The following case study is connected to the questions below: Please assist with answering the following questions in a synopsis format related to case study:

Brief Overview of Client

DSM Diagnosis and rationale (Including code)

Approach to Treat Disorder (including assessment techniques or tools)

Treatment Plan (Minimum THREE goals with measurable objectives) with following format:

Goal 1:

Objective 1:

Objective 2:

Objective 3:(Complete for minimum three goals)

Anticipated discharge criteria (i.e., When is process complete?)

Additional Information (What more information about the client would need to be gathered to better understand the client

What is one of the most common reasons individuals with antisocial personality disorder end up in therapy?

Throughout this case study, what behaviors did Dee manifest that fit a diagnosis of antisocial personality disorder?

What did Dee do that is consistent with antisocial personality disorder during her time in the emergency room?

What are the statistics regarding the gender of people with antisocial personality disorder?

How did the clinical interviews in the inpatient admission unit help inform Dee's diagnosis?

Give three examples from Dee's mother's story to her friend Marlena that suggested Dee met the criteria for antisocial personality disorder.

What are some possible biological explanations for antisocial personality disorder?

Why is treatment usually ineffective for this personality disorder?

Which of Dee's behaviors is consistent with the personality trait of psychopathy?

What is the eventual outcome for many individuals who display antisocial personality disorder?

Case Study:

Dee was a 24-year-old single, biracial, cisgender, bisexual woman recently admitted to the psychiatric unit of an academic medical center in Minneapolis. She had expressed suicidal ideation and threatened to take action the night before in an argument with her girlfriend. What started off as a joke Dee made about her girlfriend's flat chest turned to physical violence after the girlfriend called Dee cruel and lacking empathy and then accused Dee of stealing a large sum of money from her (the girlfriend's) mother. Dee, fearing she would be caught for this crime she knew she had committed, yelled and screamed in denial, claiming falsely that she had not taken the money. When her girlfriend yelled back, Dee pushed her down and stood over her, pointing her finger and telling her never to do that again.

Around 3.6% of adults in the United States meet the criteria for antisocial personality disorder (Fisher & Hany, 2021; Alarcon & Palmer, 2020). The disorder is as much as four times more common among men than women.

The neighbors in the adjacent apartment heard the commotion and called the police. When the police arrived, Dee's girlfriend was furious and agitated. Dee was calm. She lied to the police, telling them that her girlfriend had smoked some weed and become paranoid, making "crazy" accusations, and physically threatening her. Her girlfriend angrily denied these allegations. When the police saw bruises on her arms and challenged Dee, she became enraged and defensive, saying that she "may as well kill herself." The police officer asked her if she was thinking of harming herself, and she fabricated another lie, explaining that she had been thinking of killing herself for a long time, and that she just might do it after this altercation with her girlfriend. The police officer, unsure of the truth but now more concerned that Dee might harm herself, asked her if she needed to be taken to the emergency room. Dee, believing that she might otherwise go to jail for assault or theft, told the officer she was worried for her safety and wanted to go to the hospital.

At the emergency room, Dee told the psychiatric nurse practitioner that she could not bear life any longer and was thinking of ending it all. Dee said she had spent the past month writing out a plan and gathering means to kill herself. She disclosed tearfully that she had been sexually abused as a child by an uncle, and she had endured years of physical abuse from her father before he abandoned Dee and her mother. She went on to explain that she had attempted suicide before and had cut her wrists numerous times when she didn't know what else to do to take the edge off of her emotions. The nurse practitioner listened intently and took notes. Dee was new to this hospital, and there were no electronic medical records to corroborate this information. Trained to take great efforts to rapidly build rapport and trust in emergency room settings, the nurse practitioner took Dee's words at face value. Why wouldn't she?

Dee reported that she had been actively thinking about and planning to die by suicide since she was 21. She had overdosed at 18 with the intent to die, she explained. She had been hospitalized in Minneapolis when she was 22 for self-injurious behavior, that time for cutting her wrists and legs. The nurse practitioner eventually had to leave to attend to other patients, and a licensed clinical social worker later came to the emergency holding room Dee was placed in. The social worker was a young Dominican woman who appeared to be roughly the same age as Dee. Her name was Teresa, and she disclosed that she had recently finished her degree and licensure.

Teresa had an earnest way about her, and she passionately asked about Dee's personal history. She took fastidious notes and asked a lot of questions related to the risk for self-harm. To Teresa, Dee seemed deeply upset. Occasionally she would stop speaking and bury her face in her hands. When the social worker asked her which psychiatric disorder she had been diagnosed with in the past, Dee replied, "You name it, I've got it." She said that she had recently lost both her job and now her girlfriend, and currently her mother was gravely ill, among other things. She feared that unless she got some help, she was going to "go off the deep end and do who knows what to myself."

In one classic study, clinical psychologists viewed videos of statements made by individuals and evaluated their truth or falsehood. The clinicians were only able to identify 62% of the lies, a performance similar to that of federal judges (Ekman et al., 1999).

Teresa and the psychiatric nurse practitioner huddled at the nurses' station and decided it would probably be best to keep Dee in the psychiatric emergency unit holding room. This way she could be safe while the medical team conferred about the next steps. Because she was not a patient known to this medical system, the team decided later that night to play it safe and admit her to the psychiatric unit at the hospital. Luckily, there was a female bed available. Dee was transported safely to the unit, where she was checked in, given a room, and oriented to the unit rules and schedule. Soon after arriving on the inpatient unit, Dee was interviewed by a different licensed clinical social worker. This social worker asked her about her family and social history, current and past medical conditions, and a host of other questions about what kinds of things stressed her out and how she coped with stress. The attending psychiatrist and psychiatry resident on the unit knocked on the door and interrupted. A medical student stood quietly behind as the two doctors began talking to Dee. The social worker stayed and listened, hoping to learn important information that could assist with a discharge plan and smooth transition back into Dee's community. After introducing herself, the attending psychiatrist observed as the resident, Dr. Krishnan, led the conversation. It was clear to Dee that the two psychiatrists were concerned that Dee would consider suicide again. This wasn't surprising to her, given her earlier statements about being unable to restrain herself from self-harm. But Dee wasn't, in truth, considering suicide. She also had no plans to harm herself. She had impulsively made up this story as a way to evade the police officer's questions about the crime she had committed, stealing from her girlfriend's mother. Dee was saying what she needed to say, and she figured she could outsmart the doctors.

People with antisocial personality disorder are often impulsive, taking action without thinking of the possible consequences (Lykken, 2019).

Later, a unit staff member brought Dee to the nurses' station, a large semicircular area enclosed in safety glass, where a half-dozen staff were busily typing patients' notes into the computers. Upon seeing Dee, a nurse exited the station, introduced herself, and took Dee to the dining area, down a long, bare corridor adjacent to the main TV room in front of the nurses' station. In the dining area, a nurse showed Dee how to acquire food and drinks, and where to throw her garbage away. Dee ate quietly next to another woman. The food was bland and soft, "like prison food," said yet another woman across from Dee.

After eating, Dee flopped down on her bed and buried her face in her pillow. An hour later, the resident psychiatrist, Dr. Krishnan, came by to give Dee a routine physical examination, which seemed to perk her up a little. Dee greeted the physician with a friendly, "Hi, Doc," and the doctor examined her heart, lungs, blood pressure, and other vital signs. To make conversation, he remarked on an "interesting" tattoo that Dee had on her arm, an obscure Celtic symbol. With obvious pride, the patient explained, "Yeah, I got it in honor of my mom." After the physician left, Dee donned her hospital pajamas, got into bed, and slept soundly through the night.

The next morning, she joined the other patients in the dining area, where breakfast was being served. As she took her place at the table, she announced that she was "hungry as a mule," and began eating demonstratively. After she finished her own food, she glanced over at a patient across the table and noticed that the man, a patient with schizophrenia, had only nibbled at his eggs and toast. "Hey, old-timer," Dee called out, "you don't mind if I take some of your feast, do you?" The man just stared, glassy-eyed, while Dee, without waiting for a response, took his plate and started scraping its contents onto her own dish.

Another patient sitting at the table reprimanded Dee for taking the older patient's food. "We're not supposed to share food. It's against regulations. Besides, that guy is pretty sick. He has been throwing up and hasn't eaten for days. You wouldn't want to eat anything he's touched."

Dee was unimpressed by that patient's disapproval. "You the unit police?" she asked. "I guess you want all the food for yourself. Well, sorry my guy, I beat you to it." The other patients watched the confrontation with curiosity. A few walked away fearfully. Several others stayed and kept their eyes on Dee. She was a sight to behold to them. Younger than them all, brash and full of personality, Dee commanded attention. And then there were those eyes. She had piercing blue eyes which moved quickly against light brown skin. Her mother was Scottish, also with blue eyes, and her father was biracial, his own mother from France and his father from Senegal. As a result, Dee and her older brother had caramel skin and wavy black hair, long limbs, and a tall thin physique. She was an imposing person to be around, and the other patients quickly found themselves in two camps: those who were afraid of her, and those who were compelled by her.

Later that morning, Dr. Krishnan arrived to meet with Dee. Dr. Krishnan found the young woman standing on the ottoman in the television area, holding court to several patients about how she could help them get their rights back. They felt trapped, stuck, stripped of their civil liberties by being held involuntarily. She picked up on this as a primary complaint from many of the patients that morning. As a way to ingratiate herself with them, she highlighted how they really had no choices, no rights, and how this was illegal and unethical. As soon as Dr. Krishnan approached, Dee looked up and smiled. She had an appealing, cheerful quality, and at first Dr. Krishnan wasn't sure who she was. She stood tall on the ottoman and spoke clearly and passionately. It reminded Dr. Krishnan of a time he was in Hyde Park in London, back in his medical school days, listening to the soliloquies of the Sunday morning Londoners on their soap boxes. Looking at Dee, he instinctively stopped and listened. Despite being admitted for suicidal ideation and threats, this patient was seeming more like a religious leader, full of emotion and energy. Dee turned around and saw him, then stopped her preaching and stepped down, extending the warmest, happiest greeting he had seen as a new psychiatrist.

"Hey, Doc. Good to see ya,'' she said. "I'm just shooting a little straight talk here." Dr. Krishnan explained that as Dee's doctor while she was hospitalized, he was hoping to meet with her each day. They walked back to her room together. Once inside, he asked Dee to take a seat and told her that he wanted to know all about the troubles she had been having and why she had been contemplating suicide. Dee confirmed that she was "real depressed" and didn't know if life was worth living. When the psychiatrist asked what she was depressed about, the patient replied, "Everything and anything." She went on to explain that it was mainly her girlfriend but, basically, she "just felt like giving up." She said, "Frankly, Doc, it's too painful to talk about." Dee didn't look particularly pained, however.

Dr. Krishnan told her that they would have to discuss these matters eventually, if she was to get any help. At this, Dee said she didn't think that talking would do any good. "Don't they have meds for depression?" she asked. "What's there to talk about when all I need is to take a pill to feel better? How about giving me some Prozac? Or Paxil?"

Most individuals with antisocial personality disorder are not interested in receiving treatment. Those who do receive treatment typically have been forced to participate by an employer, their school, or the law (Fisher & Hany, 2021; Black, 2020).

"Did you ever take Prozac?" Dr. Krishnan asked.

"Me? Oh, no."

"Did you ever take any psychiatric drugs?" he asked.

"No," Dee insisted, "This is my first time in the loony bin, or even talking to a shrink."

"How about street drugs? Did you ever try those?" the psychiatrist asked.

"To be perfectly honest with you, I have tried marijuana but who hasn't? I stay away from the harder stuff, though."

Because Dee would not discuss her feelings, Dr. Krishnan tried a different tack, asking the young woman about her living situation, work, and family. Dee replied simply that she had been living with her girlfriend, but "I suspect that is over after what happened." She explained that she had recently lost her job as a bartender in Willard-Hay after another employee had stolen money and blamed the theft on Dee. Dr. Krishnan tried to inquire more about that matter, but Dee said she was too upset to talk about it and was getting tired. She wanted to lie down and nap.

Before he departed, the psychiatrist asked her whether she was still having thoughts of suicide. Dee replied that she was feeling more secure now that she was in the hospital, and she was hopeful that Dr. Krishnan could help her. The psychiatrist explained that, in order to help her, she would have to talk more about her feelings. The patient promised that, in time, she would. She just had to develop "more rapport" with Dr. Krishnan first. She covered her face and started to cry, then turned away.

Dee lay down and put her head on a pillow, but then sat up as if having second thoughts. She said she really appreciated the time that the psychiatrist had given her, and hoped that they could talk more. As she spoke, Dr. Krishnan observed that Dee did not have any tears on her face and did not look sad. For a moment, he considered confronting Dee with what he had just seen, but he decided to wait until another time.

The next morning, Dr. Krishnan sought Dee for another visit. This time he found her seated in the dining area. She apparently was enjoying herself immensely, laughing loudly with another patient, while the other patients stared glumly at their food or into space. As he approached, the young woman looked up and greeted him with a cheery, "Hey, Doc! I'll be ready in a minute, as soon as I am done eating." The psychiatrist walked away and waited for Dee in his office behind the glass in a secure area, completing notes from his rounding.

People with antisocial personality disorder tend to respond to warnings or expectations of stress with low brain and bodily arousal, such as slow autonomic nervous system arousal and slow electroencephalogram waves (Fariba et al., 2021). This may help explain the inability of many such individuals to experience constructive levels of fear or to learn from negative experiences.

A few minutes later Dee walked up and asked the nurse at the desk if the doc was around. He came out, and they walked back to her room. Dee told Dr. Krishnan that he had upset her, that he had hurt her feelings by leaving her in the dining area, and that she didn't trust him. Going even further, she told him that she had thought he was a better doctor than that, but that he was probably just like all the other doctors too busy in the electronic medical record writing notes to spend time with his patients. "You chose to treat the chart, but good doctors treat their patients," she mused. The psychiatrist was momentarily dumbstruck. Dee was accusing him of dehumanizing her, when he was simply doing his job. "What were you thinking walking away from me?" she asked.

Dee explained that she didn't like it when people walked away from her. "Speaking of which," she added, "I can't take being cooped up in here all day and night. I know I was suicidal before, but I think I'm coming out of it. Can I have leave soon?" Then she went on, "Look, I'm sorry about being mean to you. It was stupid of me. I had a rough childhood, remember, I'm sure you've seen what I told them in the emergency room. So sometimes I get pissed when people walk away from me. I just want to be loved, you know, and ..." She trailed off. "And, what?" Dr. Krishnan asked. Dee closed her eyes and stayed quiet for a long time. "And, nothing. Just that. I've got no one, OK, a shitty, lonely, miserable life. But I promise not to kill myself, and that I am not thinking about suicide anymore."

Dr. Krishnan explained that in order to be discharged, she would have to discuss her situation more openly. Dee's attitude then changed, and she said she was ready to speak frankly. First, she apologized profusely for any trouble she had caused. She said that if she was sometimes disrespectful, it was a front she had developed out of fear that others might take advantage of her if she didn't act like she could take care of herself. She admitted to Dr. Krishnan that she had spent time in prison for a "stupid petty theft"; while in prison, she was bullied constantly because of her appearance. The Black inmates made fun of her for having white facial features and wavy hair. The white inmates taunted her with racist language. That experience had hardened her, she said, and now she sometimes lashed out at others, even among people who had her best interests at heart. The next day, Dee's mother Emily told her friend, Marlena, that Dee had returned. She recounted her experiences raising Dee. Even when she was a toddler it seemed like there was something wrong. "Her brother had been such a sweet boy, and we expected the same from Dee. But it never happened. She had a temper, was selfish, and didn't seem to care about others. Things got much worse when she was old enough to go to school. That's when the real trouble started."

DSM-5-TR requires that there be evidence of conduct disorder prior to the age of 15 in order to meet the diagnostic criteria for antisocial personality disorder.

At about the time that Dee entered first grade, she seemed to develop a "thing" for jewelry or, more accurately, for stealing it. For example, she would take items from Emily's jewelry case and sell them one by one to classmates or to older boys in the neighborhood, often for no more than pocket change, which she would spend on candy. Emily and her husband learned what Dee was doing after she tried to sell a pair of heirloom pearl earrings to her second-grade teacher for $50.00. Emily scolded her harshly. Her father spanked her with a belt. He beat her when she was caught stealing each time thereafter. He also beat her when she was disrespectful to him. Dee grew indifferent to her beatings. Emily was at a loss. She refused to lay a hand on her daughter, but at the same time she knew she had no control and hoped her husband's discipline would have an effect. Eventually, they decided that the only way to deal with the situation was to keep their valuables credit cards, jewelry, cash under lock and key in a safe.

Emily explained to her friend how they had provided Dee with a generous weekly allowance in an effort to reduce her desire for stealing. Unfortunately, it turned out that her desire could not be satisfied so easily. By the age of 10, Dee began breaking into neighbors' houses and cars to steal items to sell. In many ways, she became quite ingenious in these break-ins. She learned from a neighbor's older brother how to pick locks, disable alarms, and slip into small openings. At the same time, however, the way in which she would dispose of the stolen items often seemed remarkably careless and thoughtless, according to her mother. She tried to sell stolen goods to people in the neighborhood, sometimes the very people whose homes and cars she had broken into. It was obvious to them she was the thief. She thought it was funny that she could steal in daylight, walking into homes when people would be away at work or church. But the daylight also brought witnesses, and she would get caught. In addition, Dee had a big mouth, and was prone to boasting about her latest thefts.

Twin research has found that 67% of the identical twins of people with antisocial personality disorder also display the disorder themselves, in contrast to 31% of the fraternal twins of people with the disorder (Poore & Waldman, 2020; Waldman et al., 2019).

Her first arrest happened at age 11, but she was remanded to the custody of her mother, her father no longer in the picture after having left for another woman. Her mother told the judge that she would figure out a way to control Dee. She did indeed try to control her antisocial ways by keeping a more careful eye on her. When Dee went to school, for example, Emily would actually escort her into the building to make sure that she was attending classes. But the girl would smile, wave her hand, wait a few minutes, and then cavalierly walk back outside, inevitably to get into some kind of trouble.

Dee's stealing eventually took a more serious turn. She joined up with a group of teenagers who made a profession of shoplifting. They saw in Dee an opportunity to acquire stolen goods with a reduced risk of detection, since Dee was much younger and less likely to be suspected. Typically, the teenagers would case a store, locate items of interest, and then send Dee inside to remove the items according to their instructions. They would then sell the items in return for cash, marijuana, and alcohol.

One study found that middle school children who were attracted to antisocial peers went on to themselves engage in antisocial behavior in order to gain acceptance (Juvonen & Ho, 2008).

Associating with these older boys led Dee to develop more varied and sophisticated interests and a precocious sexual awareness. The turning point in her antisocial childhood came when, at age 15, she lured a 12-year-old neighborhood girl into an alley behind her house, undressed her, and tried to force her to perform oral sex on her. When the young victim started screaming, a woman came running outside and discovered them up against a fence. Dee at first claimed that the girl had tried to steal from her. When that didn't work, she offered the woman $20.00 "to keep her mouth shut." The woman refused and walked toward them. Dee threatened her, telling the neighbor she had better take the money or else "shit could go down!"

With this incident, Dee entered the world of serious legal trouble and was sentenced to a year in reform school (now called juvenile training centers). There, sadly, she learned more advanced methods of taking advantage of others. As soon as she was released, she began experimenting with auto theft. She learned how to hot-wire a car and would do so whenever she needed cash or transportation. Why take the bus, she reasoned, when there were cars all around? Dee's mother estimated that she hot-wired 50 cars before finally getting caught in the act, leading to another term in reform school, this time for 2 years.

When Dee was released, at almost 18 years old, Emily explained how she tried to persuade her to return to school and pay enough attention to her studies to get a high school diploma. The teenager agreed to attend school and promised she was a changed person. Her mother had accepted that her daughter likely could have ongoing legal problems the rest of her life. She blamed herself for not doing more and for marrying a man who beat her daughter. Emily tried to get Dee help from mental health professionals, but Dee always found a reason to not stay in therapy. The therapist was a "dumb shrink," a "bitch from the suburbs," "an old clueless dude," and so on.

According to research, the parents and close relatives of people with antisocial personality disorder have a higher rate of this disorder than do people whose relatives do not have this disorder (Alvarez-Garcia et al., 2019).

Emily was crying. Her friend Marlena gave her a tissue and kept listening. Dee barely graduated from high school and never found regular employment. At age 21, she was living from home to home, sleeping on couches or staying with a boyfriend or girlfriend. She knew how to be charming, especially to people she just met, and she would use this as a tool to gain access to a place to live, food to eat, and, of course, things to steal. It all came to a head when she was caught stealing a sports car one night outside a hockey arena. During the game, she wandered through the parking lot looking for the perfect car. She wanted to be challenged, felt bored, and knew there was a rush of excitement that came with each new vehicle she stole. An Audi S7 appeared before her. The closest source of light was several cars away, and she slipped into the darkness between vehicles, dropping low and using her gadgets to swiftly slide down the base of the window, disarming the alarm system, then opening the door. It was a hack she learned a year before, and this was the most expensive ride she had used it on. The door opened, and she went inside, removing the panel to use her well-honed skills to jump the ignition. She backed the car out and drove slowly down the aisle. Turning left, moving through the arena lot, she felt the rush she was seeking. In her mind, she was already counting the dollars that this car would yield. However, due to a combination of bad luck and carelessness, Dee was pulled over for speeding within blocks of the arena. At first, she attempted to flirt her way out of trouble as she had done before, but the officer didn't bite, and it eventually became apparent that she was driving a stolen vehicle when she was unable to produce a license or registration.

After awaiting trial in jail for several months, at age 22, Dee was sentenced to 3 years in a state penitentiary. Not being the violent sort, she was paroled after 18 months for good behavior. Upon her release, she went back home to see her mother. She knocked on the door, but no one answered. Dee made her way down to a local bar, where she would meet up with some old friends from the neighborhood. For the next few years, before ending up in the hospital by threatening suicide, Dee lived with various partners. Things didn't last long with any of them. She was fun at first, but would soon show her antisocial tendencies, selling drugs, robbing, or trying to con until she got caught. She had learned how to get what she wanted, but she couldn't trick people for long. Just as she always had since childhood, Dee seemed to repeatedly make mistakes and get caught. Emily concluded by shaking her head. "Marlena, my daughter is a criminal, but not a particularly smart one." Once back home, Dee tried to reunite with her girlfriend. They exchanged texts until finally her partner agreed to talk on the phone. Dee didn't love her, but she profusely apologized and professed her love. This was her pattern with partners. Dee showed no concern about the age, appearance, or character of the partner. Rather, her interest in them seemed largely a matter of housing, money, and, to a lesser extent, sex. No feelings of love or attachment were ever involved.

At the time that Dee had been admitted to the psychiatric unit, she was, her mother believed, in truly desperate straits. Emily suspected that in seeking hospital admission, her daughter had simply been looking for a place to stay, or had been running from something else. Now that Dee had landed in Emily's home following the hospitalization, the mother insisted that her daughter share the contact information for the therapist recommended by the psychiatric team. Dee gave it to her, knowing full well that her mother had no control over her and that by allowing her mother to believe she was able to control her, Dee could maintain the upper hand. She was trying to buy more time in the house while she tried to reunite with her girlfriend. Sure, her mother had said she could only stay a few days. But Dee was certain she would be able to find a way to stay as long as she wanted.

Emily demanded that Dee go to therapy. She threatened to kick her out and never let her return unless Dee contacted the therapist she was referred to by Dr. Krishnan and his team. Dee agreed to go. The therapist was a portly man with an expressionless face and a double chin. Dee thought he looked like a cartoon character. She couldn't take him seriously. He told her that he was interested in getting to know her, that they could take as long as needed, and that he wanted to know anything about her that she was willing to share. Dee obliged, treating the session like a game. She lied about everything she could, trying to use the things she saw in his office as cues to make up stories. It was a trick she saw on a movie once. It was her favorite movie The Usual Suspects and she had always wanted to try it out. At some point, the therapist caught on, but, hoping to gain Dee's trust, he decided to not confront her and played along, answering sympathetically as she tearfully improvised imaginary traumas.

Research finds that treatments for people with antisocial personality disorder are typically ineffective (Fisher & Hany, 2021; Black, 2020).

Dee never returned to therapy. "Mom, he was a dull fat man who didn't say anything. I don't think he had any idea what to say." Emily gave her a week to find another place to live. Dee left willingly when she was able to cajole a previous girlfriend into giving her a place to crash. This failure of treatment certainly did not surprise Emily, although it did cause her disappointment. After the psychiatric hospitalization and Dr. Krishnan's referral for therapy, Emily had briefly allowed herself to feel a glimmer of hope.

After Dee moved out, Emily saw her own therapist for a follow-up booster session. She shared her disappointment over this latest episode with her daughter. They had discussed Dee's behavior before, and her therapist was unsurprised to learn that Dee had been diagnosed with antisocial personality disorder it fit with the pattern of criminal behavior, lying, impulsive and reckless behavior, and callous disregard for others Emily had previously described. The therapist explained to Emily that although many people with this personality disorder exhibit criminal behavior, their brand of criminality is, like Dee's, often marked by idiosyncratic qualities. For one, their criminal acts often seem to be inadequately motivated. The individual may, for example, commit a major crime for very small stakes. In this regard, Dee's mother recalled that Dee tried to sell her pearl earrings for far less than they were worth when she was younger. Also, the criminal acts of these individuals often seem to be committed without much sense of self-preservation. They may fail, for example, to take obvious precautions against detection when carrying out their crimes. Here, again, Emily recalled Dee's attempts to sell items to the very source from which they were stolen.

In short, Dee showed the disorder's classic overall pattern of long-standing antisocial behavior, dating from childhood, aimed largely at the immediate gratification of transient desires. Her behavior did not seem to be deterred by any sense of shame, remorse, or even plain self-interest.

Sympathizing with Emily's disappointment, her therapist told her that, unfortunately, today's clinicians have generally despaired of devising an effective treatment for antisocial personality disorder. There is a treatment known as moral reconation therapy, a cognitive-behavioral technique that aims to teach patients to apply moral reasoning to their decision making. However, this technique is normally used in prison settings, and the prognosis for outpatient therapy is not good. Perhaps the main reason for this limited success is that people with the disorder, by definition, have no recognition that their behavioral pattern is problematic. They usually reject the value of or need for psychological treatment, and so they are unlikely to initiate it or adhere to it for very long.

Studies have not typically found that efforts to improve a person's moral thinking in daily decision making, as practiced by some cognitive-behavioral therapists, are particularly successful in the outpatient treatment of antisocial personality disorder (Black, 2020).

Unfortunately, many clinicians have concluded that currently the single greatest hope for improvement in this realm may lie either with treatment during incarceration or with the simple passage of time. It appears that a number of adults with this pattern, who often begin a criminal career as teenagers, significantly reduce their level of criminal activity after age 40. That is, they experience fewer convictions and serve less time in prison as they grow older. The reason for this shift remains unclear, but, as Emily's therapist described, it may be that antisocial behavior "burns out" somewhat over time. Emily was grateful to see her therapist again, and she drove home feeling some hope. Dee was off into the world again, likely repeating the same kinds of behaviors as she had since childhood, but maybe in time Emily's daughter would make some improvements and find some peace.