PSYCHOPATHY, TREATMENT OF
The treatment of psychopathy is a controversial and
underinvestigated area of study. Many researchers
and clinicians have suggested that the pervasive and
manipulative nature of the disorder makes it unlikely
that psychopathic individuals can benefit from treat-
ment. It is of concern that the primary characteristics
of psychopathy (e.g., manipulation, deceit, and shal-
low affect) result in low treatment compliance and
efficacy. To elaborate on this point, Ivan Zinger and
Adelle Forth (1998) contend that the pessimistic
views of treating the psychopath derive from three pri-
mary sources. First, Hervey Cleckley’s description of
the psychopath’s inability to form affective relation-
ships considered necessary for effective treatment was
influential. Second, psychopaths who cause substan-
tial harm to society tend to decrease the compassion
of clinicians, thereby reducing therapist motivation.
Third, serious personality disorders have often been
considered intractable by many clinicians. Zinger and
Forth also argued that these views are entrenched in
the minds of both mental health and legal profession-
als, resulting in few objective efforts to examine treat-
ment amenability in psychopaths. Despite these early
concerns, recently there has been renewed interest in
examining the treatment of psychopathy, as some
researchers believe that treatment gains are possible if
the modality and dosage of treatment are suited to the
disorder. Recent advances in the treatment of other
personality disorders also spurred a renewed interest
in the treatment of psychopathy. Although contempo-
rary research suggests that the field has been overly
pessimistic about the prognosis for treating psychopa-
thy, there are few well-controlled studies on the topic.
It is therefore difficult to draw firm conclusions either
way with respect to treatment outcomes.
Randy Salekin first shed light on the psychopathy-
treatment relation by conducting a meta-analysis on 42
studies. The results of that study indicated that psycho-
pathic individuals could show some benefit from psy-
chotherapy; however, the treatment had to be intensive
and typically involved both the psychopath and family
members. Although the quality of the studies in the
meta-analysis was somewhat limited, the review
underscored two important points: (1) there was no
evidence for psychopathy being considered an untreat-
able disorder and (2) there was a need for a second
generation of research on the topic. Salekin’s review
and meta-analysis also highlighted several problematicareas that would need resolution before the field could
move forward with a more informative generation of
research. These problems included definitional con-
cerns, an unclear etiology of psychopathy, and few
controlled treatment-outcome studies. Each of these
concerns is reviewed in further detail below.Defining Features
Most problematic has been disagreement about the
conceptualization and defining features of psychopa-
thy. Hervey Cleckley offered a well-accepted early
version of psychopathy. However, this version was
replaced in the Diagnostic and Statistical Model
(DSM) with a behavioral model for antisocial person-
ality disorder. Lee Robins and Robert Cloninger sug-
gested that antisocial personality disorder (i.e.,
psychopathy) might be best measured by examining
behavior rather than personality because the assess-
ment of personality was less reliable. Robert Hare
offered a two-factor model for psychopathy that incor-
porated both Cleckley’s personality model of psy-
chopathy and behavioral aspects similar to those
outlined in Robins and Cloninger’s work. While these
theorists purport to be assessing the same construct,
the items of each model differ significantly, compli-
cating the psychopathy (antisocial personality) treat-
ment-outcome question. That is, depending on the
model used, psychopathy might be more or less treat-
able. However, there is little in the way of systematic
research to shed light on the treatment potential for
each of the different models.
Whatever the chosen model, current diagnostic
systems (e.g.,DSM-IV-TR[fourth edition, text revi-
sion],International Classification of Diseases, 10th
revision [ICD-10]) use cutoff points for diagnosing
disorders, resulting in various permutations for a
given disorder. This is pertinent to psychopathy
research and practice because certain characteristics
might be more resistant to treatment. For instance,
“absence of nervousness,” “manipulation,” “deceitful-
ness,” or other factors might be of most concern for
treatment. To elaborate on this point, absence of ner-
vousness, a cardinal feature of early definitions, may
generate the hypothesis that psychopathy is difficult to
treat; however, because the cutoff scores are set low
on some measures (DSM-APD [antisocial personality
disorder]) and moderate to high on others (PCL–R), it
might mean that some individuals classified as having
the disorder do not exhibit the trait that would make
them less amenable (absence of nervousness). OfPsychopathy, Treatment of——— 647P-Cutler (Encyc)-45463.qxd 11/18/2007 12:43 PM Page 647