This difficult-to-treat group almost never reports to therapy on their own initiative. Once in therapy, they are likely to belittle the therapist and may even be overtly hostile. A therapist who responds negatively is likely to be perceived as weak, and they use this perception to discount therapist interventions. In addition, they typically lack insight into their behavior and can even be indifferent to the damage they inflict. Cognitive interventions are unlikely to be successful because their thought patterns are quite rigid. Potentially useful approaches might be anger and impulse management programs, developing assertive as opposed to hostile communications, and persuading them to see that changing some of their more problematic behavior is actually in their own self-interest.