Treatment and psychopathy in forensic settings
Introduction
Do psychopathic offenders respond to treatment? For decades, clinicians and therapists held the view that the answer was probably “no” (Salekin, 2002). In this review, we will argue that the tide may be turning: there are a number of tentative signs that the treatment of psychopaths can be successful. However, a substantial barrier to progress lies in the confusion about what psychopathy is and how to measure and define it. We begin by considering the conceptualization and measurement of psychopathy, and the relevance of this work to understanding, designing, and evaluating treatment for psychopaths. Next, we review research on the treatment of psychopathy, beginning with key studies that generated and maintained pessimism before examining more recent encouraging research on psychopaths in treatment. Finally, we discuss whether psychopathy itself can be treated, concluding that this topic warrants more attention, both from treatment providers and researchers, and suggesting some foci for future attention.
Section snippets
What is psychopathy? Conceptualizing, diagnosing and measuring
An ideal model of psychopathy treatment would follow from a clear understanding of what psychopathy is and is not. From this position, we could develop enhanced understanding of its etiolog(ies)—crucial to meaningful treatment design—and a variety of methods for measuring and diagnosing it. In correctional psychology in recent years, curiosity about what psychopathy is appears predominantly to have been bypassed, as if the issue was settled. Instead, we have moved on to a discussion of how to
Clarifying conceptual confusion using the triarchic model of psychopathy
Recently, Patrick et al. (2009) proposed a triarchic model of psychopathy, with the aim of clarifying the complex nosological issues in which psychopathy is mired. According to Patrick et al.'s model, psychopathy represents the intersection of three distinct phenotypic constructs. Taken together these three constructs “represent the key to understanding psychopathy in its varying manifestations: criminal and non-criminal, primary, and secondary…” (p. 925). These constructs are disinhibition,
Negative treatment perceptions: A brief history
Negativity about the possibility of treating psychopaths, or for that matter, of their ability to change at all goes back to at least the time of Hervey Cleckley. The most influential historic figure in modern understandings of psychopathy reluctantly concluded toward the end of his career that psychopaths were untreatable, writing in the introduction to the 5th edition of The Mask of Sanity:
I have had the opportunity to see patients of this sort who were treated by psychoanalysis, by
Does treatment reduce psychopathic traits?
Reducing criminal behavior should be the main policy focus for PCL-psychopathic and other criminally high-risk people treated in criminal justice settings. However, is there any direct evidence that these newer more criminal behavior-oriented interventions are also altering the core interpersonal and affective traits of psychopathy?
In a word, no; there is no direct evidence yet in adult populations of change on criteria used to diagnose psychopathy. In fact, we know of no research that
Can psychopathy be treated?
If psychopathy itself is to be treated effectively, it must be capable of change. Is there any evidence that psychopathy—rather than the criminal behavior of psychopaths—changes over time? There has been little relevant research with adults. Harpur and Hare (1994) found that PCL-R F1 scores were similar in younger and older offenders, but F2 scores were lower in older offenders, suggesting a reduction in crime-related disinhibitory psychopathology consistent with the age–crime curve. However,
Conclusions
The developing field of treatment for high-risk offenders (see Caldwell and van Rybroek, 2013, Olver and Wong, 2013, Polaschek, 2013) is starting to bear fruit. Since offenders identified as high-risk have high PCL-R/SV scores, this research suggests that relatively psychopathic offenders can benefit from treatment, showing similar reductions in criminal risk to those of less psychopathic participants, and similar amounts of change on treatment targets linked to that risk, (e.g., Olver et al.,
Implications for treatment and research development
The successful treatment of psychopaths remains a fledgling endeavor; recent scientific evidence is tentatively encouraging; many important questions await investigation. Notable experts in the field are unsure about the extent to which the personality traits related to meanness, boldness, and disinhibition require direct attention, or should be simply “worked around”. Different programs have taken slightly different approaches and we must await the outcome data. There exist good arguments for
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