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Gordon, R.M. and Bottinelli, J. (2008), Ethics and the Difficult Patient: The Psychopath in Film and in Your Office. The Pennsylvania Psychologist Update, July/August Issue,10.
Ethics and the Difficult Person: The Psychopath in Film and in Your Office
by Robert M. Gordon
Gordon, R.M. and Bottinelli, J. (2008), Ethics and the Difficult Patient: The Psychopath in Film and in Your Office. The Pennsylvania Psychologist Update, July/August Issue,10.

On May 9th, I held my 10th annual PPF Ethic’s workshop fundraiser. I compared the DSM criteria for Antisocial personality disorder to the Psychodynamic Diagnostic Manual’s (PDM) criteria for Psychopathic personality disorder. The DSM and PDM compliment each other. The DSM is nosology based on symptoms, while the PDM is a nosology based on etiology, pathogenesis and symptoms. The PDM is more helpful at understanding the full range of people from the surface symptoms to the underlying personality dynamics. The PDM divides psychopathy into two subtypes: the passive/ parasitic (less aggressive, con artist), and the aggressive (predatory and violent).

Psychopaths can be physically dangerous, but in treatment they are more likely to act out the transference, and cheat or exploit you. They might set you up for a malpractice suit for the money. The main defensive style of the psychopath, is reaching for omnipotent control. They get pleasure over having power over, exploiting and conning others. Psychopathy is generally organized at the borderline level of severity and often combines with other personality disorders such as narcisstic, paranoid and sadistic personality patterns or disorders. There are a high number of psychopaths in prison, but the smarter ones are in any area that has power over others such as clergy, lawyers, CEOs, law enforcement, politics, etc.

They will at first seem cooperative and friendly, while they are assessing your physical, intellectual and moral capabilities. To test you, they may invade your personal space and then ask you for favors or to bend the rules for them.

Therapy is often counterproductive. Psychopaths learn how to use psychology to better manipulate others. Some limited issues may be the focus of treatment, such as anger management. Some patients with psychopathic traits who have some remorse and insight can improve in long-term psychotherapy. If they remain in treatment, they may learn to better contain their acting out.

When treating anyone with psychopathic traits, keep strict boundaries, keep them from testing your personal space, set limits consistently (or they will sense your weakness and play on it), keep goals focused, never do favors, get a consult and if you are frightened or uncomfortable, do not treatment them.

Remember APA’s ethic code, 10.10 (b) Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship.

Dr. Jennifer Bottinelli showed film clips illustrating issues about psychopathy. The first set of clips was a scene from Joel and Ethan Coen’s Fargo (1996) , a film that depicts both aggressive and passive/parasitic psychopaths working together in a kidnapping. What was meant to be a simple kidnapping for money turns into multiples murders when the aggressive type explodes. It is a rare illustration of how the different subtypes react in the same situation.

In David Mamet’s House of Games (1987), a handsome con man sucks in a female psychiatrist by making a deal with her. She asked him not to have her patient injured because of his gambling debts. He claims that he will write off her patient’s debts in exchange for informing him about the “tells” of another poker player. He charms her, invades her space, touches her, and asks for a favor in the first few minutes of their meeting.

Finally, the relationship between an aggressive psychopath, his mother, and his therapist is a key plotline in the first season of The Sopranos (1999). Tony Soprano’s mother is a cold hostile psychopath. She orders a hit on her own son. Tony is in denial about this. He argues that feelings are signs of weakness. He physically attacks his therapist when she confronts him about his mother’s borderline personality and hostility towards him. Tony acts out both his negative transference and erotic transference to his therapist, rather than grieve the loss of a good enough mother.

"What makes relationships sizzle - and why do so many fizzle? Dr. Gordon's I LOVE YOU MADLY! admirably addresses both of these thorny, age-old questions. I can't say that the book solves the entire mystery of love - for no book could do that -- but the reader certainly comes away much wiser. I know that I did."


"The wisdom, clinical experience, and humor of the author served him well in writing this book. Doctor Robert M. Gordon has created a highly readable volume in "I Love you Madly!" Reading can never remove the innate risk of being in relationship, be it friendship or romantic love, but "I Love you Madly!" goes a long way to shed light and grace upon the unconscious processes involved in relating to others."

-Brother Bernard Seif, SMC, EdD, NMD

"A remarkable book. Very few psychologists/psychotherapist would reveal and analyze their love relationships - Dr. Gordon does. Hardly any therapists, particularly those who are analytic, have the courage to show exactly what goes on in a therapy session - Dr. Gordon does. And along with this, a theoretical overview of what love relationships are about, and a comprehensive look at personality dynamics. This book offers psychologists and the general public an important understanding of what happens in a love relationship, and how they can go bad. Of particular note is the wonderfully poetic dialogue between two lovers - the grand human tragedy beautifully expressed."

-A. Katz

"Dr. Robert Gordon has created a unique, enlightening, and entertaining exploration of love and human nature. I read it and I loved it."

-Stephen A. Ragusea

"Gordon with his insight and knowledge of the science of psychology weaves between his own romance and his work with a patient with a love disturbance. The reader wonders how each will turn out. It is a great read for therapists, psychology students, patients or anyone who has both loved and lost or suffered the pains and confusion of romantic love."

-Gerd H. Fenchel, Ph.D. Dean/Director, Washington Square Institute for Mental Health and author of Psychoanalytic Reflections on Love and Sexuality, University Press of America.

"Robert Gordon is a psychologist, psychoanalyst, author and speaker.  And he is a man who understands the nature of love.  Speaking from his heart and speaking from his fund of knowledge, he teaches the reader the difference between romantic love and the kind of love that sustains us over the years. If you are in love or searching for it, read this book and heed its wisdom!"

-Daniel Gottlieb, Psychologist and Family Therapist, host of "Voices In The Family" (WHYY Radio) columnist Philadelphia Inquirer, author "Voices In The Family" and "Letters To Sam"

"This is a great book.  The reader learns a lot about love, relationships, psychology, and the usefulness of psychoanalytic psychotherapy.  Although I have been a psychologist for many years, I learned a lot from reading this book. This is a great achievement by Dr. Gordon. It is written so that both professionals and nonprofessionals can read it, and learn from it."

-Russell Eisenman, Ph.D. author of over 200 journal articles and 7 books in psychology.

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