the experiences, opinions and priorities of the people who have been assigned these label are entirely absent from the discussion.

While individuals said to have ASPD or psychopathy are often portrayed in fiction, written about in popular psychology books like Kent A. Kiehl’s The Psychopath

Whisperer and Martha Stout’s The Sociopath Next Door, and are the subject of much debate across multiple academic disciplines and contexts, real life “antisocials” have been

1 denied a voice in this discussion. Some researchers even argue that the perspective of these individuals is fundamentally unknowable and incomprehensible to “normal” people. Robert Hare claims that “for those of us who have been successfully socialized, imagining the world as the psychopath experiences it is close to impossible” (1993:78).

Genre fiction, “true crime” media, self-help and pop-psychology books often present dubious information about ASPD and its associated conditions to a lay audience, which contributes to the alarmism and stigma surrounding this disorder. In academic circles, particularly among criminologists and psychiatrists, ASPD is often approached as a problem of morally deficient individuals rather than a socially constructed label which has developed under certain political, social and historical conditions. This disorder has historically been viewed by many researchers as being “constitutional,” or a product of genetic inheritance, a belief that persists among many (Hare 1993; Milton et. al 1998:16).

The primacy of the biomedical model in discourses around this disorder has contributed to an aggressive disavowal of efforts to better understand those labeled antisocial.

Some researchers dismiss the idea that there is any point at all to social scientists or others attempting to understand the causes of ASPD or the people who are said to

“have it.” Reid writes that this population is “qualitatively different from the rest of us. I care less and less about why they’re not the same... The enemy is at our door. Most of our energy must be diverted to immediate defense, not merely to studying his motivations”

(1998:115). Such arguments not only serve to obscure the humanity of individuals with

ASPD, but also are predicated on the assumption that social problems are caused by deviant individuals rather than structural inequalities. In fact, opponents to opinions like those expressed above by Reid have written at length on how ASPD and psychopathy

2 function on an ideological level to isolate the origins of social problems like crime and violence in pathological individuals, rather than approaching these problems as a result of flaws in our social system (Jalava et. al 2015; McCallum 2001).

Whether ASPD and psychopathy are being framed by biological essentialists as having their origins in an inherently evil set of genes, or critiqued by social constructivists as an ideologically motivated smokescreen calculated to create scapegoats for social problems that extend far beyond deviant individuals, what remains absent from this discussion is the voices of people who have been assigned this hotly contested construct This project seeks to correct this problem, by drawing into the discussion the writings of individuals diagnosed with ASPD, as well as some of their friends and allies.

In the following chapters, I engage in a content analysis of blog posts on ASPD written by a total of seventy-five individuals. These writings offer a firsthand perspective on what it is like to be assigned this highly stigmatized label. My goal is to provide insight into the ways in which those diagnosed with ASPD engage with the label they have been assigned.

Research Questions

The primary research question of this project is as follows:

Do individuals diagnosed with ASPD accept this diagnosis as a valid clinical construct? When they think about their diagnosis and how it influences the manner in which mental healthcare service providers interact with them, do they look at ASPD through the lens of clinically pessimistic medicalization, reformist medicalization, or demedicalization?

This project also seeks to answer the following research questions:

3 1. Online illness communities operate around a set of mutually agreed upon

set of social norms and rules (Gold 2001). What rules exist in online

antisocial communities, and how are they enforced?

2. How does being diagnosed with ASPD impact an individual's identity and

sense of self? How does interacting with others through an online illness

community influence that sense of identity?

3. What impact does being part of a social network of individuals with ASPD

have on the way these individuals think about the diagnosis that they have

been given, the context in which they received it, and interactions with

mental health service providers?

Theoretical Approach

Medicalization is the process through which problems which had previously been considered to be nonmedical in nature come under the purview of medical authorities

(Conrad 1992). When some aspect of our lives which previously caused problems for us, the people around us, or society at large, comes to be viewed as a medical disfunction, medicalization has taken place. For example, whereas drinking to excess was previously viewed as being indicative of bad character or moral failing, this problem has since been medicalized under the label of alcoholism. ASPD as it is now defined is the result of a long, often contentious, and far from complete attempt to reframe behaviors previously considered to be the result of personal “badness” as being instead the result of

“madness,” and therefore the business of psychiatric authorities (McCallum 2001). This project approaches ASPD (as well as psychopathy and related constructs) as a contested

4 product of the process of medicalization, and seeks to understand the impact that being labeled with this disorder has on the individuals to whom it is applied.

As Conrad (1992) notes, discourses on medicalization usually, but not always, approach diagnostic labels as being socially constructed. Social constructivism posits that even supposedly scientifically objective “facts” are informed, shaped, and given meaning by human subjectivities (Bhaskar). From among the varying positions held by social constructivists, I have specifically adopted a critical realist position. Lafrance and

McKenzie-Mohr (2013:134) write that critical realism “acknowledges the reality of a material world (a realist ontology) that provides the raw material from which we begin to construct our understandings, while also maintaining that our understandings are necessarily constructive and interpretive, mediated through discourse (a relativist epistemology).” This theoretical framework allows for the acknowledgement that while there may be genetic or other biological markers that can be associated at least some of the time with at least some of the people diagnosed with ASPD, the ways in which we construct the boundaries of the diagnosis, the moral weight which is assigned to this disorder, and how we regard those who are said to “have” it are all a product of a long and complex medicalizing discourse.

Likewise, it may also be true that people who have been diagnosed with ASPD may experience similar types of emotional and cognitive neurodivergence, as well as similar life experiences, but how this diagnostic label is constructed and to whom it is applied remains rooted in historical, cultural and social contexts. We should therefore be conscious of the fact that the label may be applied punitively, and that conscious or unconscious biases - including but not limited to class and racial biases - may influence

5 both the application of this diagnosis and accepted knowledge about the causes of the disorder and its assumed prognosis. This project is interested less in the genetic or biological “reality” of ASPD than in the process through which it has become medicalized and the effect that it has on the lives of those who receive this diagnosis.

The medicalization of socially problematic behavior or thought processes under the label of ASPD has differed from most other psychiatric labels in one key way; many mental health service providers consider the disorder to be untreatable (Frances and Ross

2001; Rice et al. 1992). This attitude is accompanied by extreme pessimism regarding the ability of patients diagnosed with ASPD to benefit from treatment. In the following chapters, I have dubbed this approached clinically pessimistic medicalization.

However, some researchers have sought to intervene against this pessimism, noting that not only is there little empirical proof that these patients do not benefit from treatment, but that past studies have demonstrated that even extremely troubled patients diagnosed with ASPD or assessed with psychopathy have shown improvement along a wide range of metrics (D’Silva et. al 2004; Salekin 2002). Others are actively working with antisocial and psychopathic patients, seeking out new forms of therapy tailored specifically to this population’s needs (Bernstein 2015; Chakhssi et. al 2014). These individuals don’t reject the concepts of ASPD or psychopathy, but seek to reform the pessimism with which these patients are regarded. A third approach seeks the demedicalization of ASPD, arguing that it lacks clinical utility, serving only to stigmatize the patient (Blackburn 1988; Cameron and Margaret 1951; Millon et al. 2003; Toch

1998).

6 Going forward, I utilize medicalization as a theoretical lens to analyze the literature on ASPD. This is done by breaking the discourses around this disorder, its treatability, and its validity as a diagnostic construct into three categories; clinically pessimistic medicalization, reformist medicalization, and demedicalization. In the analysis chapter, I convey the ways in which individuals diagnosed with ASPD grapple with how this disorder was constructed and how that process of medication effects their own lives, questions which they often address directly.

Conclusion

Our current definition of ASPD is the result of a long and frequently contentious process of medicalization. While it has been long-standing conventional wisdom that patients given this diagnosis neither desire nor benefit from psychiatric care, there have always been researchers who reject this position. In recent years, the opposition has gained a stronger voice, with some rejecting the abandonment by mental health service providers of patients deemed antisocial, while others argue that the concept of ASPD itself lacks clinical merit, and is therefore too profoundly flawed to be salvaged.

Absent from this debate has been the voices of those diagnosed with ASPD. This project’s goal is to provide an academically objective picture of this often misunderstood and highly stigmatized population, one which incorporates a subjective view of this disorder from the perspective of those who experience it. In the proceeding pages, I chart the process of medicalization that has brought us the definition of ASPD as it currently stands, as well as some of the controversies surrounding that definition. I then employ content analysis to explore blog posts made by individuals diagnosed with ASPD, to provide a clearer picture of how this diagnosis impacts their lives. In particular, I focus

7 on discussions relevant to the process of medicalization, seeking to better understand how these individuals interpret the context in which they received their diagnosis, the social impact of that diagnosis, and what areas of accepted knowledge about antisocials this population contests.

8 Chapter Two

Literature Review

The process through which many of the potentially socially harmful and self- destructive behaviors and emotional problems associated with antisocial personality disorder have come to be medicalized under said diagnostic label has been long and complex. Below, I explore the debate surrounding the appropriateness of medicalizing these behaviors, and specifically the impact that this process of medicalization has had on the individuals who have been labeled antisocial. Is the medicalization of deviant behavior under the label ASPD a barrier to patients receiving care, and if so, what are the wider societal implications of this situation?

I seek to find whether the medicalization of their problems has proven to be beneficial or harmful to the population labeled as antisocial. As the goal of this project is to better understand the impact that the ASPD construct has on individuals assigned this label by medical professionals, the following literature review explores how the behaviors and emotional problems associated with ASPD came to be viewed as a psychiatric disorder. Further, I breakdown the different orientations mental health specialists have taken to the medicalization of ASPD, and how these differing approaches influence patients’ access to care (both for ASPD itself as well as comorbid disorders such as depression and anxiety), the perceptions of the general population of individuals with this disorder, and the impact that being labeled with ASPD has on self-perception.

In arguing that ASPD is a social construct forged through a long and complex process of medicalization, it is not my intent to claim that it is not “real” in the sense that it does not impact those individuals whose emotional processes and social problems fit

9 within the constellation of symptoms that defines ASPD. As will be seen in the next chapter, individuals diagnosed with ASPD report unique problems and personality traits that do correspond to the diagnostic criteria for ASPD. Because many of these individuals consider this diagnostic label to be a useful tool in understanding themselves and in finding others who experience the world in a similar manner, they are resistant to claims that the disorder is conceptually illegitimate.

Medicalization and the Creation of ASPD

Medicalization is a sociological perspective that explores the process through which problems that had previously been considered the product of individual flaws, social deviance, or simply normal aspects of the human condition, come to be viewed as medical issues, usually under the label of “illness or disorder” (Conrad 1992). Once a problem has been medicalized, it falls under the authority of the medical community, which includes physicians and psychiatrists, among other medical professionals. Many critical theorists regard medicalization as a means of exercising social control over those who express socially deviant beliefs or engage in socially deviant behaviors; said theorists for these reasons regard medicalization with suspicion (Conrad 1992).

The process of medicalizing emotional problems and antisocial behaviors under the labels of “ASPD” and “psychopathy” has been long and contentious. Like many other psychiatric labels, what would come to be dubbed “antisocial personality disorder” has historically existed in a state of conceptual flux. ASPD is only the most recent in a chain of medicalized labels, beginning in the early 1800s, which have been used to describe troubled individuals regarded as emotionally abnormal and morally and behaviorally incorrigible, due to what is usually framed as some kind of mental disorder, brain

10 anomaly or neurological defect (McCallum 2001:28-29). The origins of the construct that came to be known as ASPD is widely credited to Philippe Pinel, a man often regarded as the founder of the field of psychiatry (Arrigo and Shipley 2001; Jalava et. al 2015:3). In

1801, Pinel coined the term “manie sans délire,” or “insanity without delirium,” to describe individuals who could not seem to control their impulses towards criminal, immoral or violent behavior, despite appearing to be otherwise rational. This marked the first steps toward medicalizing what had previously been regarded as moral failings, character flaws, or sinful actions.

As evident from many of the labels above, a common theme here is the perceived inability or unwillingness of individuals who fall within their purview to understand, internalize, or adhere to conventional moral norms. These individuals have long been regarded by psychiatric professionals as frustrating, in part because while it was felt that there was obviously something “the matter with them,” there was little consensus as to exactly what the problem was or how to address it (Cleckley 1950). This remains the state of affairs in regard to ASPD; while theories as to the “cause” of ASPD abound, people who have been assigned this label are often regarded lost causes. Some have even argued that the functional use of the ASPD label is to flag troublesome patients as untreatable (Blackburn 1988 and 2007; Glyn and Appleby 1988; Millon et al. 2003; Toch

1998). This project seeks in part to explore how prevailing attitudes about people with

ASPD within the psychiatric system impact those assigned this diagnosis.

ASPD was first introduced in the third edition of the Diagnostic and Statistical

Manual of Mental Disorders (DSM-III) in 1980, replacing the DSM-II’s label

“sociopathy,” which had come to be considered an outdated term (Blackburn 1998:51).

11 Prior to the introduction of ASPD, people with similar behavioral and emotional troubles had been assigned labels that include “moral imbecility,” “moral defective,”

“psychopathic personality,” and in the first edition of the DSM “sociopathic personality disturbance” (McCallum 2001:28-29). The modern definition of what was to eventually become known as ASPD, following certain revisions to the construct, was introduced in

1941 by Hervey Cleckley, under the label “psychopathy” (Cleckley 1950; Jalava et. al

2015).

Hervey Cleckley’s The Mask of Sanity: An Attempt to Clarify Some Issues About the So-Called Psychopathic Personality was the first major work to describe what would later come to be known as ASPD. First published in 1941, with an updated edition introduced in 1950, Cleckley (1950) argues that, for the good of society and the individuals in question, the psychiatric system must recognize and take charge of the population that he labels as psychopaths. Cleckley (1950:38) writes that members of this population often go under the radar because, unlike schizophrenics and other types of mentally ill people, their behavior is not overtly “mad.” However, Cleckley contends that a close study reveals that self-destructive and socially disruptive behavior plagues the lives of these individuals. This, he claims, is indicative that beneath the “mask of sanity” which psychopaths are able to present, they are in fact “seriously disabled” and incapable of “leading normal lives.” Cleckley’s work is considered the cornerstone of modern research on psychopathy and ASPD (Arrigo and Shipley 2001). It is a textbook example of the process of medicalization.

According to Cleckley, psychopaths suffer from a “loss of insight,” meaning that a such a patient has “absolutely no capacity to see himself as others see him.” The

12 practical result of this problem is that psychopaths are unable to understand how their actions impact other people and those people’s assessment of them, which also makes self-appraisal extremely difficult (Cleckley 1950:375). Among the other traits that

Cleckley attributes to the psychopaths under his study are truancy from school, an inability or unwillingness to hold a steady job, general lack of dependability, drunkenness, failing to repay borrowed money, petty theft from family members and stores, frequent and often puzzling dishonesty, a failure to alter behavior regardless of repercussions or punishment, and an intellectual awareness of the potential consequences of their actions but the absence of the emotional inhibitions to prevent actions that are foolish or harmful to themselves or others. The above had previously been considered

(and today often still are) to be the results of poor character, bad morals, sinful actions, or youthful indiscretions, but Cleckley sought to bring individuals who he perceived as engaging in these behaviors so frequently that they could be considered especially troubled/troubling under the control of the mental health system.

Cleckley (1950) presents the population that he labels as “psychopaths” as being both a major social problem and a threat to themselves. These individuals, though not considered insane according to the models of “nervous and mental” diseases of

Cleckley’s day, were by his estimation nonetheless, “dangerously disordered.” Therefore, he calls for a broadening of the psychiatric understanding of mental illness to include the population that falls under his definition of psychopathy, and for the “treatment and restriction” of this population to be put in the hands of the psychiatric system. Cleckley’s work reflects early efforts to medicalize the negative behaviors and emotional responses associated with what would later be termed ASPD. By framing people who fell within the

13 category of “psychopath” as mentally ill, of reduced capacity, and incapable of making responsible choices about their own lives, Cleckley sought to bring them under the governance of the mental health system, rather than their families, the community, the courts, or other mechanisms of social control.

In the decades that followed its introduction, Cleckley’s psychopathy construct diverged in two different directions. The majority of his core ideas were adopted by mainstream psychiatry and the DSM under a number of different labels, before eventually being dubbed “antisocial personality disorder” in the DSM-III. The DSM-III also reframed the diagnostic criteria for ASPD around behavioral traits rather than personality traits, as the “DMS Task Force felt that the clinical inferences necessary to determine the personality characteristics of a psychopath lowered the reliability of the diagnosis” (Arrigo and Shipley 2001:337).

In the other camp, criminal psychologist Robert Hare (1993) argues that the

DSM’s concept of ASPD is too broad to be of practical use. Hare champions his own psychopathy construct, which while inspired by some of Cleckley’s ideas, focuses strongly around added measures for criminality and has a very different orientation towards the population that falls within his definition of psychopathy than did Cleckley.

In the 1970s, Hare (1991) formulated his own conception of psychopathy by borrowing from the list of traits identified by Cleckley. While Cleckley viewed the DSM-II’s definition of ASPD as an acceptable adaption of his psychopathy construct, Hare considers ASPD as a poor translation with little practical utility (Blackburn 2007; Hare

1993).

14 Confusion about the distinction between psychopathy and ASPD arise because, though psychopathy as defined by Hare is not recognized by the DSM or any other major psychological authority as a clinical disorder, the term is often used as a synonym for

ASPD, in part because the first term is more widely recognized by the general population than the second. Further, “psychopathy” and “ASPD” are often used interchangeably, though they are distinct constructs measured via different assessment tools. Whereas

ASPD is diagnosed using the criteria provided in the DSM, one is accessed as psychopathic through Hare’s psychopathy checklist-revised (PCL-R). The conflation of these two concepts introduces a deal of confusion into the discussion (Hare 1996). The individuals in this sample often write of needing to navigate popular ideas about psychopathy, whether or not they have been assessed as psychopathic. The relationship between the two constructs and their origins are therefore worth teasing out.

Criminality was not considered a defining characteristic of Cleckley’s psychopathy construct (Cleckley 1950; Salekin 2002; Skeem and Cooke 2010), yet predicting criminal behavior is the raison d'être of the PCL-R. In Arrigo and Shipley

(2001) discussion of the “diagnostic confusion surrounding psychopathy,” they note that one major area of confusion is the shift towards defining psychopathy as synonymous with criminality. Cleckley’s “focus was not on [his patients’] criminal history. Indeed,

Cleckley recognized that many psychopaths never became involved with the criminal justice system” (Arrigo and Shipley 2001:327). Hare’s psychopathy construct (and to a lesser extent ASPD) focuses on criminality in a way that Checkley did not.

Skeem and Cooke (2010:432-434) argue further that the PCL-R lacks construct validity, in large part because it frames antisocial and criminal behavior as a component

15 rather than a correlate of psychopathy. The PCL-R uses two factor analysis, with Factor 1 measuring affective and emotional problems believed to be associated with psychopathy and Factor 2 measuring antisocial and criminal behavior (Hare 1991). Because individuals can be assessed as psychopathic based on a high enough score composed of any combination of traits from Factor 1 and Factor 2, the PCL-R may capture individuals with a history of criminal behavior who do not have the emotional and affective traits believed to be at the core of psychopathy, while also failing to capture those who have said emotional and affective problems but little to no history of overt antisocial or criminal behavior. For the above reasons, as well as because they argue that there are more reliable tools for predicting recidivism than the PCL-R, Skeem and Cooke

(2010:434) argue that the “process of understanding and appropriately diagnosing psychopathy must be separated from the enterprise of predicting violence.”

Though there are significant differences between ASPD and psychopathy as defined by Hare, many writers in and outside of academia frequently conflate the terms.

While most people who would be considered psychopaths by Hare’s checklist would also qualify for a diagnosis of ASPD, the vast majority of people with ASPD are not psychopaths (Kiehl 2014:49; Hare 1996:31; Niesten et al. 2015). However, because psychopathy can be understood as a severe form of ASPD, and because considerably more research has been done on the causes and treatability of psychopathy than ASPD, studies on psychopathy have been included in this project, though only a few of the individuals in the sample have been assessed as psychopathic.

More recently, the DSM-5 defines a personality disorder as “impairments in personality (self and interpersonal) functioning and the presence of pathological

16 personality traits” (American Psychiatric Association 2013). The diagnostic guidelines for ASPD requires that the patient demonstrates “significant impairments” in “personality functioning,” which includes both “personal functioning” and “interpersonal functioning.” Impairments in the first may include issues with identity, including

“egocentrism” and a sense of self-esteem that is contingent on “personal gain, power and pleasure,” as well as issues with “self-direction,” which can include a tendency to focus one’s goals exclusively on “personal gratification” without concern for maintaining

“lawful or culturally normative ethical behavior.” Problems with interpersonal functioning are divided into two categories, of which the patient must demonstrate at least one; a lack of empathy and remorse, or an “incapacity for mutually intimate relationships.” A diagnosis is also said to require certain “pathological personality traits,” which are broken down into two domains: “Antagonism” (subdivided into

“manipulativeness,” “deceitfulness,” “callousness,” and “hostility”) and “disinhibition”

(which includes “irresponsibility,” “risk-taking,” and “impulsivity”).

Additionally, to be diagnosed with ASPD, the DSM-5 (American Psychiatric

Association 2013) requires that the above behavioral problems be severe enough to cause considerable impairment in social functioning, and to be “relatively stable across time and consistent across situations.” If the behavioral problems are better understood as reflective of the patient’s age or social context then these guidelines indicate that the patient should not be diagnosed with ASPD. The patient must also be at least 18 years old to be diagnosed with ASPD.

17 While the DSM-5 seeks to provide a more specific and detailed criteria for what constitutes ASPD, the majority of individuals included in this study were diagnosed under the criteria provided in the DSM-4, which is as follows:

A. There is a pervasive pattern of disregard for and violation of the rights

of others occurring since age 15 years, as indicated by three (or more) of

the following:

1. Failure to conform to social norms with respect to lawful behaviors as

indicated by repeatedly performing acts that are grounds for arrest.

2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning

others for personal profit or pleasure.

3. Impulsivity or failure to plan ahead.

4. Irritability and aggressiveness, as indicated by repeated physical fights

or assaults.

5. Reckless disregard for safety of self or others.

6. Consistent irresponsibility, as indicated by repeated failure to sustain

consistent work behavior or honor financial obligations.

7. Lack of remorse, as indicated by being indifferent to or rationalizing

having hurt, mistreated, or stolen from another.

The above diagnostic criteria are products of long debate on the merits of medicalizing the traits commonly associated with ASPD, how to define what constitutes

ASPD, and what to do with patients who have been assigned this label. This debate has resulted in the emergence of three major approaches that clinicians and researchers apply to orientate themselves towards the population labeled as antisocial. I’ve labeled these

18 approaches “clinically pessimistic medicalization,” “reformist medicalization,” and

“demedicalization.”

The phrase “clinically pessimistic medicalization” is inspired by two articles on the clinical pessimism surrounding the treatment of individuals with ASPD (Bernstein

2015; Salekin 2002). These articles will be discussed in more length below. Clinically pessimistic medicalization takes the position that ASPD is a “real” psychiatric disorder, caused primarily by biological rather than social factors, and that diagnosing this condition is rightly under the purview of the psychiatric system. However, while mental health professionals who ascribe to the clinically pessimistic medicalization model consider it their role to define and diagnose ASPD, they generally view efforts to treat this disorder as futile.

On the other hand, the reformist medicalization perspective still considers ASPD to be a valid diagnosis but argues against the fatalism inherent in the clinically pessimistic medicalization model. The reformist medicalization position is generally more open to considering the role that social factors may have in the etiology of ASPD.

Researchers who fall under this theme are interested in exploring new treatments for

ASPD, such as cognitive behavioral therapy and schema therapy. Finally, the demedicalization perspective does not view ASPD as a valid diagnostic construct.

Researchers who fall under this category have many reasons for rejecting the validity or utility of ASPD, but they all argue that it should no longer be applied to patients. These three themes will be discussed in more length below.

Three Orientations Towards Patients Labeled as Antisocial

19 I’ve labeled this view that patients diagnosed with ASPD do not benefit from care

“clinically pessimistic medicalization.” Those who fall within the clinically pessimistic medicalization category view ASPD as a biological reality that is the psychiatrist’s job to define and diagnose. However, whereas medicalization usually results in the positioning of medical professionals as responsible for correcting the problem that has been identified as a medical condition through treatment, ASPD is atypical in that psychiatrists operating from the clinically pessimistic medicalization approach consider ASPD to be untreatable.

In fact, as we will see, most work on ASPD and psychopathy is concerned not with treatment options, but simply the identification and classification of individuals who fit within these labels. This creates an odd situation in which individuals who have been singled out as ill are offered few resources with which to manage their newly acquired diagnosis.

On the other hand, the reformist medicalization position entertains the possibility that ASPD is caused by a combination of biological and social factors, but still considers it to be a “real” disorder, one for which they seek to find new and more effective treatment approaches. Finally, demedicalization considers ASPD to be a severely flawed construct, arguing that it lacks conceptual validity, has no clinical utility, or that it is harmful either to patients or to our society. These three orientations are discussed in detail below.

Approach One: Clinically Pessimistic Medicalization

Clinically pessimistic medicalization is the position taken by researchers, such as those discussed in the studies below, who maintain that while it is right and correct for psychiatrists to define and diagnose ASPD and psychopathy, as these are psychiatric

20 disorders that fall within their field of expertise, the prospect of treating said disorders is often viewed pessimistically, framing these conditions as untreatable (Frances and Ross

2001; Hare 1996 and 2017; Rice et al. 1992). This perspective tends to also be rooted in biological determinism. While some researchers who operate within the clinically pessimistic medicalization framework allow that social factors can have some influence on the development of ASPD and the severity of the disorder, those who subscribe to the clinically pessimistic medicalization model privilege genetic and biological causes over social factors. These researchers maintain that the presence of ASPD (or the related disorder, psychopathy) can be observed via genetic testing, brain imaging technology or through other forms of biometrics (Kiehl 2006; Motzkin et al. 2011). Others who operate within this framework are not concerned by what “causes” ASPD or psychopathy, but simply in the control of those individuals labeled with said conditions, usually through incarceration or other punitive methods (Lykken 1998; Reid 1998).

Typically, at least when taken at face value, the purpose of medicalization is to bring individuals thought to have the newly constructed illness under the management of medical professionals. This usually involves medical professionals asserting that the solution to the newly medicalized patient’s condition lies in medical retreatments, be this through the use of medications, therapy, or direct interventions on the body; if an effective treatment has yet to be discovered, then there is simply a need for more research to solve the problem. Many have noted the orientation of mental health service providers towards patients with ASPD is far different than most other conditions; later in this chapter I will explore some of the theories as to why ASPD is approached so differently from most other conditions.

21 While there are a handful of other psychiatric disorders that mental health professionals view as extremely difficult to treat, ASPD and psychopathy are nearly unique in the degree of pessimism associated with even attempting to find treatment methods aiding these patients. For example, though Hare refers to psychopathy as both a

“clinical construct” (1996) and “personality disorder” (1993), he also states that the primary purpose of the PCL-R is to function as an assessment tool to predict criminal recidivism (Hare 1996). Whether the PCL-R is effective at predicting anything is a topic of debate for another time, but it is clear that Hare’s orientation is focused on defending society from a population he likens to "bloody-thirsty... intraspecies predators" rather than providing a clinical tool to aid in improving treatment options for those dubbed psychopaths (Hare 1996:26). The PCL-R was, from its inception, designed to predict which offenders were likely to return to prison; the first effort to test the PCL-R’s validity was launched in 1988, when Hare and his colleagues used the PCL-R to assess 231 offenders prior to their release from prison (Hare 1996). In an article published two decades ago, Hare stated unequivocally that there "is no known treatment for psychopathy,” and this is a position that he continues to maintain, writing recently "that there is no credible empirical evidence that 'anything works'" (Hare 1996; Hare 2017). As will be seen below, several existing studies dispute this claim.

Researchers focused on biometric means of identifying ASPD and psychopathy frequently claim that these disorders can be observed through brain scans. Kiehl et al.

(2001) compared inmates assessed via the PCL-R as psychopathic (n = 8) to non- psychopathic inmates (n = 8) and non-incarcerated volunteers (n = 8), the latter of which functioned as the control. The researchers utilized an MRI to view the brain activity of

22 the participants. The study found that, as compared to the incarcerated non-psychopaths and control participants, the incarcerated individuals assessed as psychopathic “use alternative neural systems to process affective stimuli,” a difference which they attribute to the emotional abnormalities said to be present in psychopaths (Kiehl et al. 2001:683).

A similar study conducted by Motzkin et al. (2011) also used MRI technology to produce images of the brains of inmates assessed as psychopathic with the PCL-R (n = 14) to non- psychopathic inmates (n = 13). This study found that psychopathic inmates show

“reduced prefrontal connectivity,” which the researchers conclude is “consistent with the longstanding psychological perspective that impaired decision making in psychopathy is due to deficient integration of affective information” (Motzkin et al. 2011:17355). Put more simply, these studies seem to indicate that the brains of individuals assessed as psychopathic have difficulty processing emotion or else process those emotions in a nontypical manner.

For a number of years, clinically pessimistic medicalization was the generally accepted status quo. However, this position has increasingly been challenged. Today, many clinicians are exploring new treatment approaches for patients with personality disorders, including ASPD. Others contend that ASPD is a flawed concept that should be rejected, due either to its historic failure to benefit patients or the wider social impact this construct has on our society. I explore these two alternative viewpoints below.

Approach Two: Reformist Medicalization

The reformist medicalization orientation is not hostile toward the psychiatric system as a whole, nor do they seek to redefine or retire ASPD as a diagnostic category, but rather believe that the pessimism surrounding this disorder is unwarranted.

23 Researchers and clinicians operating under this framework consider the conventional wisdom that there are no viable treatment options for ASPD and psychopathy to either be the product of misconceptions or a failure on the part of the psychiatric system to seek out answers. Studies produced through this lens tend to either critique flaws in past studies on the treatability of ASPD and psychopathy or to seek out new forms of treatment.

While Hare and his fellow travelers present those dubbed “psychopaths” to be first and foremost a threat to society, the researcher who originated the term

“psychopath” had a very different approach. When Cleckley (1950) introduced his psychopathy construct, he painted a picture of these individuals as victims of their own self-destructive natures, and therefore in need of intervention from the psychiatric system. In a massive study, Cleckley presents more than a dozen extensive case files formed through his interactions with patients he considered to be psychopathic.

The picture that Cleckley (1950:59-65) paints of a patient called Max, focuses on this individual’s supposed intellectual and emotional shallowness. In Cleckley’s estimation, Max was totally incapable of “taking even a slight interest in the tragedy or joy or striving of humanity as presented in serious literature or art.” Cleckley writes that

Max, in addition, is completely unable to understand why such things move others: “It is as though he were colorblind… to this aspect of human existence. It cannot be explained to him because there is nothing in his orbit of awareness that can bridge the gap with comparison… There is no way for him realize that he does not understand.” Despite these problems, Cleckley stresses that “Max seldom, if ever, tried to do anyone serious physical injury.” The profile seeks not to warn the reader that Max is a threat to “the rest of us,” as

24 many current writings on psychopathy do (Stout 2005) but to impress upon the reader that Max is not at fault for his behavior, but rather due to his impairment is too irresponsible to be allowed to have control over this own life.

Cleckley (1950:65) presents the typical psychopath not as a “violent or murderous person” but rather one whose “conflicts with the law… [are] usually in the role of petty bully, sharper [con artist], thief, and braggart.” They are, instead, simply impaired by an inability to learn from experience and a lack in the “fundamental responses and emotional susceptibility” that allow others to avoid such troubles (Cleckley 1950:104). At the root of Cleckley’s (1950:127-128) argument is that the people he dubs psychopaths should not be the business of the legal system. Because “they very seldom commit serious crimes” but rather are apt to be arrested “many times” for small matters until the “police and courts tire of them,” while in the meantime they “make a nuisance of themselves to the community as a whole and often tragically wreck the lives of those close to them” through their irresponsibility, Cleckley argues that it should be made easier to commit them for extended periods so they might be more “effectively controlled.”

Cleckley (1950:40-41) did not consider this population be in possession of moral culpability for their choices and behaviors, but rather as “incompetent,” likening them repeatedly to schizophrenics. He is strongly invested in expanding the medical model to encompass what he termed to be psychopaths, in large part as a justification for subjecting this population to involuntary institutionalization. Cleckley (1950:59) frames this population as victims of their own inability to make wise decisions on their own lives, resulting in the psychopath engaging in “conduct [that] not only bring trouble to others but almost as regularly to himself.” While later models of ASPD and psychopathy

25 seek to invoke fear, Cleckley’s arguments are in large part contingent on pity. With the exception of the small minority that he found to be legitimately dangerous, Cleckley

(1950:509) unequivocally rejects the idea that this population should be incarcerated within the prison system, arguing rather that it would be “more appropriate” to hold them in an “environment fundamentally medical.” Cleckley advocated that psychopaths be placed in the control of the mental health system for this reason.

All of this places Cleckley in the reformist position not in the sense that he is responding to current clinical pessimism about psychopathy and ASPD, but rather that his work was among the first organized efforts to shift individuals who engaged in chronic antisocial behavior from the control of the legal system to that of the psychiatric system. This did not by any means guarantee a better outcome or more humane treatment for individuals deemed to be psychopathic. Though Cleckley could offer no guaranteed treatment plans, he endorsed electric shock therapy and lobotomy as promising options.

He also argued that psychiatrists should be able to commit patients deemed to be psychopathic indefinitely, even if they had committed only petty crimes (1950:506).

In a meta-analysis project, D’Silva et. al (2004) surveyed existing studies on treatment outcomes for individuals assessed as psychopathic, a population that can be understood to be comprised of the most troubled segment of those with ASPD. D’Silva et. al (2004) found that overwhelmingly these studies were marred by methodological problems and poor research design. They cite major methodological issues among existing studies on the treatability of psychopathy, including vague outcome measurements, inadequate sample sizes and a frequent failure to utilize control groups.

For example, D’Silva et. al (2004) notes that one of the studies they reviewed did not

26 report on its original sample size, nor did it distinguish between individuals who completed the treatment program versus those who only attended a few sessions. It is therefore hazardous to draw too many conclusions from these studies. That said, the majority of studies reviewed by D’Silva et. al showed that at least some of the individuals in question did benefit from treatment. As is discussed later in this chapter, the above study also throws Rice et al. (1992)’s claims that treatment only makes psychopaths

“worse” into question.

Another review of studies on psychopathic patients finds the claim that these individuals do not benefit from treatment to be nothing more than “clinical lore” (Salekin

2002). Salekin (2002:79) writes that “it is a widely held belief that psychopathic individuals are extremely difficult to treat, if not immune to treatment. This therapeutic pessimism is pervasive and undermines motivation to search for effective modes of intervention for psychopathic individuals.” In his review of existing studies on treating patients assessed as psychopathic, Salekin (2002) found that the majority of treatment programs showed positive results, as measured along a number of metrics, including a reduction in legal troubles, reduced drug and alcohol usage, better social relationships, and an increased ability to understand and manage their own emotions.

Note that D’Silva (2004) and Salekin’s (2002) studies focus on treatment methods for patients assessed as being psychopathic, with individuals included in the studies being drawn primarily from incarcerated populations. Remember that it is commonly accepted that all psychopaths have ASPD, but that only a small minority of people diagnosed as antisocial are considered destructive enough to be accessed as psychopathic. Individuals evaluated with the PCL-R as psychopathic are by definition considered to be more

27 resistant to treatment interventions than those who “only” have ASPD, yet the above studies provide at least some evidence that it is possible to provide these individuals with the tools to improve their behavior.

As noted above, it is considered a truism that all psychopaths have ASPD but that only a small percentage of people with ASPD are psychopathic, so the patients discussed in D’Silva et. al (2004) and Salekin’s (2002) reviews constitute some of the most difficult patients within this population. What of non-forensic patients who are not psychopathic?

The current outlook on the general population of individuals labeled with ASPD is not much brighter than that towards those considered to be psychopathic. Clinical pessimism remains the order of the day, and there is little literature on potential clinical approaches to help people diagnosed with ASPD cope better with their problems. However, researchers from the reformist medicalization orientation have been working to challenge these views.

The majority of existing studies on ASPD and its treatment are geared towards the special challenges associated with managing patients in substance abuse programs who also have this disorder. Mulder et al. (1994) found that both men and women with ASPD show extremely high rates of drug and alcohol addiction, and that among women with

ASPD substance abuse rates are ten times higher than among the general population.

Addiction and other self-destructive behaviors are common among antisocials, as will be seen in the analysis section of this project, but resources tailored for people with ASPD are limited.

Despite the assertion of many mental health professionals that people with ASPD neither need nor utilize services, Mulder et al. (1994) found that these claims are not

28 supported by the evidence. According to their study, women with ASPD are considerably more likely to have depression and phobias than the general population, while both men and women with ASPD have heightened risks of suicide attempts. It was also reported by

Mulder et al. (1994) that half of the women in the sample diagnosed with ASPD reported lifelong drug and alcohol addiction, 36% had attempted suicide, and 68% reported that they think about killing themselves. Substance abuse numbers are lower among women with ASPD than among men with the disorder, but women labeled as antisocial are more likely to have suicidal ideation and to attempt suicide than are men with ASPD. In addition, Mulder et al. (1994) found that both men and women with ASPD are much more likely than the general population to utilize the mental health care system, both as in and out patients; men with ASPD are more than twice as likely to utilize outpatient mental healthcare than are men without ASPD (44% vs 19%), while women with ASPD are almost three times more likely to utilize outpatient care than women without ASPD

(73% vs 25%). These figures throw into suspicion the frequently repeated claims that people with this disorder only seek out care when forced to do so by family members or the courts. Though this data has been available for decades now, the myth that people with ASPD do not seek out treatment is still frequently repeated in the literature.

More recent research backs up Mulder et al.’s (1994) findings. In a study that draws on the National Comorbidity Survey, Goodwin and Hamilton (2003) found that

54% of respondents with ASPD have a comorbid anxiety disorder. Additionally, 21% of respondents with ASPD were found to also have PTSD, a rate that was more than three times higher than that of the general population. These numbers are astonishingly grim, and the figures on suicidal behavior are even more dire.

29 The myth that people with ASPD do not experience emotional distress also persists, and in particular the belief that this population rarely makes “legitimate” attempts at suicide. In reality, Mulder et al. (1994) found that compared to men without

ASPD, men diagnosed with ASPD were 12 times more likely to try to kill themselves; further, this only measures direct attempts at suicide, and does not account for deaths caused by substance abuse, risky behaviors, and other forms of self-destructive behavior that may be motivated by a desire to die. ASPD in and of itself may be a “risk factor for suicidal behavior” (Mulder et al. 1994). More recent research also found a link between the antisocial dimensions of psychopathy and suicidal behavior (Swogger et al. 2009).

Whereas less than 2% of the general population (those who have neither ASPD or an anxiety disorder) reported attempting suicide, 11% of individuals with ASPD but no anxiety disorder reported attempting suicide, while 29% of respondents with an anxiety disorder and ASPD say that they have tried to kill themselves, a figure that is 20% higher than the rate among individuals with an anxiety disorder but no ASPD.

In their study, Gullhaugen and Nøttestad (2016) review the case files of offenders with high PCL-R scores in an effort to better understand the relationship between psychopathy, trauma, and emotional suffering. They suggest that the pervasiveness of the belief that psychopaths do not feel emotional distress stems from the “intuitively appealing” notion that someone who does not express distress in a way that is easily understandable, comfortable to be around, or socially acceptable must not be feeling anything at all. This, in turn, feeds into the idea that these patients cannot be treated because there is nothing to treat, either in the sense that the patient does not feel themselves to be in need of treatment or that the patient is subhuman or otherwise lacking

30 in the capacity to benefit from care. Gullhaugen and Nøttestad (2016) conclude that

Cleckley’s (1950) assertion that psychopaths do not experience emotional distress is incongruent with the data even among some of the worst offenders, but that these individuals often express that distress via anger, in ways that are self-destructive or violent towards others.

“As health providers, it is deeply rooted in us that when someone expresses pain, we must help. This comes with the understanding that the effort will be appreciated. But what if pain is not clearly communicated... and if helping implies a risk?” (Gullhaugen and Nøttestad 2016:365). The crux of the argument is that it is easy - and even tempting - to overlook the reality of this distress when it is expressed in ways that are discomforting, frustrating, repellent or frightening, but nonetheless it is present, and the failure to recognize this distress has undermined the ability of mental health service providers to understand the challenges faced by this population and to create productive treatment strategies. Rather than attempting to cast moral judgements on patients labeled as psychopathic or antisocial, or continuing to debate the distinction between “bad” and

“mad,” Millon et al. (2003:38) advocates instead for clinicians to “understand the range of problems in the patient who comes or is sent to treatment because of the distress and disability of being, for example, too aggressive or too impulsive to be acceptable to society.”

In recent decades, many within the psychiatric system have begun to view the prognosis for people diagnosed with a personality disorder more optimistically. This is in part due to the development of new treatment measures, including the increasing use of medication to manage some of the symptoms associated with Borderline Personality

31 Disorder (Von Knorring and Ekselius, 1998). However, ASPD is still widely considered to be one of the most damaging and difficult to treat disorders (Rotgers et al, 2005).

Research on effective treatment programs for patients with ASPD has been scant, but among the limited number of studies carried out the results have been surprising positive, given the degree of clinical pessimism associated with this disorder.

Approach Three: Demedicalization

Conrad (1992:224) writes that “demedicalization refers to a problem that no longer retains its medical definition.” Researchers who take a demedicalization position towards ASPD and psychopathy reject these labels, arguing that they should be discarded. Studies that fall under this theme may argue that these labels lack conceptual validity. Some of the researchers within the demedicalization theme are not critical of the psychiatric system as a whole, but rather consider labels like ASPD as barriers to patients receiving care for their problems (Lewis and Appleby 1988) while others engage in wider critiques of medicalization and psychiatry. Still others engage not with the outcomes for patients labeled antisocial or psychopathic, but how the widespread acceptance of the concept of psychopathy affects our society (Jalava et al. 2015; McCallum 2001).

Studies that fall under a demedicalization perspective take a social constructivist position, arguing these disorders do not exist “a priori” but rather are socially created rather than discovered (Conrad 1992). These studies may take the position that the labels

ASPD and psychopathy constitute barriers to care for other, more valid psychiatric disorders, and should therefore be “retired,” as they may do harm to those to whom they have been assigned. (Lewis and Appleby 1988). Many in this camp have argued that this lack of interest in treatment options for people labeled as having ASPD is by design,

32 because ASPD is the label assigned to patients when mental health service providers no longer wish to deal with them (Lewis and Appleby 1988). Others argue that ASPD and psychopathy as concepts provide protective cover for reactionary ideas about the origins of criminality, including degeneracy theory and eugenics (Jalava et al. 2015).

Critiques of the clinical utility of this construct appeared almost immediately after

Cleckley in 1941 introduced his criteria for “psychopathy,” which would later form the basis for the current conceptualization of ASPD. Cruvant and Yochelson (1950) express the view that psychiatrists often hold inappropriately negative and pessimistic views towards patients labeled as psychopaths, which has a detrimental effect on the patient- doctor relationship. Other early critiques of the psychopathy construct argued that it constituted an effort to pathologize social deviance which are premised on the uncritical view of social deviance as “morally bad,” and amounted to “accusations rather than descriptions” of a clinical disorder (Cameron and Margaret 1951). Millon et al. (2003:19) argues that the above issue has yet to be addressed, writing that the psychiatric system must “progress beyond the perspective of moral and social judgements as a basis for clinic concepts.” Many critics within the field of psychiatry reject ASPD and its synonyms as poorly constructed concepts based largely on antidote, and are highly vulnerable to personal bias on the part of the clinician (Blackburn 1988; Millon et al.

2003; Toch 1998). For these researchers, ASPD and psychopathy should be demedicalized because they are flawed constructs that undermine the legitimacy of the field of psychiatry.

Blackburn (1988) considers psychopathy, ASPD, and its historical antecedents to constitute a “myth.” These labels are “fictions,” Blackburn (1988) writes, that attempt to

33 group together an otherwise heterogeneous population which share few commonalities aside from socially deviant behavior, and therefore the diagnosis lacks both descriptive and prescriptive validity. Rather, Blackburn (1988) argues that ASPD/psychopathy captures a wide variety of different personality disorders under a single, poorly constructed umbrella that lacks theoretical consistency or clinical utility. Further, because

ASPD/psychopathy are largely defined by past socially deviant behavior, they “cannot provide a point of reference for clinical intervention” (Blackburn 1988:512). Blackburn

(1988:512) writes therefore that these labels should be “discarded,” as ASPD and psychopathy constitute “little more than a moral judgement masquerading as a clinical diagnosis.”

Some researchers have gone so far as to argue that is it not by unconscious bias that the designation of antisocial often limits the access of patients to care, but that this effect is deliberate. Rotgers (2005) writes that the category of personality disorder originally functioned as a means of differentiating those who behaved in manners that were considered socially unacceptable but who were not seen as being amenable to treatment from mental health professionals. Many others agree with Rotgers.

In a vignette study, Lewis and Appleby (1988) found that when psychiatrists were provided with a fictional case history in which the patient was listed as having previously been given a diagnosis of “personality disorder” (non-specified), they expressed a far more negative outlook on the patient than when the patient was not labeled as having a personality disorder. Compared to the vignette in which the patient was not labeled as having a personality disorder, the patient who was labeled as disordered was seen as

“manipulative, difficult to manage, unlikely to arouse sympathy, annoying, not deserving

34 NHS resources… [they were viewed as] noncompliant, not accepting advice, and having a poor prognosis. They were more likely to be discharged from follow-up examination, and suicide attempts were seen as attention-seeking rather than genuine” (Lewis and

Appleby 1988:47). These results led Lewis and Appleby (1988) to conclude that

“personality disorder” is a “pejorative judgement rather than a clinical diagnosis.” They argue that the concept of “personality disorder” should therefore no longer be used.

Similarly, Toch (1998) writes that the definitions of ASPD and psychopathy been so subject to change overtime and so hotly debated because the resulting diagnoses are at their core only reflective of morals and class-biases of the researchers in question; because social mores shift overtime, the ways antisocial behavior is defined also changes.

Like many others, he argues that the “diagnosis [of ASPD] is no longer a clinical description, but instead becomes a prescriptive message to others” - a means of flagging the patient as hopelessly untreatable, difficult or dangerous (Toch 1998:145).

It has also been argued that ASPD functions to obscure the social causes of crime and another antisocial behavior by ascribing these actions to a set of pathological individuals. “Current concepts of ‘psychopathy’ and its synonyms represent attempts to attribute the harmful social rule-breaking to a particular type of person” (Blackburn

2002:50). Toch (1998:154) writes that in the 1990s there was a “political market” for a construct that that could claim to draw a clear dividing line between offenders and “the rest of us;” because psychopaths are by definition constructed as being untreatable and incapable of reform, the label “simplified” the debate about the criminal justice system and public safety. Going even further, Ramon (referenced by Manning 2005) argues that personality disorders such as ASPD exist conceptually as a “smokescreen” to justify the

35 detention of “difficult people.” McCallum (2001:28-29) makes a similar argument, writing that ASPD functions as a neat explanation for much larger social problems, one which focuses the fault on the individual:

The psychopath has become a household word because it retained the

status of both explanation and cause, its function that of maintaining a

class-based social order… In the end, the description of an antisocial

personality disorder is essentially that of a 'hoodlum from a poor and

disadvantaged family', a judgement arising from the customs and preludes

of a particular group from which psychiatrists are themselves drawn and

who therefore fail to see this incongruity.

Several researchers have expressed similar concerns that the concepts of ASPD and psychopathy are utilized to Other troubled individuals. Blackburn (2007:153) argues that the PCL-R discourages efforts to understand those labeled as psychopathic, beyond a

“failure to inhibit antisocial behavior.” This failure to examine the causes of these individuals’ problems leaves the system helpless to make any meaningful intervention.

Some have argued that ASPD and its associated concepts are closely linked, historically and ideologically, to degeneracy theory and eugenics. Jalava et al. (2015) argue that the idea of psychopathy is rooted in the same dubious assumptions as degeneracy theory. The authors also link the emergence of psychopathy as a topic of popular fascination with the widespread acceptance of regressive myths such as that of

“super predators.” The authors lay out how “modern psychopathy research and theory - the modern version of the born criminal theory - is in a number of ways logically dubious and contingent on more than a few cultural, moral and metaphysical assumptions” (Java

36 et al. 2015:8). Further, they write that the data supporting the idea of “the psychopath as a distinct, abnormal human type” is at best dubious, often the product of an effort to shape the data to fit the model rather than the other way around. “The resulting media/cultural/moral narrative of scientific triumph has prevailed because it is deeply satisfying on a number of levels,” but, Java et al. (2015:9) claim, is not rooted in facts.

Rather, this concept of psychopathy serves as a vehicle for ideologically fueled narratives about social decline (Java et al. 2015:94).

Blackburn (2007) argues that the ASPD construct exaggerates the differences between those dubbed antisocial from the rest of the population, while collapsing the differences between individuals thus labeled, a framework that strikes him as congruent with the shift away from rehabilitation and towards harsher criminal penalties that coincided with the introduction of ASPD in the DSM-3. Java et al. (2015:4) write that psychopathy is the “foundation story of modern biological criminology;” it is also, they continue, “a myth.”

We see this process at work in Martha Stout’s popular book, The Sociopath Next

Door. In this book, which has spawned dozens of similar works by a wide array of authors, Stout (2005:8) claims that 4% of the population are dangerous “sociopaths,” but that normal people can learn to recognize these threats. Java et al. (2015:7) writes that this type of fear mongering allows the average reader to take part in “amateur monstrology” by seeking to identify the psychopaths among us.

Those in the demedicalization camp have many reasons for rejecting the validity of ASPD as a diagnostic construct. Many of these researchers are not focused so much on the impact that being labeled antisocial or psychopathic has on the individuals in

37 question, but rather how our society is impacted by the widespread acceptance of these constructs. Others consider the label to be a flawed construct that, deliberately or unintentionally, results in patients being denied help with their mental health problems.

Critique of the Literature

Much but far from all the research that takes an overt clinically pessimistic medicalization approach is built around Hare’s psychopathy construct. When Cleckley

(1950:40-41) formulated his psychopathy construct, he did not consider this population to be in possession of moral culpability for their choices and behaviors, but rather as

“incompetent,” likening them repeatedly to schizophrenics. He was strongly invested in expanding the medical model to encompass what he termed to be psychopaths, in large part as a justification for subjecting this population to involuntary institutionalization.

Cleckley (1950:59) framed this population as victims of their own inability to make wise decisions on their own lives, resulting in the psychopath engaging in “conduct [that] not only brings trouble to others but almost as regularly to himself.” While later models of

ASPD and psychopathy seek to invoke fear, Cleckley’s arguments are in large part contingent on pity. Because they are not responsible enough to take care of themselves,

Cleckley argues that it should be made easier to commit this population for extended periods so they might be more “effectively controlled.” With the exception of the small minority that he found to be legitimately dangerous, Cleckley (1950:509) unequivocally rejects the idea that this population should be incarcerated within the prison system, arguing rather that it would be “more appropriate” to hold them in an “environment fundamentally medical.”

38 Cleckley’s rejection of the legal system as a viable answer to the problems these patients present is by no mean universal. Arguing that psychopaths do not benefit from treatment, Rice et. al (1992) cite their analysis of data gathered from a “therapeutic community” program for mentally disordered violent offenders that operated at the Social

Therapy Unit (STU) in Penetanguishene, Canada from 1968 to 1978. While Rice et. al

(1992) claim that this therapeutic program, which was billed as an “intensive therapeutic community,” was not considered unethical at the time it was conducted, they concede that by modern standards this program violated patients’ rights in multiple ways.

The sample reviewed by Rice et. al consisted of 176 male forensic patients who spent at least two years in the program. As a control, patients within the study were

“matched” to patients of a similar age and with a similar criminal history, who were given the standard treatments. This treatment program, which was referred to as “Defense

Disruptive Therapy,” included “nude marathon encounter sessions,” which entailed depriving groups of patients of all clothing and locking them together in a room for two week long stretches (D’Silva et al. 2004). Other aspects of the STU program included eighty hours of intensive mandatory therapy sessions a week and heavy use of psychotropic drugs, including LSD (Rice et al. 1992; D’Silva et al. 2004). Patients were assigned to this program without their consent and were not allowed to dropout without the approval of a panel of doctors, who permitted only patients they felt had successfully completed the program to withdraw (Rice et al. 1992).

While the data did show that among patients assessed as psychopathic, the recidivism rates were higher among those treated in the STU program as compared to the control, D’Silva et al. (2004) note that the extreme and abusive nature of this treatment

39 program makes efforts to generalize from the results highly suspect. The STU program is far from the treatment methodologies being attempted on antisocial and psychopathic patients today. Nonetheless, the above study is cited by Hare (1996), among others, in order to argue that research shows treatment can make psychopaths “worse.” It’s worth noting that an Ontario court recently found the “Defense Disruptive Therapy” utilized by the STU program constituted both physical and mental torture. Dr. Elliott Thompson

Barker, author of multiple academic articles on designing and implementing DDT, was named as a plaintiff in the lawsuit (McQuigge 2017).

On the other hand, D’Silva (2004) and Salekin’s (2002) studies on treatment methods for patients assessed as being psychopathic, with individuals included in the studies being drawn primarily from incarcerated populations, find that most programs were beneficial to at least some patients. Remember that it is commonly accepted that all psychopaths have ASPD, but that only a small minority of people diagnosed as antisocial are considered destructive enough to be assessed as psychopathic. Individuals evaluated with the PCL-R as psychopathic are by definition considered to be more resistant to treatment interventions than those who “only” have ASPD, yet D’Silva (2004) and

Salekin’s (2002) review of past studies supply evidence that it is possible to provide these individuals with the tools to improve their thought processes, emotional problems and negative behaviors.

Yakeley and William (2014:132-134) write that contrary to common belief, people with ASPD often do seek out psychiatric care, but that service providers are often

“demoralized by patients’ chaotic lifestyles, frequent substance misuse and the difficulties in engaging them in any treatments offered.” This has resulted in these

40 patients frequently being “rejected from services,” as well as a “fundamental reluctance among psychiatrists to conceptualize the disorder as an illness requiring treatment.” That this population struggles with profound mental health problems should be apparent, but the belief that they neither need nor want help persists.

Regardless of the prevailing wisdom, is an increasing body of research that suggests new therapeutic approaches which have yielded positive results in patients with

ASPD. Mindfulness training, Cognitive Behavioral Therapy, and contingency management skills are among some of the new approaches that seem to offer new hope

(Chakhssi 2014; D’Silva 2004; Haase 2009; Salekin 2002; Taylor 2009). Taylor

(2009:199) writes that “the evidence on psychological interventions for drug misuse indicates that people with antisocial personality disorder can benefit from treatment.

There was a particularly large effect found when using contingency management to treat drug misuse in people with antisocial personality disorder.” Taylor also found evidence of productive approaches to the treatment of comorbid depression and anxiety, though is more cautious here because this research is not as easily repeated as the studies on drug abuse.

It has been argued that treating comorbid disorders improves quality of life for people with ASPD and leaves them in a better position to manage the symptoms of their personality disorder, which is beneficial both to the patient and the people they interact with (Haase 2009; Taylor 2009). Taylor also found some evidence of effective treatment strategies in managing other symptoms and behaviors directly associated with ASPD.

The methods listed above, as well as group therapy focused around teaching social

41 norms, has shown some promise (Taylor 2009:203). Further research is clearly needed in this area, as with so many other questions surrounding this disorder.

While acknowledging that antisocial patients can be extremely challenging to work with, Bernstein (2015 n.p.) asks, “Could it be possible that the field has been engaging in a self-fulfilling prophecy, withholding treatments from psychopathic patients on the basis of a largely unsupported belief?” Bernstein (2015) explains that despite this growing openness to treatment strategies for patients with some other personality disorders, the outlook remains pessimistic for patients with ASPD, and especially for forensic patients who have also been assessed as psychopathic.

Bernstein (2015 n.p.) continues:

When I was a young psychologist in training, the prospect for treating

patients with personality disorders was decidedly pessimistic. I was told

that people with personality disorders had little motivation to change or

engage in therapy, because they weren’t suffering enough. According to

one of my professors, “They don’t suffer themselves, but they do make

other people suffer!” This view was so prevalent that many mental health

professionals didn’t want to work with patients with personality

disorders…

Fortunately, the view of the treatability of personality disorders has

changed dramatically over the past thirty years. Marsha Linehan was the

first to show that a specialized therapy, Dialectical Behavior Therapy,

could greatly reduce the risk of suicide and self-harm behaviors in patients

with Borderline Personality Disorder. Jeffrey Young introduced Schema

42 Therapy, which went a step further. Studies show that Schema Therapy,

which focuses on patients’ unmet emotional needs, reduces suicide risk

while also improving core symptoms such as identity confusion and

unstable relationships, and enhancing the quality of life in these

individuals. These and other specialized treatments have brought new

hope to people with personality disorders, who were often considered

untreatable, while changing attitudes for the better in those who work with

them.

Bernstein (2015) goes on to explain that despite this growing openness to treatment strategies for patients with some other personality disorders, the outlook remains pessimistic for patients with ASPD, and especially for forensic patients who have also been assessed as psychopathic. He attributes much of this pessimism to an uncritical acceptance of older studies, such as the one carried out at Social Therapy Unit in Penetanguishene, Canada, which was discussed above. Citing extreme violations of patient’s rights, including forcing patients who had not consented to treatment to go entirely naked for days on end, Bernstein writes that such a study would never get past an ethics review board today and therefore should be viewed critically.

Finally, while there is merit to the demedicalization camp’s arguments, there is one major flaw. Jalava et al.’s (2015) argument rejects ASPD and psychopathy as dubious social constructs but in doing so neither considers nor consults with those who have been given these labels. Though there are clear issues underlying how ASPD is conceptualized and applied, a question remains; Do these flaws mean that ASPD lacks utility for those who have been given the diagnosis? Though many have argued that

43 ASPD is often used as a pretext to deny treatment (Lewis and Appleby 1988; Blackburn

2007), it may be incorrect to reject the construct without giving serious consideration to the possibility that many people who have been diagnosed with ASPD, despite whatever shortcomings of the diagnostic construct, have similar problems which may be alleviated by access to resources tailored to this group’s needs.

While it is often claimed, beginning with Checkley (1950), that patients with

ASPD reject the idea that they need psychiatric care, the data collected for this project often counteracts that claim. To date, there seems to exist no work on how frequently people this disorder choose to seek out treatment, why they do so, and most importantly what they hope to get out of treatment. This project seeks to fill some of these gaps.

Conclusion

The history of ASPD has been defined by extreme clinical pessimism. Though in recent years the outlook for patients with BPD and other personality disorders has improved to a small degree among some mental health care professionals, negative attitudes toward patients labeled as having ASPD remain deeply rooted. The prevailing fatalistic attitudes about people diagnosed with ASPD or who received high scores on the

PCL-R negatively impact access to treatment programs and other forms of mental health care (D’Silva et. al 2004).

Disorder (Von Knorring and Ekselius 1998). However, ASPD is still widely considered

44 to be one of the most damaging and difficult to treat disorders (Rotgers et al., 2005). This leaves patients with ASPD with little support and few therapeutic options.

45 Chapter Three

Methodology and Data Collection

This study applies an online ethnographic approach to the analysis of blog posts by and about individuals labeled as antisocial, with the goal of achieving a clearer understanding of what being labeled with ASPD means to the individuals in question.

How does being labeled with ASPD impact these individuals’ self-perception, social interactions, and access to mental health services? Has the medicalization of their affective and behavioral problems under the label of ASPD benefited or harmed these individuals? Do they contest their ASPD diagnosis or accept it? Utilizing interview data and content analysis of data collected from a popular blogging platform, this project attempts to achieve a clearer picture of the experiences, priorities and service needs of individuals with this diagnosis.

The majority of the data analyzed in this project was collected from public posts made on tumblr.com, a popular social media platform. The study also includes one extensive email interview with an informant who has an ASPD diagnosis. Due to the extensiveness of this data, which consists of more than 50,000 words covering a wide range of topics related to living with an ASPD diagnosis, the themes analyzed in this project have been limited along the basis of the following two criteria. Firstly, this project focuses on conversations pertaining to the process through which these individuals found their personal problems medicalized under the label of ASPD, especially when these individuals’ descriptions of their experiences break from the accepted wisdom about people with ASPD. Secondly, I attempt to focus on issues relating to ASPD that are

46 important to the individuals in question, as evidenced by the frequency in which the topics in question are discussed within antisocial social circles.

Data Collection

The text analyzed in this study was gathered from the blogging site tumblr.com, and all content was posted publicly (meaning that anyone could read these posts). After posts superfluous to this study’s focus were discarded, the final data file added up to more than 50,000 words posted by a total of 75 individuals. The study also draws upon one extensive interview, which was conducted via several weeks of email exchanges.

The data set was gathered from pre-existing blog posts on tumblr.com. From among the total sample (N=75), this project prioritizes individuals who wrote of being formally diagnosed with ASPD (N=21), focusing most closely on their writings, though some bloggers who were self-diagnosed (N=4) were also included, as were a number of people who wrote about having ASPD but whose diagnosis status could not be determined (N=26). The sample also includes some individuals who wrote insightfully about ASPD and the challenges faced by people with this diagnosis, but who never explicitly claimed the label for themselves (N=11), as well as a pair of individuals whose diagnostic status is more complicated (N=2). It also includes a small number of individuals without ASPD who took part in conversations about this disorder as friends or allies of those with ASPD (N=11). Most of the individuals without ASPD wrote of having other mental illnesses, personality disorders or other forms of neurodivergence, such as borderline personality disorder, schizophrenia, or autism.

Most of the formally diagnosed individuals who are the primary focus of the following two chapters were located via snowball sampling. My primary informant,

47 “Regina,” put me in contact with a number of other bloggers who have been diagnosed with ASPD, and voluntarily vouched for me to these individuals. Regina expressed confidence from her own experience, both as someone who was diagnosed with ASPD and as someone who had interacted with many others with the same diagnosis, that these individuals were telling the truth about having been assessed as antisocial. This was important, because at the time that this data was collected, there was a great deal of conflict surrounding the topic of self-diagnosis, with many antisocial individuals regarding those who claimed to have ASPD without having received a formal diagnosis as being harmful to those who are “legitimately” antisocial.

Those individuals whom Regina directed me towards constituted the larger portion of what is considered to be “legitimate” “ASPD tumblr.” It is this core of about a dozen individuals, loosely associated with one another and each accepted by the others as

“authentically antisocial” that makes up the central focus of data analysis for this study. I located additional bloggers with ASPD by reading through the comments left on posts made by members of this original core of well-known ASPD bloggers. This second set of bloggers tended to be composed of individuals who were less likely to interact with other bloggers, and who also tended to write about ASPD less frequently than did the core sample group.

Additional bloggers with ASPD were located using tumblr’s tagging system.

When the author tags their post with a word or phrase this allows for other users to search these terms to locate posts on the topic in question. The primary use of tags is to generate traffic to the tagged content, as tagged posts will show up in a search of the words used in tags, and will also show up in the notifications of people who track that tag. This is to say

48 that tagging is generally a deliberate invitation for others to read and interact with the tagged term. The searched tags used in this study were “ASPD” and “antisocial personality disorder.” When a new blog uploaded a post tagged with these terms, the post was read to determine its relevance to this project, and either rejected or added to the data set. The archives of these blogs were then searched for the tags “ASPD” and “antisocial personality disorder,” using the format [blog-url].tumblr.com/tagged/[search term] as a means of locating older posts. The individuals located through the tagging system tended to be less socially involved in “ASPD tumblr,” and were less likely to engage with other bloggers’ content.

About This Sample

This study draws upon data collected from a total of 75 blogs and extensive email-based interviews with one informant. From the total sample of 75, 51 individuals claimed to have ASPD or another personality disorder with antisocial traits. Of these, 21 stated that they have been officially diagnosed by mental health professionals, while 4 individuals self-diagnosed themselves with ASPD. The diagnostic status of the remainder was not discussed by the individuals in question. While an effort was made to focus around individuals who claimed to have been officially diagnosed, the four self- diagnosed individuals were included in the sample on the basis of their having been accepted as “legitimately antisocial” by many officially diagnosed individuals.

The validity of self-diagnosis is a topic hotly debated among the primary network of bloggers with ASPD that is the focus of this study, with many who self-diagnose being criticized as “edgy” fakers who use their blogs as a “fake platform to spread misinformation about [ASPD] and how we experience things.” However, self-confessed

49 self-diagnosed individuals whose behavior is not considered obnoxious or potentially damaging to officially diagnosed individuals are generally ignored, if not accepted. The conflicted dynamic between individuals who have been officially diagnosed with ASPD and those who claim to self-diagnosed is often rooted in the claim that the latter do not really know what it is like to have this disorder, but are simply repeating stereotypes about antisocials.

The remaining 26 of the total of 51 individuals who wrote about having ASPD did not explicitly say whether they have an official diagnosis. The sample total also includes

11 individuals who wrote insightfully about ASPD and who interacted frequently with antisocial bloggers, but who could not be found to have stated outright that they have this disorder. While they wrote as though they have personal experience with what it is like to have ASPD, these individuals did not reference their status on their personal bios or in any of the posts returned by searching their tags for “ASPD” or “antisocial personality disorder.”

Also included in the sample is one person who wrote that he had been diagnosed with ASPD but was later told by a different doctor that this was a misdiagnosis, as well as an individual who has been diagnosed with a different personality disorder but who has avoided seeking an ASPD diagnosis, despite their concern that they may have it, due to anxiety about the stigma that comes with ASPD. Among allies and friends who were included in the sample, there were six individuals who apparently did not have any personality disorder and another five who wrote of having a personality disorder other than ASPD. These eleven bloggers without ASPD were included in the sample because

50 they often interact with antisocial bloggers and take part in discussions about public perceptions of people with ASPD.

Many of the individuals with ASPD in this sample also have been diagnosed with a second personality disorder. Narcissistic personality disorder was the most common co- occurring personality disorder, with at least half a dozen individuals writing that they have been diagnosed with both ASPD and NPD. A smaller number of people within the sample wrote of being diagnosed with ASPD as well as borderline personality disorder or histrionic personality disorder. It is possible that a larger portion of those within the sample who have been diagnosed with ASPD have other co-occurring personality disorders, but that they did not discuss additional diagnoses online or that the data collection method employed in this study, focused as it on posts specifically about ASPD, failed to note discussions of other personality disorders. The literature seems to indicate that it is fairly common for patients who have been labeled with a different personality disorder to later be given an ASPD diagnosis, and this was the experience reported by several people within the sample.

Further Sample Demographics

This study’s sample may differ in some considerable ways from the overall population diagnosed with ASPD. For a disorder that has been at the center of so much discussion, there is a remarkable lack of demographic research done on the antisocial population. However, we do have some data that can be compared to this study’s sample.

One unusual thing about the antisocial community on tumblr is that it appears to be comprised primarily of women, a surprising dynamic as ASPD is generally considered to be far more common among men. To what extent the gender discrepancy between

51 ASPD diagnoses is reflective of differing rates of prevalence among men and women and to what extent it is a result of gender bias and stereotypes among mental health professionals is a topic of ongoing debate (Ford and Widiger 1989).The lifetime prevalence of ASPD was found to be 4.2% among the male population, whereas 1.9% of women meet the criteria for ASPD (Mulder et al. 1994). If these figures are accurate, then this study’s sample gender ratio may differ considerably from the overall antisocial population, though due to incomplete demographic information it is difficult to say for certain.

Fifteen of the individuals with ASPD included in this study identified themselves as women in their posts or blog bio, whereas eight wrote of being men. Another two individuals identified as nonbinary transgender, meaning that they consider themselves to be neither men nor women. Additionally, the sample includes two transgender women and one transgender man. The remaining individuals did not provide information about their gender. If we assume the above ratio of fifteen women and eight men with ASPD to be reflective of the entire sample, then we can say that women outnumber men two to one in this sample. This is a reversal of the figures provided by Mulder et al. (1994), as noted in the above paragraph. However, there may be any number of reasons why women who post online about having ASPD may be more likely to divulge their gender identity than people of other genders. If we assume all of the individuals who did not write of being women or nonbinary to be men, that would leave us with fifteen women and thirty-five men, a figure that would suggest that men are over-represented in this sample when compared to the general antisocial population. While it is unlikely that all individuals

52 who did provide information on their gender are men, it is not possible to draw definitive conclusions about the gender composition of this sample.

While it is not possible to determine the genders of those individuals who did not disclose that information, the core social group that made up “Antisocial Tumblr” at the time when this data was collected was composed primarily of women. Within the sample, those who identified as women tended to be more likely to interact with other bloggers, to make longer and more personal posts, and to engage in complex discussions about ASPD and both their personal experiences and their sense of how people with this diagnosis are perceived by society than did those who identified themselves as being men. Participation from those individuals who identified as men tended to be more reactive (responding to discussions rather than starting them themselves) and sporadic.

The age range of this sample appears to be roughly in line with the numbers recorded in Constill’s (2014) study on the user demographics of online blogging platforms such as tumblr.com, though again it was only possible to collect data on the ages of those individuals who disclosed their age. Most individuals in this sample who discussed their own ages wrote of being in their twenties or early thirties, though a few individuals are in their forties. Note that ASPD cannot be diagnosed in people under the age of 18. Though some minors self-diagnosis, claiming to have ASPD despite not meeting this aspect of the diagnostic criteria, individuals who gave any indication of not being legal adults were excluded from the sample, as were posts made by recent adults prior to their becoming 18 years of age.

In regards to ASPD and race and ethnicity, McGilloway et al. (2010) note that the

"existing data are sparse" but that their meta-analysis of all existing studies on personality

53 disorder diagnoses and ethnicity indicate that both personality disorders in general and

ASPD in particular tend to be diagnosed more frequently in Latinos, followed by whites, with black individuals being diagnosed least often. Establishing the racial demographics of this study’s population is a challenge. Because of the nature of online ethnography, the only information this study can draw on is that which is volunteered by bloggers, and so there is no way to establish the race of any given subject who does not discuss their heritage. Selfies (pictures of the blogger taken by the blogger) might provide clues as to the racial background of any given individual, but guessing race on the basis of photographs is a risky endeavor. Further, many tumblr users with ASPD have expressed a hesitancy to post pictures of themselves, out of concern that they might be identified by friends, family or co-workers.

The above said, it was possible to establish some information about the racial/ethnic background of some of the individuals within this study. Among the 52 individuals included in this study who claimed to have ASPD or another personality disorder with antisocial traits, nine self-identified as white and two wrote of being Latino.

Additionally, two bloggers wrote of being Catholic, while two are Jewish and one is a

Buddhist. So far as could be ascertained, none of the ASPD bloggers wrote about being

Black.

Conclusion

Online ethnography comes with both strengths and weaknesses. Because online ethnography is largely dependent upon information volunteered by the subjects (who we must trust are being honest about their backgrounds) independent of requests by the researcher, the ability to gather demographic information is limited. Additionally, the

54 nature of utilizing content analysis means that the study’s scope must be limited to what the individuals in the sample have already opted to discuss, rather than whatever research questions we might like to ask them. However, this latter point can also be a strength; because the study is limited to the topics that the sample population discuss without prompting, we can be sure that those issues are of importance to them. Because there is so little data that looks at ASPD from the perspective of the individuals with that diagnosis, this methodology provides a new lens through which to approach the topic.

Additionally, using the internet to gather data helped to ensure the anonymity of respondents while allowing for engagement with a wide range of people from different localities and backgrounds. This also provided the opportunity to explore how the internet can serve as a tool for people who are part of highly stigmatized groups to talk about their experiences and problems. In the next chapter, I provide an analysis of discussions about what it is like to be diagnosed with ASPD from the point of view of those who have had this experience, and how that diagnosis affects their self-perception, social lives, and access to care. Exploring these questions from the perspective of those labeled with ASPD allows a clearer understanding of the impact of medicalizing the problems these individuals experience.

55 Chapter Four

Analysis and Discussion

One of the unique strengths of online content analysis is that this methodology makes it possible to observe individuals discussing issues pertaining to their own situations and experiences candidly, without any influence from clinicians or researchers.

Blogs also offer the opportunity to see groups of individuals engaging directly with what others have said about people like themselves, in both the academic literature and lay sources. As with other online disability communities, individuals who have been diagnosed with antisocial personality disorder often discuss amongst themselves (as well as friends and allies who do not share the same diagnosis), for an audience of readers, what it is like to be labeled with this disorder, their experiences within the mental health system, and their opinions on how ASPD is constructed, applied and viewed by society.

In the course of gathering data for this study, discussions about medicalization and the social construction of ASPD often took place. While a small number of individuals rejected the legitimacy of ASPD as a diagnostic label, views that corresponded with the demedicalization framework, and some others accepted the clinically pessimistic position common among mental health service providers, the view expressed by most individuals with an ASPD diagnosis lined up with the reformist medicalization position discussed in earlier chapters. This is to say that the majority of individuals with ASPD in this sample agree that they have emotional and social problems that cause them to think, say and do things that make their own lives and often the lives of people they come into contact with difficult, and that these problems can be summed up under the label of “ASPD,” but also expressing frustration with the negative

56 assumptions most people make about individuals with ASPD, and in particular the clinical pessimism and unwillingness to work with them that these individuals often encounter from mental health service providers.

The exchange below exemplifies the ways in which the individuals in this sample sometimes interacted directly with the literature surrounding ASPD and psychopathy.

When one individual posted a quote about psychopathy and social stigma written by Irit

Shimrat, a critic of the medicalization of deviance and a prominent theorist and activist in the Mad Rights Movement, responses were mixed. The quote, the original source of which I was able to locate via google books, reads as follows:

Being told that you’re bad can make you more likely to do bad things.

Say, for instance, that you have been labeled a psychopath. You are told

that unlike other so-called mental illnesses, yours is not only incurable but

untreatable. It is drummed into you that you have no conscience. Everyone

expects you to behave badly, looks at you like some kind of monster, and

misinterprets everything you do. What effect will this have on your

behavior? (Shimrat 1997:166).

Whereas Camila (all names are pseudonyms), an individual with borderline personality disorder, who is friendly with many of the antisocial bloggers, responded to this quote with “wholehearted agreement,” individuals with ASPD were more mixed in their evaluations of Shimrat’s argument. Camila wrote that the experience of “being told there’s something wrong with you without being given help in figuring out what or how to fix it” was emotionally damaging to her. Further, she writes that she knows other people diagnosed with BPD who found the stigma surrounding the disorder to be

57 traumatizing, and that since she has stopped “fighting to appear normal,” she has been able to find better ways to cope with life. Camila says that in her experience the borderlines who have the most trouble are those who view themselves as “inherently broken,” whereas those who have found ways to “accept themselves” and focus on the positive aspects of having BPD are often happier and more emotionally healthy.

On the other hand, the two individuals with ASPD who engaged with this

Shimrat’s quote were critical. Flynt, who has ASPD and self-identities as a psychopath, takes a biological essentialist view on psychopathy, arguing that it is just “a new word” for what certain individuals already are. However, he also acknowledges that discrimination against people labeled with this disorder is real, and that he hides his diagnosis in order to avoid mistreatment. He believes that it is “stupid” to allow stigma against your disorder to influence your behavior, because breaking society’s rules results in a lack of access to privileges; however, were he to be denied those privileges solely on the basis of his labels rather than his behavior, he allows that he would not work nearly as hard to adhere to social norms that he “didn’t like.” He rejects the idea that there are people who are inherently good or bad, and encourages others to think critically before they judge others.

Bianca, who has been diagnosed with ASPD, writes that Shimrat is “not entirely wrong,” but appears to find the argument condescending, adding that it is also

“annoying.” Among the individuals in this sample, Bianca is one of the most forceful adherents to the clinically pessimistic view of ASPD, frequently reiterated her belief that you must have been a bad person who has done bad things to be diagnosed with ASPD,

58 and that she and people such as herself have little ability or inclination to change their behavior, especially when antisocial behaviors do not result in punitive consequences.

The above is an example of some of the ways in which individuals labeled with

ASPD or similar disorders utilize the internet to engage with public, academic and clinical perceptions about people with their diagnosis. In this chapter, I explore how individuals diagnosed with ASPD frame their experiences with being assigned this label.

I begin with an overview of the online ASPD community constituted by the individuals in this sample, surveying how these individuals interact with each other and other online disability communities, how an antisocial identity is expressed online, and the roll that medicalization plays in validating that identity.

From there, I explore early experiences as reported by individuals diagnosed with

ASPD, with a focus on the problems experienced by the sample group prior to being labeled as antisocial, in particular with a focus on their understanding of the role that abuse did or did not play in their developing the emotional problems associated with this disorder. I then move to cover the context in which these individuals were diagnosed, and the impact receiving this diagnosis had on their access to mental health services, their social relationships, and self-perception. Finally, I examine emotional problems encountered by individuals within the sample, including low empathy, issues with anger and self-destructive behaviors. This includes a discussion on the approaches they use to attempt to manage these emotional and affective issues, including interactions with mental health service providers. Throughout, I seek to understand how these individuals engage with the medicalization of their problems - whether they accept the clinically

59 pessimistic model, desire reforms to how patients with ASPD are treated, or reject the validity of ASPD as a psychiatric construct.

An Antisocial Identity in Online Spaces

Zola (1993) writes that social scientists have long recognized that the labels that we use to refer to ourselves or that others apply to us have personal and political ramifications. For this reason, the use of identity labels in relationship to disability has been a topic of great debate. Among the individuals within this study’s sample, there is a range of different opinions about which labels should be used in relationship to people with ASPD.

In discourses surrounding disability, there continues a decades-old debate about the merits of “person-first” versus “disability-first” language. Supporters of person-first phraseology tend to claim that the framing “person with X disability” focuses the discussion around the total person rather than the disability, which is favored by people from this viewpoint because they argue that disability constitutes only one facet of a whole individual. On the other hand, proponents of disability-first language argue that our disabilities are fundamental aspects of who we are, and that rather than erasing the personhood of disabled people, disability-first language stresses a collective political identity (Brickford 2004).

The person-first versus disability-first debate did not play a large role in discussions I observed regarding ASPD specifically. At first glance, this may simply be a question of linguistic pragmatics. Unlike, for example, words like “autistic” or “blind,”

“ASPD” does not lend itself well to being used as a noun. As one individual noted,

“ASPDer” and similar formations are linguistically awkward.

60 A few individuals within this sample utilized the terms “sociopath” or

“psychopath” as identity labels. “Sociopath” is a dated label that has long been retired by the psychiatric system, and “psychopath” is most frequently used in association with the

Hare Psychopathy Checklist-Revised, which uses an assessment criteria that differs in fundamental ways from the diagnostic criteria for ASPD. Due to the tendency of both these terms to be used pejoratively in the media and popular culture, well-intentioned

“allies” repeatedly reached the conclusion that “sociopath” and “psychopath” were slurs.

This idea was rejected, often forcefully, by individuals diagnosed with ASPD.

Pamela, who has been diagnosed with ASPD and BPD, as well as being clinically assessed as psychopathic, views “psychopath” as an important identity label, one that has helped her to understand herself. “The word [psychopath] sums up my goddamn existence... Studies have shown over and over again a distinct difference in the neurophysiology of psychopaths when compared to neurotypicals or even vanilla ASPD individuals. To disrespect the word by cheapening it is to disrespect me.” Pamela’s understanding of her neurotype is strongly rooted in the prevailing beliefs of forensic neurologists. She has expressed the view that “psychopathy is a real and distinct disorder,” and recommends the works of Hare, Kiehl and Fallon to those who have argued that the term is problematic or meaningless. Her writings reflect the conservative end of the reformist medicalization prospective.

Willow, who has been diagnosed with ASPD and bipolar disorder, is on the other end of the spectrum. She seeks to distance herself not only from terms like “psychopath” and “sociopath,” but from her other diagnoses as well, as she feels these labels were assigned to her without her consent and have only caused her harm. Therefore, Willow

61 writes, she identities as “crazy.” She believes that, in her case at least, the more specific labels have been pointless, because they are “stigmatized to hell,” resulting in her being denied effective care by mental health service providers. Often expressing interest in the social construction of mental illness, Willow falls closer to the demedicalization perspective.

In the middle ground on the “slur” debate, Regina, who has been diagnosed with

ASPD and NPD, takes issue with the claim that these words are slurs on the grounds that they do not carry enough weight to be considered as such. While she considers it

“annoying and inaccurate” that “sociopath” has become a “pop word for ‘bad person’” this does not in of itself mean that the term constitutes a slur, as “it certainly doesn’t hold the same power or potential for harm as something like an actual racial slur.”

While there is some difference of opinion about whether these labels have been used to harm or dehumanize people with ASPD, individuals within this sample who have been diagnosed nearly universally reject the idea that “psychopath” and “sociopath” constitute “slurs.” This debate seems to be reflective of failed efforts at allyship by individuals who do not have ASPD and have failed to ask members of this population what sort of support - if any - they would find useful. The argument about psychopathy and sociopathy tend to get picked up by those who do not have ASPD but who sincerely wish to call attention to ableism. People with ASPD who have objected to the idea that these words are slurs are often attacked as being ableist against their own disorder, a frequent occurrence which is likely the cause of much of the frustration expressed by

Pamela and others.

62 While it is evident that “sociopath” and “psychopath” are sometimes used in a manner similar to slurs, in that they are applied to dehumanize people with ASPD by rendering them as nothing more than the dangerous Other, I have deferred to the position taken by the majority of the people in this sample and do not treat these terms as slurs.

However, because “sociopath” is out of date, I have refrained from using it. Likewise, because “psychopath” only applies to those who have been assessed as psychopathic.

Following the lead of some of the individuals in the sample, I have opted to use

“antisocial” as a shorthand for someone diagnosed as having ASPD.

Similar to the way many individuals labeled with BPD were observed to refer to themselves as “borderlines,” and how some who had been diagnosed with NPD employed the labels “narc” and “narcissist,” those within the sample group sometimes refer to themselves as “antisocials.” Deferring to those individuals, I have opted to use

“antisocial” as a convenient term to refer to this population. In other places, I use the phrases “labeled with ASPD” and “diagnosed with ASPD” to stress that the individuals in question were formally diagnosed with a socially constructed label, one which was created through the complicated process of medicalization discussed in the previous chapter.

Antisocial Social Etiquette: Rules of Social Engagement within “ASPD Tumblr”

The literature on the use of online spaces by disabled, mentally ill and neurodivergent people to build communities, provide mutual support, and engage in activism is extensive (Parsloe 2015; Huang and Guo 2005; Trevisan 2016; Gold 2001).

Gold (2001) writes that disabled people participate in online communities as a means of both circumventing the physical distance between community members, which might

63 otherwise be widely dispersed and therefore socially isolated, and as a means of setting the terms of the discussion about their disabilities and themselves. It is through these means that members create a space for stigmatized voices.

Because of the nature of internet exchanges, online disability communities exist under a “rules-based fragility,” in which interactions are framed within the context of what is considered socially acceptable or unacceptable within the group (Gold 2001). If the stability of online communities is dependent upon individuals’ willingness to conform to mutually agreed upon but rarely explicitly stated rules, what does this mean for a group of individuals whose disability is in large part defined by an inability or unwillingness to conform to social norms?

While the boundaries of socially acceptable behavior were in many ways looser than I have observed in other online disability circles, the antisocial community nonetheless operated under a clearly discernible set of rules and social norms. Some of said norms fell under the category of standard internet etiquette, while others seemed to be unique to this community. When violated, these rules were enforced through social sanctions, a topic to which I will return momentarily.

Social ties between individuals with ASPD often appeared tenuous, though it is possible that more personal interactions were taking place via private messages, email, or other forms of one-on-one communication. Though there were a couple of exceptions, exchanges between individuals with ASPD seemed to be motivated primarily by mutual curiosity. Often, these questions were inspired by one individual's desire to cross-check their own experiences with those of others diagnosed with ASPD, and to contrast any conclusions drawn from the conversation with conventional clinical wisdom about people

64 with this disorder. For example, when one person shared their own assessment of the relationship between childhood trauma and ASPD, it resulted in a long conversation involving multiple people labeled with ASPD sharing their own experiences of childhood abuse, information that they had gleaned from interactions with mental healthcare professionals, and their personal understanding of how those without ASPD - both lay people and researchers - view the links between abuse, genetics and ASPD. This conversation ended with participants noting that there seemed to be an obvious relationship between childhood abuse and neglect and ASPD, one that they argued is not taken seriously enough by mental health service providers.

The need for advice was also a major driver of discussions between individuals diagnosed with ASPD. One commonly recurring question within the antisocial community was whether one should disclose a previous ASPD diagnosis to a new therapist. Regina, who is diagnosed with ASPD and NPD, advised that her experience is that many service providers will refuse to see a patient whom they know has been diagnosed with ASPD, so it is better to wait until you have a relationship with the therapist before you tell them about your diagnosis. While this may cause the therapist to feel manipulated or to view you as deceptive, it was considered by some in the sample to be an effective means of bypassing barriers to care. Others offered the opinion that if you are attempting to obtain help with symptoms associated with ASPD, it is important to be upfront about having been given that diagnosis right away, whereas if you want help with depression, anxiety, or some other mental health issue not directly related to ASPD, it is better to wait to inform your therapist that you have previously been diagnosed with

ASPD, or even to avoid telling them at all.

65 As we see above, what is sometimes referred to as “ASPD tumblr” functions like many other online disability/illness communities. It provides a place for individuals to vent about their own experiences, share information, and exchange tips on how to manage symptoms and navigate interactions with service providers. To a lesser extent than many other similar online communities, it is also a place to make friends.

While many of the individuals in this sample who have been diagnosed with

ASPD did not seem to lack for friends, it is possibly significant that most of the overt friendship duos (i.e. pairs that were demonstratively warm with each other or who referred to one another as friends) observed within this sample consisted not of two individuals diagnosed with ASPD, but rather one antisocial individual and one individual with a different form of neurodivergence, often BPD and in at least one case schizophrenia. It may be that two antisocial friends express that friendship in ways that are not easily discernible by outsiders, which in the context of online friendship might simply mean communicating via private messaging. However, this may also reflect a preference among antisocials for friends who do not have ASPD.

Keegan, who was diagnosed with ASPD but who was later told by a new doctor that this diagnosis may have been incorrect, as well as other individuals diagnosed with

ASPD, expressed the desire for empathetic friends. Because ASPD is often associated with a limited ability to process emotional empathy, individuals who experience average or atypically high levels of empathy are sometimes viewed as being able to fill gaps in an antisocial’s understanding about social interaction. Such friends, one antisocial blogger explained, are ideally able to help to provide “perspective” and serve as a “moral compass” without passing judgment or “making a big deal about the stuff I think about.”

66 This type of friend is jokingly referred to as an “empet,” a combination of “empath” and

“pet,” and individuals in this sample reported strong possessive and protective feelings towards such friends.

While “Antisocial Tumblr” is more permissive of what would in other circles be considered unacceptable behavior, as stated above there are rules to interacting with this group, and those who violated them often faced repercussions. One of the biggest social sins observed within the tumblr antisocial community was “edginess.” Many different forms of bad behavior were censored under this category. Edginess includes unprovoked rudeness or aggression, deliberately picking fights with others, boasting about having engaged in actions that were dangerous, harmful to others, or illegal, and “pretending” to have ASPD. This last category, engaging in what others interpreted as faking ASPD for the sake of appearing “edgy” to attract attention, was often condemned on moral terms, while other forms of edginess tended to be framed as unacceptable because the person in question was making an annoyance of himself or “acting like an idiot.”

These admonishments were not usually framed as the individual in question having done something morally wrong, in the sense that it was harmful to others or society, but rather that their actions were “stupid” and self-defeating. Individuals who were viewed as deliberately picking fights with other bloggers, or who were otherwise considered to be out of line, were usually sanctioned through short, mocking replies or longer messages that outlined why the other person’s behavior was unacceptable. Similar responses were incurred against the small number of persons who boasted of engaging in highly destructive or illegal behaviors, but these individuals were also frequently warned that the consequences for their actions would catch up with them, and if they persisted in

67 burning bridges “no one would help” them when they landed in trouble. The individuals who offered these warnings to others with ASPD often made it clear that they were drawing on personal experience.

Like other online disability communities, “antisocial tumblr” operates under a set of informal rules, which are enforced through social sanctions usually intended to strike at the offender’s ego, though individuals whose behavior is viewed as being out of line are often offered advice on how to avoid mistakes, however abrasively that advice might be phrased. While people who do not have ASPD are generally accepted within these social circles, especially if they have other cluster B personality disorders (such as BPD or NPD), those viewed as “faking” ASPD were rejected, especially when they conducted themselves in ways that were considered to be inauthentic and damaging to “real” antisocials. The role that the mental health system plays in authenticating an antisocial identity, even among those who are critical of the way in which the process of medicalization has affected those deemed antisocial, is discussed below.

“Poserpaths” VS “Actual Antisocials:” The Boundaries of “Antisocial Tumblr”

While being able to convincingly claim that one has been official diagnosed with

ASPD carried a great deal of weight, validity within the sample ASPD group was frequently also determined by whether an individual was deemed by others to be behaving in a manner considered “authentically antisocial.” This judgement that was typically determined by how they presented themselves on their blog and how they engaged with others. While self-diagnosed individuals were accepted or rejected on a case-by-case bases, another group was universally rejected within the “actually antisocial” circle; members of this group were dubbed “poserpaths.”

68 Those considered to be “poserpaths,” a portmanteau of “psychopath” and “poser”

(an insult for someone who acts in an affected manner for attention or to impress others) were either mocked or ignored, insomuch as they interacted with the larger ASPD community at all. One of the mains ways in which individuals deemed inauthentic were identified was through blog content. Regina expressed confidence in being able to distinguish between those who “really” had ASPD and those who were “pretending.”

One of the ways to tell, she explained, was that those who claim disingenuously to have

ASPD or psychopathy build blogs that are composed entirely of cartoonishly wicked and violent content. As one other individual in this sample put it, “fake” ASPD “bloggers never seem to have any hobbies, any unique interests, or any degree of personality in general. I bet they see cute cat pictures and want to reblog them, but can’t because they figure that liking cute little furballs isn’t very dark and brooding.” These blogs were seen as reflecting not the real experiences of people with this disorder, but rather media stereotypes of people with ASPD as being emotionally cold, calculating, convinced of their superiority over others, and violent. Further, the consensus was that “fakers” glorify these traits, boast constantly, and write in a contrive and melodramatic manner, as though they are writing a poorly developed fictional villain.

Willow, who has been diagnosed with ASPD and bipolar disorder, offered this parody of phony antisocial blogs:

“It/its pronouns, dark blog, random aesthetic gore, likes the color dark red

too much, ouch the edge, has 4533 other disorders, ‘my mask,’ cartoon

vampire threats… likes cartoon villains or serial killers [and] talks like an

69 Anne Rice vampire, just makes the disorder a weird parody of itself and

it’s annoying, is generally just all around really boring.”

On the other hand, while “real” antisocial blogs might mull over their emotional and social problems, they generally recognize these as being problems. Further, as noted by Regina, “real” antisocial bloggers have interests outside of posting about how much better they are than everyone else; there’s a full human behind the blog, with a range of experiences, hobbies and opinions. While it is nearly impossible to validate anyone’s online biography, antisocial bloggers argued that it is very easy to “clock” “psychopath

RPG bloggers.” It also became my sense as well that lack of authenticity behind these sorts of “edgy poserpath” blogs was in fact obvious. These kinds of blogs rarely interacted with this study’s core “actually antisocial” group, which was gathered via snowball sampling and through observing interactions between bloggers. Blogs that were rejected as inauthentic by that core group were not included in the final sample.

“Poserpath” blogs were condemned as being actively harmful to people who have

ASPD for three major reasons. Firstly, they undermine efforts of real antisocials to educate others about the disorder, by drowning out legitimate voices beneath myths and misinformation. This was viewed as being actively harmful to people with ASPD. Regina writes:

People who fake the disorder take the impression given to them by pop

culture, of these charming, one dimensional, mysterious, constantly

scheming monsters. We don’t experience life that way; we’re not like that.

Perpetuating that image is not just pathetic in its sad, amusing sort of way,

it’s giving people an incorrect impression of our experience.

70 The second reason that many members of this sample took issue with

“poserpaths” is that they frequently used their “disorder” as an excuse for bad behavior.

Inessa, who did not explicitly state her diagnosis, but who used the word “us” when speaking on stigma against people with ASPD, explained that the result of people who were not even diagnosed with a personality disorder claiming that they are incapable of treating others correctly because of their ASPD is an “increase in people’s distrust [of those with ASPD] and the stigma [against] the disorder itself.” She continues:

Your inexcusable bullshit is only worsening stigmas for people who are

actually diagnosed and further reinforcing the stereotypes about

personality, mood, and developmental disorders. We want to break down

the stereotype that people with PDs are considered abusive. You’re

reinforcing that by using your self dx as excuse for your abusive

behavior... I don’t want that stigma.

As Frieda, who was one of the few self-diagnosed individuals that were generally welcomed among the antisocial community wrote, “The community for people with

ASPD on this website is almost nonexistent. Our own tag is full of attacks on people with

ASPD, serial killer fetishization, slurs, misinformation and ableism.” Gage, who was diagnosed with ASPD and NPD, expresses similar frustrations. “I go through the ASPD tag and the sociopath tag to try to find cool people like myself but all I find is writing tips and ‘how to recognize a sociopath.’”

Tags, as already discussed, function in the same way as hashtags on websites like twitter and facebook, and are how tumblr users locate posts on any particular subject.

Tags for disabled or otherwise marginalized people are often deliberately filled with

71 malicious content by “trolls” (often bigoted individuals whose only goal is to upset others) so sometimes people use variations on the obvious tag to try to avoid such content. In an attempted to avoid these kinds of posts, some bloggers attempted to utilize the tags “actuallyantisocial” or “actuallyASPD,” borrowing from the “actuallyAutistic” tag used by parts of the autistic community, but the effectiveness of this approach was limited, as the same people who put malicious content in the “autistic” or “ASPD” tags often “invade” the new tags as well. Camila notes that she used to “feel bad” when she searched the tag for BPD, but after “seeing the shit people say” about people with ASPD she now “counts [herself] lucky” that borderlines aren’t attacked or dehumanized to the degree that anisocials are.

“Poserpaths” are condemned as make it more difficult for individuals who have

ASPD to find resources and build an online community. The tumblr antisocial community is considerably smaller than, for example, autistic community, despite the disorder being diagnosed at roughly the same rate (CDC 2016). Antisocial bloggers attributed this to three factors. The causes, in the assessment of these individuals, were

“poserpaths” spreading disinformation, stigma against the disorder among neurotypicals and non-antisocial neurodivergent people, and hostility on the part of other bloggers with

ASPD.

Medicalization and an Antisocial Identity

The above section discusses the phenomenon of “poserpaths” and how those professionally diagnosed with ASPD engaged with these individuals. There is, however, another group of individuals who engaged far more often with “ASPD tumblr,” though

72 the validity of their claim to an antisocial identity was often challenged. These were individuals who came to identify as antisocial via self-diagnosis.

Self-diagnosis is a process through which an individual arrives at the conclusion that they have a mental illness, disorder, or other form of neurodivergence without having been given a diagnosis from a trained mental health service provider. Sometimes, the process of self-diagnosis is backed by a great deal of time spent researching the diagnosis in question, which may include observing and interacting with online disability communities to ask questions and to compare one’s own experiences to those of individuals who have been professionally diagnosed. An individual may choose to self- diagnose because they lack the resources to pursue a diagnosis through professional challenges, or because, for personal or political reasons, they wish to avoid interacting with mental health service providers. The goal of many people who self-diagnose is to find an explanation for their emotional or cognitive differences from the mainstream population, and to find among online disability communities resources and people with similar experiences.

Lacking medical validation, self-diagnosed individuals were challenged on two grounds. Firstly, some individuals’ claims to ASPD were rejected on the grounds that their descriptions of their emotional and mental processes did not match up with the experiences of people with ASPD. Secondly, some individuals who did have problems similar to those experienced by those diagnosed with ASPD were advised against seeking out a professional diagnosis, due to the stigma attached to this disorder. It was argued that rather than identifying into ASPD, these individuals should work on managing any antisocial tendencies that they might have.

73 Usually, all of this is done with consideration and respect for those who have been officially diagnosed. However, there are individuals who appear to claim neurodivergent labels after very little research, and who behave in a way that is perceived by those who have been professionally diagnosed as disrespectful, ill-informed, or as an act of appropriation. However, others attributed the relative smallness of the antisocial community to an unwelcoming attitude among members and the rejection of self- diagnosed individuals from the community.

There is a sense among many professionally diagnosed individuals that the needs, experiences, problems, and priorities of self-diagnosed people do not line up with their own, as well as suspicion as to why someone would “choose” a diagnosis that professionally diagnosed people often feel was forced upon them by hostile mental health service providers. This suspicion is boosted by efforts by some self-diagnosed individuals to distance themselves from symptoms of ASPD that are viewed as especially distasteful or negative by others, such as low empathy. While low empathy is not an explicit part of the current diagnostic criteria of ASPD, due to the current construct being focused on outward behavior rather than internal emotional states, it has long been considered a key element of psychopathy and ASPD. Empathy in this context is understood as the ability to put yourself directly in “someone else’s shoes,” which is to say the ability to be emotionally impacted by the emotions of others. For example, if a person feels saddened because a friend or family member is sad, that individual is experiencing emotional empathy.

That an absence of the ability to process emotional empathy is a major trait of

ASPD is the accepted consensus among the diagnosed individuals in this sample. As we

74 will see later in this chapter, what empathy is, how people without ASPD experience it, and how those with ASPD differ from others due to their reduced ability to experience empathy is a major topic of discussion among individuals in this sample. Therefore, efforts by self-diagnosed individuals to claim that one can have ASPD while still experiencing “normal” empathy levels is regarded as being both alienating and suspicious among those who have been officially diagnosed.

Whitley, who has been diagnosed with ASPD, expresses puzzlement at claims that reduced empathy is not a prerequisite for having ASPD, as well as suspicion at the logic behind these claims:

What’s so inherently wrong with having low empathy? Low empathy is

poorly understood and highly demonized. Like any other symptom, it has

no inherent moral implications. So I feel like the reason people want to so

passionately argue this is because they’re still thinking of empathy in

moralistic terms. That low empathy is ‘evil, bad, awful, inhuman,’ you

know? Because why else does it matter so much?

Whitley goes on to explain that the idea that they are an inherently bad person because they have low empathy is “something I’ve struggled with for a long time, and still struggle with.” Seeing so many people who claim to have ASPD attempting to distance themselves from low empathy is, Whitley writes, alienating and harmful. The issue with self-diagnosis, for many in this sample, was that many of the people who choose to identify into ASPD were unwilling to associate themselves with the more widely demonized aspects of the disorder.

75 People who claimed ASPD while not experiencing the severe behavioral and emotional problems that those who are officially diagnosed tended to report were viewed as inauthentic, and sometimes actively harmful, though they were not opposed to the same degree as “poserpaths.” However, those who had not been diagnosed with ASPD but who clearly articulated experiences and emotional processes similar to those who had been diagnosed were approached differently. These individuals were often warned to monitor their own behavior carefully, to avoid disclosing the belief that they have ASPD to mental health service providers, and to do everything in their power to avoid receiving an ASPD diagnosis, as said diagnosis was likely to have an extremely negative effect on their lives.

Individuals who had previously been diagnosed with conduct disorder, a juvenile diagnosis which in about 10% of cases is later followed by an adult diagnosis of ASPD, were in particular warned to proceed with caution when engaging with mental healthcare professionals. Flint explained that “getting a CD diagnosis is a warning. You are being warned by your mental health professionals to shape up and learn to pass as an empath when people can observe your behavior.” There’s no expectation here on Flint’s part that the individuals toward which this warning is directed become neurotypical, or even a sense that they should desire to do so, but rather that they should have an awareness of how empaths perceive their actions, and should be careful to avoid engaging in antisocial behaviors. Drawing on his own experiences, Flint argues that a failure to “pass as an empath” has devastating consequences.

Among these consequences, Flint expressed the belief that a diagnosis of ASPD cannot be kept from many individuals who may have power over one’s life, including

76 doctors, the courts and in some situations government employees. This diagnosis, he writes, “can destroy the network of human support that you need in order to survive in this world… Everyone with access to your health information is going to be extremely prejudiced against you.” For these reasons he advises individuals who have previously been diagnosed with CD to work hard to avoid getting stuck with an ASPD diagnosis.

Natalia, who has been diagnosed with NPD and ASPD as well as depression and anorexia, offers similar advice to someone who thinks that they might have ASPD. “You don’t want the diagnosis, trust me,” she writes. Though “it can be validating in the sense that you finally know what’s making you the way you are” her experience is that having the diagnosis can make it extremely difficult to obtain mental health services. Further, her advice is that if you have been diagnosed with the disorder, you should avoid telling anyone else about it, as the stigma associated with this disorder will result in social rejection.

Regina argues that even when someone has a set of traits and symptoms that align with ASPD it is pointless to attempt to claim that label absent diagnosis:

[ASPD is] a stigmatizing label that disadvantages the people it’s

legitimately attached to. Why would someone want that? Why would they

claim or self diagnose ASPD when it doesn’t magically help them in any

appreciable way? Treat symptoms without self diagnosing: it’s safer for

the individual in question and it makes things easier for people who are

diagnosed with a specific condition.

Unlike the cases of “poserpaths” and self-diagnosed individuals who attempt to distance themselves from the more stigmatized traits associated with this disorder even as

77 they claim it as an identity label, undiagnosed individuals who are perceived as probably

“having” ASPD tend to be more accepted among diagnosed antisocials. The advice for those whose self-assessed claim to ASPD is viewed as valid is as follows: Even if you probably do qualify for an ASPD diagnosis, don’t do anything to get yourself pinned with the label if you can avoid it. While being diagnosed might lend some insight into yourself and your problems, the barriers it will introduce to your ability to access mental health care are not worth it.

While the advice that these perceived undiagnosed antisocials are offered can sometimes be abrasive, it seems to stem from a desire to help these individuals avoid being trapped with a diagnostic label that in their experience has an overwhelmingly negative effect on the lives of those to whom it has been attached. This is, implicitly, a demedicalization position, one that is in line with those researchers who have advocated the retirement of ASPD as a diagnostic label. While the clinical designation of antisocial personality disorder itself is viewed as socially harmful to the individual it has been applied to and as a barrier to care, there is still a feeling that there are some symptoms that these individuals need or want help managing, but that these problems can be addressed independently of the baggage that ASPD carries.

However, the situation is more complex than might be found if there was a total rejection of the ASPD label. Even among individuals who viewed their ASPD diagnosis as punitive and damaging to their ability to access care, they did not necessarily agree that ASPD isn’t a “real” and identifiable disorder. Moreover, despite the fact that some undiagnosed individuals were accepted, being officially diagnosed by a medical professional was viewed as the primary and key way through which an antisocial identity

78 was validated. This was true even among individuals who were critical of how ASPD is employed by mental health service providers.

ASPD and Abuse: Experiences Prior to Diagnosis

While the role that childhood abuse plays in the etiology of ASPD and psychopathy is wildly denied in the literature (Hare 1993), other researchers have found that there is frequently a strong connection between childhood trauma and a later diagnosis of ASPD (Armstrong and Kelley 2008; Arduino 2011; Johnson et. al 2006;

Luntz and Wisdom 1994; Robins 1978). "Abuse and/or neglect... was a significant predictor of the number of antisocial personality disorder symptoms, even when demographic characteristics and criminal history was controlled for" (Luntz and Wisdom

1994:670). There is a strong consensus among the individuals in this sample that severe childhood abuse is a common experience among antisocials, a position that was frequently backed up by harrowing accounts of personal experiences. There was a strong feeling among many antisocials that the link between their disorder and childhood trauma is dismissed, ignored and minimized by mental health service providers and others in order to justify denying them help and sympathy. Of particular contention were self-help blogs that engaged in the demonization of individuals with ASPD and other personality disorders.

While not every person with ASPD in this sample spoke about childhood abuse, a get number did. Often, there was an effort by individuals and in conversations with others to puzzle out the relationship between these pre-diagnosis experiences with childhood abuse and the events that lead to their eventually being diagnosed with ASPD. At other times, individuals brought up childhood abuse to counter claims that individuals with

79 ASPD or psychopathy are innately “abusive” or “evil,” arguing that this abuse heavily impacted the way they perceive themselves and others, thus either causing or intensifying antisocial thought processes and actions.

Introspective conversations about childhood abuse often involved attempts to untangle what role those experiences had in their eventual assignment of an ASPD diagnosis. The question of if they “might have turned out differently” given a different environment was a frequent theme, as was the question of how much influence genetics have over this outcome. Even those who did not directly attribute their having developed

ASPD to childhood trauma frequently spoke of surviving horrifying abuse.

Though the blog posts under analysis here were all public, I have avoided recounting stories of child sexual abuse here. However, accounts of molestation and rape were frequent. Additionally, several individuals recollected being extremely fearful as children, though the distinction between “natural” fearfulness and fear as a result of abuse is not necessarily clear. A number of individuals reported having lost or suppressed childhood memories.

Regina, whose father also has ASPD, frequently wrote of her efforts to avoid turning out like him. However, despite this desire, she often finds herself viewing the world with the same outlook that he expressed when she was young. For her, this provokes the question, “did I inherit my father’s disorder because I share his DNA or because he taught me to do things that way?” Like many others in this sample, Regina claims to have few memories of her childhood, and today attributes her tendency to

“space out” during stressful situations to an inability to cope with her father’s violence.

80 Similarly, Keegan writes that she can’t remember much about what happened before she was ten years old, but that what she does remember “involves things like screaming and being slammed into the wall.” Harley, who is diagnosed with SPD and who believes she would qualify for an ASPD diagnosis but who has avoided seeking one out due to the potential stigma, claims that she remembers nothing from before she was the age of five, except for “constant and unrelenting nightmares.” She has since become aware of the nature of the horrific abuse that was taking place at the time, but is uncertain as to what effect it had on her emotional development. “It happened so early in my life I can never remember being affected by anything at all, not even that. And so, I say that I was born like this, that perhaps it was genetic.”

Similarly, Curtis, who has been diagnosed with ASPD and SPD, expresses little uncertainty in regards to what came first, the abuse or the disorder. “I wasn’t born normal and then broken afterwards, I was born the way I still am today, with no way of knowing how normal emotions work,” he says unequivocally. However, rather than believing that he became antisocial because he was abused as a child, he believes that he was abused because he was a child with severe empathy problems. Curtis writes that his inability to understand the emotions of others made it impossible for him to “figure out what was wrong” when people became angry with him. He found others, including his parents, to be “unpredictable, impossible to understand, and often violent towards me for reasons I couldn’t fathom.” He was abused for failing to meet expectations that he did not understand, which lead to a greater “fear of social situations and of other people in general, which in turn annoyed everyone, including my own parents, and led to more violence.”

81 Though Curtis has gotten better at working out why others act the way that they do, he writes that this was a learning process that took nearly two decades, and he is still sometimes baffled as to why some people respond to him negatively. His aim has never to become a “properly sociable person” but simple to be able to understand others well enough to predict and avoid violence. The goal was “survival.” He continues: “I dedicated myself to understanding others… I was beating myself into it and shaming myself to hell and back for even the slightest misstep. I needed to make sense of the world, or else I would never be able to navigate it.” Whenever he worked out some new social norm, he says that he would change his own behavior to come into step with what was expected. He writes that sometimes this was accepted, but sometimes it wasn’t and he “got called a liar or a hypocrite. Every time I got called out on it, I was terrified abuse would follow. Sometimes it did.” Curtis writes that even after he became good enough at all of this to be well-liked, he was he was still obsessed with the fear that he would make some mistake that gave himself away, and therefore be punished.

On the other side of the “nature versus nurture” debate, Mira attributes the problems that lead to her ASPD diagnosis primarily to parental abuse. Like the individuals above, she reports to be “missing a lot of memories” from before she was 11, though she “still get flashes of some of the less than pleasant stuff.” While Mira doesn’t dismiss the possibility that she may have been “born with the chemical imbalance to make me numb towards emotions,” she believes that given the abusive conditions she was raised in she would have developed ASPD regardless of any genetic predisposition.

Like many others in this sample, Regina, Harley, Keegan, Curtis and Mira are invested in understanding the relationship between who they are and what was done to

82 them. In attempting to tease out this relationship, Curtis and Harley employ a biomedical model, one which attributes their current problems to genes rather than environment, though they allow that environmental factors such as social rejection and abuse have made their lives considerably harder. On the other hand, Mira considers environment to be the driving factor in her developing problems which lead to an ASPD diagnosis, while

Regina and Harley consider the interaction between genetics and environment to be more difficult to parse out. However, at least in the context of this discussion, ASPD is considered by all to be a real disease that they were all either born with or acquired early in life.

Many individuals with ASPD described a similar struggle to that articulated by

Curtis, the struggle to understand what made them different and to conceal those differences. The term “passing” was used frequently, in the contexts of needing to “pass as a neurotypical/an empath.” One of the reasons passing was considered to be so important was the stigma associated with ASPD. Dehumanizing ideas about people with this disorder (as well as other personality disorders and psychopathy) sometimes appeared on personal, disability rights and self-help blogs. These kinds of posts often claimed that people with ASPD were inherently abusive, lacked emotions, only had bad intentions in engaging with others, were incapable of caring about others, and were even

“evil.” Dehumanizing claims about individuals with ASPD and psychopathy often are inspired by a shallow engagement with some of the most extreme proponents of clinically pessimistic medicalization, as well as fictional accounts of murderous psychopaths. To combat these arguments, bloggers with ASPD and their friends and allies often presented personal experiences and research data on the link between childhood abuse and ASPD.

83 This was done with the goal of illustrating that their opponents were either ignorant or acting with malicious intent by perpetuating stigma against a group of disabled individuals that is largely made up of abuse survivors.

One common approach of some online self-help blogs is to frame abusers as a class as narcissists, antisocials and psychopaths. This often involved encouraging readers to “armchair diagnosis” their exes or family members as having one of these disorders, and then using that supposed diagnosis to explain why the other person was abusive. This framing was rejected by many in this sample as not only being harmful to antisocials, but also to other mentally ill people and all abuse survivors. As Shane, who has been diagnosed with ASPD and BPD, writes:

Abusers can be, and often are, neurotypical. Please do not let them off the

hook by perpetuating the idea that all abusers are neuroatypical. Please do

not exclude antisocial individuals who are abuse survivors as well. If your

safe space for survivors is targeted against a group of mentally ill people,

you need to rethink what kind of space you’re really trying to create.

Slade, who self-diagnosed with ASPD, spoke in agreement with Shane, arguing that painting an entire category of mentally ill people as “‘abusive’ and ‘dangerous’” effectively “throws all mentally ill people under the bus.” The argument here is that the result of making a direct linkage between one form of mental illness and abusers, the idea that having a mental illness makes a person abusive is validated.

Others pointed out academic research that demonstrates that many people with

ASPD are abuse survivors themselves, while others argued that this kind of discourse is ableist. Liev, who has been diagnosed with ASPD, supports the argument that blanket

84 attacks on people with ASPD constitute ableism by citing data on the numerous comorbid conditions that people with ASPD frequently experience, including alcoholism, eating disorders, depression, ADHD, and many others. He concludes, “this is why you need to include ASPD people in your anti-ableism activism. We’re disabled too.” At the heart of this discussion is the argument that, while some mentally ill people may be abusers, abusers are not abusers because they are mentally ill.

In discussing the conditions that lead to their eventually being diagnosed with

ASPD, the consensus among this study’s sample was in line with the medicalized view of

ASPD. This is to say that those who discussed this topic overwhelmingly agreed that

ASPD is a real medical disorder, though there was less agreement as to if ASPD is caused by genetics or environment. Regina presented the argument, supported by neurological research (Fallon 2014) that psychopaths have observable differences in brain functioning, making it an observable disability with biological causes. The logic of medicalization was applied as a shield when these individuals felt themselves to be the target of unjustified attack, with negative blanket statements about people with ASPD being framed as an attack on disabled people. This is the standard position taken by people who accept their diagnosis as a legitimate medical disorder.

After Diagnosis: The Effects of Being Labeled with ASPD on Access to Mental

Health Services

While discussing the factors that lead up to receiving an ASPD diagnosis, most of the individuals in this sample seemed to accept ASPD as a legitimate disorder, one which accurately describes their emotional and social problems, though there was disagreement as to its etiology. This reflects an acceptance of the basic logic of medicalization.

85 However, things become more complicated when these individuals speaking of engaging with mental health professionals, as these interactions often involves patients with ASPD coming face to face with the widely accepted clinical pessimism about individuals with this disorder. In response, individuals labeled with ASPD either accept that pessimism, wish for reforms to care providers attitudes about them, or reject the validity of ASPD as a diagnosis.

A few individuals in this sample are happy with the treatment they receive from their mental health service providers. Natalia writes that she “really appreciates” her therapist, who she characterizes as “quite a cool guy.” This service provider seems to have worked with her to actively dispel clinically pessimistic attitudes about people with

Natalia’s disorder, which she writes has kept her from internalizing them. She continues,

“normally we’re told people like us are abusers and trash and [that others] need to be wary of us, but he tells me I have a lot of potential and because I’m young I can curb a lot of the ASPD/NPD traits that will harm my future. I don’t know if he’s right, but it’s nice to be told.” This psychiatrist’s rejection of the pessimism with which patients like Natalia are usually received seems to have benefited her considerably.

Willow has conflicted feelings about her ASPD diagnosis. While she often expressed the view that there is something fundamentally “wrong” with her, she feels strongly that she was mistreated by the mental health professionals who diagnosed her with ASPD. At times, she seemed to accept this diagnosis as reflecting her belief that

“there’s nothing good about me.” At other times, she contests the diagnosis, which was received shortly after she reached adulthood, following her arrest for actions that she did not disclose, but which she characterizes as being foolish. Willow writes that she was

86 diagnosed with ASPD after a 30-minute meeting with a court appointed therapist. Her feelings about this outcome are that “the very nature of my diagnosis was ableist as shit.”

Willow’s response has also been conflicted. She writes that there isn’t a day when she doesn’t regret the situation that resulted in her being diagnosed with ASPD, but has also said that she is “grateful for getting in trouble and having a court force me into evaluation.” For her, the diagnosis has clearly been a double-edged sword. On the one hand, being diagnosed with ASPD offered an explanation for problems that she’s had and aspects of her personality that she had trouble understanding prior to this. On the other hand, now that this highly stigmatized label has been attached to her, possibly for life, she has hit a brick wall in her efforts to obtain mental health care. Because being diagnosed with ASPD “gave me a really bad stigma... that follows me around with mental health practitioners,” it is her perception that service providers now treat her with mistrust. For this reason, Willow has stopped going to therapy.

Willow’s claim that she desires to be in treatment but cannot obtain it because mental health professionals treat her badly due to her diagnosis was echoed by others in the sample. Tom writes that since he has been diagnosed with ASPD, his therapist “treats me like a fucking roach now, like an interesting roach.” Others expressed the view that when they were able to access care, they were treated as oddities rather than people.

Some wrote of attempting to access care but being turned away. Jim, who has been labeled with ASPD, writes that “I have had several psychologists refuse to even see me because of my diagnosis.” Pamela was able to find a therapist willing to work with her, but considers this a matter of her having been “lucky.” Overall, Pamela believes that

87 “the mental health industry tries to starve people with ASPD/NPD until they give up looking for resources.”

Regina describes a similar experience to Jim. After being turned away from other service providers, she opted to conceal her ASPD diagnosis from her current therapist until they had established a working relationship. Regina believes the therapist would have refused to see her had she been upfront about this information. She writes:

People with ASPD would like access to mental health resources just like

anyone else. Even if I go in for depression or anxiety and I disclose that I

have ASPD in the consultation, they generally won’t take me. Even worse,

many resources outside of psychiatric services, like forums/articles online,

are more focused on maintaining a fear-based discourse while also

perpetuating the “no cure so no treatment” misconception.

The positions taken by Willow, Tom, Regina and Pamela match most closely with a reformist medicalization position. They more or less accept the validity of their ASPD diagnosis, but are frustrated by the ways in which mental health service providers treat them. Those among the sample who advocated for a reformist medicalization position made it clear that they desire treatment but feel that most mental health service providers are unwilling or unable to help them. They argued for more efforts to find effective treatment methods, and cited studies and clinical manuals that provided information on approaches that have shown positive results. For example, Regina drew directly on current research to challenge claims that people with ASPD have no desire to access treatment:

88 Perpetuating the misconception that people with personality disorders are

untreatable is actually hurting more people than it’s helping. What

evidence, which articles are you reading that say these disorders are

untreatable? Because I just read a clinician's handbook for treating NPD or

ASPD. Do you realize that BPD was also seen as untreatable less than 5-

10 years ago? Why shouldn’t all people with personality disorders have

access to treatment? Why shouldn’t efforts be made to develop new and

effective treatment strategies for all disorders? Absolute statements about

groups of people are always wrong, precisely because individual

differences exist between members of those groups.

Another source of frustration for this population was the lack of self-help resources for people diagnosed with ASPD. While books to help manage other forms of mental illness or disorders, such as depression or anxiety, are widely available, books on

ASPD and psychopathy are focused on demonizing that population. Several individuals in the sample professed frustration with this lack of resources.

Regina frames the claim that people with ASPD don’t want or seek out treatment as circular reasoning. Writing sardonically, she says, “People with ASPD don’t want/need treatment so there is none, but there never has been any, because they don’t want/need it… Right?” Along a similar vein, Jim, who did not specify if he has been diagnosed with ASPD, noted that what is at issue is not only difficulty finding service providers who are willing to treat ASPD specifically, but also an unwillingness to treat the comorbid conditions that are common to individuals with ASPD. This means that a

89 person who is having difficulties with depression or anxiety may be turned away from treatment for those specific problems due to a prior ASPD diagnosis.

“Is ASPD Even a Real Disorder?”: Critiques of the ASPD Construct

While many of the individuals above took a reformist medicalization position, others criticized the concept of ASPD on a more fundamental level. These individuals challenged the idea that ASPD is a “real” disorder, arguing instead that it is designed to stigmatize and isolate patients. This position fits within the demedicalization approach.

Griffin, who appeared to be speaking as an ally to people with personality disorders, pointed out that psychopathy specifically is not a clinical diagnosis, but rather a tool of the criminal justice system. He then pointed out that “We don’t like the criminal justice system, remember?” in reference to critiques of that system as violent and oppressive. He went on to argue that efforts to construe violence as a product of individual deviance rather than larger institutions misses the root causes of social problems. Griffin’s argument is in large part supported by Jalava et. al (2015), who contend that psychopathy is an ideological construct designed to position crime as the result of individual pathology rather than a flawed social system.

Similarly, Vivienne, who has been diagnosed with SZPD but who often interacts with antisocial circles, argues that “ASPD is a diagnosis which exists to give a medical diagnosis of criminality and there is no considerations for the person’s own health or well being involved in such a diagnosis.” Moving specifically to the question of ASPD,

Vivienne writes that “any psychologist worth their salt knows that a diagnosis of ASPD is never done with the intention of helping the patient. It’s a big flashing warning sign to have that patient removed from therapy ASAP.” This claim is nearly identical to that

90 made by Glyn and Appleby (1988), who advocated for the retirement of the concept of personality disorders on the grounds that they were used to exclude patients from care rather than to benefit them.

Several individuals diagnosed with ASPD agreed with the above positions that these labels do not exist to benefit patients. Slade mirrors Vivienne and Griffin’s arguments, writing that psychopathy is “literally not a thing that exists outside academia and the criminal justice system,” and that the concept exists to “demonize people with personality disorders.” He claims that the effect of this kind of ideology is that abusive, violent and criminal neurotypicals are less likely to be held responsible for their actions, as blame is instead pinned on a group of mentally ill people.

Willow, who has expressed mixed feelings about her own ASPD diagnosis, presented the following question to others: “Honestly is ASPD even a real disorder?”

This question was followed by speculation as to if the term only exists to “box people in” as criminals and therefore deny them care. Vivienne responded with the following theory:

Honestly ASPD is a few things at once.

1) A medicalization of those that reject the status quo, in particular

criminals and anarchists. In this case it’s entirely a social mandate and not

a [diagnosis].

2) A catch-all term for sleazy used car salesmen and/or Wall Street types.

3) A diagnosis for adults who were untreated cases of Reactive

Attachment Disorder from severely abusive childhoods.

4) A hypothetical neurological disorder that causes a lack of emotional

affect, inability to connect to others, and lack of affective empathy.

91 A number of individuals with ASPD found this argument to be convincing. While standing firm in the belief that she and other individuals dubbed antisocial are different from neurotypicals in significant ways, Regina suggested that what is needed is a new definition of APSD that focuses on the emotional and social problems experienced by the patient. This approach, she argued, may result in a disorder that instead of being focused on criminality would be geared toward helping the patient.

Conclusion

Within this sample, individuals diagnosed with ASPD did not passively accept that label and the stigma associated with it, but nor did most of them reject the label outright. Rather, they grappled with the definition of ASPD, the effect this label had on how others viewed them, and whether it accurately encompassed their experiences. The majority considered ASPD to be a barrier to their receiving care for their mental health problems, with some arguing that service providers should respond differently to people with this diagnosis, while others felt that the label was too burdened with stigma to be of clinical value, and instead offered the suggestion of finding new ways to approach the problems this population often experiences.

92 Chapter Five

Conclusion: The Failures of “Fear-based Discourse”

Zola (1993:168) writes that once "someone has been labeled ill, all their activity and beliefs - past, present and future - become related to and explainable in terms of their illness. Once this occurs, society can deny the validity of anything which they might say, do, or stand for.” People diagnosed with antisocial personality disorder are some of the most egregiously affected by the phenomenon described by Zola. This population is by default ruled as lacking in credibility, deceptive, malicious, and lacking the insight necessary to even recognize that they have a problem, never mind seeking out treatment.

This project has attempted to intervene in the above narrative about antisocials. By engaging directly with what antisocials say among each other and friends, in a non- clinical environment, I have hoped to provide an objective picture of their sense of themselves and their experiences with mental health service providers.

The individuals in this sample did not demonstrate a lack of awareness or an indifference towards their own problems and the problems that they sometimes create for others. Instead, many of them were painfully self-aware of their difficulties functioning in a “socially normal” manner. Many expressed a desire to access mental healthcare, but have been turned away or treated with pessimism by service providers. As my primary informant, Regina put it, individuals with this diagnosis are struggling against a “fear- based discourse” that presents a major barrier to mental health care.

While the sample utilized in this study was somewhat atypical when compared to the general antisocial population, it demonstrates that many individuals with this disorder are interested in finding ways to manage their problems. Many, in fact, offer insightful

93 interventions to the rarely questioned assumptions that researchers and service providers have made about this population. The candid views from people with ASPD, as recounted in this study, puts the lie to claims that this population lacks self-awareness and is disinterested in treatment and self-improvement. As there are, to my knowledge, currently no other studies that pay heed to the patients’ perceptions as to why ASPD is supposedly so difficult to treat, this constitutes a significant contribution to the literature.

That said, I explore below some of the shortcomings of this current study and important directions for future research.

Limitations of this Study

The major limitation of this study lies in the sampling method. While content analysis of online communities presents many opportunities not available through other sampling methods, including (most importantly for this study) the ability to collect candid observations and conversations from subjects, without any risk that the researcher might influence what the subjects say or how they express themselves, this method also has its shortcomings. The major weaknesses of online content analysis are an inability to collect detailed demographic data and the potential for sampling bias.

The sampling method utilized in this study does not allow for the collection of thorough demographic information. While some individuals disclosed their race, gender, sexuality, and other demographic information on their blogs, many did not. This makes it impossible to say anything definitive about the makeup of this sample. As discussed previously, there appears to be a greater number of women in this sample than would be expected to be found among those diagnosed with ASPD, but this cannot be said for sure.

It is also possible that women within the ASPD community were more likely to disclose

94 their gender than men. While it was beyond the scope of this project, a study that is able to supplement content analysis with interviews which include the collection of demographic information would go a long way towards clearing up some of these questions.

Another issue of sampling bias present in this study also reflects some of the shortcomings of online content analysis, which is simply that by its very nature this method collects data from individuals who post their writings on the internet. This means that any study built around online content analysis is likely to collect information from individuals who have access to the internet, are literate enough to engage with other posts and to write their own, and who have the time, resources and inclination to do so. The sample therefore may be biased toward people who are younger, better educated, and who have strong opinions and a desire to share them through online communication.

Given that people with ASPD tend to experience high levels of homelessness and incarceration, a significant percentage of the population may not be able to access the internet, while others simply not be interested in discussing this topic, especially if they feel negatively about their diagnosis.

While qualitative research rarely seeks to build a representative sample, further research may be able to include segments of the antisocial population that were not able to be included in this study. While candid nature of samples taken from online discussions is a strength of this study, the findings would likely have benefited from being supplemented by more interviews with more complete demographic data. Other ways in which this study’s findings may be built upon and improved are discussed below.

Directions for Future Research

95 As discussed above, community samples, including those drawn from incarcerated individuals, would allow for a wider understanding of the experiences and service needs of individuals labeled with ASPD. Likewise, in depth interviews would fill some of the gaps remaining from the current study. This type of research constitutes an opportunity to amplify the voices of the real human beings who have this disability over the caricatures that exist within popular culture.

Quantitative studies are also needed. As discussed in the above literature review, there is very little solid data about the demographics of individuals diagnosed with this disorder. Survey data would allow us to better understand trends and communalities among individuals diagnosed with ASPD and would shine some light on many of the things we don’t know that we don’t about this population.

Just as pressing as the above is the need for better theory to aide our understanding of this diagnosis and the affect it has on patients who are labeled with it.

While critical works on ASPD exists (Blackburn 1988; Jalava et al. 2017), these tend to focus on the legal, ideological and social ramifications of the deployment of this label, rather than the direct effects that it has on the lives of the patients shouldered with an

ASPD diagnosis. What’s needed is theory that is rooted in a greater consciousnesses of the cultural and social biases in how this diagnosis is applied and framed without forgetting the voices of individuals who live with this label. In particular, the contributions of Mad and Disability Studies scholars to this discussion would be highly beneficial. While much work has been done on schizophrenia and other highly stigmatized mental illnesses, little has been written on ASPD as a disability.

96 While quite a lot has been written about ASPD, studies that attempt to communicate what being labeled with this disorder is like from the prospective of antisocials is almost nonexistent. Severe gaps exist across the literature, reflecting a need for intervention on the theoretical, qualitative and quantitative level. Hopefully in the future, once work has been done to combat the stigma associated with this disorder, it will be possible for individuals labeled with ASPD to be able to engage openly in their own projects on this disorder, without fear of social rejection.

More studies that focus on this process from the POV of those diagnosed with this disorder.

Concluding Remarks

While it is not always as difficult as it used to be for some patients labeled with personality disorders to access treatment today, should they wish to do so, considerable barriers remain. In recent decades, some mental health service providers have softened their views on the treatability of personality disorders, with advances in the treatment of borderline personality disorder particularly gaining increasing ground. However, antisocial personality disorder is still considered to be among the most difficult and damaging personality disorders, and many mental health professionals continue to believe that it fruitless to offer these patients care.

What is needed is more research that is geared towards bettering the treatment options for this population. If individuals inclined towards antisocial behavior were given the tools and support they need to learn how to manage their disability, many may be less likely to engage in behaviors that are self-defeating, harmful, and socially isolating. This

97 would yield positive results on two fronts; less toxic social behavior and interpersonal crime, but also better outcomes for the population in question and those close to them.

The above does not necessarily require the retirement of ASPD as a diagnosis, as some have argued, though it does need to be reoriented towards helping the patient with their problems rather than flagging them as difficult or untreatable. However, in regard to psychopathy there must be in the very least a movement away from regarding this label as a valid clinical construct, as it is at best a blunt tool for assessing the risk of recidivism.

Additionally, there seems to exist no work on how frequently people with this disorder choose to seek out treatment, why they do so, and most importantly what they hope to get out of treatment. These gaps need to be filled.

The “fear-based discourse” on ASPD has failed to yield productive results. It has

– perhaps by design – failed to find effective treatment options for the population labeled with this disorder. More research is needed to understand from the perspective of the patient what it is like to be labeled with antisocial personality disorder or psychopathy, in particular how these labels influence access to psychiatric care. There is a great need for more researchers who are willing to engage with these patients not as abstract social problems, constellations of negative behavioral traits, or dangerous beasts, but rather as fellow human beings. Once we begin to view these patients as fully human, many of the vexing questions associated with treating this population may finally be resolved.

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