Psychopathy Treatment

Psychopathy treatment is a controversial and underinvestigated area of study. Many researchers and clinicians have suggested that the pervasive and manipulative nature of the disorder makes it unlikely that psychopathic individuals can benefit from treatment. It is of concern that the primary characteristics of psychopathy (e.g., manipulation, deceit, and shallow affect) result in low treatment compliance and efficacy. To elaborate on this point, Ivan Zinger and Adelle Forth (1998) contend that the pessimistic views of treating the psychopath derive from three primary sources. First, Hervey Cleckley’s description of the psychopath’s inability to form affective relationships considered necessary for effective treatment was influential. Second, psychopaths who cause substantial harm to society tend to decrease the compassion of clinicians, thereby reducing therapist motivation. Third, serious personality disorders have often been considered intractable by many clinicians. Zinger and Forth also argued that these views are entrenched in the minds of both mental health and legal professionals, resulting in few objective efforts to examine treatment amenability in psychopaths. Despite these early concerns, recently there has been renewed interest in examining the treatment of psychopathy, as some researchers believe that treatment gains are possible if the modality and dosage of treatment are suited to the disorder. Recent advances in the treatment of other personality disorders also spurred a renewed interest in the treatment of psychopathy. Although contemporary research suggests that the field has been overly pessimistic about the prognosis for treating psychopathy, there are few well-controlled studies on the topic. It is therefore difficult to draw firm conclusions either way with respect to treatment outcomes.

Randy Salekin first shed light on the psychopathy-treatment relation by conducting a meta-analysis on 42 studies. The results of that study indicated that psychopathic individuals could show some benefit from psychotherapy; however, the treatment had to be intensive and typically involved both the psychopath and family members. Although the quality of the studies in the meta-analysis was somewhat limited, the review underscored two important points: (1) there was no evidence for psychopathy being considered an untreatable disorder and (2) there was a need for a second generation of research on the topic. Salekin’s review and meta-analysis also highlighted several problematic areas that would need resolution before the field could move forward with a more informative generation of research. These problems included definitional concerns, an unclear etiology of psychopathy, and few controlled treatment-outcome studies. Each of these concerns is reviewed in further detail below.

Defining Features of Psychopathy

Most problematic has been disagreement about the conceptualization and defining features of psychopathy. Hervey Cleckley offered a well-accepted early version of psychopathy. However, this version was replaced in the Diagnostic and Statistical Model (DSM) with a behavioral model for antisocial personality disorder. Lee Robins and Robert Cloninger suggested that antisocial personality disorder (i.e., psychopathy) might be best measured by examining behavior rather than personality because the assessment of personality was less reliable. Robert Hare offered a two-factor model for psychopathy that incorporated both Cleckley’s personality model of psychopathy and behavioral aspects similar to those outlined in Robins and Cloninger’s work. While these theorists purport to be assessing the same construct, the items of each model differ significantly, complicating the psychopathy (antisocial personality) treatment-outcome question. That is, depending on the model used, psychopathy might be more or less treatable. However, there is little in the way of systematic research to shed light on the treatment potential for each of the different models.

Whatever the chosen model, current diagnostic systems (e.g., DSM-IV-TR [fourth edition, text revision], International Classification of Diseases, 10th revision [ICD-iO]) use cutoff points for diagnosing disorders, resulting in various permutations for a given disorder. This is pertinent to psychopathy research and practice because certain characteristics might be more resistant to treatment. For instance, “absence of nervousness,” “manipulation,” “deceitfulness,” or other factors might be of most concern for treatment. To elaborate on this point, absence of nervousness, a cardinal feature of early definitions, may generate the hypothesis that psychopathy is difficult to treat; however, because the cutoff scores are set low on some measures (DSM-APD [antisocial personality disorder]) and moderate to high on others (PCL-R), it might mean that some individuals classified as having the disorder do not exhibit the trait that would make them less amenable (absence of nervousness). Of equal concern, because few contemporary measures of psychopathy incorporate this feature, it is possible that newer indices may identify individuals who are amenable to treatment, even though they might be labeled as psychopathic. Thus, the mix of psychopathic characteristics could be very important in making determinations of amenability (unamenability).

Even if all symptoms were to be accorded equal weight in the amenability question, it is difficult to know at what point individuals become unamenable to treatment. It is also not clear from other disorders (e.g., depression) that endorsing all possible symptoms results in a more untreatable condition. Even assuming that higher-scoring individuals are less amenable to treatment, there are no data to suggest that individuals scoring more than 30 on the PCL-R (the cutoff score most often used for adults) are the worst candidates for treatment. Assessment with such instruments rests on the assumption that all criteria carry equal weight (and this may not be the case as noted above) and that any combination of items that exceeds a predetermined cutoff score is sufficient to warrant diagnosis (and presumably a conclusion that the individual is unamenable to treatment). Thus, even the use of dimensional scores that may reflect degrees of treatment amenability (or unamenability) is not well tested. And, as mentioned, if items are not of equal weight in answering amenability queries, such a perspective would not alleviate the potential for particular symptoms to have more or less effect on treatment amenability.

Etiology of Psychopathy

The etiology for psychopathy is not well understood. Even for proposed theories, the specific linkage between etiology and treatment is not always well developed or articulated. What we do know is that the majority of prominent theories suggest a predisposition to the disorder. Specifically, temperamental style, low fearfulness, deficiency in psychopathy constraint, or a similar deficit, are frequently mentioned. Psychopathy researchers have also begun to show a genetic link to the disorder. Other theories suggest that psychopathy develops through a specific set of environmental conditions (e.g., poor attachment due to maltreatment). There is little in the theories themselves, however, even those emphasizing genetic factors, that could rule out the potential for treatment.

In sum, theories regarding the etiology of psychopathy suggest that psychopathy may develop through predisposition, harsh environmental conditions, or the interaction of temperament and environment. Even individuals with a particular temperamental style interact with others in ways that can foster either detachment and aggression or attachment and prosocial behavior. Moreover, the acceptance of linear deterministic theories that ignore the potential multiple factors that affect the development of psychopathy and are unable to account for the complexity of psychopathy symptoms will not be helpful in designing treat-ment programs. Specifically, theories that focus on only one component, or aspect, of psychopathy (e.g., frontal lobe dysfunction, deficiency in serotonin, response modulation) without explicating other manifestations (e.g., superficial charm, good intelligence, manipulation) are overly simplistic. Theories will have to be more encompassing when accounting for the symptoms of psychopathy because theory hints at methods and targets for intervention. For example, many of the current theories point toward parental practices and contextual factors as targets for potentially successful intervention. Or some theories suggest notifying psychopaths of their deficits in therapy so that they can begin to try to alter them.

Treatment-Outcome Studies of Psychopathy

Another area of concern with respect to the treatment of psychopathy is that there are not many well-controlled treatment-outcome studies. The meta-analysis mentioned earlier showed that there may be some treatment effect for psychopathic individuals. Specifically, treatment may be beneficial if it is intensive and of long duration. This meta-analysis also found that youths evidenced the most gain from psychotherapy and that incorporating family and other support groups into treatment appeared to be helpful. This review and meta-analysis suggested that, like individuals with other disorders, psychopaths probably show moderate and incremental change over time rather than a complete transformation. Although this study suggested that a second generation of research was needed on this topic, few subsequent studies have been conducted. Specifically, very few studies have systematically examined the treatment response differences between psychopaths and nonpsychopaths. In those that have, psychopathic traits tend to be seen as predicting early termination or poor treatment performance rather than targets for intervention themselves. This is particularly evident in the substance abuse literature, where the primary intervention target is substance use rather than psychopathy or psychopathic traits, even after numerous studies have demonstrated that psychopaths show fewer treatment gains using traditional interventions for substance use. Despite the limitations, these studies have a few hopeful findings that deserve greater attention. First, several programs found some positive benefits from treatment, even for individuals with high levels of psychopathy. Second, longer, more intensive treatments generally showed better effects, consistent with the view of psychopathy as a pervasive and destructive personality disorder.

The primary conclusion we can draw from past work in this area is that much more intensive and thoughtful research is needed if we are to further facilitate practice with psychopathic individuals. At present, there are few specific programs designed for treating psychopathy itself, and there are mixed findings regarding behavior and compliance while in treatment. It would be naive to conclude that treatment would not be difficult, particularly given what we know about the treatment of other severe forms of psychopathology; however, it is equally naive to conclude that psychopaths cannot benefit from treatment simply because of the complexity of the disorder. Working between these two extremes, the literature reviewed above indicates that more research is needed to study the risk, protective, and causal factors of psychopathy as well as to begin intervention development. Ultimately, the goal should be to test the efficacy and effectiveness of informed treatment programs.

Directions for Future Studies of Psychopathy

In many clinical settings, psychopaths are seen as untreatable despite a lack of scientific support for this claim. Three problem areas are clear from the research that exists on the topic. First, classification is a critical issue with regard to treatment. Further clarity regarding the features of the disorder is necessary to accurately assess treatment amenability. This clarity can be gained in part by specifying the conceptualization of psychopathy used in treatment-outcome studies as well as the specific symptomatology present that makes it difficult (or easy) to treat them. Also necessary for understanding treatment effectiveness is work on the temporal stability of psychopathy. Few studies have examined the psychopathy-treatment relation from contemporary concepts of the disorder or compared treatment effects across broad models. In a meta-analysis by Salekin, the Cleckley psychopath was the most frequently investigated conceptualization of psychopathy in treatment-outcome studies, yet most current research uses Hare’s conceptualization of psychopathy. Given that his definition differs from Cleckley’s, treatment-outcome studies that employ this definition are necessary, particularly if psychologists are to make statements about treatment amenability based on the PCL-R.

Third, to better understand the psychopathy-treatment relation, several issues should be addressed in future studies. Treatment programs specifically aimed at reducing psychopathic characteristics should be developed and ought to be based on theory regarding the etiology and maintenance of psychopathy. These studies should be controlled and systematic to determine the effectiveness of different treatment modalities. For example, researchers should use psychopathy instruments pre- and posttreatment to examine the changes in symptom level, and raters should be blind to previous scores or intervention group membership. These studies should also investigate whether external criteria, such as recidivism and conduct problems, are reduced following treatment. This type of information would inform psychologists whether there is evidence that psychological change implies reduced risk of re-offending. In addition, in light of the characteristics of psychopathy, research needs to evaluate the possibility that clients are “faking good” rather than showing evidence of substantive changes in psychopathic traits.

In sum, the literature on the treatment of psychopathy has changed from pessimistic to cautiously optimistic with the notion that carefully designed and focused interventions may be able to produce measurable change in psychopathic individuals. Through careful design and evaluation of treatment intervention programs, it is hoped that the second generation of research on treatment outcomes will allow for earlier, more effective intervention with psychopathic individuals to reduce the high societal cost of persistent offending. The eventual goal should be to use theories of etiology to initiate prevention and intervention efforts before the development of the disorder causes the individual, and society, substantive harm.

References:

1. Cleckley, H. (1941). The mask of sanity. St Louis, MO: Mosby.
2. Cloninger, C. R. (1978). The antisocial personality. Hospital Practice, 13, 97-106.
3. Hare, R. D. (2003). The Hare Psychopathy Checklist-Revised (2nd ed.). Toronto, ON, Canada: Multi Health Systems.
4. Robins, L. N. (1966). Deviant children grown up: A sociological and psychiatric study of sociopathic personality. Baltimore: Williams & Wilkins.
5. Salekin, R. T. (2002). Psychopathy and therapeutic pessimism: Clinical lore or clinical reality? Clinical Psychology Review, 22, 79-112.
6. Salekin, R. T., Rogers, R., & Machin, D. (2001). Psychopathy in youth: Pursuing diagnostic clarity. Journal of Youth and Adolescence, 30, 173-195.
7. Zinger, I., & Forth, A. E. (1998). Psychopathy and Canadian criminal proceedings: The potential for human rights abuses. Canadian Journal of Criminology, 40, 237-276.

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