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Hervey Cleckley, in his classic book "The Mask of Sanity" (1941) described psychopaths as neither benefiting from treatment nor forming the emotional bond to the therapist required for effective treatment. Some early studies were more hopeful about the effects of psychotherapy, but all suffered from severe methodological flaws, and later reviewers concluded they provided no evidence for the treatment of adult psychopaths.
One of the most popular types of program for psychopaths has been a therapeutic community. For over a decade, Oak Ridge operated a famous therapeutic community program for violent offenders, intended to be especially beneficial for psychopaths. After the program's demise, we evaluated it by comparing participants to similar offenders in prison. After ten years, the treatment showed no effect on violent recidivism for nonpsychopaths, but psychopaths in the program became more violent.
Psychopaths behaved much worse than non-psychopaths during therapy, but they were just as successful at obtaining promotion in the therapeutic community and being discharged from hospital. In a separate therapeutic community program, in Saskatchewan, psychopaths showed less motivation, were discharged from the program earlier (usually because of lack of motivation or security concerns) and showed less improvement.
Another treatment often recommended for psychopathic offenders is cognitive-behaviour therapy. Doubt about the benefits for this type of program for psychopaths, however, comes from an evaluation at Warkworth Correctional Institute. Researchers there predicted that good treatment behavior would indicate future success on parole.
Contrary to their predictions, offenders who showed the most improvement were more likely to violently re-offend, especially psychopaths. A recent meta-analysis (a statistical technique that combines results from many studies) suggested that treatment studies show a positive effective for psychopaths. But the main measure of success was therapists' impressions of clinical progress. The Warkworth study and other research shows that therapist ratings are not well related to post-treatment recidivism by psychopaths.
For such a serious problem, it is surprising that there is little good evaluation research.
1. There have been no good demonstrations of treatment effectiveness for psychopathy, only because good evaluations have yet to be done. Perhaps psychopathic offenders benefit from that treatment already shown to be effective for offenders in general. Psychopaths just need higher doses and intensities.
2. There have been no satisfactory demonstrations because an effective clinical intervention is lacking. Psychopaths are fundamentally different from other serious offenders, so that none of the therapies that work for other offenders is effective for psychopaths. Indeed, some increase the risk posed by psychopaths.
3. No treatment will ever be effective. Psychopathy is not even a clinical disorder that can be treated. All that can be hoped for is a set of strategies that limit the harm done by psychopaths by incapacitating the psychopath.
By the same token, not all clinical interventions require there to be a clinical deficit or disorder in need of a remedy. The best example is behaviour modification. Often provided for seriously disordered and disabled individuals, behavioural principles are also applied to healthy persons, such as classroom management techniques or workplace safety strategies. There is empirical evidence that this approach has worked with some offender and violent populations (although not psychopaths).
In the final analysis, therefore, we adopt Conclusion 2, although we also believe that psychopaths do not have deficits in the clinical sense. The evidence favors a strategy that applies behavioral principles to reducing the harm caused by psychopathy. Where psychopaths have already committed serious offenses and exhibit evidence of high risk of future violence, we favor the use of selective incapacitation in the form of long-term institutionalization.
1. The program is explicit and concentrates on reinforcing behavior incompatible with psychopathic conduct (i.e., delaying gratification, telling the truth, being responsible, being helpful and being cooperative) and penalties for impulsive, dishonest, aggressive, irresponsible, and of course criminal actions.
2. There is no expectation that the program will ever end.
3. Consequences for behavior are consistently monitored by institutional staff, always based on observed, overt behavior and never based on what the inmate reports about his thoughts, feelings or conduct.
It must be recognized, however, that 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. In our opinion, the greatest prospect for an effective intervention lies in the challenge of applying these wrap-around behavioural principles to psychopaths under conditional release.
Zoe Hilton (Senior Research Scientist) provided this much edited version of a book chapter by Grant Harris (Director of Research) and Marnie Rice (Director of Research Emerita).
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