When we psychologists talk to someone about what is and what is not psychopathy with someone, many questions arise. There’s one that always ends up coming up, as it’s perhaps the most interesting of all. Is it possible to treat these people psychologically in an effective way? Some people talk about treating and others talk about curing, which are very different things.
For this article we will talk about what we know today about the prognosis of psychopathy from a clinical point of view. Let’s remember that science is constantly mutating knowledge, and what we know today may not be so true tomorrow. Having said that, let’s see what the meta-analyses have to say.
Unfortunately, the diagnostic manuals do not recognize psychopathy as a clinical entity . Although these labels have many detractors – and with good reason – there is something they do serve. The clear, exhaustive and orderly appearance of the criteria of a disorder allows it to be investigated. And any research group that takes those criteria as a reference will almost certainly be studying the same phenomenon.
Psychopathy does not have this benchmark, so each research group may be studying different definitions of psychopathy. There have been successful attempts to bring the definitions together and understand psychopathy as a set of traits that often occur together. The most widespread is perhaps that of Hervey Cleckley, who extensively describes the clinical characteristics of the psychopath.
Robert Hare, later on, identifies in these descriptions two main factors : using others in a selfish, emotionally cold, hard and remorseless way and on the other hand a chronically unstable type of life, marked by the transgression of rules and socially deviated.
Naturally, research on the effectiveness of treatment in psychopathy depends largely on how we understand it. While most research uses the most widely known criteria, we should keep in mind that there is a portion of the trials that may have measured psychopathy in different terms.
Is psychopathy incurable?
Any student of psychology who has touched on personality disorders has a kind of automatic spring that causes him or her to answer with a resounding “yes” when asked this question. There is a widespread belief that psychopathy is impossible to eradicate , which is also the case with antisocial personality disorder.
Indeed, personality disorders are incurable, they do not fully remit because they are exaggerated manifestations of normal personality traits. And just as personality is mutable to some extent , rigid personality patterns are also permeable only to some extent.
It is at this point that a not entirely justified leap of faith is often made. Just because a mental disorder never remits does not mean that it cannot respond to treatment. This is why we talk about treatment, not cure. The truth is that the evidence on the treatment of psychopathy is not as strong.
The notion that this disorder is untreatable may have originated through the psychoanalytic stream , which suggests that the personality is formed during the first 5 or 6 years of development and remains virtually unchanged. But even within psychoanalysis this has been changing and the possibility of modification is conceived.
Hare himself proposed a theory of psychopathy that justified his status as “untreatable”. In this early theory he says that psychopaths suffer a lesion in the limbic system (located in the brain) that prevents them from inhibiting or interrupting their behaviour. This also predicts that psychopaths are insensitive to punishment, that they never learn that an action can bring bad consequences. In a later revision of this theory, Hare described psychopaths as emotionally insensitive , with more difficulties in processing the emotions of others.
What do the studies say?
Every theory remains speculative when it comes to therapeutic efficacy. When we want to find out if a disorder or phenomenon responds to different forms of treatment, the best way to find out is to put this hypothesis to the test.
Numerous research groups have shed the burden of clinical pessimism about psychopathy and have conducted clinical trials to assess the feasibility of treatments.
Surprisingly, most articles approach the problem of psychopathy from the perspective of psychoanalysis. Almost everyone understands the phenomenon as described by Cleckley, except for a few trials. The cases treated by psychoanalytic therapy show a certain therapeutic success with respect to the control groups. This finding points in the direction that therapies focusing on insight and disease awareness could be beneficial for psychopaths.
Cognitive-behavioral therapies appear to be slightly more effective than psychoanalytic therapies. These therapies addressed issues such as thoughts about oneself, about others, and about the world. In this way, some of the most dysfunctional traits are addressed. When the therapist combines the cognitive-behavioral approach and the insight-centered approach even higher therapeutic success rates are achieved .
The use of therapeutic communities has also been tried, but its results are only slightly superior to those of the control group. This is not surprising, as therapeutic communities have little direct contact between therapist and client, which is what the psychopath really needs.
The use of medication to treat symptoms and behaviours of psychopathy, in the absence of a larger number of clinical trials, is promising. Unfortunately, the methodological precariousness of the studies in this respect and the small number of articles do not allow us to draw final conclusions on this issue.
Dismantling the myth
It is not necessary to believe fervently in the results of the studies to realize that psychopathy is far from untreatable . Although we don’t have specific programs that address all the dysfunctional aspects of the psychopath, we do have therapeutic tools to end the most maladaptive behaviors. Whether these therapeutic benefits are maintained over time is something that remains to be seen.
One of the fundamental problems that occurs in the treatment of psychopathy, as in other personality disorders, is that it is uncommon for the client to want to go to therapy . And even in the rare case that they come of their own free will, they are often resistant to change. After all, we are going to ask the client to introduce a series of changes in his personality that are not at all easy to implement and threaten his own identity.
With these patients it is necessary to do an intense work of disease awareness and motivation for the change prior to the therapy itself. This extra effort wears down both the patient and the therapist, who often ends up abandoning or unfairly labelling the patient as untreatable. The truth is that if we can’t change a psychopath it’s only because we haven’t yet found a way to do so.