Dr. Robert Hare: Expert on the Psychopath

Before addressing the treatment issue, let's look at what the PCL-R indicates about risk factors for the tendency among psychopaths to continue to commit crimes and other social violations.  While Hare was writing Without Conscience, he was also developing an instrument to apply in another context.

During the early 1990s, the Research Network on Mental Health and the Law of the John D. and Catherine T. MacArthur Foundation examined the relationship between mental disorder and violent behavior directed against others.  In this Violence Risk Assessment Study, they devised a comprehensive list of 134 risk factors across four domains (dispositional, historical, contextual, and clinical) that had been associated with violence in prior research, were believed by experienced clinicians to be associated with violence, and were hypothesized to be associated with violence by existing theories of violence.  This list included factors not previously studied, such as social support, impulsiveness, anger control, and delusions.  Experts in these fields developed risk assessment instruments, and Hare was asked to develop a tool, based on the PCL-R, that would take less time and manpower to administer. 

He came up with the PCL:SV, or Screening Version, which included 12 items that provided the same factor structure as the PCL-R.  The total possible score was 24, with the cut-off score for psychopathy at 18.

 
The items were field tested and then submitted to a full-scale study involving 939 patients over 20 weeks after discharge from a civil psychiatric institute.  Researchers measured the criterion variables by using official arrest and hospital records, regular self-reports over a one-year period, and collateral reports from knowledgeable informants.  By the end of the study, the PCL:SV proved to be the most reliable instrument for predicting the future risk of violence.  Those with a score of 13 and higher were about three times more likely to have an episode of violence than were patients with lower scores. 

Furthermore, in a study in England of 268 prisoners, those with high PCL-R scores were found to be twice as likely to commit another crime as those with low scores, and the crime was 14 times more likely to be violent.  In prison, those with a high score were three times more likely to assault staff or other prisoners.

If the PCL-R and PCL:SV are such good predictors, can they also offer hope of making a change in the violence rate?

Hare believes that developing a good treatment plan is a new frontier of studying the psychopath.  Based on the fact that psychopaths do change their behaviors somewhat as they get older, there could be a way to devise an intervention to enact these changes at an earlier stage.

To this point, the received wisdom on the subject is that psychopaths not only do not improve with treatment, but they may actually get worse.  In treatment, they learn better ways to manipulate the system to their advantage and to play "head games" with the clinicians.

"Administrators actually took it to mean that not only are they not treatable," Hare comments, "but if they're going to be worse, let's do everybody the service of not treating them."

He interprets these results in another way.  "The problem is that the traditional programs are not designed for the psychopath.  They're designed for the average offender.  If you go to your doctor, and no matter what your illness or complaints, he gives you the same pill, you change doctors or you may die.  The criminal justice system takes the approach that one therapy will work for all offenders, but we take the position that one treatment doesn't fit all."

While he has no outcome data yet from programs specifically designed for psychopaths, this is a new arena for researchers.  Hare and his colleague, Dr. Steven Wong, Correctional Service of Canada, believe there's hope.

"We take the view that under the right circumstances, it's possible to modify the antisocial behaviors of anybody, although for psychopaths the task will be more difficult than for other offenders.  Our philosophy, based on a lot of data, is that we are not going to target some of the core psychopathic features, such as lack of capacity for empathy, grandiosity, egocentricity, or shallow emotions.  We think these features are fairly stable.  But we're going to target features of psychopathy that may be modifiable or changeable.  We have a clue to what these might be."

In fact, the research has already begun in England.  "They have adapted some of our treatment ideas and they have a number of programs ready to start in England.  One of the things we're looking for is some treatment-related change in attitudes and behavior. But how do we measure this?  The PCL-R is a static instrument based on lifetime functioning so you can't use it as a pre/post measure of treatment.  So what can you do?"

One idea is to get a consensus from professionals about what they believe can be modified in a psychopath. 

"We look at the twenty items in the PCL-R and their scores as a function of the age at which offenders were assessed.  And what we find, quite dramatically, is that across the age span from adolescence to 50 or 55 there are no appreciable changes in the interpersonal and affective characteristics of psychopathy, like egocentricity and lack of empathy.  We also find that socially deviant behaviors, such as impulsivity, the need for stimulation, and irresponsibility, actually do decrease with age.  So we have about seven or eight PCL-R features of psychopathy that are capable of changing with age.  There may be biological bases for these changes.  For example, as testosterone levels go down with age, aggressiveness may also decrease.  We can take features that change with age and use interventions to speed up the process.  We know we're not going to instill in psychopaths a sense of empathy or a strengthened conscience, but we can probably work with characteristics related to their antisocial behavior, such as impulsivity, stimulation-seeking, and irresponsibility."

In addition, Hare believes, intervention can appeal to their self-interest and make use of the best available cognitive-behavior programs. Yet this requires their active participation. "You say to them, 'Most people think with their hearts, not with their heads and your problem is you think too much with your head.  So let's change the problem into an asset.'  They understand that.  They say, 'Oh, yeah.  I'm too rational.  Like Spock on Star Trek.'"

In any event, Hare and his colleagues are not about to give up just because nothing has worked thus far. 

"If they seem to be untreatable, I say we haven't yet found and tried the appropriate treatment.  When I was growing up polio was untreatable.  Because nothing worked, we said it was untreatable.  But suddenly somebody found something that worked.  We think that with psychopaths, we should at least be able to reduce their propensity for grossly antisocial behavior."

To this end, he and Stephen Wong have developed soon-to-be-published guidelines for the institutional treatment of violent psychopathic offenders.