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Behavioral Sciences and the Law
Behav. Sci. Law 28: 235–266 (2010)
Published online in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/bsl.928
Treatment of Psychopathy: A Review and Brief
Introduction to the Mental Model Approach for
Psychopathy
Randall T. Salekin, Ph.D.*, Courtney Worley, M.A.y and
Ross D. Grimes, M.A.y
Psychopathy is thought by many to be an untreatable disorder. This article puts the
treatment of psychopathy into historical context and reviews research on the treatment
of the disorder with adults (K ¼ 8) and youth (K ¼ 5). Findings indicate that treatment
for adults shows low to moderate success with three of eight studies demonstrating
treatment gains. Treatment of youth appears to be more promising with six of eight
studies showing treatment benefits. Although less than optimal success rates with
adults, we suggest that bright line distinctions regarding the treatability of those with
psychopathic characteristics from non-psychopathic individuals are inappropriate at
this time. We conclude with directions for future research and briefly introduce the
mental models approach for the treatment of psychopathy in youths. Copyright # 2010
John Wiley & Sons, Ltd.
In the 1970s one of the American Psychological Association’s (APA’s) members
approached the APA ethics committee and recommended that all clinical members of
the organization carry with them a card to present to prospective clients that stated that
the procedure they were about to undergo was no more likely to succeed than that of
waiting in line (Smith & Glass, 1977). Eysenck’s (1952, 1965) controversial metaanalysis likely sparked such statements and some argue may have set the field back
decades. It was not until the work of Bergin (1971) and Smith and Glass (1977) that the
psychotherapy course was corrected. Bergin’s review of the findings of 23 controlled
evaluations helped to dismantle the Eysenck (1952) claim that therapy was ineffective.
Later, Smith and Glass (1977) examined the results of nearly 400 controlled
evaluations of psychotherapy showing that psychotherapy was beneficial for patients. In
addition, the authors detected no difference between class of psychotherapy (Rogerian,
psychoanalytic, behavioral, Adlerian, Gestalt) or type of outcome (e.g., self-esteem,
work/school achievement, social behavior, personality traits, physiological stress). More
recent analyses (e.g., Lipsey & Wilson, 1993) have continued to indicate positive effects
for psychotherapy, showing that well developed psychological interventions are
efficacious.
*Correspondence to: Randall T. Salekin, Ph.D., Department of Psychology, Disruptive Behavior Clinic
(DBC), Center for the Prevention of Youth Behavior Problems, University of Alabama, P. O. Box 870348,
Tuscaloosa, AL 35487 U.S.A. E-mail: rsalekin@bama.ua.edu
y
Department of Psychology, Disruptive Behavior Clinic (DBC), Center for the Prevention of Youth Behavior
Problems.
Copyright # 2010 John Wiley & Sons, Ltd.
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R. T. Salekin et al.
Seligman (1995) presented data garnered from a consumer report survey to show
that psychotherapy was not only efficacious but also effective. Seligman (1995) showed
that (a) patients substantially benefited from psychotherapy, (b) long-term treatment
did considerably better than short-term treatment, and (c) psychotherapy alone did not
differ from medication plus psychotherapy. Seligman’s (1995) seminal article
highlighted the importance of psychotherapy in settings outside of university
laboratories and it shed light on the notion that therapy in the real world is more
eclectic in nature.
More recent research has investigated psychotherapy with respect to how it might
compare with psychopharmacology in the treatment of depression (DeRubeis, Gelfand,
Tang, & Simons, 1999; DeRubeis et al., 2005; Reynolds et al., 1999) and anxiety
(Barlow, Gorman, Shear, & Woods, 2000). Much of this research has shown that
psychotherapy is as effective as psychopharmotherapy. Moreover, some original work in
this area showed that psychotherapy had a prophylactic effect, whereas psychopharmotherapy did not. In other words, depressed and anxious individuals who had received
psychotherapy were better able to stave off further bouts of depression and or anxiety.
Marked gains in psychotherapy have also been noted in personality research (Linehan
et al., 2006). Moreover, the last several decades have shown that the positive effects of
psychotherapy appear to extend to children with a variety of disorders and behavioral
difficulties, including conduct problems and delinquency (see Weisz, Jensen-Doss, &
Hawley, 2006; see also Lipsey & Wilson, 1993). Other research has shown that
behavioral interventions can be effective for youths with specific psychiatric disorders
such as attention deficit hyperactivity disorder (Molina et al., 2009; Jensen et al., 1997),
and recent questions have been raised about what specific aspects of the disorder
require treatment (Rapport et al., 2009).
General views held about the broader field of psychotherapy as well as the steady
progress of efficacy and effectiveness studies could be important to consider when
thinking about the treatability of psychopathy for two reasons. First, a negative view of
treating mental disorders appears to have occurred broadly initially (psychotherapy is
inert), before such views subsided and subsequently moved to more positive ones. This
positive outlook occurred only after innovative treatment research began to
demonstrate the therapeutic progress that was occurring. Why is this important? This
could be critical for psychopathy research because examining the history of
psychotherapy, in general, may help put in context current views on the
psychopathy–treatment relation. That is, few well designed treatment studies have
been conducted on the topic and yet many more are needed. Thus, the historical
context could serve as an example that more research is needed to fill the gap between
science and practice in this area placing more hope in the possibility that effective
interventions can eventually be developed for psychopathic individuals.
Second, it is important to consider the disorders mentioned above (e.g., depression,
ADHD) and their general responsiveness to treatment because they are heritable,
biologically based and considered difficult to treat. Recent research regarding the
heritability and potential biological underpinnings of psychopathy are occasionally
misunderstood or misinterpreted to establish a line of thought that the condition is not
reversible with interventions. This line of thought occasionally drifts further to beliefs
that if treatment were to be at all possible, there would be a need for pharmacotherapy,
gene deletion or microscopic brain surgery to effect change. Although the hereditary
nature of psychopathy and potential brain anomalies that may accompany the disorder
Copyright # 2010 John Wiley & Sons, Ltd.
Behav. Sci. Law 28: 235–266 (2010)
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Treatment of Psychopathy
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are important to discover and consider, it should also be noted that many of the
disorders mentioned above such as depression, anxiety, and ADHD also have heritable
aspects to the condition, as well as potential brain anomalies; yet, none of the etiological
theories (e.g., depression) have been used to suggest that treatment would not be
possible, or that psychotherapy could not have a positive treatment effect.
These points are important to consider and should reflect on general attitudes toward
the treatability of psychopathy. Two other key points should be considered and may
provide further hope for the successful treatment of psychopathy. First, many clinicians
believe that psychopathy is treatable. A survey from England revealed that only a very
small portion of more than 500 forensic psychologists believed that psychopathic
individuals were untreatable (Tennent et al., 1993). More than two-thirds considered
that treatment could succeed, even though they did not know of an optimal intervention.
In a similar survey examining the treatability of child and adolescent psychopathy,
psychologists from the child and adolescent division of APA (Division 53) showed that a
very similar percentage (72.5%) of clinicians believed that youth psychopathy could be
treated. Moreover, some clinicians reported successfully treating psychopathic youth in
their practices (see Salekin, Rogers, & Machin, 2001). Thus, the bulk of mental health
professions in these surveys viewed psychopathy as a treatable condition.
Second, research on the structure of psychopathy has shown the disorder to be not
taxonic, but rather dimensional (Marcus, John, & Edens, 2004; Murrie et al., 2007).
Therefore, this would suggest that there are not differences in kind per se, but rather
differences in degree. Thus, like optimism, people can have a little, or a lot, or
somewhere in between. When individuals have a lot of psychopathy, of course, it
requires treatment. Yet, much more research is needed to determine what might work
to alter the potential deleterious course of the psychopathic individual.
The aims of this article are divided into five sections. The first section provides a brief
definition of psychopathy. Here we elaborate on some of the conceptual differences in
psychopathy. 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, require researchers to understand both the rationale and scientific merit of
different conceptualizations. The second section discusses previous reviews on the
psychopathy–treatment literature. In many ways, these articles may have reflected
educated beliefs drawn from knowledge obtained after research scholars have (a) read
the literature in the area, (b) had some experience (research or clinical) with
psychopathic individuals, or (c) both. The third section is utilized to review newer
studies on psychopathy and treatment. In the fourth section, we address practical
problems when treating psychopathic offenders. Finally, we address where the field
currently stands (both strengths and weaknesses) as well as where we need to go in order
to advance science in this important area. The present article aims to show that,
although we do not yet possess sound knowledge regarding how to treat psychopaths
successfully, we have various promising indications regarding which directions research
and practice should take.
PSYCHOPATHY: DIFFERING CONCEPTIONS
Cleckley (1941) offered what some consider a clear and well accepted description of
psychopathy. Specifically, he outlined 16 symptoms that captured interpersonal,
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affective, and behavioral aspects of the disorder. These symptoms included superficial
charm and good intelligence, absence of nervousness, lack of empathy, and lack of
remorse, as well as failure to follow a specific life-plan. Via descriptive case examples,
Cleckley articulated how psychopathic individuals engaged in legal and moral
transgressions while maintaining a ‘‘mask of sanity.’’ However, not everyone agreed
with Cleckley’s conception of the disorder. Robins (1966) and Cloninger (1978)
suggested that psychopathy might be best measured by indexing behavior rather than
personality. This model moved the field away from personality features and focused on
behavioral characteristics—those that make up Antisocial Personality Disorder
outlined in the DSM-IV (American Psychiatric Association, 2000).
This shift occurred because it was believed that behavioral characteristics indirectly
tapped the personality features of the disorder and there could be no mistaking outcome
(e.g., antisocial behavior). Symptoms included characteristics such as irresponsible and
reckless behavior that violated the rights of others. Hare (1991/2003) offered a twofactor model for psychopathy that incorporated both Cleckley’s model for psychopathy
and the antisocial behavior delineated by Robins and her colleagues. Some researchers
have argued that the two-factor model for psychopathy captures both Cleckley’s (1941)
and Robins’ (1966) notions of psychopathy in a single two-factor framework. Hare’s
model serves as one example of the potential multidimensionality of psychopathy. Most
recently, the Hare conception of psychopathy has been further parsed into four facets.
This model maintains the two broad traditional factors and then parses these broader
factors further into facets (see Figure 1).
For intervention science, varying conceptualizations may have relevance to
treatment responsiveness. Different conceptualizations have obvious and less obvious
implications for what the construct means in terms of behavioral expression and
treatment. Take, as one key example, the difference between Hare’s (2003) model,
which is based on offenders, and compare it with Cleckley’s (1941) model, which
included many successful individuals in the business and medical fields. These models
have implications for successful versus non-successful, emotionally stable versus
unstable, primary versus secondary psychopathy, and so forth. Thus, the items that
make up the construct and the setting to which the construct is being applied may have
different real world meaning, including potential differences in amenability to
treatment. One potential difference is that high achievers in Cleckley’s model may
be viewed as less in need of treatment for severe antisocial behavior per se than those in
Hare’s model, who engage in serious and varied criminality.
Two other issues are important to consider in examining treatment of psychopathy.
First, isolating a set of items and treating those items as the fuller construct of
psychopathy needs further consideration. Related to factor analytic work (Frick & Hare,
Figure 1. Components of psychopathy.
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2001; Salekin, Brannen, Zalot, Leistico, & Neumann, 2006; Skeem, Mulvey, & Grisso,
2003), examining a sole factor or a specific aspect of psychopathy (affective deficits)
alone may be helpful for understanding the treatment of that particular component of
the syndrome, but it may not equate to treating psychopathy as a whole. Thus,
dismantling of psychopathy may be important to better understand treatment, but it
also will be vital to investigate treatment of psychopathy as a broader construct.
Comparing treatments that focus on component parts versus combined types, much
like the work that has been conducted on ADHD (i.e., inattentive, hyperactive, and
combined types), will help sort issues about what aspects of psychopathy are treatable,
which components are particularly difficult, and whether all components are in need of
treatment. Some individuals may simply not require treatment, and in other cases
treating one component may have a cascading effect on other components of the
disorder.
Although beyond the scope of this article, another chief and related issue is how we
measure psychopathy (see Kotler & McMahon, 2010; Lilienfeld & Fowler, 2006). That
is, there exists considerable heterogeneity across assessment tools. Part of this
heterogeneity may be based on differing conceptualizations of the disorder but part may
be based on method/setting variance. For example, self-report measures of psychopathy
may not map well with clinician interview methods. Moreover, newer self-report
measures, such as the Child Psychopathy Scale (CPS; Lynam, 1997) and Youth
Psychopathy Inventory (YPI; Andershed, Kerr, Stattin, & Levander, 2002) at the child
level, or the Multidimensional Personality Questionnaire (MPQ; Patrick, Curtin, &
Tellegen, 2002), Psychopathic Personality Inventory (PPI; Lilienfeld & Andrews,
1996), Self Report Psychopathy Scale II (SRP-II; Hare, 1991) and SRP-III (Williams,
Paulhus, & Hare, 2007) at the adult level, may differ from PCL models with respect to
conceptualization and will require further research. Such models could potentially give
us a more in-depth look at what is, and what is not, treatable within the psychopathic
personality construct. To the extent that there are method effects, research will need to
continue to determine whether self, parent, clinical interview, or some combination
(multi-measurement) of assessment is best. So long as researchers document which
conceptualization/subtype/measure they are utilizing, such an approach to investigating
the treatment outcome of psychopathy may be justifiable, viable, and most
comprehensive.
Hare’s Model As a Starting Point
Hare’s work, which was initiated in the 1970s, generated considerable theoretical and
empirical study on the topic of psychopathy and thus seems like a natural starting point
(Hare, 1970). A good part of this research focused on the structure of psychopathy and
its external correlates, and more recent investigations have begun to examine
psychopathy from new perspectives including cognitive neuroscience to determine the
particular brain structures and neurochemical functioning that may be implicated in the
development and maintenance of psychopathy (Kiehl, Hare, Liddle, & McDonald,
1999). Research on behavior genetics, as mentioned, has also emerged to examine the
heritability of the condition in adults (Waldman & Rhee, 2006). Research at the adult
level has shown that psychopathy has coherence (homogeneity of symptoms), a
relatively stable factor structure, a genetic component, and meaningful external
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correlates (Leistico, Salekin, DeCoster, & Rogers, 2008; Salekin, Rogers, & Sewell,
1996).
The migration of the concept to children has shown many similar findings, with
raters evidencing independent agreement, and measures demonstrating structural
stability and concurrent and predictive meaning (see Salekin, 2006; Salekin,
Rosenbaum, & Lee, 2009a) as well as a genetic basis (Larsson, Andershed, &
Lichtenstein, 2006; Viding & Larsson, 2010). Several research findings have shown,
however, that there may be some developmental differences in the concept of
psychopathy in childhood, in that studies tend to indicate only modest levels of stability,
greater levels of comorbidity (Kubak & Salekin, 2009; Salekin, Leistico, Trobst,
Schrum, & Lochman, 2005; Salekin, Neumann, Leistico, DiCicco, & Duros, 2004b),
and dissimilar correlates with internalizing symptoms and some performance tasks (see
Forth, Kosson, & Hare, 2003; Lee, Salekin, & Iselin, 2010; Salekin, 2006; Salekin &
Frick, 2005; Salekin, Rosenbaum, Lee, & Lester, 2009). While it remains unclear to
what extent research findings will continue to elucidate similarities and differences in
the concept of child psychopathy, scientific findings, as they currently stand, may be
encouraging for the treatment of psychopathy in children and adolescents. That is,
research results such as the overlap with internalizing disorders and potentially less
stability may be indicative of better amenability (Kubak & Salekin, 2009; Lee, Salekin,
& Iselin, 2010; Salekin & Lochman, 2008; Salekin et al., 2009b). This is because such
differences (e.g., co-existing anxiety) may give researchers more leads in understanding
the potential causal factors linked to psychopathy (Rutter, Tizard, & Whitmore, 1987).
However, these are, admittedly, mostly suppositions at this point, which leads to the
question of what do we really know about the treatment of psychopathy?
REVIEWS AND PAST PERSPECTIVES: NO SHORTAGE
OF OPINION
A perusal of the literature on psychopathy shows that there is little in the way of research
on the topic of treatment, especially in comparison to the number of descriptive,
structural, and etiological studies on psychopathy at both the adult and child level.
What is clear, however, is that there exist strong opinions and potentially ingrained
beliefs regarding the potential impact treatment might have on psychopathy. In the
absence of strong research on the topic, it is difficult to ascertain which beliefs may be
correct. Nonetheless, some history on the psychopathy–treatment relation can be
helpful in determining where we currently stand on this topic and where we need to go
with respect to research development.
One of the first chapters on psychopathy and treatment was written by Suedfeld and
Landon (1978). Suedfeld and Landon commented that a ‘‘review of the literature
suggests that a chapter on effective treatment should be the shortest in any book
concerned with psychopathy. In fact, it has been suggested that one sentence would
suffice: No demonstrably effective treatment has been found’’ (p. 347). Blackburn
(1993) later arrived at two primary conclusions regarding the treatability of
psychopathy: ‘‘First, while classical psychopaths have been shown to respond poorly
to some traditional therapeutic interventions, it has yet to be established that ‘nothing
works’ with this group [and] second, some offenders with personality disorders do
appear to change with psychological treatment’’ (p. 202). Lo¨sel (1998) noted there are
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‘‘more question marks’’ than answers regarding the treatment of psychopathy (p. 303).
Other reviewers of the literature have continued to delineate similar conclusions (e.g.,
D’Silva, Duggan, & McCarthy, 2004).1
Utilizing a data driven review, Salekin (2002) generated more optimistic
conclusions. Following a review of 42 studies, Salekin found that, on average, 62%
of patients benefitted from psychotherapy; removing case studies, 60% of patients
benefitted from therapy. Psychotherapy appeared to be effective for major classes of
therapy (psychoanalytic, cognitive behavioral,2 and eclectic) and a variety of outcomes
(improving interpersonal relationships, increasing the capacity for feeling remorse and
empathy, reducing the amount of lying, being released from probation, and maintaining
a job). In addition, effective treatments were found to be intensive, including an average
of four sessions of individual psychotherapy per week, for at least one year. Individual
psychotherapy when augmented with group psychotherapy appeared to be beneficial.
In addition, treatment programs that incorporated family members appeared to
produce better effects. Salekin (2002) concluded that the results indicated that, for
complex problems such as psychopathy, more elaborate and intensive intervention
programs, involving individual psychotherapy, treatment of family members, and
input from groups, may be needed. Thus, scope, intensity, and duration of
treatment for psychopathy were important in the overall adjustment of psychopathic
individuals.
The Salekin review and meta-analysis had strengths and limitations. With respect to
strengths, the study examined a host of treatment modalities and a variety of life
outcomes. The review included the time honored methodology of case studies, quasiexperimental designs, and control studies. The literature search drew widely from
psychopathy treatment studies, including studies such as Albert Ellis’s (1961) case
study with an adult psychopath to the controlled intervention trial with adolescents by
Ingram and colleagues (1970). The review was broad but also limited in terms of the
number of randomized control trials. This aforementioned limitation and other
limitations were outlined and articulated in the discussion section of the review and it
was suggested that a second generation of research was needed.
Harris and Rice (2006) critiqued the Salekin (2002) meta-analysis. To their credit,
they made many cogent points about how research could improve in this area. These
authors conducted their own review of the psychopathy treatment literature. Harris and
Rice (2006) acknowledged that there existed studies showing positive results for the
treatment of psychopathy, but noted that many of the studies that demonstrated
positive effects were case studies. Harris and Rice criticized our use of therapist opinion
regarding client change, and the use of measures other than the PCL, and believed that
treatment studies that did not include recidivism as an outcome were unacceptable, and
de-emphasized their importance. Finally, Harris and Rice believed that the
heterogeneity in outcome variables was problematic. Instead, these authors focused
1
D’Silva et al. (2004) offered a rating system for the quality of the studies used in their meta-analyses. They
noted why they rated each study as high or low in quality. The Rice et al. study was rated as highest in quality
and thus carried some weight in their review. However, it should be noted that this study was a retrospective
investigation that involved a treatment that was not likely to have an intervention effect.
2
Harris and Rice (2006) questioned categorizing treatments as cognitive behavior because the term had not
yet been invented. We did not intend to use the term from when it was invented but rather from what the
treatment mostly characterized. Psychologists and psychiatrists were using cognitive frameworks for many
years prior to the formalizing of the term. In fact, Alfred Adler is often credited with the founding of cognitive
psychology.
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on several treatment studies that met with their specific considerations for
appropriateness.
With the aforementioned inclusion/exclusion criteria, Harris and Rice (2006)
adopted a blend of two conclusions: ‘‘No clinical intervention will ever be helpful’’ and
‘‘no effective interventions yet exist for psychopaths.’’ Moreover, Harris and Rice
(2006) maintained their original conclusion that treatment, as it currently exists, could
‘‘make psychopathic individuals worse’’ (p. 563). Because Harris and Rice (2006)
viewed most of the treatment outcome studies in the Salekin (2002) meta-analysis as
inadequate, and, the Skeem, Monahan, and Mulvey (2002) study as flawed, their
affirmatively stated conclusions were based on the few studies they viewed as adequate
(possibly as few as two to five studies). One study used to base their conclusions was
their own, which utilized a retrospective design and has been criticized extensively in the
literature (see Caldwell, Skeem, Salekin, & Van Rybroek, 2006; Skeem et al., 2002).
One primary criticism is the retrospective design and another is having an
‘‘intervention’’ that many researchers viewed as non-therapeutic. In addition, the
authors supported their conclusion regarding the treatability of psychopathy on a very
broad etiological theory (evolutionary strategy) that they were advancing in their
chapter, which has not been adequately validated and does not necessarily lead to
conclusions that psychopathy is untreatable. Nonetheless, their review served as a
critical analysis of the state of the field and many points about the need to improve
research in this area are well taken.
Moving to other reviews, Wong and Hare (2005) briefly reviewed a portion of the
research on psychopathy and treatment. Their view regarding the treatment of
psychopathy is more positive than Harris and Rice (2006), as evidenced by their
initiation and development of a treatment program. However, Wong and Hare (2005)
are cautious regarding how much progress can be made with institutional offenders. In
addition, they too believe that only PCL studies should be considered in outcome
research and that management might be the most optimal consideration for offenders.
There appeared to be limited theory to guide their treatment program beyond general
correctional psychology programming. Nevertheless, their manual points to how
management procedures can be effective and serves as an important step forward.
Summarizing and Integrating Past Reviews
The above mentioned reviews collectively inform us that, regardless of how limited the
data might be, strong opinions about the treatability of psychopathy remain. Opinions
range from the notion that the treatment of psychopathy will (a) have no effect on the
condition (inert) (Harris & Rice, 2006), (b) worsen the condition (iatrogenic) (Harris &
Rice, 2006), or (c) potentially better the condition (Salekin, 2002; Skeem et al., 2002).
Several studies have now shown some evidence of positive outcomes for psychopathic
youths following intervention (Caldwell et al., 2006; Hawes & Dadds, 2005; Olver &
Wong, 2009; Salekin, 2002; Skeem et al., 2002), but clearly much more work is needed
in this area. Much of this research will require some consideration of how to proceed.
The above mentioned reviews differ in what they suggest can be viewed as ‘‘in
bounds’’ with regard to psychopathy classifications and life outcomes. Some reviews
viewed heterogeneity in classification of psychopathy as a positive aspect of intervention
science. Others believed that the PCL measures should be the only indices used for
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inclusion criteria. With respect to outcomes variables, some suggest that the only
outcome that matters is recidivism (Harris & Rice, 2006; Wong & Hare, 2005). Others
(e.g., Salekin, 2002) see a host of outcomes as important, and we shall attempt to make
the case for the use of a wider net of outcome variables clearer in the latter parts of this
article.
Because a comprehensive review of psychopathy and treatment has been previously
conducted (Salekin, 2002), in this article we shall use the PCL-R and PCL-YV based
models to examine psychopathy treatment management and outcome studies. These
studies could be referred to as a second generation research, in that they use structured
assessments of psychopathy with PCL-versions (Salekin, 2002). However, as
mentioned, we later argue that some diversity in psychopathy measurement (Benning,
Patrick, Salekin, & Leistico, 2005; Cleckley, 1941; Lilienfeld & Andrews, 1996;
Salekin, 2010) and outcome may be helpful in the future, as research starts to expand
our understanding of the psychopathy–treatment relation. Below, we begin with a
review of the adult treatment studies followed by a review of child and adolescent
treatment studies.
REVIEW OF TREATMENT STUDIES
Previous work on the treatment of psychopathy can be separated into roughly two
categories. The first category is those studies that consider compliance issues for
psychopathic individuals in treatment settings. The second category represents studies
that focus on treatment outcome for psychopathy. As mentioned, we present studies
that focus on the PCL and its derivatives (APSD for children); however, we later
contrast this approach to findings from the Salekin (2002) meta-analysis, which is
broader in its recruitment of research studies. This will allow the reader to consider the
relative merits of narrower versus broader recruitment strategies.
Review of Adult Treatment Studies
Ogloff, Wong, and Greenwood (1990) conducted one of the first studies to investigate
the effects of a therapeutic treatment on psychopathic offenders using the PCL as an
index of psychopathy. Ogloff and colleagues reported on the behavior of psychopathic
and non-psychopathic individuals defined by criteria outlined in the early version of the
PCL (Hare & Frazelle, 1980). They utilized a sample of 80 federal inmates
(Mage ¼ 26.90 years, SD ¼ 6.77). Compared with non-psychopaths, psychopaths
showed less motivation, were discharged earlier (typically due to lack of motivation or
security concerns), and showed less improvement. This study, however, used
retrospective data and followed up only a very small portion of the offenders
(n ¼ 28). This design is less than optimal but nonetheless adds to the literature on
psychopathy and treatment. Despite methodological flaws, this study was important in
that it served as one of the more rigorous treatment designs for its time.
Rice, Harris, and Cormier (1992), in a quasi-experimental design, examined
146 treated male offenders (Mage ¼ 23.4, SD ¼ 6.53; primarily white, >90%), who
were matched with 146 male untreated offenders (Mage ¼ 23.2, SD ¼ 6.25) on
variables related to recidivism (e.g., age, criminal history, index offense). The study
was a retrospective–prospective study in that the PCL was scored based on file
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information alone and researchers had to avoid other file information (treatment notes in
the file that followed the period in which they were attempting to rate the PCL). The
authors set the cutoff score for identifying offenders at 25. The results of their follow-up
conducted an average of 10.5 years after completion of treatment showed that, compared
with no program, treatment was associated with lower violent recidivism for nonpsychopathic individuals but higher violent recidivism for psychopathic individuals. The
authors also found that psychopathic individuals showed poorer adjustment in terms of
problem behaviors while in the program, even though they were just as likely as nonpsychopathic individuals to achieve positions of trust and early recommendations for
release. One potential problem with this investigation was its retrospective–prospective
nature and the difficulty in separating treatment notes from notes used to rate the PCL.
Moreover, the treatment offered has been criticized in the literature as not being
therapeutic, as mentioned earlier.
Hughes, Hogue, Hollin, and Champion (1997) examined nine mentally disordered
psychiatric inpatient offenders (Mage ¼ 40.96, SD ¼ 5.98) using cognitive skill based
treatment. Utilizing the PCL-R to assess psychopathy, they found an inverse
relationship between psychopathy score and therapeutic gain, even though patients
with PCL scores over 30 were excluded. This study, although advancing the field, does
not necessarily address psychopathy, because high scorers were excluded from
treatment. In addition, the very small sample size makes it difficult to determine the
extent to which the findings extend to other patients or other treatment settings.
Nonetheless, individuals with high scores in this sample showed less improvement in
treatment.
Seto and Barbaree (1999), utilizing a cognitive behavioral program and relapse
prevention program with 216 male sex offenders (Mage ¼ 37.0, SD ¼ 9.7), also showed
dismal results for psychopathic sexual offenders over a 32 month follow-up.
Specifically, these authors found that high psychopathy offenders who were rated as
having shown the most improvement (as measured by conduct during the treatment
sessions, quality of homework, and therapists’ ratings of motivation to change) were
more likely to re-offend than other participants, particularly in violent ways.
Hobson, Shine, and Roberts (2000) reported similar results for a therapeutic
community in England’s Grendon Prison. These authors reported that PCL scores for
males (Mage ¼ 32.6 years; 93% White, 5% Carribean, 1% Asian, 1% other) were related
to poor adjustment in the program. Hare, Clark, Grann, and Thorton (2000) evaluated
a cognitive behavioral prison program for 278 psychopathic and non-psychopathic male
offenders. This study also showed that high F1 psychopaths did worse in treatment and
increased their offending after treatment. However, the report of this study is limited,
and it is difficult to discern what type of treatment offenders received, as it was a
combined sample and treatment may have differed across settings. More information is
needed to fully interpret these findings.
Skeem et al. (2002) examined 871 civil psychiatric patients and a subsample of
195 patients classified as potentially psychopathic (Mage ¼ 30, SD ¼ 6; 70% White,
29% African American, 2% Hispanic). The authors were interested in future
violent offending after treatment. This study produced results that were inconsistent
with previous research findings that suggested treatment was effective for
psychopathic patients. This study demonstrated that with longer treatment times
(seven or more sessions) positive outcomes were observed for reduction of violence
(see Table 1).
Copyright # 2010 John Wiley & Sons, Ltd.
Behav. Sci. Law 28: 235–266 (2010)
DOI: 10.1002/bsl
No./sample
80 male inmates, including
28 new participants followed
from intake to discharge
146 treated male offenders
146 non-treated male
offenders
40 psychopathic (PCL-R
>30) and 40 nonpsychopathic inmates
(PCL-R < 20)
9 psychiatric inpatient (M or
F) offenders
404 incarcerated female
substance abusers
Researchers
Ogloff, Wong, &
Greenwood
(1990)
Rice, Harris, &
Cormier (1992)
Hitchcock (1994)
Hughes, Hogue,
Hollin, & Champion
(1997)
Copyright # 2010 John Wiley & Sons, Ltd.
Richards, Casey, &
Lucente (2003)
High security psychiatric
hospital in England. Treatment
encompassed three elements:
(1) establishment of a
supportive milieu, (2) group
work, and (3) individual
support and treatment as
needed
Modified TC, heuristic
systems w/ housing; HS w/o
housing
Therapeutic community. Peers
treated other inmates. In
addition, there were some
radical treatment procedures
including use of LSD and nude
encounter groups
24 week cognitive behavior
therapy
Psycho-educational and
therapeutic group treatment
Treatment type
PCL higher psychopathy
correlated with poor treatment
compliance and outcome
Compared with non-psychopaths,
psychopaths showed less
motivation, were discharged
earlier, and showed less
improvement
10.5 year follow-up showed that
treatment was associated with
lower violent recidivism for
non-psychopaths, but higher
violent recidivism rates for
psychopaths
The authors found no change in
cognitive style, socialization or
responsibility for psychopaths
when comparing pre and post
measures. However, there were
also no differences noted pre and
post therapy for non-psychopathic
individuals suggesting that the
treatment had little effect overall
Found that the higher the PCL-R
score, the poorer the treatment
gains
Treatment outcome and
compliance
Table 1. Adult treatment outcome and compliance studies
—
—
(Continues)
—
—
Treatment
outcome
Compliance
outcome
Treatment of Psychopathy
245
Behav. Sci. Law 28: 235–266 (2010)
DOI: 10.1002/bsl
Copyright # 2010 John Wiley & Sons, Ltd.
60 ID male offenders in high
security forensic setting
72 ID male offenders in a
high security forensic setting
Morrissey, Hogue,
Mooney, Allen,
Johnston, Hollin,
Lindsay, & Taylor
(2007a)
Morrissey, Mooney,
Hogue, Lindsay, &
Taylor (2007b)
Clearwater sex offender
treatment program, which is a
high intensity inpatient
treatment program designed to
provide interventions to
moderate to high risk sex
offenders
Residential therapeutic
community with four 2 month
treatment phases
The results suggest that psychopathic traits do not moderate the
effect of treatment involvement on
violence. Psychopathic patients
(based on the PCL-SV) appear
as likely as non-psychopathic
patients to benefit from adequate
doses of treatment, in terms of
violence reduction
Treatment completers (25%)
exhibited less severe psychopathy
(lower PCL-SV scores) and lower
overall psychiatric symptom
profiles. Substance use diagnosis
and mental health was unrelated
to completion
PCL-R did not predict aggressive
behaviors (r ¼ .11). Therefore,
psychopathic patients appeared
to be as compliant as nonpsychopathic individuals
ID patients with high psychopathy
scores showed less progress than
those with lower psychopathy scores
(r ¼ .27 with negative progress)
Results showed that, given
appropriate treatment interventions,
sex offenders with significant
psychopathic traits can be retained
in an institutional treatment
program and those showing
therapeutic improvement can reduce
their sexual and violent recidivism
Treatment outcome and
compliance
—
þ
þ
þ
þ
þ
þ
—
Treatment
outcome
Compliance
outcome
þ ¼ positive outcome, ¼ negative outcome, — ¼ not measured. Morrissey samples are overlapping. This table is not meant to be an extensive list of treatment studies
but rather the treatment studies that were available to us through psychology search engines and had been published in scientific journals. This group of studies does not
include dissertations (with the exception of the Hitchcock study), which may provide further information on this topic once they pass through the peer-review process.
ID ¼ intellectual disability, TC ¼ Therapeutic Community, HS ¼ Heuristic System (see Richards et al. 2003).
156 male federal sex
offenders
High security intellectual
disability
179 male individuals with a
dual diagnosis for substance
abuse and other illnesses
Van Stelle, Blumer, &
Moberg (2004)
Olver & Wong (2009)
Treatment intensive
supervision placements for
more serious misconduct
871 male (58%) and female
(42%) civil psychiatric
patients
Skeem, Monahan, &
Mulvey (2002)
Typically verbal therapy and
medication
No./sample
Researchers
Treatment type
Table 1. (Continued)
246
R. T. Salekin et al.
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DOI: 10.1002/bsl
Treatment of Psychopathy
247
Richards, Casey, and Lucente (2003) examined 404 female offenders (Mage ¼ 35.2,
SD ¼ 6.52; 64% African American, 35% White, 1% Asian/Hispanic) in a substance
abuse treatment program. Psychopathy scores were one of the inclusion criteria for the
treatment study, with participants scoring below 30 on the PCL-R included in the
treatment study. Psychopathy was significantly associated with poorer outcomes as
assessed by a number of factors (failing to remain in the program, rule violations
avoiding urine tests, and sporadic attendance). Additionally, follow-up after release
from prison revealed that those women with higher psychopathy scores were more likely
to re-offend. Additionally, Factor 1 was predictive of recidivism for these offenders. The
authors concluded that psychopathy is a valid predictor of treatment outcome and
recidivism in female offenders with substance abuse.
Van Stelle, Blumer, and Moberg (2004) examined 179 males with a dual diagnosis
for substance abuse and other illnesses in a residential therapeutic community with four
two-month treatment phases. Their results showed that treatment completers (25%)
exhibited less severe psychopathy (lower PCL-SV scores) and had lower overall
psychiatric symptom profiles. Substance use diagnosis and mental health were
unrelated to completion. However, psychopathy was a predictor of compliance
problems and non-completion of the program.
Morrissey and colleagues (2007a) examined the ability of psychopathy scores on the
PCL-R to predict aggression in an inpatient sample of individuals with intellectual
disabilities (ID). Though the relationship between psychopathy and aggression has
been demonstrated in other samples, there was not a significant relation for this sample
with ID. Thus, offenders with high psychopathy scores were no worse in treatment
settings than those with low psychopathy scores. The authors discuss several hypotheses
for why individuals with ID might differ from other populations with psychopathy and
suggest that future study is needed: in particular, research with aggressive behavior
outside the institution for this population.
In a second study, Morrissey and colleagues (2007b) examined 73 male offenders
(Mage ¼ 37.0; range ¼ 17–68) with intellectual disabilities (MIQ ¼ 66.0, SD ¼ 8.6) to
assess treatment effectiveness two years post assessment. Participants were assessed
using the PCL-R (Hare, 1991/2003). The objective of the study was to determine
whether the assessment of psychopathy (PCL-R) could predict treatment progress
more effectively than the assessment of violence. Examining both positive and negative
treatment progress within the secure system, higher PCL-R scores were found to be
predictive of a negative treatment outcome. There were positive correlations between
PCL-R total score and negative treatment progress, while negative correlations were
found for psychopathy and positive treatment progress. In examining individual factor
scores from the PCL-R, Factor 1 (the interpersonal and affective factor) demonstrated
significant positive relations with negative treatment progress. Scores of deficient
affective experience, a component of Factor 1, were negatively and significantly related
to positive progress in the sample. The authors concluded that psychopathy is
significantly related to treatment outcome in offenders with ID. This study is based on a
highly specialized setting, the sample was relatively small, and the confidence intervals
for statistics were wide. In addition, although the authors refer to the term psychopathy,
it could be argued that a diagnosis of ID should override diagnoses or measurement of
psychopathy because it could be difficult to assess psychopathy in ID patients.
Olver and Wong (2009) examined the therapeutic responses of psychopathic sex
offenders (PCL 25) among 156 sex offenders (Mage ¼ 32.8, SD ¼ 9.2; 64.3% White,
Copyright # 2010 John Wiley & Sons, Ltd.
Behav. Sci. Law 28: 235–266 (2010)
DOI: 10.1002/bsl
248
R. T. Salekin et al.
35.7% Aboriginal) with regard to treatment dropout and therapeutic change, as well as
sexual and violent recidivism over a ten year follow-up. The PCL-R was rated
retrospectively. The authors found that the psychopathic participants were more likely
than their non-psychopathic counterparts to drop out. Psychopathic offenders who
failed to complete sex offender treatment were more likely to violently but not sexually
recidivate than completers. Positive treatment changes were associated with reductions
in sexual and violent recidivism after psychopathy was controlled for. The authors
concluded that, overall, their results suggest that, given appropriate treatment
interventions, sex offenders with significant psychopathic traits can be retained in an
institutional treatment program, and those showing therapeutic improvement can
reduce their risk for both sexual and violent recidivism.
The above findings suggest that the treatment results for psychopaths range from
low–moderate to poor. However, we do not know whether poorer treatment response
means no treatment response at all, or simply less gain than the non-psychopathic
individuals, for some of these studies. Also, many of the studies were retrospective or
had other design flaws. Of the two best methodological studies (Skeem et al., 2002;
Olver & Wong, 2009), there is a glimmer of hope that some treatment may be helpful to
at least some psychopathic offenders. Two other well designed studies showed a
negative effect (Richards et al., 2003; Van Stelle et al., 2004), and research to sort out
what results in positive versus negative effects is needed. What can be taken, too, from
the studies above as a whole is that the preferred method for examining treatment
outcome would be to provide treatment first and then prospectively follow patients in
hospital and institutional settings and subsequently in the community; more studies of
this kind are needed.
Treatment Compliance With Adolescents
In one of the first examinations of the issue, Forth, Hart, and Hare (1990) found that
scores on a modified version of the PCL-R (Hare, 1991) were significantly correlated
with the number of institutional charges for violent behavior in a group of 75 male
offenders (Mage ¼ 16.3; SD ¼ 1.1; 77.3% White and 22.7% Native American). This
study was one of the first of its type to suggest that there may be treatment compliance
issues with psychopathy in typical juvenile justice settings. Brandt, Kennedy, Patrick,
and Curtin (1997) used a modified version of the PCL-R in a sample of 130 adolescent
offenders (Mage ¼ 16.1; SD ¼ 1.0; 70% African American, 28% White, and 2%
Hispanic) and found that psychopathy scores were significantly correlated with verbal
and physical rule violations with intensive supervision placements for more serious
misconduct. In a prospective investigation of 72 adolescent psychiatric patients
(Mage ¼ 14.1; SD ¼ 1.50; 37 male and 35 female; 83% White and 17% denoted as
minority), Stafford and Cornell (2003) noted that scores on the PCL-R predicted staff
ratings of overall institutional aggression, verbal and covert aggression and aggression
directed toward peers.
In a series of studies, Rogers and his colleagues (Murdock-Hicks, Rogers, & Cashel,
2000; Rogers, Jackson, Sewell, & Johanesen, 2004; Rogers, Johansen, Chang, &
Salekin, 1997) examined the relation between psychopathy (PCL-R) and several
treatment related variables at a state hospital. Specifically, Rogers and colleagues
(1997) tested 81 adolescents (Mage ¼ 15.62 years; SD ¼ 1.03; 17.3% African American,
33.3% Hispanic American, 46.9% Anglo American and 2.4% referred to as other) in a
Copyright # 2010 John Wiley & Sons, Ltd.
Behav. Sci. Law 28: 235–266 (2010)
DOI: 10.1002/bsl
Treatment of Psychopathy
249
residential program where treatment typically spanned six months. Psychopathy was
modestly associated with treatment non-compliance (r ¼ .25) and physical aggression
(r ¼ .28).
Similarly, Murdock-Hicks and colleagues (2000) examined 82 adolescent inpatients
(Mage ¼ 15.78; SD ¼ 1.02; 58 African Americans, 31 Anglo Americans, 29 Hispanic
Americans, and 2 other) from a state hospital mandated for treatment of substance
abuse with co-morbid disruptive behavior disorders. These authors used the PCL-SV
and MMPI-A to predict total, violent and non-violent infractions in this treatment
oriented facility for delinquent youth. Murdock-Hicks et al. (2000) found that
psychopathic youth manifested a significantly higher rate of violent infractions than did
non-psychopathic individuals. They also found ethnic differences in PCL:SV scores,
which raise concerns about the generalizability of the measure in this study, because
differences found in the relationship between psychopathy and infractions were based
on ethnicity. The results from this study showed that psychopathy contributed very
little to the prediction of total infractions (see Table 2).
Investigations of Treatment Outcome (and Compliance) With
Adolescent Offenders
Gretton and colleagues (2001) retrospectively examined 220 adolescent males
(Mage ¼ 14.7; SD ¼ 1.5) in an outpatient sex offender program. Files, including
treatment notes, were used to rate the PCL-YV, code criminal history, and record
demographic data for each participant. During the ten year follow-up, adolescents with
high PCL:YV scores committed significantly more violent offenses in the community
and were relatively more likely to attempt to escape from custody. The effects were
reported to be attributable to premature drop-out or termination for adolescents with
high PCL:YV scores. Only 64% of those with high PCL-YV scores completed
treatment, compared with 79–80% of those with low–medium scores (Gretton,
McBride, Hare, & O’Shaughnessy, 2000). Of those with high PCL-YV scores, only
30% who completed the treatment program recidivated violently, compared with 80%
who did not complete the program (Gretton et al., 2000). Thus, psychopathy-like youth
who received sufficient doses of treatment appeared to benefit from it. That is, offenders
with a high PCL-YV score who had remained in treatment reoffended at a rate that was
not significantly different from that of offenders with a low PCL:YV score. It is possible
that treatment had a beneficial effect on psychopathic offenders, but it is also possible
that those who remained in treatment were more motivated to change than were those
who dropped out of treatment. Either way, the results from one of the first investigations
on the topic likely argue for the importance of keeping psychopathic adolescent
offenders in treatment.
Catchpole (unpublished thesis) examined 119 violent adolescent offenders
(Mage treatment group ¼ 17. 6; SD ¼ 1.3; 58.9% Caucasian, 25% First Nations, 5.4%
Asian, and 10.7% other; Mage control group ¼ 17.2; SD ¼ 1.2; ethnicity ¼ 59.3%
Caucasian, 35.2% First Nations, 3.7% Asian, and 1.9% other) at three different
treatment facilities in Canada. Treatment programs were primarily cognitive behavioral
in nature, and lasted six to eight months. Findings from this study showed that
treatment groups had lower rates of violent and non-violent re-offending than controls,
and PCL:YV scores predicted latency to the first re-offense. Psychopathy was not found
to moderate treatment response. Treatment was associated with a similar reduction of
Copyright # 2010 John Wiley & Sons, Ltd.
Behav. Sci. Law 28: 235–266 (2010)
DOI: 10.1002/bsl
75 male adolescent
offenders
130 male adolescent
offenders
Forth, Hart, & Hare
(1990)
Brandt, Kennedy,
Patrick, & Curtin
(1997)
Rogers, Johansen,
Chang, & Salekin
(1997)
82 male adolescent
offenders
72 male and female
adolescent
psychiatric patients
220 male adolescent
sex offenders
Murdock-Hicks,
Rogers, & Cashel
(2000)
Stafford & Cornell
(2003)
Gretton, McBride,
Hare,
O’Shaughnessy, &
Kumka (2001a)
81 male adolescent
offenders
No./sample
Researchers
Copyright # 2010 John Wiley & Sons, Ltd.
Outpatient sex offender
program for adolescents
Inpatient treatment for
adolescents
Maximum security detention
center. Treatment type not
specified
Treatment intensive supervision
placements for more serious
misconduct
Residential treatment facility for
DBDs and substance abuse
problems. Treatment typically
spanned six months
State hospital where treatment
mandated for substance abuse
and DBDs
Treatment type
Psychopathic individuals exhibited a higher
rate of violent infractions than nonpsychopathic individuals (African American
r ¼ .57; .06 Anglo Americans). Non-violent
infractions had similar rs (African American
r ¼ .51; Anglo American r ¼ .20) This was
predicted by ethnicity in this study
PCL-R predicted institutional aggression
(r ¼ .49), verbal (r ¼ .48) and covert aggression
(r ¼ .60), and aggression directed toward peers
(r ¼ .33)
Treatment outcome
Psychopathy-like youth who received sufficient
doses of treatment appeared to benefit from it.
That is, offenders with a high PCL-YV score
who had remained in treatment reoffended at a
rate that was not significantly different from
that of offenders with a low PCL:YV score. It is
possible that treatment had a beneficial effect in
the psychopathic offenders, but it is also
possible that those who remained in treatment
were more motivated to change than were those
who dropped out of treatment in this study
Number of institutional charges for violent and
aggressive behavior was higher in those scoring
high on the PCL-R (r ¼ .46)
Psychopathy scores were significantly
correlated with verbal (r ¼ .31) and physical
(r ¼ .28) rule violations
Psychopathy was associated with noncompliance (r ¼ .25) and physical aggression
(r ¼ .28)
Treatment compliance
Table 2. Child and adolescent treatment outcome and compliance studies
—
—
—
—
(Continues)
þ
—
—
Treatment
outcome
Compliance
outcome
250
R. T. Salekin et al.
Behav. Sci. Law 28: 235–266 (2010)
DOI: 10.1002/bsl
Partial hospital program for
substance abusing adolescents
Court diversion treatment
program
State hospital that treated DBDs
and substance abuse
64 male adolescent
offenders with
substance abuse
problems
69 male and female
adolescent offenders
82 male adolescent
offenders
O’Neill, Lidz, &
Heilbrun (2003)
Falkenbach,
Poythress,
& Heide (2003)
Rogers, Jackson,
Sewell, &
Johansen (2004)
Residential treatment for young
offenders in Canadian facility
Treatment type
119 male adolescent
violent offenders
No./sample
Catchpole (unpublished thesis)
Researchers
Treatment was associated with a similar
reduction of general and violent recidivism
across the range of psychopathy scores. The
Catchpole (unpublished thesis) study provided
evidence for the treatment amenability of
adolescents scoring high on the PCL:YV with
two primary outcome variables
PCL-YV scores correlated negatively with days
in the program (r ¼ .42) quality of participation (r ¼ .55), and researchers’ ratings (from
discharge summaries) of clinical improvement
(r ¼ .58). Offenders were followed up for one
year after release from the treatment facility.
PCL-YV scores were significantly correlated
with the number of times they were arrested
(r ¼ .33). Limited consideration for the
treatment of psychopathy
Psychopathy was correlated with program
non-compliance (r ¼ .22–.36) and re-arrest
(r ¼ .33–.56) during a one year follow-up
Psychopathic traits did predict course of
treatment and level of improvement, but the
primary predictor for all outcome variables was
breadth of substance abuse. Approximately
26% of the sample showed a significant
decrease in psychopathic traits, with only 3.7%
showing an exacerbation of symptoms.
Management problems during the hospital
course and the eventual outcome of treatment
were improved even for those scoring high on a
psychopathy measure
Treatment compliance
Table 2. (Continued)
Copyright # 2010 John Wiley & Sons, Ltd.
(Continues)
þ
—
þ
Treatment
outcome
—
Compliance
outcome
Treatment of Psychopathy
251
Behav. Sci. Law 28: 235–266 (2010)
DOI: 10.1002/bsl
Copyright # 2010 John Wiley & Sons, Ltd.
85 male adolescent
adjudicated
delinquents
remanded for
rehabilitation
services
53 male children
85 male adolescents,
treatment 79 male
adolescents,
treatment as usual
Spain, Douglas,
Poythress, &
Epstein (2004)
Hawes & Dadds
(2005)
Caldwell, Skeem,
Salekin, &
Van Rybroek
(2006)
Children being treated for
ODD/CD with a program for
DBDs. Treatment consisted of a
manualized parent training
intervention delivered by a
clinical psychologist across
nine weeks (1 hour sessions)
Mendota treatment center for
young offenders
Psychiatric dual diagnosis
services that spanned 9–
12 months. Treatment included
medical and behavioral
components (REBT). The
program was a multi-step
program based on points earned
(lost) that could result in
advancement or demotion in the
program
Treatment type
Treatment was associated with relatively slower
and lower rates of serious recidivism, even after
controlling for the effects of non-random
assignment to treatment groups and release
status
Psychopathy measures (PCL-YV, CPS, and
APSD) were generally related to physical and
verbal aggression and administration infraction
but results were highly variable in terms of
treatment progress. Specifically, psychopathy
did not appear to be predictive of number of
days to promotion (PCL-YV was not predictive
and only the behavioral components of the CPS
and APSD were predictive of outcome.
Psychopathy also did not predict whether
individuals would have a treatment level
dropped
Boys with CU traits were reported to be less
responsive to discipline with time out than boys
without CU. CU traits did evidence a drop
from Time 1 to Time 2 and at a 6 month
follow-up (d ¼ .5)
Treatment compliance
þ
þ
þ
—
Treatment
outcome
Compliance
outcome
þ ¼ positive outcome, ¼ negative outcome, — ¼ not measured. This table is not meant to be an extensive list of treatment studies but rather the treatment studies that
were available to us through psychology search engines and had been published in scientific journals. This group of studies does not include dissertations, which may
provide further information on this topic once they pass through the peer-review process. DBD ¼ disruptive behavior disorders, CU ¼ callous unemotional traits,
REBT ¼ Rational Emotive Behavior Therapy.
No./sample
Researchers
Table 2. (Continued)
252
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DOI: 10.1002/bsl
Treatment of Psychopathy
253
general and violent recidivism across the range of psychopathy scores. The Catchpole
(unpublished thesis) study provided evidence for the treatment amenability of
adolescents scoring high on the PCL:YV with two primary outcome variables. One
potential problem with this investigation was that it was a retrospective–prospective
design. The risk here, as with the adult studies, is that treatment notes can affect
psychopathy ratings and there is the possibility for contamination when there is one
chart and two issues (assessment of psychopathy and treatment outcome).
O’Neill, Lidz, and Heilbrun (2003) examined 64 male adolescents (Mage ¼ 16.0;
SD ¼ 1.0; approximately 52% African American, 28% Hispanic, and 20% Caucasian)
who were in an intensive outpatient treatment program for substance abuse. The
program was the Youth Opportunities program in Philadelphia, PA, which was a
pretrial partial hospital program for substance abusing youth with disruptive behavior
problems. The program involved seven hours of scheduled programming per day, five
days a week. The programming followed a comprehensive treatment model that
included a number of structured intervention modalities addressing a broad range of
problems and needs. The major treatment modalities included a daily community
meeting, twice weekly one hour individual therapy sessions (based on a cognitive
behavioral framework), twice daily one hour sessions of group therapy, three hours per
day of classroom education, and daily recreational activities. The authors noted that
youths showed some benefit from the program, but that psychopathy scores predicted
worse attendance, lower quality of participation, fewer clean drug tests, lower clinical
improvement ratings, and higher recidivism. Several problems with this study should be
noted however, in that it was a treatment program primary for substance abusing
adjudicated youth and it was not designed for psychopathic youth. Perhaps even more
concerning is that it would be difficult to rate the PCL-YV with the file information,
which contained many of the outcome variables, without having these variables
influence psychopathy ratings, thereby conflating the two.
Rogers, Jackson, Sewell, and Johansen (2004) examined 82 male and female
adolescents (Mage ¼ 15.37; SD ¼ 0.91; 12.2% African American, 26.8% Hispanic
American, 41.5% European American, and 19.5% other/missing) at a state hospital
who were undergoing treatment. Treatment consisted of psycho-education and
therapeutic groups, and provided youths with increased privileges based on program
performance. The primary finding from this study was that, while psychopathic traits
did predict course of treatment and level of improvement, the primary predictor for all
outcome variables was breadth of substance abuse. Importantly, this study also showed
that approximately 26% of the sample showed a significant decrease in scores on a
measure of psychopathic traits, with only 3.7% showing an exacerbation of symptoms.
Rogers and colleagues (2004) concluded that breadth of poly-substance abuse
appeared to be the best predictor of both management problems during the hospital
course and the eventual outcome of treatment. Nonetheless, this study showed that CD
(aggressive symptoms) was predictive of hospital course and psychopathic traits were
predictive of the level of improvement.
Falkenbach and colleagues (2003) examined the relation between psychopathic
features and treatment program compliance and outcomes in a sample of 69
adolescents in a court diversion program (Mage ¼ 14.4; SD ¼ 1.9; mixed gender, 60%
boys, 40% girls; 55.1% Caucasian, 30.4% African American, 7.2% bi-racial, 1.4%
Asian American, 1.4% Native American). Psychopathic traits were assessed using the
Antisocial Process Screening Device (APSD, Frick & Hare, 2001) and a modified
Copyright # 2010 John Wiley & Sons, Ltd.
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254
R. T. Salekin et al.
version of the Child Psychopathy Scale (CPS; Lynam, 1997; Lynam, Caspi, Moffitt,
Loeber, & Stouthamer-Loeber, 2005). Falkenbach et al. (2003) found significant
correlations with psychopathy and program noncompliance and re-arrest during a one
year follow-up for both measures and across raters (parent and self-report).
In a similar study, Spain and colleagues (2004) examined 85 adjudicated delinquents
(Mage ¼ 15.77; SD ¼ 1.35; 79% White, 16% African American, and 4.9% Hispanic) in
west central Florida who were remanded for rehabilitation services. Length of stay for
youth was approximately 9–12 months. Psychiatric dual diagnoses services included
day treatment, family therapy, on-site academics, and career counseling. The program
included medical and behavioral components, with the behavioral component based on
a rational emotive behavioral treatment philosophy. The program also utilized a multistep system based on points earned (or lost) that could result in an advancement or
demotion in program levels. Three psychopathy scales (PCL-YV, APSD, and CPS)
were utilized to test the effects of treatment on psychopathy. Spain and colleagues
(2004) found that psychopathy measures were generally positively linked to physical,
verbal, and administrative infractions, but results were highly variable across
psychopathy scales for two treatment outcome variables. Specifically, psychopathy
did not appear to be predictive of the number of days to promotion (PCL:YV was not
predictive and only the behavioral components of the self-report measures were
predictive) and psychopathy scales did not predict whether a participant would have a
treatment level dropped (only the mCPS Affective scale predicted this outcome).
Potential limitations of this study include its cross-sectional nature and whether or not
self-report measures indicate state rather than trait effects within correctional settings.
To avoid this potential pitfall of retrospective designs, Caldwell and his colleagues
used prospective designs and did not examine psychopathy as a moderator of treatment
but rather examined high psychopathy scorers in treatment settings. Specifically,
Caldwell et al. (2006) examined the treatment response of 141 juvenile offenders with
high scores on the PCL:YV (Mtotal > 27). Two groups of potentially psychopathic
offenders were compared: one that participated in the Mendota Juvenile Treatment
Center (MJTC), an intensive treatment program (MJTC, n ¼ 56), and another that
received ‘‘treatment as usual’’ in a conventional juvenile correctional (JCI) setting
(n ¼ 85). Offenders in the JCI group (Mage at release ¼ 17.2; SD ¼ 1.0; 71.8% African
American) were more than twice as likely to violently recidivate in the community
during a two year follow-up than those who participated in MJTC treatment (Mage at
release ¼ 17.0; SD ¼ 0.87; 41.1% African American). Treatment was associated with
relatively slower and lower rates of serious recidivism, even after controlling for the
effects of non-random assignment to treatment groups and release status. Other work
conducted by Caldwell and his colleagues has shown similar results (see Caldwell & Van
Rybroek, 2001; Caldwell, McCormick, Umstead, & Van Rybroek, 2007). The next step
for this program is to see whether it can be transported to other settings with other
clinicians and researchers.
Treatment of Psychopathy in Children
Although the studies reviewed above were adolescent focused and primarily used the
PCL-YV, one study has emerged on the APSD with disruptive behavior disordered
(DBD) children. This study examined the effects of a standard DBD treatment on
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callousness, as indexed by the APSD and the Strengths and Weaknesses Questionnaire
(Goodman, 1997), in children. Hawes and Dadds (2005) tested the impact of callous–
unemotional (CU) characteristics on treatment outcomes and processes in a ten week
behavioral parent-training intervention with young boys referred for conduct problems
and oppositional defiant disorder. This sample was relatively small and young (n ¼ 53;
Mage ¼ 6.29). The authors found that CU characteristics3 were associated with greater
conduct problems at pretreatment. CU was also associated with poor outcomes at six
month follow-up. CU characteristics uniquely predicted clinical outcomes when
analyzed in relation to conduct problem severity, other predictors of antisocial behavior,
and parents’ implementation of treatment. Boys with high CU traits were also reported
to be less responsive to discipline with time-out than boys without CU characteristics.
Interestingly, despite these difficulties, CU scores dropped from pre-treatment to post
treatment (d ¼ .5) for these children, and this drop was significant and maintained at a
six month follow-up assessment.
What Do these ‘‘Second Generation’’ Studies Tell Us?
Overall, the findings from the studies reviewed above do not make a strong case for the
notion that psychopathy is untreatable in adults or children and adolescents. They do
speak to some of the problems that can be encountered when dealing with psychopathic
individuals. With respect to the adult studies, most studies showed that psychopathic
traits were associated with more problems in the treatment setting. Three of the eight4
studies reviewed showed that psychopathy could benefit from treatment. Although this
might be viewed as a dismal result, it also might be framed as a positive finding.
Specifically, none of the treatments were designed for psychopathy and many of the
studies had design flaws. This does not mean that they are inaccurate per se, but rather
that further research is needed with adults, and studies comparing what is working
against what is not could prove fruitful. Perhaps most importantly, three out of eight
studies may not be a bad hit rate given that none of the studies had treatment programs
designed to treat psychopathy.
With respect to child and adolescent studies, five of the five studies reviewed found
that psychopathy scores were correlated with institutional misconduct in treatment
settings. However, with respect to progress in psychotherapy, six out of eight studies
showed that psychopathic youth benefited from treatment or did no worse than nonpsychopathic youth. These results suggest that psychopathic youth may pose more
problems in treatment settings, but encouragingly they may also make progress in
treatment settings. These findings provide some hope for intervening with psychopathic
individuals. Despite the potential positive aspects of some of this research, some suggest
that psychopathic individuals have so many inherent personality and interpersonal
difficulties that they lack the capacity to make real change.
Critics will point to psychopathy characteristics themselves as a reason that
treatment will not work. Specifically, there are suppositions that certain characteristics
3
CU characteristics in this study where indexed with the APSD (Frick & Hare, 2001) and the Strengths and
Difficulties Questionnaire (Goodman, 1997). It should be noted that the measure of CU focused on the
affective component of psychopathy.
4
We used eight studies in our calculation because the Morrissey studies appear to use the same sample and
Hitchcock is a dissertation where treatment did not seem to work at all.
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of the psychopathic individual naturally make them less than ideal candidates for
psychotherapy (Seto & Barbaree, 2006; Skeem, Polaschek, & Manchak, 2009). We
address several important areas of concern and note that these are critical points that
should not be ignored. However, we also argue that such characteristics are not
necessarily reasons for conclusions about inertness or iatrogenic effects of therapy.
Instead, we argue that they should become part of the treatment plan.
PRACTICAL PROBLEM AREAS WHEN WORKING WITH
THE PSYCHOPATH
Psychopathy traits are potentially problematic in treatment settings. This appears to be
supported by the research reviewed above (Abracen, Looman, & Langton, 2008; Hare
et al., 2000; Hobson et al., 2000; Looman et al., 2005; Ogloff et al., 1990; Rice &
Harris, 1992; Rice et al., 1992; Seto & Barbaree, 1999, 2006; Shine & Hobson, 2000).
However, whether they make treatment impossible is less clear. A number of potential
problems have been outlined about the treatability of the psychopathic personality in
previous reviews. Common areas of concern include motivation to change,
manipulation and deceit (being fooled), lack of real emotion, and the risk associated
with conducting therapy with psychopathic individuals. Numerous reviews (e.g., Lo¨sel,
1998; Thornton & Blud, 2007; Wong & Burt, 2007) have addressed these topics, citing
psychopathy items that align with each of the problem areas (e.g., manipulation,
shallow affect), so we shall only cover these issues briefly here with the intent of finding
potential in-roads.
Motivation to Change
It has been frequently noted that psychopathic individuals are unlikely to perform well
in psychotherapy because they are not particularly motivated to change. While this may
be true to some extent, it does not necessarily translate to the notion that interventions
would not be effective with psychopathic individuals. Also, if level of motivation to
change was used as a reason for not proceeding with psychotherapy, mental health
professionals would knock out a good portion of psychotherapy cases, even though we
now know that many ‘non-motivated’ (e.g., depressed) patients later benefit from
treatment.
Fortunately, there has been a wave of research that has been designed to help
motivate unmotivated clients and it is possible that such treatments would also work for
psychopathic individuals. That being said, there could very well be something about the
psychopathic individuals’ particular lack of motivation that could be problematic for
treatment. Until further evidence is elucidated to show that this particular lack of
motivation is any worse than that of other disorders (including other disruptive behavior
disorders, substance abuse disorders, and so forth, which also have been shown to
benefit from psychotherapy), it should not be utilized as a reason to not embark on
therapy. Instead, motivation needs to be evaluated and innovative treatment studies
designed to enhance it.
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Deception and Manipulation
There has also been concern that psychopathic individuals will deceive others and thus
they are not likely to benefit from therapy because they will simply be playing along with
the interventionist. It is possible that this will occur. This likely occurs with other
disorders too, however, where patients feign improvement to impress therapists or other
family members, to gain early release from restricted settings (e.g., inpatient units), or
for a host of other reasons. The question is not whether or not this will occur with
psychopathic individuals, but rather how it might be treated. Better decision making in
high risk situations when releasing patients especially when they were previously
experiencing symptoms will be needed, but if clinicians can learn to determine candid
and honest reporting of symptoms from manipulation they will be in a better position to
treat and make disposition recommendations for psychopathic individuals. It should
also be noted that there has been speculation that treatment may teach psychopathic
individuals the social and emotional skills that increase their likelihood of committing
crimes without getting caught for the crime. This speculation is largely based on theory
(Gough, 1970) and perhaps the one study conducted by Rice et al. (1992). Whether
social and emotional abilities actually increase or decrease with treatment is still
unknown. More research is needed on this topic and a better understanding of
psychopathy and deception in adult and child populations is also needed (see Salekin,
Kubak, & Lee, 2008).
Lack of Deep or Lasting Emotion
Another concern about the treatment of psychopathic individuals is that they cannot
make strong attachments to others, and because they are unable to make human bonds
they are not able to do well in psychotherapy. Although some of the hallmark symptoms
of psychopathy are a lack of remorse and a lack of empathy, there is not a great deal of
evidence regarding how stable these characteristics are across time. In addition, there is
little evidence to show that alterations in affective reactions could not be made in
individuals with psychopathic characteristics. However, research on the emotion in the
psychopathic individual requires much more attention to determine whether
psychopathic individuals completely lack emotion, or whether they are likely to have
pockets of emotion, short-lived versus long-lived emotions, or some other emotional
capability. Treatment might help to further understand the emotional functioning of
individuals with psychopathic characteristics by showing which areas can be built upon
and which areas seem less likely to improve.
NEW DIRECTIONS FOR THE SCIENCE OF THE
TREATMENT OF PSYCHOPATHY
The natural conclusion from this review is that we should be doing more to attempt to
understand and potentially intervene with psychopathy. Salekin (2002), Lo¨sel (1998)
and others have pointed out that the study designs need to be improved. Since these
concerns have been outlined elsewhere, we shall not cover them in great detail here.
Rather, we suggest other areas that could be improved upon that are more conceptual in
nature. We emphasize even more the need for theory and how successful programs will
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likely need to weave theory into program development if they are to advance research in
this area.
Examining the previous reviews on the topic of psychopathy and treatment provide
important information regarding future directions. There appear to be common themes
in what previous researchers view as problematic in psychopathy treatment studies.
First, there is the concern about how to define psychopathy. This problem has now been
noted by numerous scholars in the past (Blackburn, 1998a,b; Harris & Rice, 2006;
Lo¨sel, 1998; Salekin, 2002; Thorton & Blud, 2007), and in the opening pages
of this article. There has also been concern about what the appropriate outcome
variables might be. Specifically, how do we know that psychopathic individuals got
better? Relatedly, there exist concerns about the lack of treatment development
specifically designed for psychopathy. Finally, there has been much concern about
the methodological rigor of psychopathy treatment designs. Excluding the need for
more rigorous research designs, perhaps most divergent views on these other issues are
those of Salekin (2002) and Harris and Rice (2006).
Harris and Rice (2006) suggest that the PCL should be the only index used for
assessing psychopathy and that the outcome to examine is recidivism. With respect to
theory, they are less optimistic regarding treatment because of its evolutionary style
(Harris and Rice, 2006). In the future, however, we would hope that research be
broader in scope, including a broad array of psychopathy definitions and types (e.g.,
Lynam’s CPS; Patrick’s meanness and boldness constructs; Lilienfeld’s eight factor
model) and include a wide net of outcome variables. We use the next section to outline
how this could be important for building theory and ultimately for improving our
understanding of the psychopathy–treatment relation.
Defining Psychopathy in the Up-Coming Years
Previous research (Harris & Rice, 2006; Skeem et al., 2002) has critiqued studies and
meta-analytic reviews for using differing conceptualizations of psychopathy. At the
same time, researchers have also contended that the PCL-R should not be the only
measure used to examine psychopathy research questions (Harris & Rice, 2006). The
best way to advance science in this area is to generate studies that assess the differing
conceptions of psychopathy and to examine how psychopathic individuals might benefit
from treatment. As mentioned in the introduction of this article, Cleckley’s (1941)
model of psychopathy was developed in the community and Hare’s (1991) was
developed in forensic populations. It will be important to examine the respective
models’ responsiveness to treatment. Moreover, recent models of psychopathy that
branch even further out from more traditional models of psychopathy may require study
to determine whether they are invariant with respect to intervention efforts.
Heterogeneity regarding the concept of psychopathy can be helpful in examining
what works (or does not work) with what type of psychopathic individual. Moreover,
vantage point (self-report versus clinical opinion) will be critical to evaluate.
Evaluating Outcome in Up-Coming Years: Benefits from Using a
Wide Net
In examining whether or not psychopathic individuals improve in therapy, it would be
beneficial to look at a variety of outcomes. A variety of outcome variables in reviews has
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been viewed both positively and negatively in past reviews and commentaries on the
psychopathy treatment literature (Harris & Rice, 2006; Salekin, 2002). According to
some, there is only one variable that matters in psychopathy treatment outcome
studies—whether or not psychopathic individuals recidivate. However, it could be
argued that studying various outcome variables could be very important to furthering
our understanding of the psychopathic personality and advancing treatment. There are
numerous examples in the field where using one outcome may be counter-indicated.
For instance, research on Expressed Emotion for schizophrenic patients would not have
resulted in interventions for schizophrenic patients if a return of psychotic symptoms
were a marker for failure in a treatment program. Similarly, Marlatt (1987) would likely
have not pursued relapse prevention research if he had held any subsequent substance
use as a criterion for program failure. Beck (see Clark & Beck, 1990) would not have
pursued cognitive behavior therapy under the theory of changing cognitions for
depressed patients if recurrent depressed mood were a marker of treatment failure. Few
treatment programs would have advanced if a recurrence of a problem was used as a
marker for failure.
Re-arrest, or recidivism, or even institutional infractions, are coarse indicators of
improvement. Thus, individuals who begin to make friends, improve at work or their
grades, and have better relations with family members could be deemed a failure in
therapy if one incident brings them into contact with the law. Although recidivism is,
without a doubt, a key outcome variable, other variables such as job performance,
interpersonal relationships, increased involvement in sports and hobbies, success in
romance, and other social factors are also key indicators of life success. Moreover, they
are likely to have a synergistic effect on each other, building qualities and competencies
in individuals. At this point, research on the treatment of psychopathy should ask what
effect psychotherapy has on any aspect of the condition. To be sure, if other progress
(beyond a reduction in contact with the law) is not noticed, and built upon, then few
skills will be developed, and few life successes attained.
Finding Out What Works
Meta-analytic researchers have previously noted that there may be a tendency for
researchers to evaluate the therapy they like best and to pick clients, circumstances, and
outcome measures which show therapy in the best light. This has been a concern
expressed about previous meta-analytic studies on psychopathy. Nonetheless, major
differences among therapies can appear through this procedure, providing information
about which methods may work better than others. For instance, as noted in the
introduction, Salekin (2002) showed that therapeutic communities appear to be much
less effective than dynamic and cognitive behavioral paradigms with psychopathic
individuals. Also, some basic classes of therapy seemed to be effective at reducing some
aspects of psychopathy. So, why was this the case? The reason may be that at least some
of the needed ingredients for change existed within the approaches previously used to
treat psychopathic individuals.
The analytic interventions would have included congitive control, conscience
training, and treatment that addresses emotion regulation. Today, Kochanska’s work
(1993, 1995) in this area is salient. Her term ‘‘reciprocal cooperation’’ and use of
instruction to children about right and wrong from an early age (three year olds) may
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parallel what psychoanalytic therapists were attempting to do in previous decades. With
cognitive behavior therapy, the focus would likely be on cognitive control in order to
contain and reduce antisocial behavior. Another important aspect of this meta-analysis
that makes conceptual sense was that family members were important in the treatment
process. Again, we know from past psychotherapy research that these factors seem to
increase the chances of improving client well-being.
It is likely that many of the current treatments designed for APD and conduct
disorders could also have some effect on psychopathic individuals (Alexander &
Parsons, 1973; Henggeler & Borduin, 1990; Henggeler, Schoenwald, Borduin,
Rowland, & Cunningham, 1998; Hollon et al., 2005; Kazdin & Wiesz, 2010;
McMahon & Forehand, 2003; Moretti, Holland, & Peterson, 1994). Some of the
ingredients in these programs which have commonalities may effect change in APD,
conduct disorder, and perhaps even psychopathic individuals. Although each therapy
might be investigated to determine its relative effect on psychopathy, it will be
ultimately informative to know what ingredients, in common, across programs, are able
to effect change in psychopathic individuals. Approaches could be taken to examine
behavior, cognitive behavior, and interpersonal therapies that are well validated for
APD and the disruptive behavior disorders to determine how applicable they are to
psychopathy.
In the event that therapies designed for specific adults with APD or the DBDs (e.g.,
oppositional defiant disorder) do not work well for psychopathy cases, then more
specific treatment programs will be needed to further protect psychopathic individuals
from themselves (work failure, academic failure, trouble with the law, substance abuse)
and from the community (aggression, offending). We discuss how this could be
accomplished below.
Specific Treatment Programs For Psychopathy: Providing Optimal
Interventions
If treatments that are designed for APD and disruptive youth are not optimal for
psychopathic individuals then it will be important to tailor treatments specifically to this
group. Intervention research specific to adult and child psychopathy might draw on
theory, including the conceptualization of how psychopathy starts out, how it is
maintained, how it ends or reappears, and so forth. Two foci of theory will be
particularly pertinent to the treatment question. First, researchers will need to
adequately map out the theory of dysfunction, which refers to the conceptual
underpinnings and hypotheses about the likely factors leading to psychopathy (e.g.,
amygdala anomalies, frontal lobe deficits, attachment difficulties), the process involved,
and how these processes emerge or operate. Although much work has been conducted
in this area, researchers are still a long way off from understanding the development of
psychopathy. Nonetheless, the focus is likely to be on various risk and protective factors,
paths and trajectories, and how early development results in subsequent dysfunction
(Salekin & Lochman, 2008). Models of development will likely be complex (Salekin,
2006); posing a single influence (i.e., construct) or mediator that leads to a single
outcome is unlikely to consistently be the answer to how psychopathy develops.
Nonetheless, this is a reasonable place to begin research.
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Second, theories of therapeutic change for psychopathy will be needed, and these refer
to the conceptual underpinnings of the process(es) of change during treatment. The
focus is on what therapy is designed to accomplish and through what means and
processes. How will the procedures used in treatment to influence psychopathic traits or
make it less impactful on the environment? In theorizing about therapy for psychopathy,
it is important to keep these foci separate as well as to recognize their relation.
INTEGRATION AND CONCLUDING COMMENTS
Psychotherapy research has had an interesting course as noted in the introduction, from
psychologists arguing adamantly that therapy was inert (Eysenck, 1965) to more
promising findings presented by Bergin and then an accumulation of efficacy studies
reported by Smith and Glass (1977) to more promising findings about psychotherapy’s
impact outside of university settings (Seligman, 1995). Evidence based research for
children has also been impressive over the past several decades (e.g., Kazdin & Weisz,
2003, 2010). Views regarding the treatment of psychopathy may mirror the general
course of perspectives held for psychotherapy. That is, with the small pool of studies on
the topic and the high degree of methodologically flaws, views are generally negative,
but may abate if effective treatment programs can be developed and be shown to impact
change. The hereditary component of psychopathy may contribute to views that the
disorder is untreatable, but, as mentioned in the opening pages of this article, it is not a
good reason for such views. Nor are views that psychopathic individuals are entirely
different from the remainder of the population, given that taxometric research does not
support this notion (Murrie et al., 2007).
With respect to past research in this area, the studies presented in this article are
informative and offer a first step in showing that treatment is difficult with psychopathic
individuals, but there is the hint, with a few of the articles, that something may work
with psychopathic individuals. Nonetheless, the research, particularly with adults,
shows that much more work is needed to start to effect change. The field is likely in a
much better position to design such studies on the treatment of psychopathy and major
classes of therapy. These investigations could, in fact, be tested in controlled studies.
Studies might focus on the current treatment programs to determine whether they can
alleviate the symptoms of psychopathy.
Finally, notions of what progress is, exactly, in therapy will need further
consideration. Much like the lines that represent stock market functioning, there is
not a steep and straight line indicating an increase or decrease in the earnings of
companies but rather gradual zig-zagging lines that represent a climb or reduction in
earnings. So, too, is the process of growth or declines in human functioning that occur
in psychotherapy or when treatment is not undertaken by individuals in need of
treatment. Thus, a realistic goal for treating individuals who have psychopathic
characteristics would not be to eradicate all symptoms at once, but rather to make
gradual progress over the course of therapy, acknowledging that there would also be
some bumps along the road.
Our research group has started to study the treatment of psychopathy in children and
adolescents with the Mental Models Approach for Psychopathy (Salekin, 2008) and
results, thus far, are promising. This model is based on the information gleaned from
the literature on treatment of psychopathy and motivational variables. We hope other
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researchers might also be open to investigating psychopathy in generic conduct program
programs and other interventions that might help with the reducing the problem
behavior of psychopathic individuals. We believe that some change is possible with this
group and that the focus, for now, should be on change. Key developmental differences
may make children more available to treatment options (Rutter, 1989; Rutter et al.,
1987), and as such efforts to develop and advance treatment technology in this area
should be pursued.
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