Psychopathy, treatment behavior, and recidivism: an extended follow-up of Seto and Barbaree

The contribution of psychopathic traits and substance use in the prediction of recidivism of sexual offenders

Substance use and dependence may play an essential role in the risk of reoffending by sex offenders. Research examining the influence of substance use and dependence on the criminal behaviour of psychopathic sex offenders is limited. Alcohol and drug use have been identified as factors which promote criminal behaviour and are suspected to contribute, at least partially, to the probability of reoffending. For instance, previous research showed that elevated scores on the Michigan Alcohol Screening Test (MAST) contribute to the predictability of the Hare Psychopathy Checklist - Revised (PCL-R) on recidivism. The current study retrospectively evaluated a database of incarcerated high-risk offenders registered in the Regional Treatment Center, Sex Offender Treatment Program (RTCSOTP); in order to assess the contribution of self-disclosed histories of alcohol and substance use and dependency have, in concert with measures of psychopathic characteristics, on the predictability of recidivism. Results of the retrospective data identified PCL-R and DAST (Drug Abuse Screening Test) scores as significant predictors of sexual and violent recidivism of male inmates undergoing treatment in RTCSOTP within 5 years of their release. MAST scores, however, did not significantly contribute to the predictability of sexual and violent recidivism in this population. We conclude, drug use should be considered as an important factor when addressing recidivism in sexual offenders who demonstrate psychopathic characteristics.

Working Alliance and Psychopathy: Linkages to Treatment Outcome in a Sample of Treated Sexual Offenders

The present study examined the working alliance, as measured by the full-length Working Alliance Inventory (WAI), and its association with psychopathy, treatment completion, and recidivism in a sample of 111 incarcerated adult male sexual offenders. The men completed the WAI 3 months into their treatment program, while psychopathy was measured via file-based ratings of the Hare's Psychopathy Checklist-Revised (PCL-R), and outcome data were collected via the Canadian Police Information Centre. The majority (85%) of high PCL-R scoring men (PCL-R 25+) successfully completed their treatment program, and by and large, the men demonstrated strong working alliances with their primary therapists. The WAI scale components showed differential associations with the structural features of psychopathy. Specifically, the Affective facet was significantly associated with weaker Bond scores, while the Lifestyle facet was associated with lower Task scores; these results were upheld after controlling for scores on the other PCL-R facets. Strength of alliance, however, was not significantly associated with any recidivism outcomes, irrespective of controls for psychopathy. Implications for the treatment of offenders with high levels of psychopathic traits are discussed in light of extant findings and unique features of the therapeutic alliance.

How Does Offender Rehabilitation Actually Work? Exploring Mechanisms of Change in High-Risk Treated Parolees

Offender rehabilitation is typically thought to have been successful if a higher proportion of a sample of treatment completers avoids being reconvicted for an offence than a comparison sample. Yet, this type of evaluation design tells us little about what brings about these outcomes. In this study, we test whether change in dynamic risk factors during treatment is a recidivism-reducing mechanism in a sample of high-risk offenders. We also examine the extent to which change after treatment-in the period of reentry from prison to the community-mediates this relationship. We found that although individuals made statistically significant change during treatment, this change was not significantly related to recidivism. We did, however, find tentative support for an indirect relationship between treatment change and recidivism, through change that occurred during reentry. These findings signal the importance of the reentry period for understanding how change in treatment is related to long-term outcomes.

Early life predictors of callous-unemotional and psychopathic traits

Psychopathy is a disorder that occurs primarily in males. Offenders with psychopathic traits are responsible for a disproportionate amount of crime in society, particularly violent crime. Early childhood is a time when individual differences in empathy and guilt-key indicators of the construct of psychopathy-are first evident. A growing number of longitudinal studies have begun to investigate how factors in infancy and early childhood predict psychopathic-like traits in later childhood, adolescence, and adulthood. These studies have suggested that parenting styles during infancy (parental sensitivity, maternal harsh intrusion, commenting on the emotional state of the child) as well as attachment styles are predictive of later psychopathic-like traits. In addition, child characteristics such as temperament and the functioning of biological systems such as the autonomic nervous system and hypothalamic-pituitary-adrenal axis are predictive. Overall, studies have suggested that at least some of the origins of psychopathic traits are present in infancy and early childhood, which is consistent with the perspective of psychopathy as a neurodevelopmental disorder. A recent evolutionary-developmental model provides hypotheses regarding how psychopathy may develop and why it is more common in males than females. This model, and its implications for intervention, is discussed in the context of the longitudinal studies that have been conducted on psychopathy.

Mental Health Professionals' Attitudes Toward Offenders With Mental Illness (Insanity Acquittees) in Ghana

Mental health professionals' attitudes toward offenders with mental illness have significant implications for the quality of care and treatment rendered, making it imperative for these professionals to be aware of their attitudes. Yet, this topical issue has received little research attention. Consequently, the present study investigates attitudes toward offenders with mental illness (insanity acquittees) in a sample of 113 registered mental health nurses in Ghana. Using a cross-sectional survey and self-report methodology, the participants respond to measures of attitudes toward offenders with mental illness, attitudes toward mental illness, conviction proneness, and criminal blameworthiness. The results show that mental health nurses who reportedly practiced for a longer duration (6 years and above) were more likely to be unsympathetic, while the male nurses who were aged 30 years and above were more likely to hold offenders with mental illness strictly liable for their offenses. Importantly, the nurses' scores in conviction proneness and criminal blameworthiness significantly predict negative attitudes toward the offenders even after controlling for their attitudes toward mental illness. Yet, when the nurses' conviction proneness and criminal blameworthiness were held constant, their attitudes toward mental illness failed to predict attitudes toward the offenders. This initial finding implies that the nurses' views regarding criminal blameworthiness and conviction may be more influential in understanding their attitudes toward offenders with mental illness relative to their attitudes toward mental illness.

Sex Offender Risk Assessment and Management

Sexual violence is common and can have profound effects on victims compared with other forms of violence. This violence includes unwelcome and forced sexual contact on adults or children. Assessment of individuals who perpetrate sexual violence starts with a comprehensive biopsychosocial evaluation after a finding of guilt. Clinicians should then evaluate risk. Based on this assessment, a risk management plan should be developed, directed at the specific risk of the offender. Management options include external control (eg, incarceration, probation), psychotherapeutic interventions, pharmacologic interventions, and treatment of comorbidity. This organized approach aids in reducing the risk of future sexual violence.

Risk reduction treatment of psychopathy and applications to mentally disordered offenders

Therapeutic nihilism on treating psychopathy is widespread and is largely based on many outdated and poorly designed studies. Important recent advances have been made in assessing psychopathy and recidivism risks, as well as in offender rehabilitation to reduce reoffending, all of which are now well supported by a considerable literature based on credible empirical research. A 2-component model to guide risk reduction treatment of psychopathy has been proposed based on the integration of key points from the 3 bodies of literature. Treatment programs in line with the model have been in operation, and the results of early outcome evaluations are encouraging. Important advances also have been made in understanding the possible etiology of mentally disordered offenders with schizophrenia and history of criminality and violence, some with significant features of psychopathy. This article presents a review of recent research on risk reduction treatment of psychopathy with the additional aim to extend the research to the treatment of mentally disordered offenders with schizophrenia, violence, and psychopathy.

The appropriateness of treating psychopathic disorders

The received wisdom is that there is no known effective treatment for psychopathic disorders. Although outcome studies have not identified an effective programmatic treatment for psychopathic disorders, such studies tend to leave the question open. If behavioral science has not established that psychopathic disorders respond to a particular programmatic approach, neither are psychopathic disorders convincingly proven to be absolutely resistant to treatment. If no treatment is known to be effective in psychopathic disorders, then any treatment seems to squander resources. What is often missing from the discussion is effective therapeutic measures to treat other behaviors that often co-occur, if they do not represent a domain of pathology of psychopathic disorders, such as impulsive aggression. After a brief summary of results of programmatic treatment of psychopathic offenders, this review focuses on the pharmacotherapy of impulsive aggression in psychopathic disorders. If the impulsive aggression that occurs with psychopathic disorders can be better controlled, treatment can have substantial benefits and would be most appropriate.

Long-term patterns in interpersonal behaviour amongst psychopathic patients in secure inpatient treatment: A follow-up study

Psychopathy is a disorder that is partly defined by with maladaptive interpersonal behaviour and has significant effects on treatment outcomes. A previous study (Draycott et al., ) found that higher levels of psychopathy led to a specific interpersonal 'trajectory' amongst patients in a secure psychiatric treatment programme during the first 9 months of their admission. In that programme, more psychopathic patients became increasingly dominant over time, and less psychopathic patients became increasingly hostile. This study is a longer-term follow-up and extension of that study, extending the window of observation to 33 months of treatment. It was found that the more psychopathic patients' increased dominance returned to baseline levels by 33 months, as did the less psychopathic patients' increased hostility. This suggests that treatment for this group is not idiopathic but leaves unanswered the question as to what these divergent trajectories represent.

Altering the Cognitive-Affective Dysfunctions of Psychopathic and Externalizing Offender Subtypes with Cognitive Remediation

Cognitive remediation is a treatment approach with the potential to translate basic science into more specific, mechanism-based interventions by targeting particular cognitive skills. The present study translated understanding of two well-defined cognitive-emotion dysfunctions into novel deficit-matched interventions and evaluated whether cognitive remediation would demonstrate specific and generalizable change. Two antisocial-subtypes, individuals with psychopathy and externalizing traits, are characterized by cognitive-affective problems that predispose them to engage in significant substance abuse and criminal behavior, culminating in incarceration. Whereas individuals with psychopathy fail to consider important contextual information, individuals with externalizing traits lack the capacity to regulate affective reactions. Training designed to remedy these subtype-specific deficits led to improvement on both trained and non-trained tasks. Such findings offer promise for changing neural and behavioral patterns, even for what many consider to be the most recalcitrant treatment population, and presage a new era of translating cognitive-affective science into increasingly specific and effective interventions.

Psychopathy: developmental perspectives and their implications for treatment

Psychopathy is a mental disorder marked by deficient emotional responses, lack of empathy, and poor behavioral controls, commonly resulting in persistent antisocial deviance and criminal behavior. Accumulating research suggests that psychopathy follows a developmental trajectory with strong genetic influences, and which precipitates deleterious effects on widespread functional networks, particularly within paralimbic regions of the brain. While traditional therapeutic interventions commonly administered in prisons and forensic institutions have been notoriously ineffective at combating these outcomes, alternative strategies informed by an understanding of these specific neuropsychological obstacles to healthy development, and which target younger individuals with nascent symptoms of psychopathy are more promising. Here we review recent neurobehavioral and neuroimaging literature that informs our understanding of the brain systems compromised in psychopathy, and apply these data to a broader understanding of its developmental course, ultimately promoting more proactive intervention strategies profiting from adaptive neuroplasticity in youth.

Reducing psychopathic violence: A review of the treatment literature

Psychopathy reflects a pathological form of personality that predisposes individuals to risk for perpetration of chronic and severe violence across their lifespan. The violence attributable to psychopathic persons constitutes a substantial portion of the societal burden to the public health and criminal justice systems and thus necessitates significant attention by prevention experts. However, there is a relatively nascent literature that has examined psychopathic persons' response to treatment, especially considering violence as an outcome. Nevertheless, there have been repeated averments about the amenability (or lack thereof) of psychopathy to treatment. In the present paper, we attempt to provide a comprehensive review of studies assessing the relation of psychopathy to violence outcomes following intervention. Our review of studies suggests there is reason to suspect that specific and tailored interventions which take into consideration psychopathic persons' unique patterns of behavioral conditioning and predispositions may have the potential to reduce violence. However, equally important, certain interventions may potentially exacerbate these persons' violent behavior. The nature of the outcomes is likely highly dependent on the specific components of the intervention itself. We conclude that future research should increase methodological rigor by striving to include treatment control groups and increasing the transparency of the implemented interventions.

Sex offender treatment outcome, actuarial risk, and the aging sex offender in Canadian corrections: a long-term follow-up

The present study is an examination of sex offender treatment outcome in a large national cohort of Canadian Federally incarcerated sex offenders followed up an average of 11.7 years postrelease. A brief actuarial risk scale (BARS), which predicted sexual and violent recidivism, was created for the purposes of the present study to control for risk-related differences between treated and untreated offenders. In total, 732 offenders were identified as having completed (n = 625) or not attended (n = 107) a sex offender treatment program and for whom sufficient information was available to complete the scale. Controlling for risk and individual differences in follow-up time using Cox regression survival analyses and an 8-year fixed follow-up period, treated sex offenders demonstrated significantly lower rates of violent, but not sexual, recidivism. When the treated and untreated groups were stratified by risk level, significant differences were observed only among moderate or high risk offenders. Some significant group differences also emerged on indicators of recidivism severity, with treated offenders demonstrating slower times to sexual reoffense and lower scores on a quantified metric of sexual and violent recidivism severity after controlling for risk. Differences in recidivism base rates between treated and untreated offenders were also larger in magnitude for younger offenders (i.e., under age 50 at release), than for older offenders; however, interactions between age and treatment were not found. The findings are consistent with the risk principle and have possible implications regarding the dynamic nature of sexual violence risk.

The influence of risk and psychopathy on the therapeutic climate in sex offender treatment

The current study examines the relationship between therapeutic climate of sexual offender treatment groups, risk level, psychopathy and phase (i.e., early/later) of treatment. The participants were 137 sexual offenders detained indefinitely under Wisconsin's Sexually Violent Person's Law who attended a treatment group based on their level of psychopathy: higher levels of psychopathy (i.e., PCL-R scores of 25 or above) or lower levels of psychopathy (i.e., PCL-R scores of less than 25). Using MANOVA with aspects of the therapeutic climate as the dependent variables, the therapeutic climate did not differ as a function of the risk level of the participants. However, the overall therapeutic climate of the two treatment tracks (Lower vs. Higher PCL-R) differed significantly. The mean therapeutic climate scores for both treatment tracks were in the medium to high range (with exception of group cohesion, which was low in the Higher PCL-R track), indicating a fairly positive therapeutic climate in both treatment tracks overall. The therapeutic climate also differed as a function of phase of treatment for each of the treatment tracks, with some aspects being rated more positively early in treatment and others in more positively in later phases. In particular, group cohesion was viewed more positively for the Higher PCL-R group in later phases of treatment.

Validity of the Modified Child Psychopathy Scale for Juvenile Justice Center Residents

Adult psychopathy has proven to be an important clinical and forensic construct, but much less is known about juvenile psychopathy. In the present study, we examined the construct validity of the self report modified Child Psychopathy Scale mCPS; Lynam (Psychological Bulletin 120:(2), 209-234, 1997) in a sample of 57 adolescents residing in a Dutch juvenile justice center, aged between 13 and 22 years. The mCPS total score was reliably related to high externalizing problems, low empathy, high anger and aggression, high impulsivity, high (violent) delinquency, and high alcohol/drug use. Unique relations were found for the antisocial-impulsive (mCPS Factor 2), but not the callous-unemotional facet of psychopathy (mCPS Factor 1). Our findings support the validity of the mCPS in that it encompasses the antisocial-impulsive facet of psychopathy, but it is less clear whether the mCPS sufficiently captures the affective-interpersonal facet of psychopathy.

Treatment engagement as a predictor of premature treatment termination and treatment outcome in a correctional outpatient sample

BACKGROUND

It is widely assumed that the outcome of correctional treatment largely depends on the patient's treatment engagement; however, evidence for this notion is scarce.

AIM

In this study, the Treatment Engagement Rating scale (TER) was used to investigate the relationship of a patient's treatment engagement with premature treatment termination and treatment outcome, defined as reduction of the risk of reoffending.

METHOD

Employing a prospective design, this study addressed the relationship of the behavioural treatment engagement of correctional outpatients (N = 138) with treatment non-completion and treatment outcome, respectively.

RESULTS

Treatment engagement as measured by the TER emerged as an accurate predictor of treatment non-completion (area under the curve = 0.76; odds ratio = 4.1) and was also significantly correlated with treatment outcome (rho = 0.41). The prediction was more accurate for sex offenders than for violent offenders, for expulsion from the treatment than for dropout, and when treatment engagement was assessed closer to the end of the treatment.

CONCLUSIONS

The study provides evidence that the outcome of correctional treatment depends to a substantial degree on the behavioural efforts that the patients make for the treatment. Periodic assessment of treatment engagement in correctional treatment facilities would be useful, and the TER seems to be a practical, reliable and valid instrument for this purpose.

Early environmental predictors of the affective and interpersonal constructs of psychopathy

Early childhood maltreatment (i.e., physical, sexual, emotional abuse) and caregiver disruptions are hypothesized to be instrumental in altering the neurobiology of the brain, particularly the amygdala, and contributing to the development of the affective deficits examined in individuals with psychopathy. Exposure to early untoward life events in models of rodent and nonhuman primates changes the neurobiology of the stress response. It is hypothesized that these changes may permanently shape brain regions that mediate stress and emotion and therefore play a role in the etiology of affective disorders in humans. The significance of experience (e.g., the intensity/severity, chronicity/duration, and developmental timing of experiences) and how the accompanying changes in the activity of the hypothalamic-pituitary-adrenocortical system affect alterations in the amygdala are discussed as critical contributors to the etiology of psychopathy. A model is proposed in which early maltreatment experiences contribute to alterations to the amygdala and produce a blunted or dissociative response to stress, a key factor in the affective deficits observed in psychopaths.

The mangled butterfly: Rorschach results from 45 violent psychopaths

Participants were 45 violent California male prison inmates scoring 30 or more on the Psychopathy Checklist-Revised (PCL-R; Hare, 1991, 2003). Inmates were evaluated using Rorschach and neuropsychological test data. The participants' intellectual functioning was within the low-average range and displayed a lack of flexibility. Rorschach data were not suggestive of chronic narcissism and anger as in other psychopathic samples. This group resembled Exner's normative sample of high Lambda adults. Consistent with previous studies, psychopaths demonstrated poor emotional modulation, diminished reality testing, little interest in people, and virtually no attachment capacity. Most utilized a simplistic, avoidant, and concrete style. This appeared to be consistent with the concrete thinking and fragmentation attributed to the criminal personality. Concrete thinking is based upon literal interpretations of events. Fragmentation is associated with attitudes that are situation specific and self-serving.

Sex Offender Civil Commitment: Recommedations for Empirically Guided Evaluations

Evaluations of sex offenders in the context of civil commitment occur both pre- and post-commitment. Pre-commitment evaluations must address the relevant prongs of the state's civil commitment statute including the presence of a mental disorder or abnormality, likelihood of future sexual violence, and the volitional link between the two. Post-commitment evaluations must assess treatment progress and readiness for release. A thorough understanding of assessment and diagnostic issues relating to sexual offender civil commitment are essential in conducting both pre- and post-commitment evaluations. The high stakes nature of sex offender civil commitment demands rigorous and empirically based evaluations.

Treatment of sexual offenders with psychopathic traits: recent research developments and clinical implications

This article provides a review of recent literature related to the treatment of psychopathy in forensic settings, with particular focus on studies with sexual offenders. The lack of empirical support for the position that psychopaths are untreatable is noted, and data suggesting optimism is discussed. Research demonstrating an interaction between psychopathy and substance abuse and between psychopathy and sexual deviance is also presented. Both substance abuse disorders and inappropriate arousal are frequently encountered in high-risk groups of sexual offenders. These topics are of relevance, in that the question of whether treatment is beneficial with high-risk sexual offenders, including those who are psychopathic, cannot be answered unless groups presenting with typical concurrent disorders (paraphilias, substance abuse, dependence) are discussed. It is argued that, although the evidence is still preliminary, there is reason for optimism with reference to whether psychopathic sexual offenders are responsive to treatment, including offenders presenting with concurrent disorders.

The relationship between developmental variables, personality disorder, and risk in sex offenders

Previous research on the evaluation of the Challenge Project, a community treatment program for sex offenders in southeast London, identified the potential role of key developmental variables as enhancing actuarial risk measures to identify individuals at highest risk for community failure. The aim of the current study was to assess the relationship between developmental variables and later personality dysfunction in adult-hood, and the contribution of these factors to assessing risk for sexual recidivism, in a wider group of sex offenders managed in the community by the probation service. Over an 8-month period, 241 participants were assessed, including 162 child molesters and 79 rapists. A wide range of background data were collected, including the administration of several psychometric measures. A strong relationship was found between key developmental variables and adult mental health and personality difficulties, as well as a range of risk measures. The implications of the findings for further research are discussed.

Effectiveness of sex offender treatment for psychopathic sexual offenders

Meta-analyses have suggested that sexual offender treatment (SOT) completion is associated with lowered sexual recidivism rates for convicted sexual offenders. The paucity of properly designed studies allows for the alternative explanation of less recidivism among treated samples as reflecting that lower risk offenders disproportionately self-select into treatment. A test of the "self-selection explanation" can occur by investigating treatment effect on known high-risk offenders. Psychopathy correlates with increased sexual recidivism risk, such that an exploration of the SOT effect on psychopathic offenders could clarify the accuracy of the self-selection hypothesis. Additionally, the debated degree to which psychopaths are treatable might obtain clarification by a research review. This article examines empirical findings concerning the effectiveness of SOT for psychopathic sexual offenders. Ten studies were found to meet the minimal quality standards used, stemming from only four data sources. Shortcomings of existing research precluded clear conclusions, though trends in the data are delineated.

Validation of the Treatment Motivation Scales for Forensic outpatient treatment (TMS-F)

The validity of the Treatment Motivation Scales for outpatient offender treatment (TMS-F), a self-report questionnaire with scales for the motivation of patients to engage in the treatment and six cognitive and emotional determinants of this motivation, is evaluated in two studies. In Study 1 (N = 620), the construct validity of the TMS-F is investigated applying a multitrait-multimethod design with a therapist-rating instrument as the criterion method. All scales were found to have adequate convergent validity and acceptable discriminant validity. In Study 2 (N = 328), the criterion validity of the TMS-F is addressed. Applying covariance structure analysis, the instrument is found to predict therapist ratings of the treatment engagement of patients to a substantial degree. Treatment engagement is best predicted by the scales for Motivation to Engage in the Treatment and Perception of the Suitability of the Treatment and not by the scales for Distress and the Perceived Legal Pressure.

Psychopathy: a clinical and forensic overview

There is a substantial amount of empirical evidence that psychopathy, as measured by the PCL-R and its derivatives, is a predictor of recidivism and violence in prison, forensic psychiatric, and civil psychiatric populations. The PCL-R is one of the most generalizable of the risk factors identified thus far, and for this reason it is included in various actuarial and structured clinical risk assessment procedures. Although psychopathy is not the only risk factor for recidivism and violence, it is too important to ignore, particularly with respect to violence. Treatment and management are difficult, time-consuming, and expensive, but new initiatives based on current theory and research on psychopathy and the most effective correctional philosophies may help to reduce the harm done by psychopaths.

Sex offenders' response to treatment and its association with recidivism as a function of psychopathy

This study examined the relationship between recidivism and ratings of response to specialized cognitive behavioral treatment conducted in a prison setting among 418 sex offenders released to the community for an average follow-up period of over 5 years. As well as testing for a main effect for treatment ratings, the potential role of psychopathy assessed using the Psychopathy Checklist--Revised (PCL-R) as a moderator of response to treatment was investigated. Ratings of response to treatment failed to predict either serious (violent including sexual) or sexual recidivism. For the more inclusive outcome of serious recidivism, there was no significant interaction between psychopathy and treatment ratings; however, the ubiquitous effect of psychopathy on recidivism was found to be significant. For sexual recidivism, psychopathy was not significant as a main effect, but a significant interaction between psychopathy and treatment ratings was found. Among sex offenders with PCL-R scores of 25 or higher, those with ratings reflecting a more negative response to treatment recidivated sexually at a faster rate than others. This interaction effect was not significant when treatment noncompleters were removed from the data set. The results were discussed in terms of the methodology involved in the assessment of response to treatment among sex offenders.