Morality and the treatment of the character disorders

Abstract

Persons with character disorders?the alcoholic, the homosexual, the drug addict, and the sociopath?present some of the most difficult treat ment problems for the psychotherapist. Their behavior and personalities also provoke some of the most problematic feelings in the psychothera pist. The aim of this paper is to examine our moral concepts involved in a psychotherapeutic view of these patients. One of the crucial elements in the training of the psychotherapist is learning to see beyond behavior and the presenting personality, to see the basic human being and learn how to respond in helpful fashion to him. Yet it is remarkable that, when faced with a person whose trouble is known as "character disorder," psychotherapists experience great dif ficulty in maintaining a "therapeutic attitude." A psychiatrist conduct ing research on alcoholism said to me, "I don't want ever to see another dirty alcoholic." A clinic director said, "We just aren't interested in treating homosexuals." Another therapist remarked, "The guy was nothing but a rotten sociopath." Such remarks are not atypical of ex perienced clinicians, much less uncommon among young therapists. One might be tempted to explain such negativistic reactions as due to the facts that character disorders are indisputably difficult to treat, that persons afflicted with them are often obnoxious and obstreperous, and that the therapeutic success rate is not high. However, several things show that these are not the only factors involved. First, the negative reactions of psychotherapists are usually not uttered as a reasoned scientific evaluation, but are expressed with vehemence, disdain, sarcasm, or condemnation. Second, other patients with severe psychiatric disorders do not elicit the same type of con temptuous rejection, even though they may be as difficult, or more so, to treat as the character disorders. Indeed, in his system of classification