Written by Alicia Spidel and the Research Committee
This article examines whether psychopathy is an untreatable mental health condition. It reviews previous research on the treatment of psychopathy in adults and youth. The review demonstrates that treatment in adults has been found to have low or moderate levels of success. However, treatment of youth was found to be more promising. The authors suggest that making distinctions about the treatability of individuals based on whether or not they have psychopathic characteristics is inappropriate. The article provides some directions for future research and briefly introduces the mental models approach, which may be used in the treatment of psychopathy in youth.
Overall summary:
This article first reviews the changing perceptions of the effectiveness of treatment (psychotherapy). Research evidence is provided to note that psychotherapy is not only efficacious but also effective. Research is listed to show that (a) individuals have benefited from psychotherapy, irrespective of the type of therapy or outcome goals, (b) long-term therapy produces better results than does short-term therapy, (c) psychotherapy is as effective as medication when used to treat depression and anxiety, (d) psychotherapy may be able to stave off further bouts of depression and anxiety, (e) psychotherapy has positive results for individuals with personality disorders, and (f) psychotherapy has been found to be effective for children and youth.
The article then moves on to look at the current perception of treating psychopathy and the flaws within this perspective. Two key points are provided: (a) the authors note that the shift in perception of psychotherapy from it being unhelpful to it being an effective treatment is important when considering the current perceptions of treatment for psychopathy. The authors reflect on how increased research into the effectiveness of psychotherapy proved its value. The same applies for psychopathy: more research is needed to determine whether it can be treated. (b) It is noted that psychopathy is currently perceived to have some form of biological basis, such as genetics passed down the family line. However, the authors note that many mental health conditions, such as depression, can have biological factors too. As a result, it is inappropriate to consider psychopathy as being untreatable based on not having enough research in the field or by assuming that it has a biological basis.
Evidence in favor of psychopathy being perceived as a treatable disorder is then reviewed. Using research from surveys, it is noted that the majority of mental health professionals perceive psychopathy to be a treatable condition. The authors also note that research on psychopathy has identified it to exist on a spectrum. This means that different individuals can vary in their degrees of psychopathic traits.
The main part of the article then focuses on treatment and psychopathy, and the aims are divided into five sections.
Section 1: Definition of and conceptual differences in psychopathy
The definition of psychopathy was previously based on personality features but the definition of Antisocial Personality Disorder outlined in the DSM-IV (American Psychiatric association, 2000) focused on behavioural characteristics. It was believed that behavioural characteristics, such as irresponsibility and recklessness, are linked to personality features of psychopathy. Hare (1991/2003) offered a model for psychopathy that included components of both personality features and behavioural characteristics. Research in the field suggests that it is difficult to examine the treatment of psychopathy as there is a lack of consensus on how it is defined, and because the different assessment tools and methods used to assess it are not comparable to each other.
Since the 1970’s, there has been more research in the field examining the structure of psychopathy and associated behaviours. More recently, research has also looked into determining if genetics, or particular brain structures or brain chemicals may be related to psychopathy. At the adult level, different research studies appear to agree on the symptoms, genetic components and certain behaviours that are associated with psychopathy. In addition to these factors, research indicates that there may be some developmental differences related to psychopathy in childhood.
The authors highlight that the lack of a clear consensus on both the symptoms of psychopathy and the measurement of those symptoms, when coupled with significant implications such as treatment, requires researchers to better understand both the rationale and scientific merit of different conceptualizations.
Section 2: Previous reviews on the psychopathy–treatment literature
Despite there being not enough research in the field, there appears to be a potentially ingrained belief that psychopathy cannot be treated. However, researchers have reviewed previous studies and found that different types of psychotherapy can be effective in creating positive outcomes for those with psychopathic traits. Such research has been critiqued in that it only looked at treatability of psychopathy in experimental settings and/or reflected a limited number of studies and did not measure outcomes very well. Such critiques invited scientists in the field to look at research beyond experimental settings and examine the treatment of psychopathy in real-life settings too.
Section 3: Review of newer studies on psychopathy and treatment
The authors of this paper then move on to reviewing adult and child treatment studies. They note that more recent studies have examined the treatability of psychopathy by examining outcome in federal inmates, treated and untreated criminal offenders, psychiatric inpatient offenders, sex offenders, offender groups across different ethnic backgrounds, and offenders with intellectual disabilities. Only 3 of the 8 studies showed that treatment could be beneficial for offenders with psychopathy. The results from the review indicated treatment for psychopathy to have low-moderate to poor success rates. In one case, treatment was found to have the opposite effect. It is important to note that psychopathic traits were also found to be associated with more problems in the treatment setting. Such results need to be interpreted with caution as many of the studies included in the review have design flaws. One of the biggest design flaws was noted to be the data used in some of these studies which had been collected historically (after individuals with psychopathy had been treated). The authors of this article suggest that it is important for research to begin during an earlier stage in the treatment process. For example, a study in which assessments of psychopathy would be made first, which would then be followed by treatment, and finally further prospective assessments may be able to provide better results.
After reviewing the research examining treatment of psychopathy in adults, the authors turn to investigating these ideas in adolescents and children. This review also included some prospective studies. Again, the review includes studies of treatment of psychopathic traits in adolescents who were also offenders, sex offenders, and with different ethnic backgrounds. Most of the studies were based in hospital settings. Many of these studies have found that individuals who completed treatment had lowered rates of reoffending. Specifically, 6 out of 8 studies show that treatment could be beneficial for youth. However, some conflicting evidence has also been reported. One of the key challenges noted was that psychopathy has been found to be associated with a higher chance of non-compliance with treatment. Only one study examining conduct problems in children was reviewed by the authors of the article. They note that the results indicate a reduction in conduct problems for children that received treatment for traits related to psychopathy.
These sections conclude that overall these studies do not make the case that psychopathy is untreatable but do indicate some of the problems that can be encountered in treating individuals with psychopathic traits which is the topic of the next section.
Section 4: Practical problems
In the fourth section, the authors address practical problems when treating psychopathic offenders which include: a lack of motivation to change, deception and manipulation and lack of deep or lasting emotion. They conclude that these areas are central to and must be addressed when attempting to treat psychopathic offenders.
Section 5: Strengths, weaknesses and future directions
Finally, the authors address where the field currently stands as well as where we need to go in order to advance science in this important area. The authors point out that the natural conclusion from this review is that we should be doing more to attempt to understand and potentially intervene with people with psychopathic traits, and the study designs need to be improved. However, the authors of this review believe that some areas in which advances are needed are conceptual in nature. These are: how to define psychopathy, concern about the methodological rigor of psychopathy treatment designs, and that research should be broader in design.
In conclusion, the present article shows that, although we do not yet possess sound knowledge regarding how to treat individuals with psychopathy successfully, there are various promising indications regarding the directions that research and practice should take.
Reference: Salekin, R., Worley, & Grimes, R. D. (2010). Treatment of psychopathy: A review and brief introduction to the mental model approach for psychopathy. Behavioral Sciences and the Law, 28, 235-266.
