ABSTRACT
Psychoanalysts tend to make their diagnostic formulations by beginning treatment. The interaction between themselves and their patients, principally through transference and countertransference, provides them with a sense of the patients’ personality organization and their amenability to treatment. This reversal of the medical model—which calls for diagnosis first, treatment second—also captures the evolutionary history of our understanding of psychopaths. Psychoanalysts have studied the psychic architecture of psychopaths during the past century by continuous interaction with them through treatment efforts. Relatively recently we have begun to make diagnostic formulations, both clinical and empirical, to spell out similarities and differences when such patients are compared to various other groups of narcissistic individuals.
