When psychologists talk to someone about what psychopathy is and what it is not, many questions arise. There is one that always ends up coming out, since it is perhaps the most interesting of all. Is it possible to effectively treat these people psychologically? Some talk about treating and others talk about curing, which are very different things.
For this article we are going to talk about What do we know today about the prognosis of psychopathy? from a clinical point of view. Let us remember that science is knowledge that constantly mutates, and what we know today may not be so true tomorrow. With the warnings made, let’s see what the meta-analyses say.
Unfortunately, diagnostic manuals do not recognize psychopathy as a clinical entity. Although these labels have many detractors – and rightly so – there is something they do serve. When the criteria for a disorder appear in a clear, exhaustive and orderly manner, this allows it to be investigated. And any research group that takes these criteria as a reference will almost certainly be studying the same phenomenon.
Psychopathy does not have this reference point, so each research group may be studying different definitions of psychopathy. There have been fruitful attempts to unite definitions and understand psychopathy as a set of traits that usually occur at the same time. The most widespread is perhaps that of Hervey Cleckley, who extensively describes the clinical characteristics of the psychopath.
Robert Hare, later, identifies in these descriptions two factors main ones: using others in a selfish, emotionally cold, harsh and remorseless way and on the other hand a chronically unstable type of life, marked by the transgression of norms and socially deviant.
Naturally, research into the effectiveness of treatment in psychopathy depends largely on how we understand it. Although most research uses the best-known criteria, we must keep in mind that there is a portion of trials that may have measured psychopathy in different terms.
Is psychopathy incurable?
Any psychology student who has dealt with personality disorders has a kind of automatic mechanism that causes them to respond with a resounding “yes” when asked this question. There is a widespread belief that psychopathy is impossible to eradicate something that also occurs with antisocial personality disorder.
Indeed, personality disorders are incurable; they do not completely resolve because they are exaggerated manifestations of normal personality traits. And in the same way that personality is mutable to some extent rigid personality patterns are also permeable only to a certain extent.
It is at this point where a not entirely justified leap of faith is often made. Just because a mental disorder never goes away does not mean that it cannot respond to treatment. This is why we talk about treating, and not curing. The truth is that the evidence on the treatment of psychopathy is not so compelling.
The notion that this disorder is untreatable may have originated through the psychoanalytic current, which suggests that personality is formed during the first 5 or 6 years of development and remains practically 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 its “intractable” status. In this theory he first says that psychopaths suffer a lesion in the limbic system (located in the brain) that prevents them from inhibiting or interrupting their behavior. This also predicts that psychopaths are insensitive to punishment, that they never manage to learn that an action can have bad consequences. In a later review of this theory, Hare described psychopaths as emotionally callous with more difficulties processing the emotions of others.
Every theory remains speculation when we talk about 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 test this hypothesis.
Numerous research groups have thrown off the burden of clinical pessimism about psychopathy and conducted clinical trials to evaluate the feasibility of treatments.
Main results
Surprisingly, most articles address the problem of psychopathy from psychoanalysis. Almost everyone understands the phenomenon as Cleckley described it, except for a few essays. The cases treated through psychoanalytic therapy show a certain therapeutic success compared to the control groups. This finding points in the direction that therapies focused on insight and awareness of illness 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, others, and the world. In this way, some of the most dysfunctional characteristic features are addressed. When the therapist combines the cognitive-behavioral approach and the insight-focused approach even higher therapeutic success rates are achieved.
The use of therapeutic communities has also been tested, but their results are only slightly superior to those of the control group. This is not surprising, since 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 behaviors typical of psychopathy, in the absence of a greater number of clinical trials, is promising. Unfortunately, the methodological precariousness of the studies in this regard and the small number of articles do not allow us to draw final conclusions on this issue.
It is not necessary to fervently believe in the results of the studies to realize that psychopathy is far from untreatable. Although we do not 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 up in the air.
One of the fundamental problems that occurs in the treatment of psychopathy, as in other personality disorders, is that it is rare for the client to want to go to therapy. And even in the rare case that they come of their own volition, they are often resistant to change. After all, we are going to ask the patient to introduce a series of changes in his personality that are not at all easy to put into practice and threaten his own identity.
With these patients it is necessary do intense work on disease awareness and motivation for the change prior to the therapy itself. This extra effort wears out both the patient and the therapist, who often ends up abandoning or unfairly labeling the patient as untreatable. The truth is that if we cannot change a psychopath it is only because we have not yet found a way to do so.
