Exploring Therapists’ Emotional Responses with Individuals Diagnosed with Antisocial Personality Disorder: A Scoping Review

Abstract Aims: To provide a review of journal articles on therapists’ emotional responses (i.e., countertransference) when treating individuals with antisocial personality disorder (ASPD) and/or psychopathy. A secondary aim is to explore therapists’ experiences and perspectives on the clinical management of these individuals. Methods: A scoping review was conducted according to PRISMA-ScR guidelines. A systematic search was performed in PubMed, Web of Science, and EBSCO/PsycINFO for studies published between January 1, 1990, and December 6, 2023. Eligible studies included therapists providing clinical care to individuals diagnosed with ASPD or psychopathy using standardized and validated tools, focusing on their cognitive, emotional, and behavioral responses. No restrictions were applied regarding context, location, or study design (protocol: https://osf.io/eaquj). Results: Twelve studies were included, predominantly from Europe, with most focusing on therapists working with individuals with ASPD. Only two studies examined psychopathy. Key findings were categorized into four main concepts: (a) “common emotional responses of therapists”, which included nervousness, fear of aggression, detachment, and frustration when working with these individuals; (b) “willingness to deliver clinical care”, indicating the key role of therapists’ confidence in their knowledge and skills when delivering psychological treatment. Motivation to provide care was higher among therapists working in forensic settings compared to those in non-forensic settings; (c) “emotional responses related to misogynistic behaviors”, related to the additional challenges reported by female therapists working in group therapy settings; (d) “opinions about clinical management and therapeutic alliance”, which emphasized effective treatment relied on respect, recognition, and the ability to maintain flexible yet firm boundaries within the therapeutic relationship. Conclusion: Working with individuals with ASPD poses significant emotional challenges for therapists, emphasizing the need for specialized training and supervision to enhance their skills and confidence. The lack of cohort studies and randomized controlled trials examining therapists’ emotional responses toward individuals with ASPD represents a gap in the literature that should be addressed in future research. Moreover, the limited evidence on psychopathy highlights the need for further investigation.