Is Psychopathy Treatable?

In 1806, French doctor Philippe Pinel created a category of mental disorder, manie sans délire, or insanity without delirium, which was a forerunner to modern psychopathy.¹ His case studies of some who presented intractable and immutable disorders were harbingers of the long-held belief that the disorder may be irreversible and untreatable.

Nearly 150 years later, American psychiatrist and psychopathy pioneer Hervey Cleckley cataloged cases of psychopaths he had analyzed in his seminal work, The Mask of Sanity, and developed a list of character traits that were common to all.² Based on these cases and informed by his other psychiatric practice, he reached a conclusion that still resonates and causes consternation among some researchers: Cleckley determined that treatment was unavailing.³

In the 1988 and final version of The Mask of Sanity, Cleckley wrote:

"I have now, after more than three decades, had the opportunity to observe a considerable number of patients who, through commitment or the threat of losing their probation status or by other means, were kept under treatment not only for many months but for years. The therapeutic failure in all such patients observed leads me to feel that we do not at present have any kind of psychotherapy that can be relied upon to change the psychopath fundamentally. Nor do I believe that any other method of psychiatric treatment has shown promise of solving the problem."⁴

This assertion was largely reinforced by the work of the preeminent psychopathy researcher Dr. Robert D. Hare in the 1970s and 1980s. He summarized his observations based on his experiences with clinical psychopaths who scored 30 or above on his gold-standard instrument, the Psychopathy Checklist-Revised ("PCL-R").

In his popular work, Without Conscience, he posited that psychopaths are “poor candidates for therapy,” noting that "many such [treatment] programs, do little more than provide psychopaths with new excuses and rationalizations for their behavior and new insights into human vulnerability.”⁵

Does That Mean All is Lost?

Notwithstanding these strong statements from Cleckley and Hare, many researchers embarked on a quest for treatment approaches that they believed would provide some hope and benefit.

While it was generally recognized that those who scored 30 or higher on the PCL-R would probably be very resistant to therapeutic interventions, it was hoped that it might still be possible to ameliorate some traits and provide some benefit to society. In addition, for adults with scores below 30 or juveniles displaying substantial callous-unemotional traits, the pressure to verify reproducible treatments is manifest.⁶

Some Treatment Approaches and Their Efficacy

In the 2018 second edition of the Handbook of Psychopathy, researchers Dr. Devon Polaschek and Dr. Jennifer Skeem summarized several treatment methodologies and approaches that may have some promise.⁷

They discuss the potential benefits of the use of the RNR (“risk-need-responsivity”) model of offender treatment. This method targets intensive services to higher-risk offenders, focuses on changing empirically documented risk factors, and maximizes offenders’ engagement in the treatment process.⁸ They conclude that studies of the RNR model demonstrate a “modest but important” impact on crime.⁹

They also noted the potential benefit of “aggressive behavior control” programs and also discussed studies showing benefits for adult offenders using psychotherapy combined with psychotropic medication.¹⁰

Polaschek and Skeem believe that various juvenile treatment modalities may offer help to youth designated as high in callous-unemotional traits. They summarize studies that suggest significant positive outcomes for high-risk youth through intensive custodial treatment, coupled with social skills acquisition and aggression replacement therapy.¹¹

In addition, they discuss research that used multisystematic therapy (“MST”), an intensive family-based program designed to reduce the need for out-of-home placement.¹² Another study featured some benefit from emotion regulation therapy (“ERT”), suggesting that “youth with callous-unemotional traits showed significantly greater improvement in conduct problems over a 6-month follow-up period.”¹³

Psychopathy Essential Reads

Psychology’s Latest Thinking on Psychopathy

Revising My Ideas About a Kid Who Killed

More and Better Research Is Needed

Polaschek and Skeem bemoan the dearth of quality research into treatment options for both adults and youth. They state, “With adults, we have found no methodologically sound research demonstrating changes in symptoms of psychopathy as a function of treatment.”¹⁴ Similarly, in relation to studies involving juveniles, they note, “High-quality research specific to the treatment of juvenile offenders with psychopathic features is not extensive.”¹⁵

As psychopathy researchers Jason Smith, Carl Gacono, and Ted Cunliffe have noted as well, “Few studies exist on treating psychopathy.”¹⁶ Only one PCL-R study examined treatment outcomes in a group of female offenders. It suggested, as might have been expected, that higher-scoring individuals presented numerous negative treatment issues.¹⁷

In Without Conscience, Dr. Robert Hare underscores the value of better research when he plaintively noted: “Perhaps the most frustrating thing about reading the treatment literature is that the diagnostic procedures often are hopelessly inadequate or so vaguely described that it is impossible to determine whether a given program had anything at all to do with psychopathy.”¹⁸