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Internet Editor’s Note: Drs. Chakhssi, de Ruiter, and Bernstein recently published an article, along with their co-author Dr. Truus Kersten, titled “Treating the untreatable: A single case study of a psychopathic inpatient treated with schema therapy” in Psychotherapy.

Can Individuals with Psychopathy Be Treated?

From its first conceptualization in modern psychiatry, psychopathy has been surrounded with therapeutic pessimism (Cleckley, 1941; D’Silva, Duggan, & McCarthy, 2004; Salekin, Worley, & Grimes, 2010).

Psychopathy is a severe form of antisocial personality disorder characterized by a lack of empathy and remorse, self-aggrandizement, a manipulative interpersonal style and poor behavioral controls and can best be determined on the basis of a structured clinical rating scale such as the Psychopathy Checklist-Revised (PCL-R; Hare, 2003).

Many experts believe that these characteristics are difficult, if not impossible, to ameliorate (Harris & Rice, 2006), and the findings of some studies suggested that treatment makes psychopaths more dangerous (e.g., Rice, Harris, & Cormier, 1992; Seto & Barbaree, 1999). Possibly as a result of the entrenched therapeutic pessimism about psychopathy, very few empirical studies have examined psychopathy’s responsiveness to psychological interventions. To date, no randomized controlled trials of psychological interventions for psychopathy have been published in the clinical literature. Recent reviews, however, conclude there is little compelling empirical evidence that psychopathy is either immutable or amenable to psychological treatment, mainly because of a lack of treatments based on sound theoretical models of psychopathy (e.g., Salekin et al., 2010).

Forensic hospitals in the Netherlands have a long history of treating severe personality disordered offenders, where more than two-thirds of the patients have a personality disorder without a concomitant major mental disorder, in contrast to forensic hospitals in the United States (de Ruiter & Trestman, 2007). Under Dutch legislation, offenders who have committed a severe crime and who suffer from a mental or developmental disorder, including personality disorders, can be sentenced to involuntary treatment in a forensic hospital. They remain within the forensic hospital as long as the offender is deemed a danger to society, subject to review by the court every 1 or 2 years. In Dutch forensic hospitals, prevalence rates up to 35% have been reported for offenders with PCL-R psychopathy (Hildebrand & de Ruiter, 2004).

Forensic hospitals in the Netherlands mostly offer a cognitive behavioral treatment program with a focus on relapse prevention (e.g., Laws, Hudson, & Ward, 2000), although no controlled studies of treatment outcome have been published. Earlier studies on the efficacy of treatment in Dutch forensic hospitals showed that the outcome in naturalistic terms is positive.

One of the first prospective studies of change in personality disorder pathology during forensic treatment was conducted by Greeven and de Ruiter (2004). They investigated 59 (54 men and five women) personality disordered offenders after two years of forensic treatment. Reliable change analyses (cfm. Jacobson & Truax, 1991) showed that 39% of the patients significantly improved in personality disorder pathology as measured by the Personality Diagnostic Questionnaire-Revised (PDQ-R; Hyler & Rieder, 1987). Moreover, 27% of the patients showed clinically significant change on PDQ-R scores, indicating that they no longer fulfilled the criteria for a personality disorder. More recently, Chakhssi, de Ruiter, &

Bernstein (2010) investigated change during forensic treatment in personality disordered offenders with and without psychopathy. Seventy-four personality disordered offenders were divided into psychopathic and nonpsychopathic cases (psychopathy was defined as PCL-R total score > 26).

Over a period of 20-months of forensic treatment, all offenders were assessed repeatedly by psychiatric nurses on risk-related behaviors. Group and individual level analyses showed few significant differences between psychopaths and nonpsychopaths in terms of degree of change. Psychopaths, as well as nonpsychopaths, showed significant improvements in adaptive social behavior, communication skills, insight and attribution of responsibility. However, a subgroup of psychopaths (22%) deteriorated during treatment with regard to physical aggression, whereas none of the nonpsychopathic patients did.

Similar results were reported by Hildebrand and de Ruiter (2012) who examined change during forensic treatment in psychopathic versus nonpsychopathic offenders in a sample of 87 mentally disordered offenders, including offenders with schizophrenia and other psychotic disorders. The offenders were administered a battery of tests including self-report inventories, performance-based personality test, and observer ratings upon admission and after 20 months of treatment. Their findings showed no significant differences between psychopathic and nonpsychopathic patients on the indicators of dynamic risk factors such as impulsivity, distrustful attitudes and hostility (Hildebrand & de Ruiter, 2012).

These findings from Dutch forensic hospitals, as well as those of other studies (see D’Silva et al., 2004; Salekin et al., 2010), challenge the widely held view that patients with psychopathic features cannot be treated, or that treatment makes them worse (Rice et al., 1992; Seto & Barbaree, 1999). To the contrary, these findings suggest that some patients with psychopathy may actually benefit from psychological treatment.

Applying Schema Therapy to Patients with Psychopathy

Psychopathy represents a mental disorder and like all other disorders, in the absence of sufficient evidence concerning its (un-)treatability, continued treatment efforts and further research into effective treatment strategies are warranted. To further our insight into the assessment and treatment of personality disorders in forensic settings, including psychopathy, Young’s schema therapy model (ST: Young, Klosko, & Weishaar, 2003) may prove useful.

Schema Therapy was specifically developed for patients who are considered difficult to treat with traditional cognitive therapy. Often, patients with severe personality disorders fail to respond to, or relapse from, traditional cognitive therapy (Young et al., 2003).

ST expands on the cognitive-behavioral approach developed by Beck, Freeman and colleagues (1990) by placing much greater emphasis on exploring the childhood origins of psychological problems, on experiential techniques, on the therapist-client relationship, and on maladaptive coping styles (Young et al., 2003).

ST has shown effectiveness in four clinical trials of non-forensic patients with severe personality disorders, including three randomized controlled trials (Bamelis, Evers, Spinhoven, & Arntz, 2014; Farrell, Shaw, & Webber, 2009; Giesen-Bloo et al., 2006) and one open trial (Nadort et al., 2009).

Given its goal of forming a genuine emotional connection with the patient, and altering the patient’s core personality traits, ST represents a departure from other cognitive-behavioral treatments for psychopathy that assume that changing psychopathic personality features is impossible due to these patients’ serious emotional deficits (Wong & Hare, 2005).

Bernstein, Arntz, & de Vos (2007) adapted ST for forensic patients with serious personality disorder pathology. They theorized that patients with psychopathy/antisocial personality disorders make prominent use of five overcompensating schema modes that involve maladaptive coping styles:

Attempts to con and manipulate (“conning and manipulative mode”), Self-aggrandizement and devaluation of others (“self-aggrandizer mode”), Attempts to bully and intimidate (“bully and attack mode”), Focusing of attention to detect a hidden threat or enemy (“paranoid over-controller mode”), and Cold, calculated aggression aimed at eliminating a threat or rival (“predator mode”).

Recent research suggests that early maladaptive schemas and schema modes are prevalent in patients with antisocial personality disorder and psychopathy (Chakhssi, Bernstein, & de Ruiter, 2012; Lobbestael, Arntz, Cima, & Chakhssi, 2009).

Preliminary findings of a multicenter randomized clinical trial using ST with personality disordered forensic patients suggests treatment reduces future violence risk and improves the ability to be open and vulnerable during therapy sessions (Bernstein et al., 2012).

Individual Schema Therapy: A Case Study

A single case study examined the process of individual ST with a forensic inpatient with psychopathic features (Chakhssi, Kersten, de Ruiter, & Bernstein, 2014). This case analysis detailed the first apparently successful ST treatment of a psychopathic patient and suggests that ST may enhance motivation and responsivity for treatment for individuals with psychopathy / antisocial personal disorders (Chakhssi et al., 2014).

The patient had been sentenced to a mandatory treatment in a Dutch forensic hospital in relation to a sexual assault. Change during treatment was assessed using independent assessments of psychopathic traits, cognitive schemas according to Young’s schema theory, and risk-related behaviors over the 4-year treatment period. Reliable change analyses showed significant improvements on psychopathic traits, cognitive schemas, and risk-related outcomes.

As treatment of psychopathy should be evaluated by an outcome measure of psychopathic traits, the PCL-R was administered pre- and post-treatment.

By the end of the ST treatment, the patient’s scores on PCL-R items for prominent psychopathic features such as lack of empathy, impulsivity, and failure to take responsibility, were reduced to the point that the patient did not fulfill the criteria for a diagnosis of psychopathy. At 3-years post-treatment, the patient’s mandated treatment order was terminated by court and he lived independently in the community and had not reoffended.

Summary

Clearly more research is needed into the responsiveness to psychological treatment of patients with psychopathy / antisocial personality disorder. However, the few studies that have been published suggest that at least a portion of these patients may prove amenable to treatment, if they are given an evidence-supported therapy that specifically targets the core aspects of their disorder.