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Psychopathy Treatment and the Stigma of Yesterday's Research
Rasmus Rosenberg Larsen
Kennedy Institute of Ethics Journal, Volume 29, Number 3, September 2019,
pp. 243-272 (Article)
Published by Johns Hopkins University Press
DOI:
For additional information about this article
Access provided at 4 Nov 2019 13:12 GMT from University of Toronto Library
https://doi.org/10.1353/ken.2019.0024
https://muse.jhu.edu/article/736765
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Kennedy Institute of Ethics Journal Vol. 29, No. 3, 243–272 © 2019 by Johns Hopkins University Press
Rasmus Rosenberg Larsen
Psychopathy Treatment and the
Stigma of Yesterday’s Research
ABSTRACT. The psychiatric diagnosis of psychopathic personality—or psychopa-
thy—signifies a patient stereotype with a callous lack of empathy and strong
antisocial tendencies. Throughout the research record and psychiatric practices,
diagnosed psychopaths have been predominantly seen as immune to psychiatric
intervention and treatment, making the diagnosis a potentially strong discrimi-
nator for treatment amenability. In this contribution, the evidence in support of
this proposition is critically analyzed. It is demonstrated that the untreatability
perspective rests largely on erroneous, unscientific conclusions. Instead, recent
research suggests that practitioners should be more optimistic about the possibil-
ity of treating and rehabilitating diagnosed psychopaths. In light of this finding,
concrete ethical challenges in the forensic practice surrounding the psychopathy
diagnosis are discussed, adding to a growing body of research that expresses
skepticism about the forensic utility of the diagnosis.
INTRODUCTION
Psychopathy is one of the most studied and recognized psychiatric
diagnoses in mental health research (Hare, Neumann, and Widiger
2012). The clinical prototype of a psychopathic patient includes
traits of grave antisocial conduct, pathological lying, and a callous lack
of empathy (Cooke et al. 2012). Relatedly, psychopaths are believed to
be overrepresented in the criminal populace. Whereas psychopaths are
estimated to make up about 1% of the general population, it is projected
that some 30% of all incarcerated individuals might be psychopaths (Hare
and Neumann 2008). As a result of these estimates, the psychopathy diag-
nosis has predominantly been researched and applied in forensic settings,
yielding actuarial nontrivial information about behavior prediction, risk
evaluation, treatment amenability, institutional placement, parole deci-
sions, etc. (Gacono 2016; Hare, Black, and Walsh 2013).
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While many of the traits associated with psychopathy also overlap
with other personality and conduct disorders (Crego and Widiger 2015),
psychopaths are nevertheless considered importantly unique on a number
of parameters. One such central difference is the prevailing belief that—
different from most psychiatric conditions—psychopathy is an essentially
chronic, untreatable disorder (e.g. Hare, Black, and Walsh 2013). For
example, in a survey of Swedish forensic practitioners (n = 90), Sörman
and colleagues (2014) found that participants generally endorsed the
view that (a) psychopaths cannot change, (b) that there is no treatment
that can cure a psychopath, and (c) that criminal psychopaths cannot be
rehabilitated. These findings were consistent with a 1993 survey of UK
forensic practitioners (n = 515) that found that only 1% thought that
psychopathic personality was always remediable; most answered that only
in some cases could patients benefit from treatment (Tennet et al. 1993).
The view that psychopaths are immune to various forms of psychiatric
intervention and rehabilitation is not a new development, but echoes a
long-standing truism in the research history (e.g. Cleckley 1988; Hare
1998; Harris and Rice 2006; Maibom 2014; McCord and McCord 1964;
Suedfeld and Landon 1978). Presumably as an effect of these beliefs,
researchers have reported on widespread evidence that the psychiatric
diagnosis is generally applied, not as an indicator of psychiatric treatment,
but moreover as a discriminator for treatment and rehabilitation programs
(Polaschek and Skeem 2018). As was recently argued by a team of leading
researchers, forensic practitioners are better off considering management
a more appropriate goal than treatment when dealing with psychopathic
patients, given that there is “no evidence that treatment programs result in
a change in the personality structure of psychopathic individuals” (Hare,
Black, and Walsh 2013, 244–45).
Mirroring a growing sentiment among researchers, this article argues
that the untreatability view about psychopaths is medically erroneous
due to insufficient support of scientific data. Moreover, the aggregate of
recent research appears to paint a comparatively more optimistic picture
of psychopaths’ response to psychiatric intervention. Such a perspective, if
reasonable, raises novel ethical concerns expedient to the field of forensic
psychiatry—for example, whether the clinical narrative and forensic
practice concerning psychopathy meet the ethical standards for proper
psychiatric professionalism. Speaking to this suspicion, new cautionary
directions for future practices and research are discussed.
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THE PSYCHOPATHY DIAGNOSIS AND ITS FORENSIC APPLICATION
The psychopathy diagnosis is arguably among the historically and currently
most researched psychiatric conditions (Hare, Neumann, and Widiger
2012), and as a result, its research paradigm has become an increasingly
large and challenging affair to navigate. These complexities are further
amplified by pop-cultural and unscientific anecdotes that surround the field,
colorfully portraying psychopaths as vile intraspecies predators, sometimes
deviating wildly from the basic tenets of the empirical research (Berg et
al. 2013). Thus, one strategy for a sober and informative discussion of
psychopathy research is to start with some basic perspectives in terms of
what exactly psychopathy is and is not.
It should be noticed that psychopathy is not an “official” psychiatric
diagnosis, in the sense that its details are recognized by the broader
psychiatric community. For instance, the diagnosis is not explicitly
included in the latest edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5). Instead, the DSM-5 includes canonical
psychopathic personality traits as specifier criteria under the diagnosis of
Antisocial Personality Disorder (ASPD), ostensibly cataloging psychopathy
as a subcategory to ASPD (for a discussion of the differences, see Crego
and Widiger 2014). This should not necessarily be seen as a problematic
aspect, though. Some researchers have argued that our understanding of
psychopathy has greatly surpassed our understanding of ASPD, since the
majority of research efforts (and funding) has migrated away from ASPD to
the psychopathy diagnosis (e.g. Gacono 2016; Hare and Neumann 2008).
More fundamentally, though, classificatory descriptions of psychopathy
in the psychiatric nomenclature can vary depending on the researchers we
consult. For instance, some describe psychopathy as a personality disorder,
others as a clinical construct, and some have argued that psychopathy is
merely an adaptive lifestyle (e.g. Glenn, Kurzban, and Raine 2011; Hart and
Cook 2012). In addition to these perspectives, the many different scientific
theoretical accounts of the diagnosis are multifaceted. For instance, some
posit psychopathy to be a cognitive disability, and others think it is an
impairment of emotion dispositions (for a discussion of the contemporary
accounts, see Brazil and Cima 2016). While these disagreements in the field
are substantial, a more generous interpretation might be that they reflect
a growing suspicion among researchers that psychopathy is a much more
heterogenous disorder than previously assumed, that the diagnosis might
consist of, or be divided into, several subtypes (e.g. Hicks and Drislane
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2018) with varying underlying etiologies (e.g. Jurjako and Malatesti 2018;
Stratton, Kiehl, and Hanlon 2015).
However, aside from these divergences, the more fundamental motivation
for applying the diagnosis is that the diagnosis itself aims at signifying
a common patient stereotype encountered in the psychiatric clinic. That
is, over the decades of psychiatric professional practices, clinicians have
come to a sort of consensus that there exists a specific class of patients who
demonstrate a peculiar constellation of personality and behavior; namely,
a markedly callous personality disposition (e.g. lack of empathy, glibness,
grandiosity) and strong antisocial tendencies (e.g. violence, pathological
lying, impulsivity). These are the concrete individuals that clinicians aim
to demarcate when they apply the term ‘psychopathy’ (i.e. regardless of
whether they see it as a disorder, construct, or something else).
More decisively, though, the majority of researchers generally agree
that the syndromic constellation of so-called psychopathic traits is a
sign of abnormality, positing that the homogeneity of observed traits
across this particular “patient class” is caused by a discrete and shared
underlying etiology (or a suite of different, yet discrete etiologies).
Importantly, psychopaths are not seen as merely ill-behaved people
with a socially appalling character. Certainly, there is not necessarily
something psychologically abnormal about being deceitful and violent;
we might even say this is what eventually differentiated Homo sapiens
from other mammals (Wolin 1963). Rather, when psychologists refer to
psychopathy as a psychiatric diagnosis, what is conveyed is a claim about
a discrete condition or symptom, hypothesized to be caused by one or
more likewise discrete etiological mechanisms (e.g. genes, neurobiological
structures, cognitive functions, emotion deprivations, etc.) (Hare and
Neumann 2008). Thus, when average people are deceitful and violent, this
would be different from when psychopaths are so, since their behavior is
caused or premediated by their psychological abnormality. Furthermore,
this hypothesis also substantiates the larger forensic and criminological
interest in psychopathy insofar that if psychopathy has discrete etiological
mechanisms, we might be able to intervene medically with the violent
antisocial behavior allegedly associated with psychopathy (e.g. Reidy et
al. 2015).
When we speak of the field of psychopathy research, then, what we are
really referring to is a largely-coordinated scientific effort to corroborate this
main hypothesis: The observed patient stereotype makes up a homogenous
class of individuals, undergirded by one or more discrete etiologies.1
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Although this research effort is multifaceted, it can be roughly divided
into three interrelated, yet independent, research efforts: (1) theoretically
accounting for what exactly makes psychopaths’ psychology abnormal
compared to normal individuals (e.g. Blair, Mitchell, and Blair 2005;
Fowles and Dindo 2006; Hamilton and Newman 2018); (2) empirically
measuring the etiological mechanisms of psychopathy (e.g. Ferguson 2010;
Stratton, Kiehl, and Hanlon 2015; Werner, Few, and Bucholz 2015); and
(3) an applied effort to build reliable and valid assessment tools capable
of distinguishing psychopaths from non-psychopaths in the populace (e.g.
Hare 2003; Lilienfeld and Widows 2005; Patrick, Fowles, and Krueger
2009).
In light of these different efforts, one common ground of confusion
when speaking about psychopathy is when the various branches of
research are conflated with or mistaken for one another; for example,
when (1) theoretical accounts of psychopathy are conflated with (3) the
work of building valid assessment tools. Indeed, the former is concerned
with accounting for the mechanics behind observed traits, while the latter
regards the methods to reliably and validly demarcate psychopaths from
non-psychopaths based on observable traits. Analogously, this example
equals comparing theoretical studies of diabetes (e.g. accounting for
the mechanics of cellular abnormalities in the pancreatic islets) with the
diagnostic testing for diabetes (e.g. measuring blood sugar levels). Although
the two are importantly related, they are obviously two very different
things. The former regards what diabetes is, while the latter is a proxy
measure of diabetes. Conflating the former into the other in psychopathy
research and practices will result in the mistaken belief that a psychopathy
measure is psychopathy (indeed, a common misconception, e.g., Skeem
and Cooke 2010).
Why is this nuance important? Because most of the times when the
psychopathy diagnosis is introduced in forensic settings, what is really
being discussed is (3) the measure of psychopathy. And as it is with all
forms of psychiatric diagnostic assessments, there exists the very real
possibility that the individuals we measure to have psychopathy are, in
fact, not psychopaths (i.e. that they do not carry the hypothesized etiology).
In such cases, we would be dealing with false positives, and many of the
scientific inferences that we make about the psychiatric condition would
not apply to the patient. It equals falsely asserting that a person has diabetes
based on irregularities in blood sugar levels, which likewise would make
the patient respond very differently to insulin injections (for a discussion
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of such false positives in psychopathy research, see Larsen 2018; Skeem
and Cooke 2010).
This point should not be taken lightly, since there are good reasons to
believe that our psychiatric assessments in general yield a high number
of such inaccurate diagnoses. Compared to biomedical diagnostic
assessment tools, say, a test for diabetes, psychiatric assessment tools are
much less accurate for a number of reasons. First, researchers broadly
disagree on how exactly to account for an alleged disorder (i.e. theoretical
disagreement). Second, research in psychiatric etiology is scarce and
ambiguous (i.e. disagreement and unfamiliarity about causality). Third,
because of theoretical disagreement and lack of etiological insight, the
assessment tools being developed will naturally have fundamental inbuilt
uncertainties. For instance, when we do not have a clear theoretical
understanding of a disorder, let alone know its cause(s), it trivially follows
that we cannot know with certainty that our assessments measure what
they purport to measure. While it is obvious that many medical disorders
seem straightforward to measure even in the absence of theoretical and
etiological insight (e.g. scientists were relatively accurate when demarcating
diabetic patients before they knew what diabetes was), psychiatric
conditions are presumably theoretically and etiologically more complex,
and their signs and symptoms relatively more elusive than “somatic”
disorders. So, since a traditional biomedical diagnostic method (e.g.
measuring diabetes) yields a surprisingly high number of false diagnoses
notwithstanding its comparatively high accuracy rates,2 we can soundly
assume that psychiatric tools are comparatively much more erroneous
due to both the basic nature and our epistemic limitations about what
we are measuring.
With this cautionary note on psychiatric diagnostics in mind, the term
‘diagnosed psychopath’ shall in the following refer to a person who meets
the, so to speak, clinical standard or threshold of psychopathy, namely, a
person who has been assessed to be psychopathic with official field-specific
assessment tools.
The most widely used psychopathy assessment method is the Hare
Psychopathy Checklist-Revised (PCL-R) (Hare 2003) (see Figure 1). The
PCL-R consists of 20 trait items, of which 18 load on two factors (and
four facets). The assessment is carried out by analyzing patient records
and conducting a semi-structured interview with the patient and scoring
each of the 20 items from 0 to 2 points. The score zero is given if the
trait is not present in the patient; score 1 if the trait is partially present;
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or score 2 if the trait is a stable mark of the patient. Thus, the PCL-R
score ranges from 0 to 40, where a conventionally decided cut-off score
of a proper diagnosis is understood to be somewhere between 25 and
30 points. The diagnostic cut-off, however, is not implied as a hard line
between psychopathic and non-psychopathic. Instead, the psychopathy
diagnosis is broadly considered to be dimensional, where a score is better
representative of the level of psychopathy in a patient (i.e. score 40 is
considered “full blown” psychopathy) (for a peer-reviewed discussion
of the PCL-R as a valid diagnostic tool, see Hare and Neumann 2008).
Figure 1. The Hare Psychopathy Checklist-Revised, two-factor and four-facet model
(adapted from Hare and Neumann [2008]). In addition to these 18 factor-correlated
traits, the PCL-R also includes the traits of many short-term marital relationships and
promiscuous sexual behavior; although these two traits do not load on any factor, they
are nevertheless believed to depict a shared characteristic of the patient class.
One of the advantages of the PCL-R is its clinical reliability, i.e. the extent
to which two or more clinicians independently give the same patient
a similar score (Blais, Forth, and Hare 2017). This makes the PCL-R
particularly apt at discerning the patient class (i.e. so-called psychopaths)
based on the aforementioned observable traits. Notice, again, that this does
not mean that the PCL-R selects actual psychopaths (i.e. those who carry
the hypothesized etiologies). It merely means that, if we take a random
group of people, the PCL-R can reliably pinpoint which individuals belong,
so to speak, to the patient class.
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Because of this reliability, the PCL-R has been considerably effective
in actuarial scientific research, measuring specific behavioral tendencies
correlated with the patient class across various demographics. For example,
one forensically-useful type of information that can be derived from
applying the PCL-R is its correlation with violent recidivism in the criminal
populace (e.g. Serin, Brown, and Wolf 2016; Yang, Wong, and Coid 2010).
Thus, when we point to such correlations, what is really communicated is
a data-driven statistical probability about future behavior (e.g. violence)
insofar as one belongs to a reliably-demarcated patient class. This process
is methodologically identical to how, say, an insurance company calculates
the risk of driver accident probability; namely, associating the assessed
person with generalized data on specific traits, say, age, gender, address,
or occupation (Serin, Brown, and Wolf 2016).
It is primarily because of such actuarial data-driven efforts that the
psychopathy diagnosis has gained its reputation as a legitimate tool for
forensic application, not only for violence prediction, but also on a suite of
other related issues, such as (though not limited to): child custody hearings,
parole hearings, capital sentencing hearings, preventative detention,
culpability, institutional placement, and treatment amenability (DeMatteo
et al. 2014a; DeMatteo et al. 2014b; Edens and Cox 2012; Hare, Black,
and Walsh 2013; Walsh and Walsh 2006).
TREATING THE “UNTREATABLE”
One particularly-widespread usage of the psychopathy diagnosis (e.g., a
PCL-R assessment) is to introduce it when making decisions regarding
psychiatric treatment and rehabilitation program placements. In this
context, a high psychopathy score (i.e., 25 or higher on the PCL-R) will
thus be interpreted as indicating unamiable qualities in terms of successful
treatment outcomes, which may then bar such a person from entering said
programs (e.g., Polaschek and Skeem 2018). This practice expresses a deep
clinical pessimism about diagnosed psychopaths insofar as the diagnosis
is not invoked for treatment purposes, but, instead, for justifying clinical
passivity (i.e., mere clinical management). In this section, the validity of the
clinical pessimism surmounting diagnosed psychopaths will be reviewed,
demonstrating that the belief is scarcely supported by the scientific research.
Such a finding raises pressing ethical concerns for forensic psychiatrists,
which will be discussed in the final section.
The clinical pessimism concerning psychopathy is not only alive and
well today, but it has arguably been the prevailing view for the better part
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of the research history. One of the founders of contemporary psychopathy
theories, Hervey Cleckley, famously characterized the paradoxical nature
of treating psychopaths. In his five-edition opus, The Mask of Sanity
(first published in 1941), Cleckley spends several pages musing about the
difficulties of treating psychopathic patients. According to Cleckley, one
peculiarity about psychopaths is that, contrary to his other psychiatric
patients, psychopaths did not appear to find their attitudes and behaviors
problematic, let alone psychologically vexing—to Cleckley a strong
indicator of futility in treatment efforts (2015, 26–32). Although Cleckley
actually concludes his work with a hair of optimism on future treatment
options, his overall assumption about the then-current state of clinical
efforts is short and dire: There is not really much that can be done (2015,
439).3
The clinical pessimism also made it into the single most read and cited
book about psychopathy, Robert Hare’s 1993 Without Conscience, which
concludes with a snub:
Many writers on the subject have commented that the shortest chapter in
any book on psychopathy should be the one on treatment. A one-sentence
conclusion such as, “no effective treatment has been found,” or, “nothing
works,” is the common wrap-up to scholarly reviews of the literature.
(1993, 194)4
Along these lines, the PCL-R manual—which makes up the foundation
of the professional training of clinicians administering the PCL-R
diagnoses—includes a similarly unenthusiastic section on treatment efforts
(Hare 2003, 158–62). Here, the leading narrative is that, in general,
“clinicians and researchers are rightly pessimistic about the treatability
of psychopaths with traditional methods” (2003, 158). But, on top of
this, the PCL-R manual also emphasizes a discomforting phenomenon
in treatment research; namely, that diagnosed psychopaths have shown
iatrogenic, or adverse reactions, to treatment efforts. Treatment actually
makes them more antisocial, prompting institutional violence and post-
release recidivism.
The particular study mentioned in the PCL-R manual showing
adverse effects is a retrospective follow-up study by Rice, Harris, and
Cormier (1992). This research examined the recidivism rates of 176
treated offenders and 146 untreated offenders from a maximum-security
institution over the course of 10.5 years. Among these patients were 92
diagnosed psychopaths, of which 46 received treatment (i.e. an intensive
therapeutic community treatment program [Barker 1980]). Expectedly, the
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study found a significant difference in the general recidivism rates between
psychopaths and non-psychopaths. However, the more interesting (and
surprising) finding was that violent recidivism rates were substantially
larger for treated psychopaths (77%), compared to nontreated psychopaths
(55%). As such, violent recidivism was positively (i.e., adversely) associated
with treatment efforts in diagnosed psychopaths. The study concluded on
a speculative note: Community treatment programs that generally seek
to cultivate pro-social empathic and caring qualities might inadvertently
make psychopaths better equipped to “facilitate the manipulation and
exploitation of others,” and such treatment efforts could, therefore, be
“associated with novel ways to commit violent crime” (Rice, Harris, and
Cormier 1992, 409).
The study by Rice and colleagues (1992) was based on a relatively small
number of patients with a specifically nondiverse demographic, yielding
unique and surprising results. Therefore, its generalizability should have
been interpreted with caution. Nevertheless, the impact of the study has
turned out to be nothing short of profound. As was noted in a review of
the treatment literature on psychopathy, the study by Rice and colleagues
effectively “slammed the lid shut for many on the advisability of even
attempting treatment” (Polaschek and Daly 2013, 195).
Despite their own, and a community-wide, inability to replicate these
adverse effect findings, the authors accentuated their conclusion in a 2006
review article of the psychopathy treatment literature (Harris and Rice
2006). In conclusion, they highlighted their 1992 findings, emphasizing
that there was no compelling evidence for positive treatment outcomes of
psychopaths, and that there were potential adverse outcomes of treating
psychopaths:
We believe that the reason for these findings is that psychopaths are
fundamentally different from other offenders and that there is nothing
‘wrong’ with them in the manner of a deficit or impairment that therapy can
‘fix.’ Instead, they exhibit an evolutionarily viable life strategy that involves
lying, cheating, and manipulating others. (Harris and Rice 2006, 568)
The larger point is that actual treatment might be too optimistic; instead,
practitioners should focus on managing the antisocial patterns of diagnosed
psychopaths. Hence, practitioners should use the psychopathy diagnosis
as a discriminator for clinical treatment.
If we pause for a moment and consider these adverse effect perspectives,
they should, as a minimum, give ground to critical suspicion. One initial
problem is that, while we might be satisfied with the claim that the patient
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class selected by using the PCL-R potentially could be associated with
adverse treatment effects, the way researchers here seem to qualify this
view is not with a reference to a patient class, but, rather, with reference
to an underlying belief about the nature of psychopathy. But if it is the
etiological aspect—i.e., psychopathy proper—that is correlated with
adverse effects, we are left wondering how exactly this effect can be
strongly correlated with a patient class that, all things considered, must
include a great number of false positives. It is important to emphasize
that, when we make actuarial projections based on a patient class (e.g.
PCL-R score > 25), these projections are entirely mute to any theory
about underlying etiology (i.e., the actuarial claim is in and by itself a
mere statistical observation). It therefore amounts to a logical leap of faith
when these claims are translated into a narrative about adverse effects due
to etiology that recommends management over treatment for the entire
patient class (e.g. Hare, Black, and Walsh 2013). It is not that such claims
are unintelligible from a hypothetical standpoint, though; it is, rather, that
they seem insufficiently paired with critical scrutiny.
However, another problem with this narrative about untreatability and
adverse treatment effects is that it is simply not supported by the overall
research data, or, at least, the evidence in support of the widespread clinical
pessimism is greatly disproportionate to the extent of the claim. For one,
the study by Rice and colleagues (1992)—which arguably serves as the
most compelling, fundamental evidence in favor of clinical pessimism—
was based on patients undergoing an infamously problematic treatment
program at the Oak Ridge Social Therapy Unit in Ontario, Canada. The
treatment program was so harrowing that a class lawsuit was raised against
the institution and its practitioners in 2000. In May 2017, a Canadian
judge ruled in favor of the plaintiffs, comparing the alleged treatment to
torture (Fine 2017).5, 6 The details of the lawsuit confirmed widespread
denigrating treatment procedures, such as chaining nude patients together
for up to two weeks, keeping patients locked up in windowless rooms,
feeding patients liquid food through tubes in the wall, experimenting with
hallucinogens and delirium-producing drugs, and a complete disrespect
and rejection of patient rights (Berg et al. 2013; D’Silva, Duggan, and
McCarthy 2004; Ronson 2011).
In a 2016 interview, a former (recidivating) psychopathic patient from
Oak Ridge, Jim Motherall, said that, when he was released from the
institution in 1976, he was broken down and dysfunctional: “I wasn’t
ready to be on the street, I couldn’t function on the street [. . .] I was angry.
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I hated them [the practitioners]. I hated what they did, I hated what they
stood for. And I couldn’t control the anger. I had lost any ability to get
hold of that anger” (Sherren 2016). To Motherall, and presumably many
of his fellow patients forced through the torturous “treatment” program,
his anger led to multiple violent offences after his release, and decades of
additional confinement.
The remaining question is, of course, whether (psychopathic) patients
such as Motherall had their hypothesized condition exacerbated and,
therefore, recidivated faster and more violently, or whether the violence
frequencies were a result of some other factors related to their treatment.
To answer this question in an accurate scientific manner, we would have
to look closer at the psychological profiles of each recidivating patient and
also know the details of the exact treatment program they underwent. For
example, perhaps we would find that only certain personality traits (and
not PCL-R psychopathy as such) were correlated strongly with elevated
aggression. Unfortunately, such details are not present in the research data
of Rice and colleagues (1992), nor have we seen any serious efforts in re-
evaluating the research conclusion in light of the malpractice disclosure,
for example, either retracting the study or further qualifying the data
collection, methods, research results, etc. (which, of course, is common
practice when the integrity of a study is compromised).
But perhaps asking these questions about adverse effects, let alone trying
to answer them, is also rather futile. For instance, Polaschek and Daly
(2013) have argued that there is ample evidence that, in generalized and
trivial ways, some treatment methods can potentially generate adverse
outcomes in any patient class regardless of psychological disorder (e.g.
Lilienfeld 2007; Skeem, Polaschek, and Manchak 2009). However, this
is qualitatively different from claiming that specific treatment efforts (e.g.
concrete maltreatment), or more profoundly, conventional treatment,
generally makes diagnosed psychopaths at higher risk of recidivating—a
grand view that needs more evidence than what can be drawn from a
single compromised study (Polaschek and Daly 2013, 595). So far, Rice
et al. (1992) remains the only cited evidence for the belief about adverse
effects,7 raising the question why it continues to play a significant role in
the treatment literature.
Notwithstanding the discussion of potential adverse effects, there is
actually evidence suggesting that the overall clinical pessimistic conclusions
about psychopaths are too precarious. The first study to suggest this was
by Randall Salekin (2002), who reviewed 42 treatment studies, positing
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the unambiguous conclusion that the clinical pessimism associated with
psychopathy has little scientific basis. Salekin highlighted a number of
aggravating factors; mentioning a few should suffice. First, the study
found a clear lack of valid generalizable data. For instance, out of the
42 studies, only four studies (9%) were based on the PCL-R, raising the
question whether the different studies were actually studying individuals
with the same traits or condition (i.e., unknown diagnostic compatibility).
Second, although treatment outcomes varied greatly across studies, only
one study reported adverse effects; namely, the study by Rice and colleagues
(1992). This suggested to Salekin—presumably unaware that this treatment
method would later be described as torture by a Canadian court—that
the specific program of therapeutic community treatment administered by
that particular institution was only possibly worsening the psychopathy
condition (Salekin 2002, 105).
Curiously, although Salekin (2002) was arguably the most comprehensive
large-scale review of the treatment literature of its time,8 the publication of
the second edition of the PCL-R in 2003 barely mentions these findings,
merely declaring the following:
Although some reviewers (e.g., Salekin 2002) have suggested that clinical
pessimism might be replaced with clinical optimism, most clinicians and
researchers are rightly pessimistic about the treatability of psychopaths with
traditional methods. (Hare 2003, 158)
Thus, even though there was poor scientific basis for making such a
claim—as demonstrated by Salekin (2002)—the creators of the PCL-R
manual continued to insist on a speculative perspective. They write:
Some clinicians and administrators hold the uncritical view that psychopaths
who have participated in prison treatment programs must have derived some
benefit. This may help to lull the criminal justice system and the public into
the false belief that the psychopaths with whom they must deal have derived
tangible benefits from treatment, simply because they and their therapist say
so. Many psychopaths take part in all sorts of prison treatment programs,
put on a good show, make “remarkable progress,” convince the therapists
and parole board of their reformed character, are released, and pick up
where they left before they entered prison [Hare 1998].9 (Hare 2003, 158)
It is difficult to see such a narrative as anything else than incongruent with
scientific standards, and thus, at best, anecdotal. While the PCL-R cites
the Salekin (2002) study, it fails to acknowledge it as compelling, which,
of course, is odd given that the study is a substantial peer-reviewed survey
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of the research literature. If extensive reviews and meta-analyses are not
compelling scientific evidence, what is? Further, the literature raised in
support of this alternative perspective in the PCL-R manual includes an
extensive discussion of the study by Rice and colleagues (1992). We must
assume, then, that the creators of the PCL-R, at the time of writing, were
unaware of the fact that two to three years earlier to publication, a class
action had been raised against the institution where Rice and colleagues
(1992) collected their data, making public a mountain of evidence about
disturbing psychiatric malpractices at Oak Ridge Social Therapy Unit.
For the past five to 10 years, however, a comparatively clearer, nuanced,
and more optimistic picture about psychopathy and treatment has started
to take shape. First, a few years after Salekin (2002), a review was
published by D’Silva, Duggan, and McCarthy (2004) that specifically
sought to investigate the hypothesized adverse effects of treatment
associated with the PCL-R diagnosis. The team systematically evaluated
24 studies and found that, above all, the aggregate of research was in such
a condition that it was poorly equipped to answer their basic question
about adverse effect (e.g., lack of control groups, lack of methodological
rigor, poor data quality). They argued that, when researchers actually
do draw the conclusion that psychopathy is related to adverse treatment
outcomes (i.e., untreatability), such an interpretation amounts to a “logical
error” (2004, 175). Therefore, they expressed regret about the common
practice that diagnosed psychopaths “are now being denied treatment on
the basis that they are either untreatable or that treatment might make
them worse” (2004, 175).
Less than a decade after the publication of Salekin (2002) and D’Silva,
Duggan, and McCarthy (2004), a review study by Salekin, Worley, and
Grimes (2010) stressed a number of salient points. First, although they saw
emerging developments in the field toward addressing the unique challenges
related to treatment of diagnosed psychopaths, the collective research effort
did not make a “strong case for the notion that psychopathy is untreatable”
(2010, 255). Second, there was ample evidence that (adult) diagnosed
psychopaths could indeed benefit significantly from standard treatment
programs (2010, 255). Although researchers and practitioners still battle
with overcoming the seemingly unwarranted clinical pessimism, the two
points stressed by Salekin and colleagues can now be traced broadly in the
research field, though it is allegedly still far from a prevailing viewpoint
among practitioners (Sörman et al. 2014).
Indeed, in the most recent and detailed evaluation of the treatment
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literature, Polaschek and Skeem (2018) notice that perhaps the strongest
barrier for scientifically answering the question about treatability is,
ironically, the notable “dearth of research,” perhaps propelled in part
by the prevailing belief among both researchers and practitioners that
the question about treatability has long been answered; namely, that
psychopaths cannot be treated (2018, 710). What makes all of this ironic
is that, instead of being a ground for neglecting treatment, diagnosed
psychopaths should—according to canonical treatment guidelines—be
viewed as prime targets for treatment efforts due to their common status
as high-risk patients. Generally, treatment efforts are directed where it is
likely to make an actual robust impact (i.e. the Risk-Need-Responsivity
model). In other words, treatment should be aimed at individuals who,
for example, are likely to recidivate. Naturally, high-risk patients, such as
diagnosed psychopaths, would fall within this group (712).
With regard to effective treatment, Polaschek and Skeem (2018)
underline that knowledge about concrete treatment methods is so far
scarce, but they notice that there is evidence of positive treatment outcomes
across the literature (e.g. Polaschek 2011; Skeem, Monahan, and Mulvey
2002; Wong et al. 2012). So, while research is certainly lacking, and,
therefore, increased efforts should be expected to shed further light on the
issue, Polaschek and Skeem also stress the importance of simply beginning
to encourage and facilitate treatment efforts. Such attempts may “restore
faith among members of the public that psychopathic individuals are not
intractable threats who must be indefinitely detained,” promoting the view
that our justice system ought to “provide access to rehabilitation for all
adjudicated individuals in need of it” (Polaschek and Skeem 2018, 726).
In addition to the studies highlighted by Polaschek and Skeem, novel
approaches to treatment programs have in recent years shown that
optimism is generally warranted. For example, Wong and colleagues (2012;
2015) developed a model using the PCL-R factor scores to guide treatment
efforts insofar as some cognitive-behavioral treatment strategies10 tend
to be more efficient in psychopathic patients scoring high in Factor 2
items (i.e. typical criminogenic behavioral features), suggesting “that
psychopaths and violent offenders in general have qualitatively similar
treatment targets” (Wong and Olver 2015, 305). Utilizing this model,
Sewall and Olver (2019) examined the correlation between psychopathy,
treatment, and sexually violent recidivism in a group of men (n=302)
and found that diagnosed psychopaths benefitted equally from treatment
compared to non-psychopaths (consistent with other results, e.g. Polaschek
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and Ross 2010). The authors concluded that their study “fuels optimism
about the potential for psychopathic men to make meaningful risk-related
changes akin to their nonpsychopathic counterparts” (Sewall and Olver
2019, 68). Similarly, Baskin-Sommers and colleagues tested a training
program that purported to improve robust deficits found in psychopaths
(e.g. attention deficits), and results strongly indicated that psychopaths
“are capable of overcoming their subtype-specific deficits with practice
and that receiving deficit-matched training results in generalizable change
in these subtype-specific deficits” (Baskin-Sommers, Curtin, and Newman
2015, 51). Echoing this optimism, Brazil et al. (2018) highlighted the
somewhat commonsensical point that as cognitive and behavioral research
progresses, and new etiological insights about psychopathy are disclosed,
such information is expected to yield comparatively much more precise
intervention strategies.
As has been demonstrated, the research literature is rather clear with
respect to two main points. First, there is virtually no concrete evidence that
the psychopathy diagnosis should be adversely correlated with treatment
efforts. Second, while there is significant evidence (though limited in scope)
of successful treatment efforts, there is next to no scientifically based
evidence in support of the thesis that psychopaths are generally immune to
psychiatric intervention. In other words, the widespread untreatability view
pertaining to diagnosed psychopaths is medically erroneous. Currently
the untreatability view is rejected by the research record while forensic
practitioners still maintain a widespread adherence to the precarious
conclusions of outdated research narratives, which should raise a suspicion
about the professional and ethical standards in the field.
PSYCHOPATHY AND THE STIGMA OF YESTERDAY’S RESEARCH
In the remainder of this article, ethical perspectives and issues related
to administering the psychopathy diagnosis will be discussed with a
special focus on the matters concerning its use as a treatment amenability
assessment. The aim of this final section, however, is not only to draw
conclusions from the foregoing analysis, but also to add some general
remarks to a growing sentiment in psychopathy research that encourages
contributions in ethics (e.g., Edens, Petrila, and Kelley 2018; Lyon, Ogloff,
and Shepherd 2016; Pickersgill 2009). It should be underlined, though, that
ethical discussions in forensic psychiatry are somewhat meager due to its
status as a relatively young field (Appelbaum 2008). Further, thoughtful
discussions about the ethics of psychopathy research and practices are
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not just meager but next to nonexistent (perhaps due to its even younger
status as a field). Serious discourse has yet to manifest broadly across the
paradigm (although some admirable efforts have been made analyzing
the role of psychopathy with respect to specific legal issues, e.g., Edens,
Petrila, and Kelley [2018]).
Before examining the specific ethical challenges that emerge in the
practice of utilizing the psychopathy diagnosis, a short comment is needed
in order to establish which ethical principles we should use to assess the
following discussion. While the American Psychiatric Association provides
a general set of guidelines for the psychiatric profession (the so-called
Principles of Medical Ethics), some researchers have sought to amend
these guidelines with crucial nuances specifically applicable to forensic
psychiatry (for an overview, see Austin, Goble, and Kelecevic [2009];
Niveau and Welle [2018]).11 For example, Paul Appelbaum (1997; 2008)
has developed what he calls the standard position, two basic principles
to define the ethical obligations of forensic psychiatric practitioners, in
particular.
The first principle is that of truth-telling; namely, practitioners’ testimony
must always reflect their truthful, honest opinion. But it cannot be not
just any true opinion. If that were the case, ignorant psychiatrists would
then be able to serve any side and any objective ethically, as long as their
statement were genuinely believed. Rather, Appelbaum (2008) stresses
that there is an ethical obligation for forensic psychiatrists to accurately
base their testimony on concrete “scientific data on the subject at hand
and the consensus of the field,” regardless of which side in the adversarial
court system their comments may favor or disadvantage (2008, 196).
At first glance, this principle sets an increasingly high standard for an
ethical guideline, since the scientific data of psychiatric research can be
unreliable, and its theories are often non-validated and disputed, raising
the question whether there really are scientifically-truthful psychiatric
claims. However, Applebaum holds that when psychiatric research has
established something akin to a consensus, practitioners may report on
such information regardless of it being robustly validated. For example,
where different forms of psychotherapy might lack peer-reviewed validity,
some practitioners and clients may still benefit from such procedures,
making them perfectly justified in terms of ethical standards. Indeed, one
can still do good with unestablished science.
The second principle is that of respect for persons; namely, that in
the quest of giving truthful, scientifically-accurate testimonies, forensic
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psychiatrists must qualify their expertise so they always “respect the
humanity of the evaluee,” refraining from engaging in “deception,
exploitation, or needless invasion of the privacy” of the people being
examined, reported, or testified about (Appelbaum 1998, 197). This
principle has several moderating applications. For one, if this principle
were not applied, it would then follow that practitioners could engage
in any practice as long as it were connected to seeking or conveying the
truth; for instance, they could deceitfully exploit an unprepared witness
to get to the truth. Another qualification of the second principle is that it
sets limits for what and how specific information is introduced to various
stakeholders (e.g., in the adversarial court system). Where scientific truths
might be conveyed with a genuine incentive, the forensic practitioner ought
also to exert some standard awareness of, say, what potentially negative
effects such information may have on the individual.12
With these ethical principles in mind, let us briefly consider the
common practice with regards to applying the psychopathy diagnosis in
treatment amenability processes. As mentioned, the psychopathy diagnosis
is introduced in court or a correctional setting primarily as a way to
provide data-driven actuarial testimonies about a patient, specifically by
correlating and inferencing the specific patient to a reliably established
patient class (i.e., PCL-R diagnosed psychopaths). That is, by assessing a
patient with psychopathy (i.e., a particular PCL-R score), we can thereby,
due to established empirical research, make an inference to the specific
behaviors that are tested for in the research. This practice, of course,
deviates markedly from drawing inferences based on mere “professional
opinion.” As such, the practice of making data-driven (i.e. actuarial)
inferences is seemingly on par with the first principle in the standard
position (i.e. truth-telling) since it is based on widely accepted scientific
procedures (e.g. Serin, Brown, and Wolf 2016).13
Notice, though, that according to the standard position, the scope of
what exactly can be inferred from a psychopathy diagnosis will be fully
contingent on the actual peer-reviewed research. That is, the psychopathy
diagnosis can be used only as an inference about issues that have been tested
for and validated by the research community. For example, it has been
shown that there is a weak to moderate correlation between a high PCL-R
score and violent recidivism (e.g., Yang, Wong, and Coid 2010). With
this knowledge at hand, a forensic psychiatrist can therefore truthfully
inform the court or correctional system of such specific probabilities and
the extent to which they translate to the concrete case. Again, what makes
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such an inference truthful is simply that it is a scientific peer-reviewed
qualified statement.
Regretfully, though, there is growing evidence that the psychopathy
diagnosis has been used to make inferences to actuarial issues that have
never been tested for. In a review study of how the psychopathy diagnosis
has been introduced in court cases, Lyon, Ogloff, and Shepherd (2016)
found a number of problematic applications. For example, they identified
one case in which the psychopathy diagnosis was introduced in court
to argue that the patient was incapable of reading and comprehending
intricate information, due to his high PCL-R score (2016, 194). As the
authors stressed, since there are no particular studies that test for such a
hypothesis in the patient class, that inference is invalid. In accordance with
the first principle in the standard position, then, introducing such invalid
references (e.g., reading and comprehension capabilities) will thus amount
to an instance of unethical practice due to it being scientifically untruthful.
Similarly, then, it appears clear that the use of the psychopathy diagnosis
as a treatment amenability discriminator, specifically as an instrument to
explicitly prohibit diagnosed psychopaths from entering rehabilitation
and treatment programs, fails to meet the ethical demands of the first
principle in the standard position. As it was shown, not only is the evidence
for the untreatability hypothesis scarcely supported, but evidence of the
stronger narrative about adverse effects is also insufficient. Instead, it was
shown that the research literature has yielded increasing positive evidence
for treatment and intervention effects on diagnosed psychopaths (e.g.
Polaschek 2011; Polaschek and Skeem 2018; Sewall and Olver 2019;
Skeem, Monahan, and Mulvey 2002; Wong et al. 2012). As a minimum,
it is safe to say that there is no established consensus that psychopaths
are untreatable (Olver 2018).
Moreover, the case for unethical practices might be stronger than merely
providing misinformation to the court and correctional institutions.
Not only does the practice of treatment discrimination fail on the first
principle (i.e., truth-telling), but it also appears to fail on the second
principle (i.e., respect for persons). Indeed, the patients in question are
not offered the treatment they rightfully need. This omission effectively
eclipses the broader standing guidelines of administering psychiatric
intervention, specifically, that high-risk patients are fundamentally high-
priority individuals (i.e., the Risk-Need-Responsivity model). Arguably,
such practices are not only problematic from the patient’s perspective (as
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their well-being is neglected), but, from the perspective of the greater good
of society, such practices effectively increase social risks, as high-profile
dangerous individuals are eventually released back into society without a
proper attempt at rehabilitating treatment.
In addition to this deeper ethical suspicion, it is perhaps worth noticing
that the psychiatric pessimism that appears to frame practitioners’
dealings with psychopaths does not only boil down to a question of actual
treatment, but it may also amount to a kind of harmful stigma. Its effects
may transport deeply into the judicial system, well beyond the psychiatrist–
patient relationship. Indeed, the belief that psychopaths are unlikely to
rehabilitate, or, so to speak, are untreatable, seems to also have stabilized
among lay people. For example, in a survey of people attending jury duty (n
= 400), Smith et al. (2014) found that respondents were generally doubtful
about whether criminal psychopaths could successfully rehabilitate back
into society, and they remained largely undecided about the scenario of
curing or treating psychopaths (2014, 496). Although one might argue
that lay people are outside of the proper forensic psychiatric concern,
there are reasons to treat such findings seriously. Indeed, nonexperts are
importantly involved in everything from jury duty to parole decisions to
the forming of public policies, which makes them central stakeholders for
forensic psychiatrists.
Speaking to this suspicion of a broader stigmatizing effect of the
untreatability narrative, Edens, Petrila, and Kelley (2018) noted that
many key decisions in the legal system (e.g. parole decisions, capital
sentencing, institutional placement, permanent detention) rest pointedly
on evaluating whether the patient will be dangerous in the future. When a
high-risk patient is assessed with psychopathy and, therefore, considered
psychiatrically untreatable (as opposed to treatable), it is not far-fetched to
suggest that this is taken to imply the aggravating notion that such a person
is highly unlikely to change, let alone be responsive to correctional restraint
and deterrence, and thus represents as a chronic future institutional and
social risk (for similar perspectives, see DeMatteo et al. 2014a; DeMatteo
et al. 2014b; Edens et al. 2013).
In sum, there are good reasons why we should be ethically worried
about the practice of introducing the psychopathy diagnosis for treatment
amenability purposes. First, it is insufficiently based in scientific research.
Second, it seems to violate the respect psychiatrists ought to have for
their patients, unjustifiably stripping patients of serious rehabilitation
efforts (with potential harm to them and the broader society). Third, we
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speculate that the untreatability perspective presents judges and jurors
an aggravating, stigmatizing perspective of chronic antisocial behaviors,
which adds extrajudicial, unfair hurdles to the patient’s process in the
judicial and correctional system. In other words, the probative value of a
PCL-R assessment is outweighed by its prejudicial effects.
In light of such a conclusion, we might ask what ought to be done in
forensic psychiatry to alleviate this seemingly unethical procedure. Although
one obvious recommendation is to stop using the psychopathy diagnosis
in treatment amenability assessments, there might be reasons to suggest
more critical and wider-ranging recommendations. In their recent article,
which surveyed a handful of important legal and ethical issues related to
psychopathy and violence risk assessment, Edens, Petrila, and Kelley (2018)
concluded with a critical question; namely, whether forensic psychiatrists
should “abandon the use of psychopathy assessments, particularly PCL-R
scores, to influence decision making” in court and correctional settings,
given a growing evidence of forensic misuse and limited scientific validity
(2018, 746). Their question seems to signal a growing skepticism in the
field about the broader motivations and incentives behind the use of the
psychopathy diagnosis, as well as a scientifically critical attitude toward
the alleged truths communicated by the diagnosis. Perhaps it is time for
the field to stop and more profoundly reconsider research and practices
regarding the psychopathy diagnosis. Indeed, it is becoming increasingly
clear that, although researchers might find it unproblematic to study this
alleged pathology through their lenses in the ivory tower, the nuances
and complexities that immerse this diagnostic category are lost in the
adversarial process of court and correctional settings.
ACKNOWLEDGEMENTS
I would like to acknowledge the reviewers for their constructive feedback,
which led to substantial improvements of the initial manuscript. All
potential mistakes are entirely my own.
NOTES
1. Notice that when researchers pursue the view that psychopathy is not ho-
mogenous, but instead a heterogenous construct that covers over several
subtypes, these subtypes are then hypothesized to make up a homogenous
(sub)class, with one or more discrete etiologies.
2. For an example of how to estimate the extent of false positive in diagnosis,
see van Stralen et al. (2009).
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3. Ironically, the first person to suggest the existence of the psychopathy diag-
nosis, the American polymath Benjamin Rush, was rather optimistic about
the role of the psychiatrist, professing that medical insight into this disorder
eventually would contribute to eradicating social evils at large (Rush [1786]
1972, 37).
4. Hare is here paraphrasing a well-known quote from Suedfeld and Landon
(1978).
5. Barker v. Barker, ONSC 3397 C.F.R. 2017.
6. In an official statement, Judge Perell said: “I appreciate that apart from pro-
fessional renown and advancement, there was no self-serving gratification for
the Defendant physicians at the expense of the Plaintiffs [but] it is a breach
of a physician’s ethical duty to physically and mentally torture his patients
even if the physician’s decisions are based on what the medical profession at
the time counts for treatment for the mentally ill” (Fine 2017).
7. One study has reported adverse effects associated with specific PCL-R traits
(i.e. Factor 1), although adverse effects were not correlated with the total
PCL-R score (Hare et al. 2000). This finding, however, has not been replicated.
For the opposite findings, namely, that the same PCL-R traits can be associ-
ated with positive treatment outcomes, see Burt, Olver, and Wong (2016).
Another study found indications of adverse effects (Seto and Barbaree 1999).
This study, however, was later retracted after a follow-up study (Barbaree
2005).
8. However, there were some attempts at reviewing the treatment literature
before Salekin (2002). For instance, a study by Garrido, Esteban, and Molero
(1995) reported on two separate meta-analyses, though without providing the
needed detail on references and methods. A book by Dolan and Coid (1993)
offered a comprehensive review of the treatment literature and concluded that
the collective research suffered from lack of stable diagnostic criteria, had
problematic sampling procedures, ill-described treatment processes, and an
unsystematic measure of treatment outcomes, making it difficult to draw any
scientifically meaningful conclusions. For a similar portrayal of the research
efforts before Salekin (2002), see Harris and Rice (2006).
9. For what it is worth, the reference included at the end of this quote from
the PCL-R manual is to Hare (1998), a book chapter that includes a three-
paragraph section titled, recidivism following treatment. In this section, Hare
includes an extensive discussion of the study by Rice and colleagues (1992).
10. For an anthology on cognitive-behavioral treatment, see Kazantzis, Reinecke,
and Freeman (2010).
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[ 265 ]
11. Notice that forensic psychiatry is a subspecialty in psychiatry insofar as the
profession deals with mental functioning and behavior in legal and cor-
rectional settings (Bloom and Schneider 2016). Although the concrete role
of a forensic psychiatrist can vary, it typically involves providing nontrivial
information to the court and correctional settings, assisting the evaluation
of fitness to stand trial, responsibility, sentencing, institutional placement,
parole decisions, treatment, rehabilitation, and more (Bloom and Schneider
2016, 693–718).
12. While the standard position has been broadly endorsed by practitioners and
theorists, it is not without its strong critics. Alan Stone (2008) has argued
that the standard position can never claim any neutral ethical worth. For
instance, as Stone argued, due to the adversarial system in a court setting,
forensic psychiatrists are bound to deliver statements that can potentially be
both good and bad for the patient in question. As Stone puts it: “Psychiatrists
are immediately over the [ethical] boundary when they go into court” (2008,
168).
13. This is not necessarily an unproblematic claim. Although the forensic psy-
chiatric profession is ethically challenging (in both practical and theoretical
affairs), we might here stress that it is not obvious that actuarial data meet the
standard of “truth telling.” Indeed, actuarial science is inherently uncertain
due to its probabilistic nature. As one reviewer of this article pointed out,
maybe the overall actuarial data on diagnosed psychopaths are simply too
weak to make any truthful assertions about the patient class (this concern is
also raised in Serin, Brown, and Wolf [2016]). Such a reservation would be
even stronger if we weigh the possibility of large-scale false positives within
the PCL-R patient class (Larsen 2018).
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