equal concern, because few contemporary measures
of psychopathy incorporate this feature, it is possible
that newer indices may identify individuals who are
amenable to treatment, even though they might be
labeled as psychopathic. Thus, the mix of psycho-
pathic characteristics could be very important in mak-
ing determinations of amenability (unamenability).
Even if all symptoms were to be accorded equal
weight in the amenability question, it is difficult to
know at what point individuals become unamenable to
treatment. It is also not clear from other disorders
(e.g., depression) that endorsing all possible symp-
toms results in a more untreatable condition. Even
assuming that higher-scoring individuals are less
amenable to treatment, there are no data to suggest
that individuals scoring more than 30 on the PCL–R
(the cutoff score most often used for adults) are the
worst candidates for treatment. Assessment with such
instruments rests on the assumption that all criteria
carry equal weight (and this may not be the case as
noted above) and that any combination of items that
exceeds a predetermined cutoff score is sufficient to
warrant diagnosis (and presumably a conclusion that
the individual is unamenable to treatment). Thus, even
the use of dimensional scores that may reflect degrees
of treatment amenability (or unamenability) is not
well tested. And, as mentioned, if items are not of
equal weight in answering amenability queries, such a
perspective would not alleviate the potential for par-
ticular symptoms to have more or less effect on treat-
ment amenability.Etiology
The etiology for psychopathy is not well understood.
Even for proposed theories, the specific linkage
between etiology and treatment is not always well
developed or articulated. What we do know is that the
majority of prominent theories suggest a predisposi-
tion to the disorder. Specifically, temperamental style,
low fearfulness, deficiency in psychopathy constraint,
or a similar deficit, are frequently mentioned.
Psychopathy researchers have also begun to show
a genetic link to the disorder. Other theories suggest
that psychopathy develops through a specific set of
environmental conditions (e.g., poor attachment due
to maltreatment). There is little in the theories them-
selves, however, even those emphasizing genetic fac-
tors, that could rule out the potential for treatment.In sum, theories regarding the etiology of psy-
chopathy suggest that psychopathy may develop
through predisposition, harsh environmental conditions,
or the interaction of temperament and environment.
Even individuals with a particular temperamental style
interact with others in ways that can foster either
detachment and aggression or attachment and proso-
cial behavior. Moreover, the acceptance of linear deter-
ministic theories that ignore the potential multiple
factors that affect the development of psychopathy and
are unable to account for the complexity of psychopa-
thy symptoms will not be helpful in designing treat-
ment programs. Specifically, theories that focus on
only one component, or aspect, of psychopathy (e.g.,
frontal lobe dysfunction, deficiency in serotonin,
response modulation) without explicating other mani-
festations (e.g., superficial charm, good intelligence,
manipulation) are overly simplistic. Theories will have
to be more encompassing when accounting for the
symptoms of psychopathy because theory hints at
methods and targets for intervention. For example,
many of the current theories point toward parental
practices and contextual factors as targets for poten-
tially successful intervention. Or some theories sug-
gest notifying psychopaths of their deficits in therapy
so that they can begin to try to alter them.Treatment-Outcome Studies
Another area of concern with respect to the treatment
of psychopathy is that there are not many well-con-
trolled treatment-outcome studies. The meta-analysis
mentioned earlier showed that there may be some
treatment effect for psychopathic individuals. Specifi-
cally, treatment may be beneficial if it is intensive and
of long duration. This meta-analysis also found that
youths evidenced the most gain from psychotherapy
and that incorporating family and other support groups
into treatment appeared to be helpful. This review and
meta-analysis suggested that, like individuals with
other disorders, psychopaths probably show moderate
and incremental change over time rather than a com-
plete transformation. Although this study suggested
that a second generation of research was needed on
this topic, few subsequent studies have been con-
ducted. Specifically, very few studies have systemati-
cally examined the treatment response differences
between psychopaths and nonpsychopaths. In those
that have, psychopathic traits tend to be seen as648 ———Psychopathy, Treatment ofP-Cutler (Encyc)-45463.qxd 11/18/2007 12:43 PM Page 648