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Journal of Threat Assessment and Management
Are Psychopathy Assessments Ethical? A View From Forensic Mental Health
Rasmus Rosenberg Larsen, Peter Koch, Jarkko Jalava, and Stephanie Griffiths
Online First Publication, July 18, 2022. http://dx.doi.org/10.1037/tam0000184
CITATION
Larsen, R. R., Koch, P., Jalava, J., & Griffiths, S. (2022, July 18). Are Psychopathy Assessments Ethical? A View From
Forensic Mental Health. Journal of Threat Assessment and Management. Advance online publication.
http://dx.doi.org/10.1037/tam0000184
Are Psychopathy Assessments Ethical?
A View From Forensic Mental Health
Rasmus Rosenberg Larsen
1
, Peter Koch
2
, Jarkko Jalava
3
, and Stephanie Griffiths
4
1
Forensic Science Program and Department of Philosophy, University of Toronto Mississauga
2
Department of Philosophy, Villanova University
3
Department of Interdisciplinary Studies, Okanagan College
4
Department of Psychology, Okanagan College and Werklund School of Education,
University of Calgary
Psychopathic personality disorder, or psychopathy, is a psychiatric diagnosis associated
with callous personality traits and chronic antisocial behaviors. During the past 2 decades,
psychopathy assessments have been routinely utilized to inform violence prediction,
threat management, sentencing, parole, etc. However, recent empirical research has
questioned the reliability and utility of psychopathy assessments, sparking concerns
about the ethics of their use. The present contribution adds to this ethical discourse,
arguing that forensic mental health practitioners should refrain from using psychopathy
assessments because they violate two of the most fundamental ethical standards in their
disciplines to “promote well-being”and “to do no harm,”traditionally labeled the principle
of beneficence and the principle of nonmaleficence. Indeed, psychopathy assessments
provide no clear benefit to the patient, and there are de facto and potential harms causally
associated with their intended use, which are evidentially not outweighed by any significant
social benefits. The article concludes by recommending a near-universal cessation of
psychopathy assessments, a recommendation that is especially pressing due to the
availability of alternative assessment strategies and the risk of professional–ethical
sanctions.
Public Significance Statement
We survey the forensic use of psychopathy assessments and analyze whether they
comply with ethical standards in forensic mental health. We conclude that there are
pressing ethical problems with these assessment tools as they are associated with
nonbeneficial and harmful consequences and minimal social benefits, thus calling for
an immediate and universal cessation of psychopathy assessments in forensic settings.
Keywords: psychopathy, psychopathic, ethics, beneficence, nonmaleficence
Psychopathic personality disorder, or psy-
chopathy, refers to a broadly recognized psychiat-
ric diagnosis associated with callous personality
traits and chronic antisocial behaviors (e.g., De
Brito et al., 2021;Hart & Cook, 2012). A
stereotypical psychopath is commonly described
as a dangerous social predator who lacks emotional
concern for others (e.g., Cleckley, 1988;Hare,
1993;Helfgott, 2019). Although psychopathy is
not contained in the Diagnostic and Statistical
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Rasmus Rosenberg Larsen https://orcid.org/0000-
0002-9294-8645
The authors declare no conflict of interest.
Correspondence concerning this article should be
addressed to Rasmus Rosenberg Larsen, Forensic Science
Program and Department of Philosophy, University of
Toronto Mississauga, 3359 Mississauga Road North,
Maanjiwe nendamowinan 5th floor, Mississauga, ON L5L
1C6, Canada. Email: rosenberg.larsen@utoronto.ca
1
Journal of Threat Assessment and Management
© 2022 American Psychological Association
ISSN: 2169-4842 https://doi.org/10.1037/tam0000184
Manual of Mental Disorders (DSM-5;American
Psychiatric Association, 2013b), it has neverthe-
less been described as one of the most researched
and best validated personality disorders (Hare et
al., 2012), and it is widely recognized among
forensic and legal practitioners (e.g., Kiehl &
Sinnott-Armstrong, 2013;Patrick, 2018). Psy-
chopathy assessments are among the most uti-
lized clinical tools in forensics (e.g., DeMatteo
& Olver, 2022;Singh et al., 2014), routinely
applied to inform a variety of objectives such as
violence prediction, threat management, sentenc-
ing, institutional placement, juvenile transfers,
rehabilitation strategies, and parole (e.g., Gacono,
2016a;Hare, 2016;Polaschek, 2022).
For most of its history, psychopathy played
only a minimal role in the legal system (e.g.,
Cleckley, 1988;Hare & Schalling, 1978;Lewis,
1974;Sass & Felthous, 2014). However, this
began to change in the 1990s with the develop-
ment of new assessment tools (e.g., Gacono,
2016b;Skeem et al., 2011), including the Hare
Psychopathy Checklist—Revised (PCL-R; Hare,
2003), and its two subversions, the Screening
Version (PCL:SV; Hart et al., 1995) and the
Youth Version (PCL:YV; Forth et al., 2003).
Although there are other psychopathy assess-
ment tools, such as the Comprehensive Assess-
ment of Psychopathic Personality (Cooke et al.,
2012), Psychopathic Personality Inventory
(Lilienfeld & Widows, 2005), and the Triarchic
Psychopathy Measure (Patrick et al., 2009), the
three PCL scales are widely considered the “gold
standard”in psychopathy assessment (e.g., Hare &
Neumann, 2008), and field surveys show that
they are preferred by most forensic mental health
practitioners (e.g., Hill & Demetrioff, 2019;
Hurducas et al., 2014;Singh et al., 2014;
Viljoen, McLachlan, et al., 2010).
All three PCL scales are designed to measure
the same conception of psychopathy derived from
the work of Cleckley (1988; see also, Hare &
Neumann, 2008). In practice, evaluators use
semistructured interviews, clinical records, and
collateral information to rate the clinical subject
on a numeric scale. The PCL-R consists of a
checklist of 20 diagnostic items (see Figure 1),
which are assessed by scoring each as 0, 1, or
2 depending on how closely a person matches
them. Total PCL-R scores thus range from 0 to 40,
and the score represents the degree to which an
individual resembles a prototypical psychopath.
Although the assessment is dimensional, scores 30
or above are conventionally seen as the threshold
for clinical psychopathy (see Hare, 2003,for
clinical guidelines).
The main justification for using psychopathy
assessments in forensic contexts is their perceived
ability to yield reliable and valid diagnostic prog-
noses about the disorder, hereunder statistical
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Figure 1
Item Checklists of the Three PCL Scales
Glibness/Superficial Charm Glibness/Superficial Charm
Grandiose Sense of Self Worth Grandiose Sense of Self Worth
Pathological Lying Pathological Lying
Conning/Manipulative Conning/Manipulative
Lack of Remorse or Guilt Lack of Remorse or Guilt
Shallow Affect Shallow Affect
Callous/Lack of Empathy Callous/Lack of Empathy
Fail to Accept Responsibility Fail to Accept Responsibility
Need for Stimulation/Proneness to Boredom Need for Stimulation/Proneness to Boredom
Impulsivity Impulsivity
Irresponsibility Irresponsibility
Parasitic Lifestyle Parasitic Lifestyle
Lack of Realistic, Long-Term Goals Lack of Realistic, Long-Term Goals
Poor Behavioral Controls Poor Behavioral Controls
Early Behavioral Problems Early Behavioral Problems
Juvenile Delinquency Juvenile Delinquency
Revocation of Conditional Release Revocation of Conditional Release
Criminal Versatility Criminal Versatility
Hare Psychopathy Checklist: Screening Version
Hare Psychopathy Checklist-Revised
Factor 1
Factor 2
Impulsive
1
t
eca
F
la
no
sre
p
re
tn
I
2
te
ca
F
e
vi
t
c
e
f
fA
Factor 1
Factor 2
Superficial
Grandiose
Deceitful
Lacks Remorse
Lack s Empat hy
Doesn't Accept Responsibility
Facet 1
Interpersonal
Facet 2
Affective
Factor 1
Factor 2
Hare Psychopathy Checklist: Youth Version
Facet 4
Antisocial
Facet 3
Lifestyle
Poor Behavioral Controls
Lack s Goals
Irresponsible
Adolescent Antisocial Behavior
Adult Antisoial Behavior
3
te
c
aF
e
l
yt
se
f
i
L
4 te
ca
F
l
a
i
c
o
sitnA
Note. The items load onto a two-factor model (from factor analysis), where the PCL-R and PCL:YV are further divided into
four facets (adapted from Hare et al., 2018). PCL =Hare Psychopathy Checklist; PCL-R =Hare Psychopathy Checklist—
Revised; PCL:SV =Hare Psychopathy Checklist—Screening Version; PCL:YV =Hare Psychopathy Checklist—Youth
Version.
2 LARSEN, KOCH, JALAVA, AND GRIFFITHS
inferences about behavior, which may then be
used to inform forensic decisions (e.g., Hare &
Neumann, 2009;Reidy et al., 2015). What is
often highlighted as particularly relevant is the
evidence linking individuals who are diagnosed
as psychopaths to higher rates of criminal recidi-
vism, serious instrumental violence, poor treat-
ment/rehabilitation outcomes, and a pronounced
lack of conscience (e.g., De Brito et al., 2021;
Hare, 1996,1998,2016;Kiehl & Hoffman,
2011). It is arguably because of the alleged ability
of psychopathy assessments to predict and
explain these objectives that they have been
gradually endorsed by forensic practitioners
(e.g., DeMatteo & Olver, 2022;Gacono, 2016a;
Patrick, 2018), and the reason why many have
accredited some psychopathy assessment tools—
such as the PCL scales—as among the most
important innovations to the criminal justice
system (e.g., Babiak et al., 2012;DeLisi, 2016;
Gacono, 2016b;Hare, 1998,2016;Harris et al.,
2001;Monahan, 2006b).
Recently, however, psychopathy assessments,
and especially the PCL scales, have been criti-
cized based on empirical evidence showing that
their clinical reliability and forensic utility are
significantly overstated (e.g., Blais et al., 2017;
DeMatteo et al., 2020a;Larsen et al., 2020). For
example, while it is commonly stated that the PCL
scales are strong predictors of violent and general
recidivism (e.g., Hare, 1996,1998,2016;Hare &
Neumann, 2008), meta-analyses in risk predic-
tion have consistently shown only weak to mod-
erate effect sizes when comparing diagnosed
psychopaths to nonpsychopaths (e.g., Leistico
et al., 2008;Singh et al., 2011;Yang et al.,
2010). Nor are the PCL scales a strong predictor
of serious forms of crime, such as sexual and
instrumental violence (e.g., Blais et al., 2014;
Camp et al., 2013;Harris et al., 2017;Larsen
et al., 2020). Further, many researchers are now
questioning the presumed chronicity of the con-
dition, with studies showing that psychopathic
offenders appear to gain from treatment and reha-
bilitation programs in similar ways as ordinary
offenders( e.g., Larsen, 2019;Larsen et al., 2020;
Olver, 2018;Polaschek, 2019;Polaschek &
Skeem, 2018;Skeem et al., 2009). Last, review
studies in conscience, remorse, empathy, and
moral judgment have found that individuals diag-
nosed as PCL psychopaths do not appear to have
any fundamental differences compared to con-
trols (e.g., Borg & Sinnott-Armstrong, 2013;
Larsen et al., 2020;Marsden et al., 2019;
Marshall et al., 2018).
As these findings question many widely held
beliefs about psychopathy, some researchers are
beginning to raise ethical concerns about the
current role of psychopathy assessments in foren-
sic practices (e.g., DeMatteo et al., 2020a;Edens
et al., 2018;Larsen, 2019;Polaschek & Skeem,
2018). For instance, DeMatteo et al. (2020a)
recently published a Statement of Concerned
Experts voicing strong reservations about using
the PCL-R to inform capital sentencing decisions
(see also, DeMatteo et al., 2020b; cf. Olver et al.,
2020). Others have expressed concerns that prac-
titioners may be excluding psychopaths from
treatment based on the erroneous assumption
that psychopathy is chronic and untreatable
(e.g., DeMatteo & Olver, 2022;Edens et al.,
2018;Larsen, 2019;Polaschek & Skeem, 2018).
There is also mounting evidence of adversarial
allegiance in courts, whereby PCL-R scores differ
significantly depending on whether the assessor
is retained by the defense or prosecution (e.g.,
Boccaccini et al., 2017;DeMatteo et al., 2014;
Edens et al.,2015;Hare, 2016;Murrie et al., 2009).
Finally, some researchers have highlighted a
potential risk of prejudicial impact when openly
labeling a person as a “psychopath”in trials,
as studies suggest that jurors and judges often
associatepsychopathy with exaggerated risk levels
(e.g., Gardner et al., 2018;Gendreau et al., 2002;
Keesler & DeMatteo, 2017;Kelley et al., 2019;
Smith et al., 2014;Sörman et al., 2020;Truong
et al., 2020).
The present contribution adds to this broader
discourse about the ethics of psychopathy assess-
ments. We argue that the use of psychopathy
assessments violates well-established and core
professional ethical standards in the forensic men-
tal health disciplines, namely, the commitment to
the principle of beneficence and the principle of
nonmaleficence. These ethical principles assert
that practitioners ought to (a) give primacy to
the interests and well-being of patients, and
(b) under no circumstances inflict undue harm
and/or compromise the well-being of patients.
We discuss and demonstrate that a psychopathy
assessment offers no benefit to the patient,
and that there are de facto and/or potential
harms directly associated with its intended and
current uses. The article concludes by recom-
mending a near-universal cessation of psychop-
athy assessments in forensic mental health,
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ARE PSYCHOPATHY ASSESSMENTS ETHICAL? 3
a recommendation that is especially pressing
due to the availability of alternative assessment
strategies and the risk of professional–ethical
sanctions.
The Ethical Frameworks of Forensic
Mental Health: A Brief Overview
Forensic mental health practitioners come from
a variety of different professional disciplines with
the shared aim of addressing a complex and broad
range of mental health issues as they pertain to
and arise in the legal system, hereunder providing
services that inform questions about risk man-
agement, fitness and competence to stand trial,
culpability and sentencing, malingering, place-
ment, rehabilitation, and so forth (e.g., Cima,
2016;Heilbrun et al., 2014;Melton et al., 2018;
Slobogin et al., 2014). In North America, two of
the most prominent and largest forensic mental
health disciplines are forensic psychiatry (e.g.,
Gold & Frierson, 2018) and forensic psychology
(e.g., Cutler & Zapf, 2015). However, practitioners
from other disciplines such as forensic nursing
(Hammer et al., 2013) and forensic social work
(e.g., Barker & Branson, 2000) also play a signifi-
cant role in addressing forensic mental health issues
broadly conceived (see also, Heilbrun, 2001).
Just as each of these disciplines provides differ-
ent expertise and services to the legal system, they
also operate within (nominally) different, yet over-
lapping ethical frameworks. For example, the two
leading ethical frameworks for forensic psychia-
trists in North America are those of the American
Psychiatric Association (2013a) and the American
Academy of Psychiatry and the Law (AAPL,
2005), bothof which are directly adapted or aligned
with the nine ethical principles (Table 1)setbythe
American Medical Association (AMA, 2021a,
2021b). Likewise, the main ethical framework
for forensic psychologists, as formulated by the
American Psychological Association, while not
self-identifying as a medical profession/organiza-
tion, endorses a set of principles that are closely
aligned with medical ethics (APA, 2013b,2017).
Due to this multidisciplinarity in forensic mental
health, the professional community has not explic-
itly endorsed a single uniform ethical framework
(e.g., Koocher & Keith-Spiegel, 2016).
However, despite variations among ethical fra-
meworks, scholars have identified robust agree-
ments and similarities between them. For example,
it is broadly recognized that there are (at least) two
ethical commitments that appear to clearly tran-
scend disciplinary boundaries, commonly referred
to as the principle of beneficence and the principle
of nonmaleficence (e.g., Allan & Grisso, 2014;
Koocher & Keith-Spiegel, 2016;Leach, 2012;
Melton et al., 2018;Sadler et al., 2014).
1
Accord-
ing to these two ethical principles,f orensic ment al
health practitioners (a) ought to give primacy to
the interests and well-being of their patients,
and correlatively, (b) under no circumstances
inflict undue harm and/or compromise the well-
being of their patients (see Beauchamp &
Childress, 2019, for a detailed account).
That these two ethical commitments are central
to all disciplines working within forensic mental
health is perhaps unsurprising. Indeed, these com-
mitments have historically composed a shared
assumption, or something akin to an “axiom”in
professional ethical codes in contemporary Western
medicine and health disciplines (e.g., Baker et al.,
1999;Gillon, 1994). For example, the American
Medical Association, founded in 1847, and con-
stituting the largest professional association of
physicians, residents, and medical students in the
United States, recognizes the substance of these
commitments in its preamble to the Principles of
Medical Ethics: “The medical profession has long
subscribed to a body of ethical statements devel-
oped primarily for the benefit of the patient”
(AMA, 2021a). Further, we also find these com-
mitments stressed in the familiar historic pre-
scription derived from the Hippocratic Oath
(and explicitly invoked in the 18th century)
primum non nocere,“firstdonoharm”(see also,
Beauchamp & Childress, 2019).
Following this tradition, the principles of
beneficence and nonmaleficence are given pri-
macy and thus articulated in the various subdis-
ciplines in forensic mental health. For instance,
we find them explicitly invoked in the following
two principles in the American Medical Associa-
tion’s ethical code (AMA, 2021b), which are
adopted by forensic psychiatrists:
Principle 1: A physician shall be dedicated
to providing competent medical care with
compassion and respect for human dignity
and rights.
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1
Other candidate ethical principles that appear to clearly
transcend disciplinary boundaries are the principle of justice
and the principle of autonomy (e.g., Beauchamp & Childress,
2019;Gillon, 1994;Koocher & Keith-Spiegel, 2016).
4 LARSEN, KOCH, JALAVA, AND GRIFFITHS
Principle 8: A physician shall, while caring
for a patient, regard responsibility to the
patient as paramount.
In addition to these two principles, the Amer-
ican Psychiatric Association also offers anno-
tative comments on how these principles apply
to the specific context of psychiatric practices.
For example, in terms of Principle 1, they
write that:
A psychiatrist shall not gratify his or her own needs by
exploiting the patient. The psychiatrist shall be ever vigi-
lant about the impact that his or her conduct has upon the
boundaries of the doctor–patient relationship, and thus
upon the well-being of the patient. These requirements
become particularly important because of the essentially
private, highly personal, and sometimes intensely emo-
tional nature of the relationship established with the psy-
chiatrist. (American Psychiatric Association, 2013a,p.3)
And with regards to Principle 8, the American
Psychiatric Association further adds that:
When the psy chiatrist’s outside relationships conflict with
the clinical needs of the patient, the psychiatrist must
always consider the impact of such relationships and
strive to resolve conflicts in a manner that the psychiatrist
believes is likely to be beneficialto the patient. (American
Psychiatric Association, 2013a,p.10)
Connotations to beneficence and nonmalefi-
cence are also expressed in the American Psy-
chological Association’sEthical Principles and
Code of Conduct, for example:
Standard 3.04 Avoiding Harm: Psychologists take rea-
sonable steps to avoid harming their clients/patients,
students, supervisees, research participants, organiza-
tional clients, and others with whom they work, and to
minimize harm where it is foreseeable and unavoidable.
(APA, 2017,p.6)
Further, the American Psychological Associa-
tion offers five general principles, which are
additions to their ethical standards, meant to serve
as aspirational goals and intended “to guide and
inspire psychologists toward the very highest
ethical ideals of the profession”(APA, 2017,
p. 2). The first of these general principles is
tellingly entitled, “Beneficence and Nonmalefi-
cence,”stating that:
Psychologists strive to benefit those with whom they
work and take care to do no harm. In their professional
actions, psychologists seek to safeguard the welfare and
rights of those with whom they interact professionally
and other affected persons, and the welfare of animal
subjects of research. When conflicts occur among psy-
chologists’obligations or concerns, they attempt to
resolve these conflicts in a responsible fashion that
avoids or minimizes harm. Because psychologists’sci-
entific and professional judgments and actions may
affect the lives of others, they are alert to and guard
against personal, financial, social, organizational, or
political factors that might lead to misuse of their
influence. Psychologists strive to be aware of the possi-
ble effect of their own physical and mental health on
their ability to help those with whom they work.
Thus, while we should recognize that the dif-
ferent disciplines in forensic mental health prac-
tices endorse different ethical frameworks, it
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Table 1
The American Medical Association—Principles of Medical Ethics
Principles Description
No. 1 A physician shall be dedicated to providing competent medical care with compassion and respect for human
dignity and rights.
No. 2 A physician shall uphold the standards of professionalism, be honest in all professional interactions, and
strive to report physicians deficient in character or competence, or engaging in fraud or deception, to
appropriate entities.
No. 3 A physician shall respect the law and also recognize a responsibility to seek changes in those requirements
which are contrary to the best interests of the patient.
No. 4 A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard
patient confidence and privacy within the constraints of the law.
No. 5 A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to
medical education, make relevant information available to patients, colleagues, and the public, obtain
consultation, and use the talents of other health professionals when indicated.
No. 6 A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom
to serve, with whom to associate, and the environment in which to provide medical care.
No. 7 A physician shall recognize a responsibility to participate in activities contributing to the improvement of the
community and the betterment of public health.
No. 8 A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
No. 9 A physician shall support access to medical care for all people.
Note. Adapted from American Medical Association: Principles of Medical Ethics (AMA, 2021a).
ARE PSYCHOPATHY ASSESSMENTS ETHICAL? 5
remains clear that these disciplines both adhere to
the principles of beneficence and nonmalefi-
cence: to give primacy to patient well-being
and the correlative injunction against causing
undue harm (similar commitments are also found
in the ethical frameworks in forensic social work
and nursing, see Butters & Vaughan-Eden, 2011;
Hammer et al., 2013;International Association of
Forensic Nurses, 2008).
The failure to fulfill these professional ethical
principles is not an inconsequential matter com-
parable to simply “breaking a promise.”Rather, it
can be compared to breaching a contractual com-
mitment insofar that ethical principles form the
foundation of a contract between the individual
disciplines and society. This contract is as fol-
lows: On the one hand, society allows disciplines
(such as psychiatry, psychology, nursing) to
monopolize their knowledge base, enjoy consid-
erable autonomy as a profession,and self-regulate;
on the other hand, these disciplines provide society
with a valuable and necessary service, accom-
panied by the promise of maintaining high stan-
dards of both competency and comportment
(e.g., Cruess et al., 2002,2004). The failure of
either party to fulfill their terms of the contract
undermines the trust between society and that
profession, and therefore also undermines the
central provision of forensic mental health prac-
tices (see also, Koocher & Keith-Spiegel, 2016,
pp. 606–607).
For this reason, professional organizations
(e.g., American Psychological Association) and
independent certification boards (e.g., the American
Board of Forensic Psychology) have assumed the
adjudicative role of a regulatory body tasked with
reviewing suspicions and accusations of potential
ethical violations by their members and/or certified
practitioners, thus overseeing investigative work
and issuing sanctions for violations of their ethical
standards. For example, the American Psycholog-
ical Association has established the Ethics Com-
mittee, which has the fundamental objective to
promote ethical conduct and adjudicate ethics
violation cases, aiming “to maintain ethical con-
duct by psychologists at the highest professional
level, to educate psychologists concerning ethical
standards, to endeavor to protect the public against
harmful conduct by psychologists”(e.g., APA,
2018, p. 3). As such, if a psychologist operating
under the auspices of the American Psychological
Association violates the ethical code, this behavior
may have a range of different consequences
depending on the gravity of the violation. Potential
sanctions include reprimand, censure, expulsion or
voiding membership, stipulated resignation, and
probation (APA, 2018, p. 6). For instance, vio-
lations that cause “substantial harm to another
person”may warrant an expulsion from the
organization or a stipulated resignation; in effect,
such a sanction would present substantial difficul-
ties to continue practicing forensic psychology in
many jurisdictions, including obtaining appropri-
ate professional certification (for case examples,
see Bersoff, 2019;Brodsky & McKinzey, 2002;
Haeny, 2014;Heilbrun et al., 2014;Koocher &
Keith-Spiegel, 2016;Nagy, 2011).
Considering the social ethical–contractual
aspect of the forensic mental health profession,
it is worth noting that some forensic practitioners,
due to the nature of their work environment, are
often positioned in situations that deviate from
the ordinary therapist–patient relationship, instead
serving in the role as a dual-client provider: serving
both society as a whole as represented by the
judicial system (e.g., servicing a court ordered
assessment) and the individual involved in a
judicial process (e.g., servicing the client as a
defendant). While it is often the case that both
the interests of society and the client converge,
dilemma-like challenges may arise that make it
difficult for a forensic practitioner to determine
how to balance their ethical responsibility toward
society and the client. For example, if a court
orders a psychological assessment of a defen-
dant, a practitioner might be worried that the
assessment could impede the legal defense strat-
egy (e.g., contribute to aggravated sentencing),
but on the other hand, the assessment might be an
important piece of information in reaching a just
decision in court (e.g., enhancing accuracy in
sentencing). To assist navigating situations like
these, the professional organizations usually
offer consultancy on a case-by-case basis, as well
as including in their ethical frameworks heuristics
for resolving ambiguous scenarios (e.g., AAPL,
2005;APA, 2013). These include guiding and
supporting practitioners in their right to refuse
providing services that can reasonably be deemed
ethically problematic (even if it is legally man-
dated), and importantly prioritizing the ethical
responsibility to the individual client unless social
benefits are heavily outweighed by the individual
harms (we shall return to this issue later; see
Adshead, 2000;Grisso, 2001;Sen et al., 2007;
Slobogin, 2003, for a more detailed discussion).
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6 LARSEN, KOCH, JALAVA, AND GRIFFITHS
From this brief overview, we can reiterate a
basic characterization of forensic mental health
practices as: (a) a multidisciplinary profession
that consists primarily of psychiatrists, psychol-
ogists, nurses, and social workers; (b) operating
with nominally distinct ethical frameworks; and
(c) yet these frameworks overlap in the sense that
practitioners are expected and mandated to
adhere to the principles of beneficence and non-
maleficence. While different mental health disci-
plines may have worked with the public to set
additional ethical requirements for their respective
professionals—such as mandatory professional
certifications for special roles and services—these
two ethical demands are shared by the largest
(if not all) forensic mental health professions
(for a deeper discussion of the ethical standards
and challenges in forensic mental health, see
Allan & Grisso, 2014;Appelbaum, 2008;
Igoumenou, 2020;Kennedy et al., 2019;Koocher
& Keith-Spiegel, 2016;Leach, 2012;Sadler et al.,
2014;Sadoff, 2010;Shapiro, 2016).
The Forensic Use of Psychopathy Assessments
Psychopathy assessments are generally acknowl-
edged as having two different (though closely
interrelated) types of accepted uses. The primary
type is for clinical diagnostic purposes. As such,
most psychopathy assessments are designed to
ascertain/measure to what degree a person has
the disorder (or syndrome or clinical construct)
that is referred to as psychopathy or psychopathic
personality disorder (Gacono, 2016a). Thus, when
apersonscoressufficiently high on a psychopathy
assessment (e.g., above 30 on the PCL-R), the
score is then interpreted as a diagnostic claim.
According to the PCL-R guidelines, this type
of use is “strictly speaking”what the PCL-R is
designed to do (Hare, 2003, p. 15). A secondary
type of usage is to interpret psychopathy assess-
ments as a statistical inference, meaning that an
assessment score is a predictive inference about
future behaviors. It is important to emphasize
(as mentioned above) that psychopathy assessments
were usually not developed for this purpose, but it
has nevertheless become one of the most frequent
ways of using them (e.g., DeMatteo & Olver, 2022;
Hare, 2016).
It should be stressed that while we can easily
distinguish between diagnostic and statistical
uses—because they are generally based on sep-
arate sciences and serve different application
purposes—anecdotal evidence and field studies
show that psychopathy assessments are com-
monly used for both purposes. For instance, once
a person undergoes a PCL-R assessment, the
outcome is interpreted by practitioners both as a
diagnostic measure of psychopathy and as a
statistical inference to predict relevant behaviors
such as institutional misconduct, criminal recid-
ivism, parole violation, and rehabilitation (e.g.,
Archer et al., 2006;DeMatteo et al., 2014;Hill &
Demetrioff, 2019;Hurducas et al., 2014;Jonnson &
Viljoen, 2021;Viljoen, McLachlan, et al., 2010).
This sort of dual-type usage is also recommended
by psychopathy assessment developers and re-
searchers. For example, while the PCL-R was
solely developed for diagnostic purposes, the
clinical manual explicitly outlines how the tool
may be used by clinicians to predict crime-
related behavior and rehabilitation strategies
and outcomes (Hare, 2003, pp. 131–158). Further,
researchers generally justify this dual-type usage
on the assumption that it allows for explaining
(i.e., the diagnosis) why the assessment is pre-
dictive of forensically relevant behaviors (i.e.,
its statistical inference), which they altogether
understand to be the unique justification of using
psychopathy assessments (e.g., Gacono, 2016c;
Hare et al., 2018;Hemphill & Hare, 2004).
The use of a psychopathy assessment as a
diagnostic inference may strike some readers as
fundamentally problematic insofar that the diag-
nosis is not recognized in the conventional clinical
nomenclature such as the DSM-5.Sincepsychop-
athy is not an “official”psychiatric diagnosis,
perhaps practitioners should not be using assess-
ments like the PCL-R as a diagnostic claim.
However, some researchers have argued that
psychopathy bears enough resemblance to the
DSM-5 diagnosis of antisocial personality dis-
order (ASPD) that the two diagnoses may be
interpreted as essentially the same type of dis-
order, but where psychopathy is a more severe
instantiation of ASPD (e.g., Crego & Widiger,
2015;Drislane et al., 2019;De Brito et al., 2021;
Hare et al., 2012;Poythress et al., 2010). This
interpretation may fit into how theDSM-5 has been
shifting from a categorical understanding of per-
sonality disorder to a dimensional understanding
(e.g., Krueger & Hobbs, 2020;Skodol et al., 2005).
In addition, the DSM-5 recognizes the historical
link between ASPD and psychopathy when it states
that the essential feature of ASPD (i.e., pervasive
pattern antisocial orientation) has historically been
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ARE PSYCHOPATHY ASSESSMENTS ETHICAL? 7
“referred to as psychopathy”(p. 659). Further,
the DSM-5 also includes what it refers to as an
“alternative”model for ASPD, which lists a num-
ber of “psychopathic features”that act as speci-
fiers, effectively taxonomizing psychopathy as a
subtype of ASPD (pp. 764–765). We recognize
that the issue of psychopathy not being an “official”
diagnosis is potentially problematic and might not
allow for a simple solution, and that practitioners
may rightly dismiss using psychopathy assessments
as a diagnostic tool on the grounds of this concern
alone (and there could be separate ethical issues
related to theseincongruities). This, however, does
not change the fact that psychopathy assessments
areroutinelyusedbymanyforensicpractitionersas
a diagnostic inference (see also, Crego & Widiger,
2014;Ogloff et al., 2016;Strickland et al., 2013).
This potential contention aside, the overall pur-
pose of conducting psychopathy assessments—
whether diagnostic or statistical—is somewhat
straightforward, namely, to provide “surplus”
information about the person being assessed
(Lilienfeld et al., 2013), which corresponds
with the intention of using the assessment to
inform and guide legal and clinical decisions
(e.g., Hare, 2016;Polaschek, 2022). How exactly a
psychopathy assessment informs these decisions
changes significantly depending on the person/
patient’s place in, and advancement through
the legal system (e.g., DeMatteo & Olver, 2022;
Gacono, 2016c;Melton et al., 2018). For example,
a judge might use this information to inform
sentencing (e.g., disregard appeal for mitigating
factors like remorse, under the assumption that
psychopaths cannot feel remorse), a prison psy-
chiatrist may use the information to set rehabilita-
tion expectations (e.g., reject a person’s request for
enrolling in a rehabilitation program under the
assumption that psychopaths cannot change),
and a correctional supervisor may use the infor-
mation in risk management (e.g., infer high risk
of institutional violence under the assumption
that psychopaths are extraordinarily dangerous;
e.g., DeMatteo & Olver, 2022;Gacono, 2016c;
Hare, 2016).
It is important to note, however, that psychop-
athy assessments are rarely used in isolation, but
the measure is most likely to be used as part of a
broader forensic evaluation of the person of
interest. Such an evaluation typically involves
conducting several standardized assessments using
different context-specific tools (e.g., personality,
malingering, risk, rehabilitation amenability), as
well as incorporating a comprehensive (and some-
times eclectic) list of available information about
demographics, socioeconomics, family history,
past criminal record, mental health, substance
abuse, and so forth (e.g., DeMatteo & Olver,
2022;Glancy et al., 2015;Loza, 2003;Neal &
Grisso, 2014;Skeem & Monahan, 2011;Melton
et al., 2018). The central aims of forensic eva-
luations can vary substantially from case to case,
but they often involve ascertaining where the
person of interest resides on a risk spectrum—
ranging from low to high risk—regarding foren-
sically relevant behaviors such as risk of institu-
tional infraction and postrelease recidivism (e.g.,
Andrews & Bonta, 2017;Brown & Singh, 2014;
Monahan, 1996,2006a;Skeem & Monahan, 2011).
It is toward these ends that psychopathy assess-
ments are broadly acknowledged as an important
piece of information (e.g., DeMatteo & Olver,
2022;Hare et al., 2018). For instance, some
researchers have characterized psychopathy as
an unprecedented and powerful risk factor in
violence predictions (e.g., De Brito et al., 2021;
DeLisi, 2016;Porter et al., 2009;Salekin et al.,
1996). Others have argued that practitioners
have a professional and public responsibility
to consider psychopathy in forensic evaluations
(e.g., Hare, 1996,1998;Hare & Neumann, 2009;
Harris & Rice, 2006;Hart, 1998;Kiehl &
Hoffman, 2011;Reidy & Bogen, 2022). Further,
in some jurisdictions, psychopathy assessments
have become legally mandated, such as Sexual
Violent Predator evaluations in the USA (e.g.,
Boccaccini et al., 2017;Miller et al., 2005;
Felthous & Ko, 2018;Witt & Conroy, 2009)
and Dangerous Offender hearings in countries
such as U.K., Australia, and Canada (e.g., Doyle
et al., 2011;Heilbrun et al., 1999).
That psychopathy assessments are perceived to
be of high importance is also reflected in surveys
of forensic practitioners and court proceedings. For
example, a study by Viljoen, McLachlan, et al.
(2010) questioned 215 psychologists on their foren-
sic evaluation procedures. They found that approx-
imately 90% of practitioners use psychopathy
assessments to estimate risk levels and that 69.7%
explicitly state in their reports that the person of
interest is a psychopath and/or has psychopathic
traits (see also, Archer et al., 2006;Edens & Cox,
2012;Hill & Demetrioff, 2019;Lally, 2003).
Relatedly, a study by Boccaccini et al. (2017)
surveyed the reporting habits of 95 Sexual Violent
Predator evaluators and found that 80% of
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8 LARSEN, KOCH, JALAVA, AND GRIFFITHS
practitioners utilized the PCL-R, and 95.7%
included the total PCL-R score in their report
(though only 7.4% explicitly labeled the offender
a“psychopath”; see also, Jackson & Hess, 2007;
Lally, 2003). Finally, there is also an evidence that
courts have been increasingly accepting psychop-
athy assessments as evidence during the trier of
fact, one study by DeMatteo et al. (2014) found
that between 2001 and 2011, there was an eight-
fold increase in the frequency of use (see also,
DeMatteo & Edens, 2006;Lloyd et al., 2010).
While these observations all point to a wide-
spread use of psychopathy assessments, it must
be noted that there is currently limited data on
how much, or to what degree, these assessments
influence forensic decisions (e.g., DeMatteo &
Olver, 2022;Hare, 2016;Skeem et al., 2011).
This lack of insight is partially due to the diffi-
culty of measuring the incremental impact of a
forensic evaluation on decision processes. For
example, from a research standpoint, it is virtu-
ally impossible to reliably and validly quantify
to what degree an offender’s high PCL-R score—
which is just one part of a larger, complex forensic
evaluation—contributed to a parole board decision
(though see Blais & Forth, 2014;Guy et al., 2015;
Mooney & Daffern, 2014;Truong et al., 2020).
Another obstacle has to do with the potential
disconnect between the person making the forensic
evaluation and the individuals who make use of it in
the forensic decision process. Assessment informa-
tion is typically written into the offender’sforensic
record and can thereafter be used by any author-
ity in the judicial system (e.g., judges, attorneys,
parole boards, correctional wards, clinicians),
making it excruciatingly difficult to track the influ-
ence of this information across time and contexts.
With these qualifications in mind, in Table 2,we
have briefly sketched the arguably best documen-
ted ways in which psychopathy assessments influ-
ence forensic decisions, namely: sentencing and
placement,capital sentencing,treatment and reha-
bilitation amenability,dangerous offender status,
sexually violent predator status,andparole.We
note in passing that the research literature also
discusses other uses of psychopathy assessments—
such as informing decisions on juvenile trans-
fers to adult courts (e.g., Jones & Cauffman,
2008;Viljoen, McLachlan, et al., 2010)—but to
our knowledge there is comparatively much less
information about these user cases (see also,
Gacono, 2016a;Kiehl & Sinnott-Armstrong,
2013;Patrick, 2018).
From these examples, it can be highlighted that
there is broad consensus among researchers and
practitioners that the (actual/real) impact of psy-
chopathy assessments is typically constrictive in
nature (e.g., DeMatteo & Olver, 2022;Gacono,
2016b;Hare, 1996,2016;Walsh & Walsh, 2006).
As such, if a person scores high on a psychopathy
assessment (e.g., score 30 or above on the PCL-R),
this information will primarily serve to constrain
the person of interest in the legal system (i.e., it will
not serve to ease or mitigate judiciary restraints).
Thus, from the perspective of the person being
assessed, it is undeniably far better to score low on a
psychopathy assessment (like the PCL-R) than
scoring high; a sentiment that is perhaps supported
by the fact that psychopathy assessments are vir-
tually never used by defendants in court (e.g.,
DeMatteo et al., 2014;Viljoen, MacDougall, et
al., 2010),and when they have, these attemptshave
been unsuccessful (e.g., DeMatteo et al., 2016;
Lloyd et al., 2010;Walsh & Walsh, 2006). That is,
in cases where the psychopathy diagnosis has been
introduced by the defense as a mitigating factor
(e.g., as a biologically based disorder mitigating
culpability), the court has found such arguments
unpersuasive (e.g., Edenset al., 2015;DeMatteo &
Edens, 2006;Hughes, 2010).
This raises the question of whether there are any
patient-focused or constructive uses of psychopa-
thy assessments, such that it would be beneficial
for a person to undergo a psychopathy assessment.
To our knowledge, there have only been few
attempts in the research community at developing
patient-centered constructive uses, and these have
never manifested in widespread forensic practices
(see also, DeMatteo & Olver, 2022;Walsh &
Walsh, 2006). For example, in the early days of
psychopathy research, some argued that the diag-
nosis should be understood as a mitigating aspect
in terms of culpability (e.g., Maudsley, 1874), an
argument that has since been uniformly dismissed
in the legal literature (Jones, 2016;Rafter, 2008).
2
There are alsoexamples of potentiallyconstructive
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2
Using the psychopathy diagnosis as a mitigating factor in
culpability questions has been attempted a few times in the
USA. For instance, in the 1979 pretrial hearings of the
American serial killer, Ted Bundy, his defense argued
(unsuccessfully) that Bundy’s psychopathy diagnosis made
him legally inculpable (Larsen, 1980). More recently, in
2009, the defense team of Brian Dugan argued (unsuccess-
fully) that the defendant should be given a mitigated sentence
due to his alleged brain