The Last Word

CrossCurrents

Howard E. Barbaree

In the accompanying article, Grant Harris and Marnie Rice state that treatment is potentially harmful for psychopaths. The “treatment causes harm” hypothesis has been articulated by leading scholars in the field. In their 1997 chapter in the Handbook of Antisocial Behavior, Steve Hart and Robert Hare suggested it was possible that “group therapy and insight-oriented programs help psychopaths to develop better ways of manipulating, deceiving, and using people but do little to help them to understand themselves.”

If treatment does cause harm to psychopaths (or to put it more aptly, if treatment causes them to harm others more frequently), some very difficult problems arise. While specific treatment is rarely provided for psychopathy per se, psychopaths are often included in treatment programs targeting other problem behaviours, such as substance abuse, sexual deviance and anger management. Such treatment programs are regular features in psychiatric and correctional settings. Should psychopaths be excluded from them?

The implementation of such a policy in most hospital and correctional settings would be complex and difficult, raising all sorts of questions about a patient/inmate’s right to treatment. If release to the community is contingent on successful treatment, as it often is, exclusion from treatment could impair their access to community release.

The “harm” hypothesis also speaks to the assessment of the psychopath’s suitability for release to the community. Detained inpatients or inmates who are seeking some kind of community release depend on favourable decisions by parole or review boards. Would psychopaths be viewed as less deserving of community release if they had participated in treatment? Of course, in the present climate, the reverse is in effect – the more treatment the offender has successfully completed, the more likely he is to receive a favourable decision. The “harm” hypothesis places psychopaths in a veritable “catch-22.”

The important question to address is whether sufficient empirical evidence exists in support of the “harm” hypothesis to justify taking the drastic step of excluding psychopaths from treatment.

In a 1992 article in Law and Human Behavior, Harris and Rice, along with co-author Catherine Cormier, describe their evaluation of a therapeutic community intervention as the strongest support for the hypothesis. Inpatients treated in a therapeutic community in a maximum-security psychiatric hospital were compared with untreated subjects sampled from a correctional setting. Comparing the groups overall, there were no differences in recidivism. However, separating the groups into psychopathic and non-psychopathic sub-groups, treated psychopaths were more likely to re-offend violently than untreated psychopaths, whereas treated non-psychopaths were less likely to re-offend violently than untreated non-psychopaths.

In the sex offender treatment literature, Harris and Rice have been the harshest critics of studies that claim a treatment benefit. They have set out standards for what they claim are minimally informative evaluations of treatment efficacy. These standards promote the use of the randomized controlled trial (RCT) over other research designs. According to their 2003 article in the Annals of the New York Academy of Sciences, Rice and Harris state, “To be even minimally useful, the groups need to be comparable on (1) established static predictors of recidivism, (2) jurisdiction and cohort, and (3) volunteering and completing treatment.”

Since I cannot think of any rationale for recommending or accepting different standards for evaluating treatment harm compared with treatment benefit, it might be helpful to apply their standards to their 1992 follow-up study.

First, the study was not a prospective RCT, but a retrospective convenience design. Second, the treated group was detained in a psychiatric hospital having been found “not guilty by reason of insanity” (NGRI). The untreated group were men who had been referred to psychiatric hospital for assessment, but who were not found NGRI. These two groups were therefore not equivalent in some important aspect of criminal responsibility.

Third, the treated group was released to the community through the mental health system of outpatient follow-up where mental health professionals would have had no legal jurisdiction forcing compliance to treatment directives. In contrast, the comparison group was released to the community through a process of case management in the federal and provincial probation and/or parole services. In this system, the authorities can re-arrest and re-incarcerate for non-compliance with a case manager’s directions. I would argue that these two groups were not comparable in jurisdiction. In Ontario, the mental health system operates quite differently from the correctional system.

Harris and Rice propose a treatment for managing psychopaths in institutional and community settings. Interestingly, that treatment is similar in many respects to how correctional authorities have come to manage psychopaths and other difficult criminals. Institutional rules are established and communicated. Infractions to the rules are punished with absolute (as far as possible) consistency. Most psychopaths learn to live without difficulty in an environment with this kind of structure. Contrast the structure in the correctional facilities with the complete absence of structure in the therapeutic community. Perhaps a better way of conceiving of the study result is to think of the correctional structure as the treatment, its absence in hospital as the comparison or control condition, and the group differences described by Harris and Rice as indicating an effective treatment for psychopaths.

The current empirical support for the “harm” hypothesis is weak and does not justify excluding psychopaths from treatment programs that target specific problem behaviours using cognitive-behavioural therapeutic techniques.

Dr. Howard Barbaree is professor and head of the Law and Mental Health Program in the Department of Psychiatry at the University of Toronto, and clinical director of the Law and Mental Health Program at the Centre for Addiction and Mental Health.