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CDPXXX10.1177/0963721414535211PolaschekCriminals With Psychopathy
Adult Criminals With Psychopathy:
Common Beliefs About Treatability and
Change Have Little Empirical Support
Current Directions in Psychological
Science
2014, Vol. 23(4) 296­–301
© The Author(s) 2014
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DOI: 10.1177/0963721414535211
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Devon L. L. Polaschek
Victoria University of Wellington
Abstract
Criminals with psychopathy have historically been thought to be resistant to change and unresponsive to psychological
treatment. But despite vast amounts of empirical research on psychopathy, very little of it has investigated treatment
or change. In this article, I review a small and recent scientific research literature suggesting that (a) psychopathic
characteristics, especially those most related to criminal offending, can change over the life course; (b) although adult
criminals with psychopathy are among the hardest to work with in treatment, treatment causes them—like other
offenders—to reoffend less; and (c) there is no good evidence that criminals with psychopathy take advantage of
treatment services to wreak havoc on therapists or the community. Taken together, these findings suggest that like
other high-risk criminals, those with psychopathy can benefit from psychological treatment.
Keywords
criminal psychopathy, psychological treatment, treatability, PCL-R
Imagine this: You are a member of a parole board. In
front of you stands a man who has been imprisoned for
12 years for attempted murder. His psychologist’s report
says he is a psychopath. But the man himself declares
that he has changed—he has been rehabilitated. It is your
job to decide whether he is safe to be released. You have
heard that psychopaths are consummate manipulators
and cannot change who they are. Or can they? Answering
this question is the purpose of this article.
Psychopaths—or, more correctly, people with psychopathy—have a personality disorder. They can be
grandiose, fearless, superficially charming, callous, irresponsible, manipulative, impulsive, emotionally shallow,
hot headed, cold hearted, and stress resilient. Intuitively,
they must be challenging to treat and resistant to change:
At best, they sound unpleasant and difficult to work with;
at worst, as if they could easily get the better of a hapless
therapist.
Although people with psychopathy can be found
throughout society, the ones who strike fear among ordinary people are not the Fortune 500 CEOs but the sometimes violent, mostly male, habitual criminals. In this
article, I focus on these men, addressing three common
misconceptions: (a) that criminal psychopaths cannot
change who and what they are, (b) that treatment does
not reduce their potential for crime, and (c), worse still,
that they misuse treatment for antisocial ends.
Before tackling these misconceptions, it is important
to establish how psychopathy is diagnosed. Because
accurate diagnosis is a prerequisite for any research on
mental disorders, we might consider turning to the fifth
edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5; American Psychiatric Association,
2013) for assistance. But psychopathy was omitted from
the DSM-III (American Psychiatric Association, 1980), and
this trend has continued to the present day.1 Consequently,
an alternative diagnostic tradition has developed based
on a widely accepted and psychometrically validated
tool, the Psychopathy Checklist–Revised (PCL-R; Hare,
2003). The PCL-R was originally designed with two correlated factors—interpersonal-affective and antisocial—
that were later divided again into two facets each. As
Figure 1 shows, the four resulting components describe
Corresponding Author:
Devon L. L. Polaschek, School of Psychology, Victoria University of
Wellington, P.O. Box 600, Wellington 6140, New Zealand
E-mail: [email protected]
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Criminals With Psychopathy
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Psychopathy Checklist–Revised (PCL-R)
100
Factor 1: Interpersonal-Affective Scale
80
Recidivism (%)
Facet 1: Interpersonal
Facet 2: Affective
Factor 2: Antisocial Scale
Facet 3: Lifestyle
Facet 4: Antisocial
Psychopathic Personality Inventory–Revised (PPI-R)
PPI-I: Fearless Dominance
60
56.7
48
40
34.5
23.1
20
0
Low
PPI-II: Self-Centered Impulsivity
ModerateLow
ModerateHigh
High
Change
Fig. 1 Factor structure of two psychopathy measures: the Psychopathy Checklist–Revised (Hare, 2003) and the Psychopathic Personality
Inventory–Revised (Lilienfeld & Widows, 2005).
interpersonal, affective, lifestyle, and antisocial aspects of
psychopathy (Hare, 2003). Although PCL-psychopathy is
a dimensional construct, cutoff scores (e.g., 30 or more
out of 40; Hare, 2003) are often used to make a dichotomous diagnosis.
Conveniently for this article, the PCL-R was developed specifically for use with adult criminals. Scores on
the PCL-R rely heavily on past criminal behavior, and as
it turns out, those scores—especially on the combined
antisocial scale—moderately predict future criminal and
violent behavior. But there are alternatives. For example,
a more recent instrument that does not require a history
of criminal behavior for completion is a self-report questionnaire known as the Psychopathic Personality
Inventory–Revised (PPI-R; Lilienfeld & Widows, 2005). It
also has two major factors, known as PPI-I (fearless
dominance) and PPI-II (impulsive antisociality; see Fig. 1).
A second important preliminary issue is to establish
whether “ordinary” adult criminals—those with little or
no psychopathy—are leopards who can change their
spots. After all, if these “ordinary” criminals cannot
change, how could their psychopathic counterparts be
expected to improve? Many people seem unaware that
psychological treatments can help rehabilitate a wide
variety of criminals, including the most persistently antisocial. In fact, a substantial body of research over the last
20 years has shown that when criminals take part in certain treatment programs, they are less likely to be reconvicted—the proxy for reoffending—than similar criminals
who do not take part. The most effective programs have
four important characteristics. They (a) provide services
only where they can have the most impact: to those most
likely to reoffend; (b) base the goals of treatment on the
Fig. 2. Violent-crime recidivism rates in a 3-year fixed follow-up among
criminals in a treatment program as a function of level of therapeutic
change. Adapted from “The Violence Risk Scale: Predictive Validity and
Linking Changes in Risk With Violent Recidivism in a Sample of HighRisk Offenders With Psychopathic Traits,” by K. Lewis, M. E. Olver, and
S. C. P. Wong, 2013, Assessment, 20, p. 157. Copyright 2013 by Sage.
Adapted with permission.
changeable correlates of reoffending, such as a criminal’s
relationships with criminal peers, “pro-crime” attitudes
and beliefs, and misuse of alcohol and drugs; (c) use
methods with good empirical support to help criminals
change (e.g., modeling of desired behavior, positive reinforcement for change); and (d) monitor therapists and
programs carefully to minimize drift away from these
core principles (Andrews & Bonta, 2010). Most of these
treatments are based on cognitive behavioral therapy
approaches and take place in groups: in prisons, hospitals, or juvenile secure institutions, and in the community
(e.g., Polaschek & Kilgour, 2013).
How do we know if these treatments work? At a time
interval after men who complete programs have been
released into the community, they are compared with a
like sample of untreated released men. One can determine if there is a treatment effect by examining whether
the proportion with new convictions is significantly
lower for treated criminals than for untreated criminals.
In a meta-analysis of 374 studies, the (weighted) mean
of this difference was about 0.12 (Andrews & Bonta,
2010), a small but important effect2—especially compared to the effect of imprisonment on reconviction,
which at best is approximately 0.00 (Cullen, Jonson, &
Nagin, 2011).
Of course, examining what happens to criminals
months or years later is an indirect method for judging
the effectiveness of an intervention. A more direct
method is to measure how men change (or do not
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Polaschek
298
change) on the factors above between the start and the
end of a treatment program. As we would hope, research
adopting this approach has shown that significantly
fewer of those who change the most are reconvicted
(e.g., Lewis, Olver, & Wong, 2013; see Fig. 2). In short,
there is little evidence that criminals really are the leopards of the clinical kingdom. Instead, these “ordinary”
criminals can benefit from certain psychological-­
treatment programs, and in fact, these types of programs
are among the few interventions that do anything to
counteract the ineffectiveness of punitive criminal-justice
sanctions (Andrews & Bonta, 2010).
We are now on solid footing to evaluate the extent to
which psychopaths are capable of change and whether
psychological treatments can help criminal psychopaths
to become less criminal, and perhaps even less
psychopathic.
Is Psychopathy Mutable?
The only constant in life is change, according to the preSocratic Greek philosopher Heraclitus. Even our personalities—which we may think of as particularly resistant
to environmental influences—change modestly during
the course of normal development and aging (e.g.,
Ferguson, 2010). Many people believe that psychopaths
cannot change, though there is almost no research
addressing this issue. One widely cited study of psychopathic criminals suggested that some aspects change
while others do not (Harpur & Hare, 1994). In this study,
although the interpersonal and affective aspects of psychopathy were unrelated to age, the lifestyle and antisocial aspects were less prominent in older than in younger
criminals. But this study was not longitudinal—that is,
the same men were not examined at different ages—so
these results may have simply reflected generational differences rather than change over the life span.
Nonetheless, a recent longitudinal study of men measured at age 17 and then again at age 24 with a different
measure of psychopathy (the PPI-R; see Fig. 1) showed
a similar overall pattern, although change was also seen
in affective and interpersonal qualities in some (Blonigen,
Hicks, Krueger, Patrick, & Iacono, 2006). Taken together,
these studies suggest that psychopathy does attenuate,
although the most distinctive personality characteristics—the affective and interpersonal qualities—may be
more resistant to spontaneous change than the lifestylerelated aspects.
Of course, clinical scientists aim to do better than simply waiting around for psychopaths to “grow out of it.” I
have already described how psychological treatments
can help rehabilitate more ordinary criminals, but can
psychological treatments help rehabilitate psychopathic
criminals?
Can Treatment Make Criminal
Psychopaths Less Criminal?
Prominent experts on psychopathy are among those who
have taken the view that no effective treatments are available for psychopaths (Cleckley, 1988; Hare, 2003; Harris
& Rice, 2007). But at least three studies with criminal
samples have examined whether psychopathy is related
to outcomes in programs designed to reduce recidivism,
with incarcerated youths (Caldwell, Skeem, Salekin, &
van Rybroek, 2006), with community psychiatric patients
(Skeem, Monahan, & Mulvey, 2002) and with prisoners
(Olver, Lewis, & Wong, 2013). The first two studies
showed that treated people were significantly less likely
to be reconvicted than similar untreated criminals, regardless of the severity of their psychopathy. A caveat: Both
of these studies used quasi-experimental designs. That is,
rather than randomly assigning cases to treatment or not,
researchers statistically matched treated and untreated
people retrospectively on key criteria that are themselves
predictors of reconviction (e.g., age). But although prospective experimental designs offer more rigor than
quasi-experimental designs, they are difficult to conduct
in these settings, and other research on criminals has
found surprisingly little difference between the two
designs in patterns of effects (see Hollin, 2008).
A third study showed significant treatment change
with adult psychopathic male prisoners, demonstrating
that those who made more change were less likely to be
reconvicted for violence (Olver et al., 2013). However,
the authors rated treatment change and psychopathy retrospectively from file notes, no specific data were
reported on rater reliability, and there was no comparison group. Considered together, and with these caveats,
these three studies lead to the conclusion that psychopathy per se may have no bearing on the success of treatment designed to reduce a criminal’s risk of committing
new crimes. Treated psychopaths avoid reconviction
about as often as other similar criminals and more often
than their untreated counterparts; they do indeed change,
and the amount of change they make inversely predicts
whether they will be reconvicted.
Although at first glance these findings seem like good
news, they raise another concern. Perhaps in treatment,
while other criminals avoid reconviction by learning
helpful prosocial skills, psychopaths achieve their success by more nefarious means, instead teaching themselves how to mislead people more skillfully, lie to parole
boards, get released under false pretenses, and then
evade apprehension. Although no research has targeted
this question directly, we can partially address the concern by turning to what we know about how criminals—
including those with psychopathy—use treatment to
reduce their risk of new convictions. At the heart of this
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research is the Violence Risk Scale (VRS; Wong & Gordon,
2000); in using it, a therapist identifies a criminal’s pretreatment risk factors: impulsivity, contact with criminal
peers, lack of community support, and so on. The criminal’s goal in treatment is to improve on those factors. At
the end of the program, therapists again complete the
VRS to measure the criminal’s progress. If all goes well,
the result is an empirically measured amount of positive
change unique to each criminal. The difference between
post-treatment and pre-treatment scores represents
(hopefully) the amount of reduction in risk associated
with undertaking treatment.
Research with the VRS suggests that the more psychopaths change on these important treatment goals, the less
likely they are to be convicted for new violent and sexual
crimes—exactly the same effect we would expect for
nonpsychopaths in treatment (Olver et al., 2013; Wong,
Gordon, Gu, Lewis, & Olver, 2012). On the face of it,
then, we might conclude that psychopaths tend to
respond to the treatments the way other highly risky
criminals do and make the same kinds of changes on the
same factors.
But these findings are only part of the story. To complete the picture, we might also consider whether psychopaths are harder to work with than other criminals
and less likely to make it through to the end of treatment. Indisputably, men with high PCL-R scores have
difficult personal characteristics that can make treatment
challenging. They are evasive, argumentative, hostile,
resistant to change, less committed and compliant, and
less likely to finish treatment—whether because they
leave prematurely or because therapists terminate their
treatment early (Polaschek & Daly, 2013). Naturally, therapists notice their difficult behavior, rating such clients
as less motivated and less malleable (e.g., Hobson,
Shine, & Roberts, 2000). But studies of other highrisk offenders—identified using tools unrelated to
—have revealed that many of them also
psychopathy­
behave badly. So, rather than concluding that psychopathy leads to difficult behavior in therapy, it may simply
be that high-risk criminals in general behave that way.
These high-risk criminals are in turn the highest priority
for treatment, so dealing with poor behavior may just be
part of the fabric of working therapeutically with these
criminals, psychopathic or not.
Is There a Risk That Psychopaths Will
Use Treatment for Antisocial Ends?
Perhaps the evidence thus far has been intriguing, raising
the possibility that good psychological treatment programs can help both ordinary criminals and psychopathic
criminals. But are psychopaths not consummate liars
who charm and manipulate others? If so, then surely they
can manipulate therapists, using treatment as a means of
learning new ways to wreak havoc with ordinary people.
Therapists and others have shared these concerns (Harris
& Rice, 2007).
Indeed, anxiety about psychopathic nefariousness
blossomed from the results of the infamous Canadian
“Oak Ridge study” (Harris, Rice, & Cormier, 1994), whose
investigators used the PCL-R retrospectively to examine
the outcomes of a radically innovative 1960s hospital
program. By modern standards, this treatment program—
involuntarily attended by mentally disordered Canadians,
including people with psychopathy—would be considered unethical and probably harmful. Much of the time,
patients mingled freely, with little staff oversight. They
were sometimes forced to spend days together naked in
“encounter bubbles” with wall-mounted feeding tubes.
Patients received various psychoactive substances—
including alcohol, methedrine, and LSD—to help break
through psychic defenses.
The researchers examined the criminal records of
those people who had been released from the program,
comparing the proportion who had new convictions with
that of a group of untreated prisoners whose PCL-R
scores were equivalent. A much greater percentage of
psychopathic patients were convicted of new violent
crimes compared with psychopathic prisoners: 78% versus 55%. This pattern was seen only in convictions for
violent crimes, and only for psychopaths; convictions for
nonviolent crime did not differ between the two groups,
and among those who had been convicted, patients and
prisoners with low PCL-R scores did not differ from each
other on either type of new crime (Rice, Harris, &
Cormier, 1992).
Does the pattern of apparently increased post-­treatment
violence fit with the idea that psychopaths had learned in
treatment how to better manipulate and exploit people?
Rice et al. (1992) proposed this explanation. But although
no published evidence supports or refutes it, the explanation seems unlikely for two reasons. First, if these psychopaths had developed excellent skills in manipulating
others, they should have been less prone to adopt a
crude method of manipulation such as violence in favor
of something more sophisticated. They should also have
been more capable of avoiding both capture and conviction. After all, fewer than 10% of violent offences ever
result in conviction, so there is plenty of scope for avoiding detection (Farrington, 2007). But that is not what the
Oak Ridge researchers found. Instead, they found that
psychopaths were more likely to have been convicted for
violence. Second, there is a more plausible alternative
possibility: The Oak Ridge program’s regime of punishment increased psychopaths’ propensity for violence. In
fact, other Oak Ridge data fit with this possibility:
Regardless of whether patients were psychopathic, time
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spent being punished for “noncompliant behavior” in
treatment was correlated with later convictions for violent crimes. Unsurprisingly, psychopaths were more difficult patients; they were punished more, spent more
time locked in bare cells on their own, and received
more potentially harmful drugs (Rice et al., 1992).
Remember, patients could not leave this program of their
own accord; their experiences may simply have made
them more angry and hostile—potential risk factors for
new violence.
Thankfully, the Oak Ridge treatment program is a far
cry from programs of today. Its results have sometimes
been used to deny psychopaths treatment on the grounds
that trying to treat them risks more harm than good. But
although people fear that psychopaths’ personal characteristics may enable them to use what they learn in treatment to better exploit others, there is no compelling
evidence for this concern.
Conclusions
Psychopaths have sometimes been excluded from criminal-justice interventions because of beliefs about psychopathy’s immutability and their untreatability. A small
and recent research literature suggests that populist
ideas about psychopaths and their treatability largely
lack substance—findings that should open the way for a
revitalization of research on psychopathy, treatment, and
change. This revitalization is sorely needed. The research
reported in this article primarily limited the notion of
psychopathy to “what the PCL-R measures,” reflecting
the dominance of the PCL-R as both a measurement tool
and a model of psychopathy in criminal populations. A
much more interesting future for treatment research lies
in breaking away from this tradition, which hides the
surprising degree of disagreement and confusion within
the scientific community about what psychopathy is, and
is not.
Just as important, it is not yet clear whether treatments
that reduce the risk of criminal behavior in those with
and without psychopathy have any effect on psychopathic characteristics themselves: Does treatment improve
behavior but leave core interpersonal and affective features largely intact?
Finally, research on children and adolescents has
been excluded from this article, but the indications from
that field are that (a) the diagnosis of psychopathy is
even more controversial in children (Salekin & Lynam,
2010) and (b) early findings hold promise that the key
personality traits—particularly callous-unemotional
traits—may respond to treatment (Hawes & Dadds,
2007). An integration of research across the life span is
needed to inform diagnosis, treatment design, and
i­nterventions if we are to further unravel the intriguing
complexity of psychopathy.
Recommended Reading
Andrews, D. A., & Bonta, J. (2010). (See References). An empirically grounded approach to the assessment and effective
treatment of criminals, in use in most Western nations.
D’Silva, K., Duggan, C., & McCarthy, L. (2004). Does treatment
really make psychopaths worse? A review of the evidence.
Journal of Personality Disorders, 18, 163–177. A review of
the treatment-response literature for psychopaths.
Harris, G. T., & Rice, M. E. (2007). (See References). An overview of the historically important Oak Ridge program that
argues for therapeutic pessimism regarding the treatment
of psychopaths.
Olver, M. E., Lewis, K., & Wong, S. C. P. (2013). (See
References). A recent empirical article linking therapeutic
changes by psychopathic violent offenders to reductions in
violent reconvictions.
Patrick, C. J. (Ed.). (2006). Handbook of psychopathy. New
York: Guilford. A comprehensive reference source on psychopathy, mainly pertaining to adults.
Polaschek, D. L. L., & Daly, T. (2013). (See References). A more
detailed review of the issues traversed in this article.
Salekin, R. T., & Lynam, D. R. (Eds.). (2010). (See References).
A comprehensive source for theory and research on psychopathy prior to adulthood
Salekin, R. T., Worley, C., & Grimes, R. D. (2010). Treatment
of psychopathy: A review and brief introduction to the
mental model approach for psychopathy. Behavioral
Sciences and the Law, 28, 235–266. A review of historical
context and recent studies of treatment in both youths
and adults.
Skeem, J. L., Polaschek, D. L. L., Patrick, C. J., & Lilienfeld, S. O.
(2011). Psychopathic personality: Bridging the gap between
scientific evidence and public policy. Psychological
Science in the Public Interest, 12, 95–162. A lengthy and
­comprehensive review of the state of scientific theory and
research on psychopathy, and the implications for policy
and practice.
Acknowledgments
My thanks to Maryanne Garry, Scott Lilienfeld, and two anonymous reviewers for their helpful comments on earlier drafts of
this manuscript.
Declaration of Conflicting Interests
The author declared no conflicts of interest with respect to the
authorship or the publication of this article.
Notes
1. Psychopathy is included as one of the specifiers for antisocial personality disorder in the alternative model for personality disorders at the end of the DSM-5. It is omitted from the
main section, “Diagnostic Criteria and Codes.” In contrast to the
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DSM-III, the DSM-I and the DSM-II also omitted psychopathy as
a diagnosis but included antisocial-personality diagnoses that
somewhat resembled psychopathy.
2. An effect size of .12 here indicates a 12% difference between
the two groups in the proportion of people reconvicted. So, for
example, if half of the untreated comparison group were reconvicted, the corresponding proportion for the treatment group
would be .38—a relative reduction of 24%.
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