Rehab for psychopaths

Nudity, mind-altering drugs and encounter groups bring out the worst in psychopaths behind bars. That’s not a pitch for a new reality television show — not yet, at least. It’s an evidence-based conclusion. An infamous experimental treatment program for violent criminals, conducted mainly from 1968 to 1978 in a Canadian maximum security psychiatric facility 90 miles north of Toronto, tried those tactics to prepare men for life on the outside. Offenders with psychopathic personalities graduated from the program more violent than ever.

The results of that study played a big part in stoking fears, still common today, that psychopaths exploit psychological treatments to become better criminals. Mounting evidence indicates, however, that better-designed prison programs can help criminals with psychopathic personalities live less violently once released, says psychologist Devon Polaschek of Victoria University of Wellington in New Zealand.

In the Canadian study, prisoners participated in a “therapeutic community.” Men developed their own rules and sanctions for misbehavior with little supervision. Rule breakers were confronted and challenged by their peers in prisoner-led therapy sessions. Those who adapted well to the system sat on committees that meted out penalties to others for bad behavior. Staff sometimes forced prisoners to spend days together naked in a room with wall-mounted feeding tubes. Men received alcohol, LSD and other drugs to help break down their psychological defenses during group encounter sessions. At the time, the study was considered a bold attempt to rehabilitate previously untreatable criminals.

It failed. Ten years or more after release from the facility, 78 percent of psychopaths who were tracked after graduating from the program had been arrested for further violent offenses , versus 55 percent of their untreated counterparts. Nonpsychopathic criminals did not become more violent after completing the unorthodox prison program.

Treatment backfired among psychopathic prisoners for good reason. Psychopaths in prison tend to get far more belligerent and aggressive when criticized or punished than nonpsychopathic criminals do, Polaschek says. Often glib and charming on the surface but callous and uncaring underneath, criminal psychopaths dig in their heels when harshly disciplined.

Unsurprisingly, psychopaths placed in the Canadian program broke far more than their share of community rules. The men — almost all guilty of violent crimes — got increasingly hostile as punishments piled up. A regular diet of harsh penalties made already violent psychopaths even more dangerous.

Current treatment programs for prisoners are nothing like the Canadian experiment. And the reasons go beyond a tightening of ethical standards. Treatments being tested today attempt to help prisoners readjust personal goals and control anger. This approach works best with nonpsychopathic criminals, but psychopaths appear to benefit as well. Simple computer programs show early promise in helping psychopathic prisoners, specifically, to see beyond their immediate needs and become more aware of those around them.

“Although criminals with psychopathy are among the hardest to work with, psychological treatment causes them, like other high-risk criminals, to reoffend less,” Polaschek says. 

Personality check

Modern notions of psychopathy have been heavily influenced by psychiatrist Hervey Cleckley. In 1976, he characterized psychopaths as masking a shallow and irresponsible nature with a confident demeanor. They could sometimes become violent or predatory.

Cleckley saw no hope for the psychotherapy of his time changing psychopaths’ attitudes or behaviors. That conviction remains popular today, along with misconceptions of psycho­paths as evil, homicidal villains akin to Charles Manson or fiction’s cunning Hannibal Lecter (SN Online: 1/14/14).

Psychopathy is not an official psychiatric diagnosis, largely due to a lack of consensus on how to define this personality pattern in the general population. Clinicians today emphasize that people with psychopathic personalities can be fearless, impulsive, emotionally shallow, charmingly manipulative, hot-headed and cold-hearted. Psychologist Mark Olver of the University of Saskatchewan in Saskatoon and his colleagues use a 20-item checklist to determine which offenders have psycho­pathic personalities that create special problems for prison staff and treatment providers. The checklist, developed by psychologist Robert Hare of the University of British Columbia in Vancouver, covers four general areas (see table below).

Hare has estimated that psychopathic personalities characterize about 1 percent of the general population, with roughly equal prevalence in men and women. Research on psychopaths in and out of prison has focused almost exclusively on men.

“Psychopaths are not one type of person,” Olver says. “Some are scheming and nonviolent, for instance, and others have emotional deficits and can be violent.”

Olver splits violent psychopathic criminals into two broad groups: One group is callous, deceitful and emotionally shallow; the other is highly anxious and impulsive, his team reported in May in the Journal of Abnormal Psychology. With therapy that targets certain group-specific characteristics, both display comparable reductions in reoffending after treatment, he says. Olver’s team found that rates of new violent crimes following release drop by 30 percent or more among psychopathic offenders who complete intensive, therapist-led group programs.

Psychopathic criminals receive the same treatment as other violent prisoners do, with adjustments based on individual needs. In what is known as cognitive-behavioral treatment, therapist-led groups work on ways to control anger and meet needs, such as feeling in control, without breaking the law.

If a particularly belligerent prisoner decides in group therapy, for example, to try calming down with a few deep breaths when frustrations arise during the day, prison staff may support his efforts. Physicians, cafeteria workers and others who cross paths with the man will give him time to collect himself during interactions. Staff members then report back to the therapist on what happened. Gradual behavior improvement may lead to a part-time job in the prison, providing more practice at dealing with others and handling frustrations.

Treatment is also provided, as needed, for alcoholism, drug addiction, depression and other mental ailments that can accompany psychopathy.

Therapists need patience, skill and a thick skin to work with psychopathic prisoners, Olver says. Having typically grown up as victims of various types of abuse, many psycho­pathic criminals arrogantly and deftly manipulate others without remorse, in his experience. These are not men who view psychological treatment favorably or form warm relationships with a therapist, Olver says. The goal is for each man to live peaceably among others and stay out of prison. That’s success, even if many psychopathic offenders remain abrasive and emotionally distant after completing treatment.

“It’s not illegal to be an asshole,” Olver says. “It’s illegal to beat people up and steal from them.”

Olver’s team tracked data on new offenses committed five to 10 years after release from prison by violent and sexual offenders in three previously published Canadian studies of cognitive-behavioral treatments.

Group treatments lasted an average of eight to nine months. In the largest study, 29 percent of 321 sex offenders had psycho­pathic personalities. Nearly three-quarters of those men completed treatment. An average of 10 years after being released from prison, roughly 60 percent of treatment completers had been arrested for violent crimes, versus 92 percent of men who didn’t finish treatment. The disparity in rearrest rates specifically for sex crimes was smaller: 42 percent for treatment completers versus 50 percent for the others.

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In all three studies, rates of reoffending progressively dropped among psychopathic men who showed the most improvement during treatment, Olver and his colleagues reported in the December 2012 International Journal of Forensic Mental Health. In one investigation, only 23 percent of men who responded well to treatment got arrested for further violent offenses, versus 57 percent of those who took poorly to treatment but completed it. Improvement during treatment was measured via observed behavior changes, such as a drop in explosive reactions when dealing with prison staff.

In a more than seven-year follow-up of 32 treated and 32 untreated violent, psychopathic offenders, treated men spent an average of 2.4 fewer years in prison for new offenses than untreated men. By Olver’s calculations, that reduction in prison time would save more than $233,000 for each offender.

Reading context

Achieving the gold standard of treatment research — assigning psychopathic offenders at random to different programs or to no treatment — is nearly impossible. Yale University psychologist Arielle Baskin-Sommers and her colleagues have come close, though. They assigned psychopathic criminals to one of two computer-training courses to refocus the men’s attention. One course may help deter future lawbreaking, Baskin-Sommers’ team reported in the January Clinical Psychological Science.

Their approach is built on research led by psychologist and study coauthor Joseph Newman of the University of Wisconsin–Madison, who found that prisoners with psychopathy focus only on their own goals and ignore situational contexts. While working on simple memory or judgment tasks, for example, psychopathic criminals are not startled by sudden noises and they don’t notice when images on the computer screen are mislabeled. That form of myopic, goal-oriented attention translates into, say, ignoring one’s own nervousness while conning people out of their life’s savings.

Baskin-Sommers’ group randomly assigned 56 psychopathic inmates in Wisconsin to one of two computer-training programs. In one, participants learned to notice the context of experimental situations. For instance, the men viewed a series of mug shots and had to press a key on the right when the pictured person’s eyes looked right and a key on the left when his eyes looked left. But when faces showed predesignated emotions, such as fear, the men had to switch their responses: If eyes looked right, push the left key; eyes left, push the right key. In the other training regimen, inmates practiced self-control, such as holding their breath despite discomfort and refraining from pressing computer keys in a game until after hearing a sound played through loudspeakers.

Inmates completed weekly one-hour training sessions over six consecutive weeks. By the program’s end, the men doing context training got substantially better at those tasks. And they scored higher than before training on attention and emotional control tasks.

No such improvement occurred among psychopathic offenders who completed the self-control program. The researchers suspect that psychopaths’ root problem is more about overfocusing on their immediate aims and ignoring consequences than overreacting to frustrations.

Baskin-Sommers’ group plans to track study participants for the remainder of their sentences and after release from prison to see if context training leads to declines in criminal behavior.

“I suspect context training makes psychopathic offenders more receptive to other interventions,” Baskin-Sommers says. Group treatments, such as those studied by Olver, might work even better with men trained to be clued into their surroundings. It’s worth investigating, she suggests, and might reduce initial resistance to treatment programs.

Even if context training helps psychopathic offenders become less crime-prone, that doesn’t confirm Baskin-Sommers’ claim that myopic attention is a core part of their personalities and criminal behavior, remarks psychologist Scott Lilienfeld of Emory University in Atlanta.

Psychopaths display weak or no stress responses while awaiting fearful noises or disturbing images that they know are coming, Lilienfeld says. That type of anticipation typically sets off anxiety alarms in nonpsychopathic volunteers.

“The reason psychopaths don’t attend to fear-provoking stimuli may simply be that they are not especially afraid of them in the first place,” he suggests.

Even so, he says, if Baskin-Sommers’ program lessens violence among psychopathic men released from prison, it won’t matter whether context-blindness is a cause or a symptom of their problem.

Avoiding trouble

It’s an open question whether context training on its own will make prisoners more law-abiding after release or more responsive to cognitive-behavioral treatments in prison. Further studies may support other types of computer training for psychopathic offenders, such as programs designed to improve recognition of emotional expressions on other people’s faces.

Researchers also know virtually nothing about how some psychopathic ex-cons stay out of prison, even without psychological treatment. A small study of such men conducted more than a decade ago begs for a larger follow-up.

As part of his 2003 doctoral thesis, New Zealand psychologist Nick Wilson interviewed 14 psychopathic men who had avoided prison time for five years after serving sentences for murder, sex offenses and other serious crimes. Many of the men had moved to rural spots, far from illegal temptations and hard-scrabble buddies. Most were unemployed but had wives or girlfriends who worked and discouraged alcohol and drug binges. Ex-cons continued to think about committing serious infractions and two admitted having manipulated younger men into carrying out crimes.

But a desire to escape the indignities of prison kept psychopathic offenders from directly acting on their worst thoughts, concluded Wilson, now at the Department of Corrections in Hamilton, New Zealand.

Olver recalls treating a psychopathic offender who fit that bill. A big, burly man, he frequently threatened to hurt others and gave in to urges to peep into strangers’ windows and seek sex with underage girls. The man developed some strategies for controlling his impulses in treatment and got a job after leaving prison. Despite those achievements, he confided to Olver that he still couldn’t bring himself to care about what happened to other people.

But knowing what it would be like to grow old alone and behind bars provided a reality check, Olver says. “He just wanted to avoid coming back to prison.”