Treatment of psychopathy: oxymoron or clinically feasible?

by Joye C. Anestis

The treatment of psychopathy - seems like an oxymoron, right?  The very nature of psychopathy makes it seem like something that's not very amenable to treatment.  Can you remedy traits like pathological lack of empathy, lack of emotionality, lack of guilt and remorse?  Or can you at least change the behavioral manifestations of those traits?  In this article, I will review the psychopathy treatment literature to determine if these assumptions are true (see my previous post for clarification about what psychopathy is).

Before delving into this discussion, it is important to note that none of the treatments referred to below are considering empirically-supported treatments for psychopathy.  The psychopathy treatment literature contains multiple methodological problems (e.g., few control groups, lack of proper assessment), rendering it difficult to draw many firm conclusion.  Furthermore, there have been no rigorous randomized controlled trials for psychopathy.  We are a long way from establishing best practices for dealing with psychopathic clients.  Also, unless otherwise noted, the treatment discussed below are for adults only.  For a more in-depth discussion of this topic, see Harris & Rice's (2006) excellent chapter in Patrick's Handbook of Psychopathy.

• Therapeutic communities for offenders.  The theory behind the therapeutic community for the treatment of psychopathy is that perhaps a reshaped social milieu might alter the deviant personality characteristics and social behavior of the psychopath.  The composition of these therapeutic communities are often similar to inpatient rehabilitation facilities for substance abuse/dependence, and they have been attempted in prison, hospitals, and other institutions.  Several studies have been conducted to evaluate the utility of these communities in reducing recidivism (i.e., re-offending).  Rice, Harris, & Cormier (1992) matched 146 treated offenders with 146 nontreated offenders.  Almost all of these offenders had a history of violent crimes.  They used the Psychopathy Checklist-Revised (PCL-R; Hare 1991, 2003), considered to be the "gold standard" measure of psychopathy with incarcerated individuals, to assess psychopathy.  The study reports results after following these offenders for an average of 10.5 years.  They found that for nonpsychopaths, the treatment was effective - this group had lower violent recidivism than the nontreated group.  However, the treated psychopaths had higher rates of violent recidivism than the nontreated group.  These were very provocative findings, and the conclusions drawn from these results were/are disturbing.  In this study, it appears that both the nonpsychopaths and the psychopaths who received treatment learned more about things like emotions, empathy, the use of emotional language, being socially skilled, and the delay of gratification.  The nonpsychopaths used these skills to adjust socially and behave in prosocial manners.  The psychopaths appeared to usemthese skills to become better psychopaths, learning new ways to manipulate and exploit.  Other studies in different therapeutic communities have found that therapeutic communities at the least result in no improvement and at the worst are iatrogenic (Hobson, Shine, & Roberts, 2000; Ogloff, Wong, & Greenwood, 1990; Richards, Casey, & Lucente, 2003).  Thus, it appears that a treatment in which psychopaths learn more about emotions and appropriate social behavior enables them to be more skilled in their deviance.

• Cognitive-behavioral approaches for offenders.  Studies examining cognitive-behavioral approaches in the treatment of psychopathy are not any more promising. Seto & Barbaree (1999) found that, in a sample of sex offenders, those high in psychopathy who were rated as showing the most improvement were more likely to reoffend, especially in violent ways.  Hughes, Hogue, Hollin, & Champion (1997), using a psychiatric inpatient offender sample, found that the higher the PCL-R score, the poorer the treatment gains.  Hare, Clark, Grann, & Thornton (2000) reported that psychopathic offenders who received treatment had significantly higher rates of recidivism than nontreated offenders.

So what do we do with this discouraging news?  For those out there who are grappling with how to handle a psychopathic client, Harris & Rice (2006) offer a number of suggestions for reducing the harm produced by psychopaths.  It is important to note that their treatment recommendations have not been studied in psychopathic sample, so while they seem like reasonable techniques to try, their efficacy has not been established.

• Behavioral modification.  A variety of studies (including a meta-analysis of meta-analyses) support the use of clear behavioral contingencies to modify a wide variety of behavior (e.g., Lipsey & Wilson, 1993).  There is no reason to believe at this point that this would be an iatrogenic method by which to modify deviant behaviors in psychopaths.  In fact, token economies can effectively be implemented across facilities (e.g., an entire prison).  In this manner, reinforcement principles could reinforce the manifestation of psychopathic tendencies into more socially acceptable ways.
• Multisystemic therapy (MST).  MST has been shown to be highly effective for juvenile delinquents and has demonstrated efficacy in RCTs (Borduin, Schaeffer, Ronis, & Scott, 2003; Brown, Borduin, & Henggeler, 2001; Brown et al., 1997; Randall & Cunningham, 2003; Weisz, 2004).  MST is based on a systems theory of criminal behavior: that adolescent criminal activity is a natural response to the system in which the adolescent operates.  MST is very flexible and individualized, addressing problems within the specific systems each adolescent experiences.  Although MST has never been used in adults, it seems reasonable to hope that it can work in adult psychopaths.  Perhaps psychopathic behavior is maintained because opportunities are favorable for the occurrence of such behavior (Harris & Rice, 2006).  By invoking consequences and monitoring into these systems, perhaps the psychopathic behavior will decrease.

Finally, Harris and Rice (2006, pp. 567-577) offer the following recommendations for novice forensic clinicians encountering psychopathic clients:

1. Read Robert Hare's Without Conscience: The Disturbing World of the Psychopaths Among Us .
2. "Reputation matters..."
3. Do no rely solely on the offender's account of events.  Confirm his/her statements against records and other informants.
4. Pay attention not only to how he/she behaves toward you but how he/she treats everyone (e.g., peers, staff, family).
5. "Beware of flattery."
6. Be suspicious if the client asks you to break any rule or to maintain a confidence about something illegal.
7. Consult with trusted colleagues about your relationship with the client.  Beware if others are suspicious.

We already knew from my previous post that psychopathy is a pernicious and devastation personality syndrome.  So far, the clinical psychology world has not figured out an acceptable and efficacious way to treat these individuals and, if not remove their symptoms, at least redirect their manifestation.  There are many hypothesized reasons for this failure.  One primary problem is the nature of the beast at hand.  Psychopathic individuals rarely, if ever, present for treatment voluntarily.  Additionally, many researchers argue that psychopathy is actually an evolutionarily viable life strategy (e.g., Harris & Rice, 2006).  From this point of view, nothing is "wrong" with them in the manner of a deficit that therapy can "fix."  Another problem with the identification of treatments for psychopathy is the nature of the research.  Very few adequate studies have been conducted, leaving the clinical world scratching its head about exactly what to do.  Many studies using random assignment and control groups are needed before we can feel confident about best practices with this condition.  As of now, the conclusion to be drawn is that treatment of psychopathy seems to be an oxymoron - in fact, the treatments that have been attempted were iatrogenic.  They resulted in an increase in deviant behavior.  But we are learning more every day...

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.