What treatment should psychopaths receive?

CrossCurrents

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Grant T. Harris and Marnie E. Rice

So little well-controlled research exists that no conclusions can be drawn about the efficacy of treatment for psychopathy. But the available work does offer some ideas about what is contra-indicated. Some readers might recall our research on an intensive therapeutic community designed for the treatment of psychopaths in the 1960s and 1970s, which appeared in a 1992 issue of Law and Human Behavior. It emphasized insight-oriented therapy, was emotionally evocative and placed patients in clinical leadership roles. The program was faithful to its operating principles and based on the best available information about psychopathy. Clinicians and outside experts felt the program was effective. Our follow-up research showed, however, that although the program reduced recidivism among non-psychopaths, it increased the violent recidivism of psychopaths (compared to prison).

We think this reveals valuable lessons: Clinicians cannot assume their efforts are beneficial; it is possible to do harm. This has been demonstrated elsewhere – some well-intentioned services increase the likelihood of crime. Treatments to reduce recidivism must follow treated patients after release to assess recidivism, and evaluation must include an untreated comparison group.

Our study showed that psychopaths actually behaved more poorly in the program (compared to other patients), but were as likely, or even more likely, to be trusted by clinical staff. Other researchers have shown that clinicians’ impressions are a poor index of the benefits of therapy, especially concerning psychopaths. Perhaps most important: Psycho-dynamic, insight-oriented, emotionally evocative therapy should not be provided.

Researchers have attempted to identify what programs are effective for criminal offenders in general (not necessarily psychopaths). The reviews all arrive at similar conclusions: Insight-oriented, emotion-based therapy should not be provided. More severe punishment and trying to “scare ‘em straight” are also ineffective. Effective programs teach something useful – academic, vocational, social or personal management skills. Effective programs are firm but fair. Although offenders might appear depressed, deliberately targeting self-esteem would not decrease risk and might even increase it. Psychopaths generally have high self-esteem, and among offenders, high self-esteem is related to aggression.

We believe that psychopaths do not have deficits in the clinical sense. Natural selection has designed psychopaths to follow a fundamentally different life strategy - one emphasizing deception, aggression and indifference to the welfare of others. What is known about psychopaths is consistent with the view that they do not have a mental disorder as it is usually defined.

Fortunately, not all clinical interventions, even psychopharmacological ones, require a clinical deficit in need of a remedy. Is there a drug that would reduce the risk of psychopaths? There is not much research on drug treatment for psychopathy, but it is a sensible avenue for exploration. Psychopaths have a different physical make up; giving them a drug to make their neurophysiology more similar to ours might make them less dangerous. But careful evaluation is essential; impressions of efficacy cannot be trusted.

The best example of a clinical intervention that does not require there to be a disorder is behaviour modification. There is empirical evidence that this approach has worked with some offender and violent populations (although not psychopaths). We believe the evidence favours a strategy that applies behavioural principles to reducing the harm caused by psychopathy. Where psychopaths have already committed serious offenses are at high risk of future violence, we favour using selective incapacitation in the form of long-term institutionalization with behavioural methods to manage day-to-day psychopathic behaviour.

We also favour the use of a sophisticated token economy. Such a program is explicit and concentrates on reinforcing behaviour incompatible with psychopathic conduct (i.e., delaying gratification, telling the truth, being responsible, being helpful, being cooperative) and penalizing impulsive, dishonest, aggressive, irresponsible and criminal actions. There is no expectation that the program will ever end. Consequences for behaviour are consistently monitored by staff and always based on observed, overt behaviour, never on what inmates report about thoughts, feelings or conduct.

However, conditions would permit the use of this strategy with only a minority of psychopaths (and a very small minority of offenders). For most psychopathic offenders, release to the community in the form of parole or probation will inevitably occur. The greatest prospect for an effective intervention lies in the challenge of applying these wrap-around behavioural principles to psychopaths under conditional release.

There are no data indicating that any treatment targeting psychopathy has been effective in reducing anti-social conduct. The available evidence affords no guarantee that intensive versions of current offender programs will be effective for psychopaths because research shows that psychopaths are fundamentally different from other offenders. Therapists’ impressions of improvement should not be trusted in the evaluation of treatment. Insight-oriented, emotionally evocative, relationship-based therapy should not be provided. Therapy should not seek to increase self-esteem. Because there is a real possibility that an intervention could cause harm, all interventions should be accompanied by rigorous evaluation assessing violent and criminal recidivism. No assurances from clinicians should permit them to escape this requirement.

Dr. Marnie E. Rice is the scientific director of the McMaster-Penetanguishene Centre for the Study of Aggression and Mental Disorder in Penetanguishene, Ontario.

Dr. Grant T. Harris is the director of research at the Mental Health Centre Penetanguishene.