Clear Lessons From The Past On Treating Psychopaths

In my last column, I described our recent research on psychopaths supporting the idea that psychopathy is not a disorder. If psychopathy is not a disorder, but an adaptation instead, what kinds of treatment and therapy should psychopaths get?

Some of you may recall the research we did several years ago on the effects of the Social Therapy Unit (STU), a very intensive therapeutic community that operated in the 1960's and 1970's. It emphasized insight-oriented therapy, was emotionally evocative, and placed patients in clinical leadership roles. The program was very faithful to its operating principles and was based on the best available information about psychopathy.

The STU clinicians and outside experts all felt the program was effective. Our follow-up research showed, however, that the program reduced recidivism among patients who were not psychopaths, but increased the violent recidivism of psychopaths (compared to prison). We think this research teaches some valuable lessons: Clinicians cannot assume that their efforts are beneficial; it is possible to do harm. This fact has been demonstrated elsewhere -— some well-intentioned services actually increase the likelihood of crime.

The only way to know whether services are effective is to evaluate outcomes. Our research showed that psychopaths actually behaved more poorly in the program (compared to the other patients), but were as likely, or even more likely, to be trusted by the clinical staff.

Other researchers have shown that clinicians' impressions are a poor index of the benefits of therapy especially concerning psychopaths. But perhaps the most important lesson is that psychodynamic, insight-oriented, emotionally evocative therapy should not be provided for psychopaths.

Researchers have attempted to identify what kinds of programs are effective for criminal offenders in general. These reviews have all arrived at similar conclusions: Insight-oriented, emotion-based therapy should not be provided for offenders. Making punishment more severe, or trying to "scare 'em straight" are also ineffective. Effective programs teach offenders something useful -- academic, vocational, social or personal management skills. Effective programs are firm but fair.

Even though psychopaths might appear depressed, deliberately targeting self-esteem would probably not decrease risk and might even increase it. Psychopaths have generally high self-esteem even without therapy. Among offenders, high self-esteem is associated with aggression. Is there a drug that would reduce the risk of psychopaths? There has not been much research on drug treatment for psychopathy, but it is a sensible avenue for exploration.

Psychopaths have a different physical make up from other people, and giving them a drug to make their neurophysiology more similar to the rest of us might make them less dangerous -- if one could ensure the drug was taken. There have been reports that lithium reduced the aggression of "character disordered" prisoners, but, of course, the prisoners disliked taking the lithium (or "kryptonite" as many patients call it). Thus, other, more tolerable drugs might reduce the risk posed by psychopaths, but the lesson of the STU should not be forgotten -- a careful evaluation is essential; impressions of effectiveness cannot be trusted.

Another way to deal with the risks posed by psychopaths suggests doing something, not for psychopaths, but for the rest of us. Some research suggests that those people who aren't psychopaths would be interested in learning about the nature of psychopathy. If they knew how to recognize psychopaths, and how psychopaths operate, people might better protect themselves and reduce the harm psychopaths cause.

An important part of such education would emphasize that people should not trust their intuitions and impressions of strangers, and should rely instead on reputations earned over time. The more that people did that, the harder it would be for psychopaths to exploit others. Theoretically, at least, young women comprise the group that would benefit most from such "anti-psychopath" training.

The idea that psychopathy is not a disorder but is instead an adaptation leads to this notion of "anti-psychopath" training which is a way of reducing the environmental niche for psychopathy. What else would make that niche smaller? Theoretically, psychopaths should thrive when resources are scarce and when there is a lot of social instability so that people frequently have to deal with strangers.

Thus, a typical North American urban environment may be just the place to foster psychopathy not because that environment causes psychopathy directly, but because such an environment provides a large niche for its expression.

Conversely, social policies that increase social and economic equity, and enhance family and community cohesiveness, while decreasing social isolation and anonymity might be exactly those that make it difficult for psychopaths to prosper. Over generations such policies might actually reduce the incidence of psychopathy.

Certainly, making big social policy changes is beyond the day-to-day ability of clinicians working with violent offenders. But the lessons from the past are clear: programs and treatment should teach useful skills and avoid just trying to delve into offenders' intrapsychic forces. Learning new skills might lead to enhanced self-esteem, but boosting self-esteem should not be the primary focus of therapy. Because treatment can cause clients to become more dangerous, evaluation of actual outcomes is essential.