Reid Meloy, on treating psychopathy:
It is the stereotypical judgment that all psychopathically disturbed individuals, or antisocial personality disorders, as a class, are untreatable by virtue of their diagnosis. Such a judgment ignores both individual differences and the continuous nature of severity of psychopathology. I have most commonly observed this reaction in public mental health clinicians who are assigned patients on referral from probation, parole, or the court; and assume, because of the coercive nature of the treatment referral, that ... any psychotherapeutic gain is impossible. Such reactions are often the product of attitudes that have been internalized as an “oral tradition” during training from senior, teaching clinicians. They are rarely the product of direct, individual experience. It is, in a sense, a mass retaliatory attitude where moral judgment impinges on professional assessment. The behavioral pathology of the psychopath, to devalue and dehumanize others, becomes the concordant identification of the clinician doing to the psychopath what the clinician perceives the psychopath doing to others.
I haven't had any treatment successes with patients who have a psychopathic personality organization. I've actually seen relatively few and none recently in my practice. Most often, when I was consulted, it was to placate a girlfriend who gave the patient an ultimatum or because the patient had a court date pending. IIRC, in all but one case, those I saw came for no more than two or three sessions, sufficient time to feel superior to me. Their maneuvers were interesting. One wealthy patient asked me on his way out the door after his first session: "Where do you live, Kenilworth?"
The question reflected more than idle curiosity on the patient's part. I was a young therapist and my hourly rate wouldn't remotely put me in house in Kenilworth, a small, wealthy enclave on Chicago's North Shore. And though the question might not sound like a big deal, there was something in his offhand delivery after an entire session of attempts to diminish me that caught me off balance and left me feeling inadequate. I was very far from the possibility of living in Kenilworth, and we both knew that to be the case. He had established with me the extent of his enormous wealth during the session and now he wanted me to experience, front and center, my own insecurities and sense of inferiority as a young psychologist.
The power of such a question might be difficult for those who haven't sat in the psychotherapist's chair to appreciate, but I'm sure my psychotherapist readers know what I'm talking about. For psychopaths, it's all about establishing absolute superiority over others. It isn't just the words they use; it's their keen sense of vulnerabilities and a delivery that goes beyond mere words. It's a predatory posture, sometimes unvarnished, and sometimes wrapped in charm.
Now, somewhere deep in the adult psychopath, there exists an unbearable, weak, victimized self, but the psychopath long ago learned to completely avoid this aspect of inner experience through a reliance on projective identification--inducing in others the thoughts and feelings he cannot himself bear to experience. They are masters of this psychological defense, turning relations with others into relations between a predator and its prey.
I read Meloy's book a couple of years after it was published but, without ongoing cases and supervision, I don't feel I can work productively with psychopaths. I can't say I know from personal experience, but I wouldn't be surprised to learn that in the one place a therapist could gain this experience--the penal system--there is a tendency to reject the idea of psychotherapy for psychopaths, just as Meloy says. I don't think there are many clinicians who can handle the experience of the work without burning out or withdrawing investment in the therapeutic endeavor. So the psychopaths become "bad patients," just as I saw patients with borderline personality organizations become "bad" patients in the eyes of staff members in psychiatric hospitals. My hat is off to anyone who does this work without succumbing completely to the challenges it entails.