Definitii Tratament Psihopatie

UNDERSTANDING THE CRIMINAL MIND:
PSYCHOANALYTIC PERSPECTIVES REGARDING THE
ETIOLOGY AND TREATMENT OF MALE VIOLENT PSYCHOPATHS
A Clinical Dissertation
Presented to the Faculty of
The California School of Professional Psychology
San Francisco Bay Campus
ALLIANT INTERNATIONAL UNIVERSITY
In Partial Fulfillment
Of the Requirements of the Degree
Doctor of Psychology
By
Louis D. Monaco, M.S.
January 2004
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UNDERSTANDING THE CRIMINAL MIND:
PSYCHOANALYTIC PERSPECTIVES REGARDING THE
ETIOLOGY AND TREATMENT OF VIOLENT PSYCHOPATHS
This clinical dissertation by Louis D. Monaco, M.S., has been approved by the
committee members signed below who recommend that it be accepted by the
faculty of the California School of Professional Psychology San Francisco Bay
Campus In partial fulfillment of requirements for the degree of
DOCTOR OF PSYCHOLOGY
Clinical Dissertation Committee:
Christopher D. Tori, Ph.D.

Chairperson
Murray Btfmes, Ph.D.
Date
ii
Copyright by Louis D. Monaco, M.S., 2004
All Rights Reserved
iii
DEDICATION
To my family, I thank you for shaping me into who I am today. For showing me
that I could achieve whatever I put my mind to and for your love and support
throughout the years.
To Nicole Fisherman, Tiffany Brown, Jane Dube, Kathleen Anne Elizabeth Ellard
Harding, John Macneil, Gail Inwin, Cindy O'Connor, Sara Kendall, Kirsten
Halbrook, Shelley Curnow, Andrea Shelley, and Rana DeGil: My friends with
whom I have shared my ups and downs and who have supported, helped, loved,
cried, and laughed with me.
To all the incredibly thorough, mindful, and clinical experts in the field of
psychopathy who paved the way for my efforts to achieve the completion of this
dissertation.
I thank all of my professors and clinical supervisors at San Francisco State
University and the California School of Psychology because it is they who and
made it possible for me to be myself, to be able to achieve all that I have, and the
possibility to achieve all that I aspire to.
iv
ACKNOWLEDGMENTS
To Dr. Christopher Tori for his support, advice, good humor, and patience. From
him, I have learned a great deal about writing, research, and presenting clinical
material.
To Dr. Murray Bilmes for assisting me with the psychoanalytical theory portion of
this study, and for helping me to create a better dissertation.
To Dr. Margaret Singer for sharing her extensive experiences working with
psychopaths, and for agreeing to be a part of my dissertation committee. This
dissertation is dedicated to her memory.
To Dr. Carl Norris for his many editorial suggestions and for calmly guiding me
through the final phases of the dissertation and defense process.
Special thanks to the staff of Jail Psychiatric Services for their assistance.
Special thanks to the interns and staff at Manhattan Psychiatric Center and Kirby
Forensic Psychiatric Center for their expertise and support in this endeavor.
TABLE OF CONTENTS
Page
Dedication............................................................................................................. iii
Acknowledgments.................................................................................................. v
List of Tables............................................................................................................ vi
I. Statement of the Problem.................................................................................... 1
II. Psychopathy: A Brief History.............................................................................. 16
III. Assessment and Diagnosis: Antisocial Personality Disorder

Vs. Psychopathy...........................................................................................34
IV. Psychoanalytic Theories about Psychopathy............................................... 52
V. Biological Contributions to Psychopathy...........................................................89
VI. Treatment of Psychopathy.................................................................................97
VII. Conclusion.......................................................................................................... 119
References................................................................................................................155
vi
LIST OF TABLES
Page
1. Hares ChildhoodSigns of Psychopathic Behavior......................................12
2. Brief History of How Psychopathy has been Understood.......................... 17
3. Kraeplins Psychopathic Categories.............................................................. 28
4. Cleckleys Psychopathic Categories............................................................... 30
5. Hare Psychopathy Checklist-R Factor Items and Descriptions...................49
6. Childhood Experiences of Psychopaths......................................................... 63
7. Meloys Defensive Structuring of the Psychopath......................................... 76
8. Kernbergs Classification of Personality Disorders

in which Antisocial Features are Prominent...................................................... 81
9. Kernbergs Antisocial Personality Disorder Symptoms............................... 82
10. Meloys Psychopathic Personality Organization........................................ 85
11. Martens Biological, Psychological, and Social Determinants of

Psychopathy................................................................................................ 95
12. Strasburgers Countertransference Responses in Working with

Psychopaths................................................................................................ 109
13. Meta-analysis Results for Psychopathy Intervention Studies....................115
14. Millon and Davis Ten Types of Psychopaths.............................................. 138
15. Psychopharmacological Treatments.............................................................142
vii
1
Chapter I
Statement of the Problem
Why has this man done these terrible things? Because he is a

psychopath. And how do you know that he is a psychopath?
Because he has done these terrible things (Ellard, 1988, p. 387).
Psychopathy was the first personality disorder identified and described
by psychiatry, and the term was initially used to refer to those personalities
that were extreme variants of what was considered normal (Millon, Simonsen,
Birket-Smith, & Roger, 1998). Historically, there has been extensive debate
regarding the causes, essential features, and diagnostic criteria that identify
psychopathy (Void, Bernard, & Snipes, 1998). The confusion surrounding this
mental condition has been exacerbated by the use of terms with complicated
and contradictory implications to describe the personality organization and
behavioral characteristics of those who behave impulsively, violently, and
without remorse. The terms psychopath, sociopath, or psychopathic inferior
have been used often interchangeably in the psychiatric literature for some
time. The fluidity of this nomenclature and the shifting emphasis between the
moral, religious, and behavioral aspects of the disorder demonstrates the
complexity of the historical evolution of this construct.
Regarding the label itself, the diagnostic criteria and classification of
psychopathy has been, and remains to a large degree, uncertain. Today,
there is confusion about the relationship between the D S M -IV Antisocial
Personality Disorder diagnosis and the construct of psychopathy as first
2
defined in 1941 by Cleckley (Table 4) and later researched and quantitatively
measured by Hare (Arrigo & Shipley, 2001).
There have been many empirical studies, particularly over the past
decade, that have attempted to describe the range and severity of the
societal problems caused by the psychopaths behavior. For example,
Woodworth and Porter (2002) found that 15% - 25% of the federal offender
population is at high risk for recidivism and violence when they are identified
as psychopathic. Given the scope of this problem (i.e., more than 2 million
prisoners in the United States), it is surprising that an understanding of
psychopathic cognitive and affective functioning is so limited (Editorial, 2003).
This integrative literature review explores the development of the mind of the
violent psychopath from a psychoanalytic perspective. It examines the
interactions of biological, cognitive, social, and object relational factors that
seemingly result in violent psychopathic behaviors. I will begin by describing
an actual case of violent psychopathic behavior in order to illustrate the
frightening mystery of this problem.
Case Examples
To exemplify the dynamics of a psychopath, I selected the case of
Richard Kuklinski who was the son of a violent, emotionally absent, alcoholic
father. His mother, also quite violent, vented her resentment on her children.
Richard quickly learned to emulate violent behavior and, as a child, he
admitted to having tied two cats together and thrown them over a
clothesline in order to observe them mangling each other. He also kicked
dogs off roofs and tied them to the backs of buses. When asked during the
televised HBO interview (2002) what this made him feel, he replied,
excitement... but it wasnt much of a challenge.
Kuklinski had been living in New Jersey with his family (his wife
Barbara, two daughters and a son) but, unlike his own father, he spent much
of his free time with his wife and children. He frequently gave his family
spontaneous vacations, expensive jewelry, and new cars. Apparently, the
cost was not an issue. Anthony Bruno (1993) in The Iceman, (a biography
written with Kuklinski's full cooperation), noted that Kuklinski first killed
someone in 1949, when he was fourteen years old. Reportedly, Kuklinski
was protecting his territory against a bully and fatally beat his adversary,
which filled him with a sense of power. He now perceived himself as
someone special, and developed into a controlling man who did not tolerate
defiance or disrespect.
In a televised documentary on HBO (Ginsberg, 2002), Kuklinski
described his first premeditated murder as an adult. In Jersey City, New
Jersey, he had used a car bomb triggered by gasoline to kill a man. As he
walked away from the exploding car, he felt only cold satisfaction. He
detached himself from his victims, a style that he claims developed from
having to detach himself from the abuse his drunken father inflicted on him as
a boy. According to Kuklinski, no one would ever treat [me] with disrespect,
and he wanted them to know that the last thing they ever saw was me.
4
Outside of his home Kuklinski was known as The Iceman, a
professional hit man. Bruno (1993) wrote that Kuklinski earned this name
because he had kept one of his victims in a freezer for over two years, out of
curiosity, in an attempt to see if he could disguise the victims actual time of
death. In nearly four decades of his brutal, cold-blooded killings, (and a body
count of over one hundred), the authorities were unable to capture Kuklinski.
He was finally apprehended by the undercover operations of the Bureau of
Alcohol, Tobacco, and Firearms and the New Jersey Attorney General's
Office. By the time of his trial in 1988, at age 53, he had reportedly killed
more than 100 men by shooting, stabbing, choking or poisoning them (Bruno,
1993). Kuklinski is currently incarcerated in Trenton State Prison and will not
be eligible for parole until he is 111 years old. The question for psychologists
is: Why did he become a man who could kill without remorse, guilt, or
hesitation?
This case example illustrates what is generally considered to be
severe, violent psychopathic behavior. To society this is someone who is
frightening and deranged, who represents the worst qualities of human nature
(Turvey, 1999). Although dramatic and frightening, Kuklinskis case is just
one example of violent psychopathic behavior. Other high-profile serial killers
have also been the center of clinical attention, and serve as continuing
reminders of the need to develop a better understanding the etiology of this
disorder.
5
Another example is John Wayne Gacy who worked as a clown, an
occupation that gave him access to young boys. Gacy lured his victims to
secluded places, and then typically, handcuffed, beat, raped, and recited
bible verses to them before eventually strangling them. Gacy was highly
organized in his killing, planning out each murder in detail. When he was
finally caught, the police found 30 bodies buried underneath his house
(Retrieved October 6, 2001 from http://www.mavhem.net/Crime/serial.html).
The case of Jeffrey Dahmer, who murdered 17 gay, African American
men, received worldwide attention. After meeting his victims at gay bars, he
brought them to his home, ostensibly for sex, then drugged, killed, and
sometimes ate them (Norris, 1992). It is reported that he attempted to make a
zombie out of one of his victims by lobotomizing him with a drill and pouring
acid into the drill holes (Schwartz, 1992). When Dahmer was finally
apprehended, the police found three decomposing bodies in 55-gallon acid
vats (Tithecott, 1997). They also found four severed heads, seven skulls,
several skeletons, and a penis (Jaeger & Balousek, 1991).
Another infamous case was Ted Bundy. Bundy was, by all accounts,
an attractive, intelligent, and charming man (Michaud, Aynesworth, & Bundy,
2000). He was also one of the most prolific serial killers of recent times.
Bundy killed at least 22 young women in several states by using his charm
and handsome appearance to attract women on college campuses and in
shopping malls. At times, Bundy would put his arm in a sling to generate
sympathy in order to lure his victims into his car before killing them.
6
Cousins Kenneth Bianchi and Angelo Buono are known collectively as
the "Hillside Strangler." Bianchi and Buono impersonated police officers,
arrested prostitutes, and then raped and killed them (Newton, 2000). The
pair left their victims corpses in various poses in the hills of Los Angeles.
After his arrest, Bianchi attempted to malinger by faking a multiple personality
disorder in order to evade punishment, but he was unsuccessful. Afterward,
he wrote the following statement that both asks for our pity and denies
responsibility for his crimes:
It is profound to me that I have had to experience more

confusion and mistrust and insincerity in society. If only the
right people had been wise enough to follow through with their
responsibilities, during the years of forming me into the mold of
adulthood, I wouldnt be where I am now. Theres a sadness in
misunderstanding, an emptiness like a hollow egg. The egg
which can produce life in two ways, one in creation and one in
sustenance and not realizing the potential of either (quoted in
Meloy, 1988, pp. 181).
Some Characteristics of Psychopaths
Although gender is not a primary focus of this investigation, it is
noteworthy to mention that the majority of research studies and clinical
examples investigating the psychopathic disorder have been conducted with
male subjects. However, female psychopaths also exist. For example,
Nesca, Dalby, and Baskkerville (1999) investigated the social history and
personality dynamics of a severe female psychopath, and found that her
history included early antisocial behavior, poly-substance abuse, and sexual
acting out. The authors also conducted psychodiagnostic testing, which
indicated that this woman was often quite angry, tended to be sexually
7
aggressive, and had a personality structure organized along hysterical lines.
Their results also uncovered the presence of paranoid ideation and poor
reality testing when confronted with stressful situations. The authors
concluded, however, that the patient did not suffer from impulse control
deficits or pathological narcissism.
Salekin, Trobst, and Krioukova (2001) have suggested that the
disorder presents somewhat differently in females than males. Perhaps
because of this Antisocial Personality Disorder is diagnosed five times more
often in males than in females (Meloy, 2001). The difference may be due a
lower frequency of violent behavior among females than males, and rater
errors (i.e., not expecting psychopathy among females). For the purpose of
this review, however, only the violent behavior of male psychopaths will be
examined.
Some researchers have described the psychopath as impulsive and
unorganized, while others have suggested they are, in fact, quite clever and
able to effect long-term planning. Millon (1998) concluded that this apparent
dichotomy stems from stressful and conflictual life experiences that lead to
personality organization of opposites which render individuals capable of
heinous criminal behavior while, at the same time, maintaining an external
demeanor of calm and composure. Thus, he recommended that psychopathy
be conceptualized as a continuum, with less violent behavior (e.g., white-
collar crime, bribery, and ethics violations) at one extreme, and violent,
sadistic acts at the opposite end.
8
Despite their often sadistic actions and manipulative intentions, many
violent psychopaths can present as quite personable and charming, which
makes them all the more dangerous. Violent psychopaths can be callous,
predatory, without conscience and feeling no guilt about the harm they do to
others. Turvey (1999) observed that, The real psychopath ranks as an
extremely dangerous person... Individuals of this type are often responsible
for perverse and murderous attacks on children frequently noticed in
newspapers. If true and full sadistic tendencies are combined with the
psychopaths lack of compunction, a formidable menace to others is likely to
emerge" (p. 84).
Despite the lurid and sensational nature of their actions,
psychopaths of this sort actually represent only a small percentage of
criminals, perhaps 15 to 20 percent (Hare, 1995; Pitchford 2001; Woodworth
& Porter, 2002). Those meeting the Cleckley/Hare criteria, discussed in detail
later in this review, probably account for about one percent of the
incarcerated population (Hare, 1993). Despite their relatively small number,
these individuals cause major societal problems with half of all serial rapists
suffering from psychopathy, while the recidivism rate of psychopaths is
roughly double that of other offenders (Hare, 1993).
Woodworth and Porter (2002) found that psychopaths are
responsible for more than 50 percent of the serious crimes committed and, in
addition, are responsible for the majority of violent crimes. Psychopaths also
commit twice as many aggressive acts as non-psychopaths, have higher
9
recidivism rates (Woodworth & Porter, 2002), and are more likely to repeat
past behaviors (Heinze & Paladino, 2000). For violent psychopaths, murder
is the most extreme expression of their psychopathic behavior, yet it is the
least studied and least understood aspect of the disorder (Woodworth &
Porter, 2002). The criminal justice system has responded to psychopathic
behavior with more restrictive laws and more prisons, yet there is no
consensus as to the provision of effective treatment or rehabilitation, mostly
because there are so few insights into the truly disturbed nature of the
psychopathic mind.
As violent crime continues to rise, social policy considerations are
pressing the need for effective treatment of the disorder (Meloy, 1988).
Salekin (2002) observed that ...continued problems with adult and juvenile
offending indicate that untreated offenders will continue to create serious
problems for society in both the short and long run...these problems are likely
to include violent crimes...stemming from individuals who lack important
human characteristics such as empathy and remorse (p. 80).
Law enforcement, too, is hoping that psychology may provide insights
as to the nature and development of psychopathy. Yet to date, few
meaningful strides have been made in understanding the development, and
perhaps more importantly, the treatment of juvenile delinquents or adult
psychopaths. This problem is particularly pressing because the harmful social
consequences of psychopathy begin early and are manifested throughout the
lifetime of the individual. Methvin (1997) observed that children aged 16 to 18
10
commit the majority of serious crimes in this country and that most of them
began before the age often.
A personal definition of the construct of psychopathy must be
described and applied throughout the remainder of this thesis. As with any
operational definition, some may disagree, however from my perspective,
psychopathy is a pervasive, developmental pathology characterized by
deficits in the development of the superego and object relational capacity for
attachment that is best understood as a variant of narcissistic personality
disorder with egosyntonic aggressive features.
Understanding the Mind of the Psychopath
Because developmental theories suggest there may be a genetic
predisposition to psychopathy, early intervention is important in order to
reduce the costs to society (Salekin, 2002). Early intervention, however,
requires early detection. Hare (1993) identified some characteristics of the
psychopathic disorder that are first detectable in childhood. These are
characterized as transgressions from what is considered normal
development. Early warning signs that appear to mark the onset of the
disorder are shown in Table 1. Another view is presented in the Diagnostic
and Statistical Manual of Mental Disorders-IV (DSM-IV) which requires
evidence of a conduct disorder before age 15, which is defined as:
A repetitive and persistent pattern of behavior in which the basic

rights of others or societal norms or rules are violated, as
manifest by the presence of three or more of the following
criteria in the past 12 months, with at least one criterion present
in the past six months (DSM-IV, pg 00).
11
The criteria are: (a) often bullies, threatens, or intimidates others; (b) often
initiates physical fights; (c) has used a weapon that can cause serious
physical harm to others; (d) has been physically cruel to people; (e) has been
physically cruel to animals; (f) has stolen while confronting a victim (e.g.,
mugging, purse snatching, extortion, armed robbery); (g) has forced someone
into sexual activity; (h) has deliberately engaged in fire setting with the
intention of causing serious damage; (i) has deliberately destroyed others'
property (other than by fire setting); 0) has broken into someone else's house,
building, or car; (k) often lies to obtain goods or favors or to avoid obligations;
(I) has stolen items of nontrivial value without confronting a victim; (m) often
stays out at night despite parental prohibitions, beginning before age 13
years; (n) has run away from home overnight at least twice while living in
parental or parental surrogate home; and (o) is often truant from school,
beginning before age 13 years.
Despite the long history of the psychopathic disorder, the etiology of
psychopathy has eluded social scientists. The primary focus of researchers
and clinicians has been on identifying and describing the characteristics of
the disorder. During the past few decades, for example, the Federal Bureau
of Investigations (FBI) Behavioral Sciences Unit has methodically studied
psychopaths and their motivation for killing, and this has helped scientists
make substantial gains in identifying and characterizing psychopathy
(Anderson, 1994). The FBI has developed extensive training and literature on
how to "profile" (using crime scene evidence) the serial killers psychological
Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.
12
motivations for violence. According to Douglas (1996), profiling may be
defined as a technique for identifying the major personality and behavioral
characteristics of an individual based upon an analysis of the crimes he or
she has committed (p. 405). While profiling has been effective in helping to
apprehend criminals, it sheds little light on the etiological determinants of
psychopathy, and even less focused on the treatment of the disorder or how
to prevent it. Treatment and prevention remain the more difficult problems (J.
E. Douglas, 1996).
Table 1
Hares Childhood Signs of Psychopathic Behavior___________________________

1. Repetitive, casual, and seemingly thoughtless lying.
2. Indifference to, or inability to understand the feelings, expectations, or pain of
others.
3. Defiance of parents, teachers, and rules.
4. Continually in trouble and unresponsive to reprimands and threats of
punishment.
5. Petty theft from other children and parents.
6. Persistent aggression, bullying, and fighting.
7. A record of unremitting truancy, staying out late, and absences from home.
8. A pattern of hurting or killing animals.
9. Early experimentation with sex.
10.Vandalism and fire setting.____________________________________________
Note. From Without Conscience: The Disturbing World of the Psychopaths Among
Us (p. 158), by Robert Hare, 1993, New York: The Guildford Press.
Traditionally, the psychopath has been deemed incurable and
development of effective treatment models based on scientific findings has
been severely lacking (Arrigo & Shipley, 2001; Cleckley, 1988; Hare, 1993;
Millon et al., 1998; Rabin, 1979; Strasburger, 2001). Hare (1995) noted that
most interventions have been behaviorally oriented and of limited success. In
fact, there is some evidence to suggest that current treatment methods may
be no better than if the individual had no treatment at all. Cognitive behavioral
13
programs and other modes of treatment typically found in jails and prisons
are primarily designed for patients that can identify a problem behavior and,
with help, curtail it. Since most psychopaths have no regard for societal
values and do not view their behavior as problematic, these behavioral
interventions are rendered ineffective.
Hare (1995) further stated that psychopaths were almost four times
more likely to commit violent crimes after release from an intensive
therapeutic community program than were other patients, including
psychopaths who were left untreated. "They had learned enough psychiatric
and psychological jargon to convince therapists, counselors, and parole
boards that they were making remarkable progress, but they used that
knowledge only to develop new rationalizations for their behavior and better
ways to manipulate and deceive" (p. 2). When incarcerated, psychopaths
also display more violent and aggressive behaviors (Ogloff, Wong, &
Greenwood, 1990), are frequently segregated (McCord, 1982), and are more
likely to violate orders of conditional release (Wong, 1984).
The existing interventions are limited by the lack of a cogent
understanding of the psychological complexity of the psychopath including
the constellation of factors that contribute to the development of the disorder.
It is imperative to gain a better phenomenological understanding of the
psychopaths thought process and affective life which has been largely
ignored by professionals because of its frightening and disturbing content.
Along with this, better theoretical models are needed to elucidate the
14
behavior, intrapsychic process, and intrinsic motivation involved in
psychopathy. To accomplish this, psychoanalytic theory presents itself as a
likely candidate to provide a comprehensive explanation of the motivating
forces that guide psychopathic behavior. Although Freud did not specifically
study psychopaths, psychoanalysts such as Cleckley (1988), Reich
(1925/1972), and Kernberg (1975) have made valuable contributions
regarding the origins and treatment of psychopathy.
This psychodynamic understanding may need to be supplemented by
neurobiological research. More recently, Meloy (1988) hypothesized that
there may be a psychobiological predisposition to the psychopathic disorder,
with deficient and conflictual primary object experiences that determine its
phenotypic expression (p. 6). The current psychoanalytic perspective is
increasingly open to the evidence that neuroscience presents. Research in
this area has already led to the identification of brain functions that affect
certain cognitive and affective processes in psychopaths. While some
evidence for a genetic etiology of psychopathy has been postulated, this area
of study remains in its infancy. Nevertheless, it is possible for dynamically
oriented formulations to incorporate these findings into the existing theoretical
understanding of the psychopathic personality structure.
Despite this complexity, it is the responsibility of psychologists to seek
an understanding of the disordered mind of the psychopath with the hope that
effective talking and pharmacological treatments as well as preventive
measures will one day be developed. Although promising research has
15
provided some hope of identifying individuals with this disorder, the search
continues for the underlying psychological processes supporting frightening
antisocial conduct.
In this dissertation, I will attempt to provide a psychoanalytical
perspective of the etiology of psychopathy by first presenting an integrative
summary of the historical development of the diagnosis. From there, I will
examine the psychoanalytic literature concerning the development of a
psychopathic personality structure. Then I will review current research
concerning the biological and environmental influences of psychopathy.
Finally, I will discuss treatment recommendations from an analytic
perspective.
It is hoped this analysis will contribute to clinical practice by providing
social scientists, mental health practitioners, and law enforcement officials
with a better understanding of the mind of the psychopath. This literature
review may also have heuristic value by stimulating the development of
theoretical thinking that may result in improved practice and innovative
research.
16
Chapter II
Psychopathy: A Brief History
For many centuries, philosophers have described the personalities of
people displaying unique patterns of behavior generally regarded as breaking
social mores of their time. Theophrastus described what he called The
Unscrupulous Man:
The Unscrupulous Man will go and borrow more money from a

creditor he has never paid...When marketing he reminds the
butcher of some service he has rendered him and, standing
near the scales, throws in some meat, if he can, and a soup-
bone. If he succeeds, so much the better; if not, he will snatch
a piece of tripe and go off laughing (quoted in Millon et al.,
1998, p. 3).
The term psychopath and its meaning have been through quite a
number of formulations. The concept has been marked by much clinical
debate and shifting foci (e.g., on the individuals morality, volitional control,
and deterministic personality traits) as time has passed, and a great deal of
confusion still exists regarding the diagnostic criteria of and treatment
recommendations for the psychopathic disorder.
Changes in the Understanding of Psychopathy and its Causes over Time
In order to show how the understanding of the construct of
psychopathy has evolved, I will present a chronology of the changing
dimensions of psychopathy and a brief description of the unique contributions
of those individuals who were instrumental in developing these
understandings. Arrigo and Shipley (2001) categorized the fluid construct of
17
psychopathy by tabulating the evolving philosophical and scientific viewpoints
of social condemnation and treatment prognosis as in Table 2 below.
Table 2
Brief History of How of Psychopathy has been Understood Part I

Date Theorist Nomenclature Description Social
Prognosis
Condemnation
1801 Pinel Manie sans Insanity without Morally neutral Moral
delire delirium treatment;
no bleeding
1812 Rush Moral Total perversion Enter social Tx preferred

alienation of of moral faculties condemnation in medical
the mind settings
1835 Prichard Moral insanity Deplorable defect Social No volitional

in personality castigation control;
intensifies should be
legal
defense
1891 Koch Psychopathic Strictly congenital Attempts to Depends on

inferiority personality types shed social the type;
condemnation chronic or
temporary
1897 Maudsley Moral Criminal class Criminal class Useless to

imbecility affected by status punish
cerebral deficits those that
cannot
control their
behavior
1904 Krafft- Morally Savages in Severe Without

Ebing depraved society condemnation prospect of
success -
asylums
indefinitely
1915 Kraepelin Psychopathic Most Moral Poor

personalities vicious/wicked; judgment/
born criminals, social
liars... condemnation
18
Brief History of How of Psychopathy has been Understood Part II

Date Theorist Nomenclature Description Social Prognosis
Condemnation
1941 Cleckley Psychopath Detached/ Pejorative Poor
Narcissistic
interpersonal style
1952 APAS Sociopathic More social Pejorative Poor

DSM personality perspective;
disturbance; Cleckleys
antisocial/disso features and
cial sociopath some criminal
behaviors
1968 DSM -II ASPD Still focused on Pejorative Poor

the personality
traits
1980 D S M -III ASPD Chronic violation Pejorative; Typically

of social norms includes most poor, but
offenders symptoms
diminish
with age
1985 Hares Psychopathy 2 factor model; Pejorative Poor; can

PCL/ reliable and valid become
PCL-R worse with
treatment
1994 DSM- IV ASPD Focused on Pejorative Poor, but

behavioral criteria equated with symptoms
criminal diminish
with
treatment
Note\ From The Confusion Over Psychopathy (I): Historical
Considerations, by B. Arrigo and S. Shipley, 2001, International Journal of
Offender Therapy and Comparative Criminology, 45(3), pp. 325 - 344.
I will present a brief literature review describing the development of this
diagnostic category, starting with its inception in the early 19th century,
continuing through the contemporary contributions to the literature in this
area.
19
19th Century Contributions to the Understanding of Psychopathy
Most writers on the topic of psychopathy credit French physician
Philippe Pinel as the first to scientifically study these individuals over 200
years ago. He coined the term manie sans delire, meaning madness without
confusion or insanity without delirium, to describe patients who presented
with impulsivity and violent behaviors yet were otherwise lucid with intact
reasoning abilities (Arrigo & Shipley, 2001; Hare, 1996; Lykken, 1995; Millon
& Davis, 1998; Rabin, 1979). Pinel (1801/1962) stated I was not a little
surprised to find many maniacs who at no period gave evidence of any lesion
of understanding, but who were under the dominion of instinctive and abstract
fury, as if the faculties of affect alone had sustained injury (p. 9).
Prior to Pinels observations, mental illness was believed to be an
impairment in the functioning of the brain, and insanity was considered to be
a loss of reason and intellect (Millon et al., 1998), but Pinel argued that one
could act impulsively, i.e., exhibit violent behavior, and cause harm to self
and others without the classic symptoms of mental illness. Further, he
insisted that these people knew full well that they were behaving irrationally.
It is worth noting that Pinel, for the first time, linked these individuals to
persons suffering from traditional mental disorders since both seemed unable
to control their symptoms (Muntz, 1998).
Over time, clinicians worldwide began to treat and describe patients
similar to those described by Pinel. In 1812, the American psychiatrist
Benjamin Rush (a signer of the Declaration of Independence) stated that
20
psychopaths had an innate, preternatural moral depravity...There is probably
an original defective organization in those parts of the body which are
preoccupied by the moral faculties of the mind (Toch, 1998, p. 112). While
Pinels description of this disorder was more affect-based, Rush believed
there was an underlying genetic, inherited etiology for the condition of
psychopathy to which the environment contributed situational factors that
favored or decreased the chance of its expression (Arrigo & Shipley, 2001).
Rush is also credited with being the first to turn psychopathy into something
socially condemnable (Arrigo & Shipley, 2001; Millon et al., 1998). He wrote:
The will might be deranged even in many instances of persons

of sound understandings...the will becoming the involuntary
vehicle of vicious actions through the instrumentality of the
passions. Persons thus diseased cannot speak the truth upon
any subject...their falsehoods are seldom calculated to injure
anybody but themselves (quoted in Millon et al., 1998, p. 4).
In 1835, British physician J.C. Pritchard spoke of moral insanity
(Lykken, 1995), and believed that psychopathic personalities were a form of
mental derangement (Rabin, 1979). He became the major spokesperson of
the view that there was a significant defect in the personalities of persons
with this condition that deserved social condemnation. According to Millon et
al. (1998), Pritchard also broadened the scope of the original syndrome by
including under the label moral insanity a wide range of previously diverse
mental and emotional conditions (p. 5). Pritchard described the
symptomology of psychopaths as follows:
There is a form of mental derangement in which the intellectual

functions appear to have sustained little or no injury, while the
disorder is manifested principally or alone in the state of the
21
feelings, temper or habits. In cases of this nature the moral or

active principles of the mind are strangely perverted or
depraved, the power of self-government is lost or greatly
impaired, and the individual is found to be incapable, not of
talking or reasoning...but conducting himself with decency and
propriety in the business of life (quoted in Millon et al., 1998, p.
6)
In addition, Pritchard believed that psychopathy was a disease, and
that despite their intellectual ability to understand their behavior, psychopaths
were overpowered by affections forcing them to behave in ways
unacceptable to society. Pritchards description of the symptoms and the
disorder accentuates the clear lack of impairment in intellect or reasoning,
and in particular, the absence of psychotic symptoms such as hallucinations
or delusions (Arrigo & Shipley, 2001; Millon et al., 1998).
Maudsley felt that punishment for psychopaths was not warranted
because they could not control their behavior, and further, incarceration
would not rehabilitate individuals suffering from the disorder (Toch, 1979).
Instead, he cited cerebral deficits as the root of psychopathy, and believed
there was a specific cerebral center underlying natural moral feelings
(Millon et al., 1998, p. 7). He wrote as evidence:
When we find young children, long before they can possibly

know what vice and crime means, addicted to extreme vice, or
committing great crimes, with an instinctive facility, and as if
from an inherent proneness to criminal actions...and when
experience proves that punishment has no reformatory effect
upon them - that they cannot reform - it is made evident that
moral imbecility is a fact, and that punishment is not the fittest
treatment of it (quoted in Toch, 1988, p.147).
Often overlooked in the historical reviews of psychopathy, Lombroso
developed a typology of born criminals, insane criminals, and criminaloids
22
(Arrigo & Shipley, 2001). In 1889, he described the criminaloid as individuals
whose mental and emotional makeup was such that under certain
circumstances they indulge(d) in vicious and criminal behavior (quoted in
Void, Bernard, & Snipes, 1998, p. 34). Lombroso proposed the notion that
someone could be a born delinquent, and added to the literature the idea
that there were certain physical characteristics that distinguish these people.
According to Lombroso, the psychopaths tendency toward criminality was
somehow linked to an innate return to pre-historic functioning. He stated,
constitutionally disposed criminal types displayed a notably large and
projective lower jaw, outstretched ears, retreating forehead, left-handed ness,
robust physique, precocious sexual development, tactile insensibility,
muscular agility, and so on... (quoted in Millon et al., 1988, p. 7).
Koch (1891) replaced moral insanity with the phrase psychopathic
inferiority, which characterized those who seemed to behave abnormally due
to biological factors, but who were not psychotic or insane (Ellard, 1988;
Lykken, 1995; McCord & McCord, 1964; Rabin, 1979). Koch described the
condition by noting that all mental irregularities, whether congenital or
acquired, that influence a man in his personal life and cause him, even in the
most favorable cases, to seem not fully in possession of normal mental
capacity. They always remain psychopathic, in that they are caused by
organic states and changes which are beyond the limits of physiological
normality (quoted in Millon et al., 1988, p. 8). Further, Koch divided the
psychopathic inferiority into three categories: (a) psychopathic disposition,
23
which was characterized by sensitivity and tension; (b) psychic inferiority or
psychopathic taint, which manifested as impulsive anger and egocentricities;
and (c) psychopathic degeneration, which might be seen as borderline mental
states (Arrigo & Shipley, 2001). Despite his efforts to focus less on the moral
and social condemnation of the disorder and more on the biological causes of
abnormal behavior in psychopaths, the label itself continued to remain
pejorative (Arrigo & Shipley, 2001; Millon et al., 1998).
As the 19th century came to a close, there seemed to be a general
agreement among psychologists that there was a disorder in which patients
presented with marked impulsivity, socially deviant, and at times, violent
behavior. These persons also showed no evidence of impaired reality testing,
impaired intellectual abilities, or other deficits in functioning. What was not
clear yet was the diagnostic terminology to be used with these individuals.
Over the next century social scientists and clinicians expanded upon Pinels
initial work, hoping to understand the nature of this affliction.
20thCentury Contributions to the Understanding of Psychopathy
Adolf Meyer, convinced that American psychiatry had become
stagnant and hopeless, introduced the German psychiatric models to
American psychiatrists early in the 20th century, and was instrumental in
acquainting them with the construct of psychopathy (Werlinder, 1978). Meyer
believed that genetic predispositions played a large role in the development
of psychopathology. In 1905, he published a classification of
psychopathology in which he described the constitutional inferiority of
24
psychopaths. These individuals were considered to be neurotic, with general
defects in their constitutional make-up and development (Werlinder, 1978).
Meyers writings about the constitutional inferiority condition came to replace
what was known in America as moral insanity.
Krafft-Ebing was probably among the first to comment that
psychopaths could not be treated successfully, and that those afflicted with
the disorder should be housed permanently in asylums in order to ensure
public safety (Toch, 1998). Ellard (1988) believed that Krafft-Ebings
sentiments were the beginning of a trend to link pathology with social
deviance and further promulgated the notion that the condition of
psychopathy was untreatable. Perhaps a more noteworthy contribution, in
terms of this review, is that Krafft-Ebing also introduced the terms sadism
and masochism into the psychological jargon, and wrote about what he
considered to be the violent psychopaths innate desire to humiliate and
hurt. Krafft-Ebing believed that this desire, considered an otherwise normal
element of male sexuality, would be heightened in psychopaths and thus
render them more likely to act upon this innate aggression (Millon et al.,
1998).
Kraepelin expanded upon the description of Kochs psychopathic
inferiority and categorized several different types of psychopathy that
essentially described the most devious, devastating, and most frequently
seen characteristics of the disorder (Arrigo & Shipley, 2001). He first
published these typologies in his landmark text Psychiatry: A Textbook for
25
Students and Physicians and, throughout subsequent editions, he solidified
the characteristics and description of the psychopath as he developed
expertise in operationalizing the disorder (Kraepelin & Quen, 1990).
In the second edition of his text, Kraepelin (1887/1904) stated The
morally insane suffer congenital defects in their ability to restrain the reckless
gratification of...immediate egotistical desires (p. 281), and suggested there
might be some personality trait that develops in these individuals. In the fifth
edition of his text (1896) Kraepelin used the term psychopathic states,
which he believed to be trademark personality characteristics that remained
relatively consistent across the lifespan of the psychopath.
Kraepelin also believed that psychopathic states were degenerative
and likened to other syndromes such as obsessions, impulsivity, and sexual
perversions. Millon et al. (1998) stated that Kraepelins categorizations
effectively shifted the focus of psychopathy to a moral, pejorative, and social
deviation that had limited response to treatment. In the 1904 edition of his
textbook, Kraepelin created and defined four categories of psychopaths (see
Table 3), and Millon et. al. (1998) and Arrigo and Shipley (2001) noted, these
categories closely reflect what is now considered as Antisocial Personality
Disorder in the contemporary nomenclature.
By the eighth edition of his text (1915), Kraepelin began to narrow the
focus of his categories to those specific characteristics that were most often
seen in the institutional setting, and used the term psychopathic personality
to describe the amoral or immoral personality types of the psychopath
26
(Lykken, 1995), and considered them to be the most harmful to society
(Arrigo & Shipley, 2001). Instead of his previous concept of four categories
(Table 3), he now conceptualized psychopathy more broadly into two
categories. The first, morbid disposition, consisted of obsessives,
impulsives, and sexual deviants (Millon et al., 1998; Arrigo & Shipley, 2001).
The second category, personality peculiarities, was expanded into seven
different subtypes: (a) excitable, (b) unstable, (c) impulsive, (d) eccentric, (e)
liars and the swindlers, (f) antisocial, and (g) quarrelsome. Of particular note,
the antisocial type Kraepelin identified was the precursor to what is now
known clinically as Antisocial Personality Disorder. He described these
individuals as:
...the enemies of society...characterized by a blunting of the

moral elements. They are often destructive and
threatening...[and] there is a lack of deep emotional reaction;
and of sympathy and affection they have little. They are apt to
have been troublesome in school, given to truancy and running
away. Early thievery is common among them and they commit
crimes of various kinds (quoted in Millon et al., 1998, p. 10).
As behaviorism began to take hold in psychology, the term sociopath,
was often used interchangeably with psychopath. This stemmed from a
desire to root the etiology of the diagnosis in social conditioning as opposed
to organic causes. Still popular today, the term is sociopath is credited to
Birnbaum (1909), who believed that antisocial behavior only rarely stems
from inherent immoral traits of character; rather it reflects most often the
operation of societal forces that make the more acceptable forms of behavior
and adaptation difficult to acquire (Millon et al., 1998, p. 11).
27
During this period, the term sociopath, was often used
interchangeably with psychopath. This stemmed from a desire to root the
etiology of the diagnosis in social conditioning as opposed to organic causes.
Still popular today, the term is sociopath is credited to Birnbaum (1909), who
believed that antisocial behavior only rarely stems from inherent immoral
traits of character; rather it reflects most often the operation of societal forces
that make the more acceptable forms of behavior and adaptation difficult to
acquire (Millon et al., 1998, p.11).
Schneider (1958) wrote about those individuals that performed criminal
acts, a behavior also evident in adolescence. He believed there were many of
these individuals who existed undetected in society or were politicians and
other powerful people. Schneider designated a particular type of
psychopathic personality as the impulsively violent type, that correlates to
the current conception of Antisocial Personality Disorder. He described those
suffering from this affliction as follows:
...personalities with a marked emotional blunting mainly but not

exclusively in relation to their fellows. Their character is a
pitiless one and they lack capacity for shame, decency,
remorse and conscience. They are ungracious, cold, surly,
and brutal in crime...The social moral code is known,
understood but not felt and therefore this personality is
indifferent to it (p. 126).
Cleckleys (1941) monumental contribution, The Mask of Sanity, hailed
the onset of modern concepts of psychopathy, and was a groundbreaking
work which attempted to identify observable behaviors and characteristic
actions of the psychopath (Table 4).
28
Table 3
Kraeplins Psychopathic Categories

Term Description
Morbid liars and swindlers Glib and charming, but lacking in

inner morality and a sense of
responsibility to others; they
made frequent use of aliases,
were inclined to be fraudulent
con artists, and often
accumulated heavy debts that
were invariably unpaid.
Criminals by impulse Individuals who engaged in such
crimes as arson, rape, and
kleptomania, and were driven by
an inability to control their urges;
they rarely sought material gains
for their criminal actions.
Professional criminals Were neither impulsive nor
undisciplined; in fact, they often
appeared well mannered and
socially appropriate, but were
inwardly calculating,
manipulative, and self-serving.
Morbid vagabonds Strongly disposed to wander
through life, never taking firm
root, lacking both self-confidence
and the ability to undertake adult
responsibilities.
Note: From Psychopathy: Antisocial, Criminal, and Violent Behavior, by T.
Millon, E. Simonsen, and M. Birket-Smith (Eds.), 1998. New York: The
Guilford Press.
29
For most of his career, Cleckley scrutinized the psychopathic
personality and his work remains widely accepted as a major contribution to
the field, sparking a new interest in the identification and assessment of
psychopathy (Muntz, 1998). Cleckley also recognized that the condition,
which he unsuccessfully attempted to label semantic dementia, was not
limited to those housed in jails, prisons, or mental institutions (Cleckley,
1988). Rather, there seemed to be a difference between criminal behavior
and true psychopathy. Cleckley believed that successfully psychopaths
never actually became part of the criminal justice system and were more
likely to be found as successful businessmen, politicians, or in schools, and
even seemingly normal families (Arrigo & Shipley, 2001). Cleckley
characterized noting, ...a very deep seated disorder often exists. The true
difference between them and the psychopaths who continually go to jails or
psychiatric hospitals is that they keep up a far better and more consistent
outward appearance of being normal (Cleckley, 1988, p. 198).
It is interesting to note that Cleckley also introduced the term
semantic aphasia, which he used to describe the psychopaths uncanny
ability to understand the concrete meaning of words without grasping the
affective charge they have. Muntz (1998) stated that Cleckley referred to this
phenomenon as knowing all the words to a song, but not the music (p. 14).
Cleckley analyzed and published detailed case studies of his
psychopathic patients, providing the first detailed clinical accounts combined
with a conceptual framework for psychologists to think about the
30
development, presentation, and subsequent treatment of the psychopath.
Arrigo and Shipley (2001) stated that Cleckleys work led him to the
conclusion that what might be considered normal socializing experiences
were not motivating or effectual with the psychopath (p. 334).
Table 4
Cleckleys Psychopathic Characteristics_________________________________

1. Superficial charm and good intelligence
2. Absence of delusions and other signs of irrational thinking
3. Absence of nervousness or psychoneurotic manifestations
4. Unreliability
5. Untruthfulness and insecurity
6. Lack of remorse or shame
7. Inadequately motivated antisocial behavior
8. Poor judgment and failure to learn by experience
9. Pathologic egocentricity and incapacity for love
10. General poverty in major affective reactions
11. Specific loss of insight
12. Unresponsiveness in general interpersonal relations
13. Fantastic and uninviting behavior with drink and sometimes without
14. Suicide rarely carried out
15. Sex life impersonal, trivial, poorly integrated
16. Failure to follow any life plan
Note. From The Mask of Sanity, (5tn ed.), by H. Cleckley, 1988, p. 19. New
York: The C.V. Mosby Company.
This is not quite correct, instead Cleckley explored their intrapersonal
characteristics or inferred, non-observable, processes...such as lack of
judgment, impulsivity, an inability to feel remorse or guilt, an inability to learn
from punishment, and rationalizing or blaming others for ones behavior (p.
31
334). This core belief shifted the focus away from criminal behavior and
highlighted the impact of heredity, the environment, and intrapsychic
psychological forces at work simultaneously in the psychopathic mind.
Cleckley (1988) described the psychopaths behavior quite eloquently:
The [psychopath] is unfamiliar with the primary facts or data

of what might be called personal values and is altogether
incapable of understanding such matters. It is impossible for
him to take even a slight interest in the tragedy or joy or the
striving of humanity as presented in serous literature or art.
He is also indifferent to all these matters in life itself. Beauty
and ugliness, except in a very superficial sense, goodness,
evil, love, horror, and humour have no actual meaning, no
power to move him. He is, furthermore, lacking in the ability
to see that others are moved. It is as though he were
colour-blind, despite his sharp intelligence, to this aspect of
human existence. It cannot be explained to him because
there is nothing in his orbit of awareness that can bridge the
gap with comparison. He can repeat the words and say
glibly that he understands, and there is no way for him to
realize that he does not understand (Cleckley, 1988, p. 90).
Rabin (1979) also noted that Cleckleys description of psychopathic
characteristics essentially described what the psychopath was not, i.e.,
specifically highlighting the notion that the psychopath was clearly not
psychotic, neurotic, or mentally retarded.
Hares Conception of Psychopaths
Robert Hare, described by Lykken (1995) as the most productive and
significant player among psychopathy researchers since 1965 (p. 166),
expanded on Cleckleys description of psychopathy. Hare (1995) defined and
described psychopaths as:
Intraspecies predators who use charm, manipulation,

intimidation, and violence to control others and to satisfy their
own selfish needs. Lacking in conscience and in feelings for
32
others, they cold-bloodedly take what they want and do as

they please, violating social norms and expectations without
the slightest sense of guilt or regret...they form a significant
portion of persistent criminals, drug dealers, spouse and child
abusers, swindlers and con men, mercenaries, corrupt
politicians, unethical lawyers, terrorists, cult leaders, black
marketers, gang members, and radical political activists (p.
27).
Hare also added that these individuals are not delusional, psychotic, or
mentally ill in the traditional sense. Rather, he believed that, unlike psychotic
individuals, psychopaths are completely rational and fully cognizant of their
behaviors, know why they were engaging in them, and are freely choosing to
do so. Hare is also credited for his development of a valid instrument to
assess psychopathy. I will present a detailed and cogent description of Hares
assessment instrument in the following chapter.
Because of Cleckleys work, the term psychopath became popular in
both clinical and public domain as an explanation for and a cause of
depraved and frequent criminal behavior (Ellard, 1988, p. 387). However,
Cleckley did not have the final word. Today, terms psychopathy and
sociopathy are often used interchangeably, though the choice of term is
often used to avoid confusion with psychoticism and insanity...and reflects
the users views on whether the determinants of the condition are
psychological, biological, and genetic on the one hand or social forces and
early experience on the other (Hare, 1993. p. 23).
Much time has passed since Pinel documented what he called the
insane, but not confused, patients, since Cleckley advanced the clinical
understanding of the psychopathic mind and clinical research built upon his
33
work. Still, the debate surrounding the etiology, clinical characteristics,
identification, and treatment of psychopathy continues in psychology.
In many ways, the construct and definition of psychopathy changed
with the mores and norms of society and, in fact, so did the field of
psychology. With the onset of the categorization of mental disorders, there
had been much discussion about the essential characteristics and features of
psychopathy. Currently, the ongoing debate among researchers, clinicians,
and other professionals is focused on what the official diagnostic criteria for
psychopathy should be for inclusion in the DSM-V.
While psychologists know more about psychopathy than ever before,
thanks largely to the clinical research discussed in the following chapter,
there is still a great deal to understand about the diagnosis, assessment, and
effective treatment of this disorder.
34
Chapter III
Assessment and Diagnosis:Antisocial Personality Disorder vs. Psychopathy
As the construct of psychopathy was evolving, the term became a
diagnostic wastebasket (Rabin, 1979. p. 323) for patients that did not
present in treatment as either neurotic or psychotic. Although general
agreement was beginning to coalesce about what characteristics
psychopaths displayed, psychologists, social scientists, and professionals
were still far from reaching consensus regarding the diagnostic criteria which
best described the disorder.
The DSM Definition of Psychopathy
In 1952, the first edition of the Diagnostic and Statistical Manual of
mental disorders (DSM) was published, and replaced what was becoming
known as psychopathy with the Sociopathic Personality Disturbance (Millon
et al., 1988; Rabin, 1979). While the new criteria did included much of
Cleckley's description of psychopathy, the prominence of the behaviorist
movement in the United States influenced the disorder to evolve into a more
behavioral concept which focused on deviant behaviors rather than internal
psychodynamics (Arrigo & Shipley, 2001; Meloy, 2001). McCord and McCord
(1964) believed this shift allowed for social and cultural considerations
contributing to the disorder to be taken into account. However, Arrigo and
Shipley (2001) explain that by focusing on deviant behaviors (p. 336) the
35
Sociopathic Personality Disturbance categorized many different types of
criminals, thus made the disorder overly broad and inclusive.
Also included in the original version of the DSM were two subtypes of
Sociopathic Personality Disturbance, labeled the antisocial and the dyssocial
sociopaths. The antisocial type was characteristic of those individuals who
are always in trouble, profiting neither from experience nor punishment...they
are frequently callous and hedonistic, showing lack of responsibility...and lack
of judgment (Rabin, 1979, p. 323). The dyssocial sociopath was described
as a "professional criminal" (Smith, 1978b), or more simply put, a member of
organized crime.
The Revised DSM-II Definition
There were not many changes made to the criteria with the publication
of the D S M -II in 1968, however the category of dyssocial sociopath was
dropped and the DSM officially began to use the term Antisocial Personality
Disorder. Smith (1978a) believed the dyssocial subtype was easily
eliminated, as it represented only illegal behaviors and had nothing to do with
the true characteristics of psychopathy.
Ongoing DSM-III and DSM lll-R Revisions
Twelve years later, the D S M -III continued to use the term Antisocial
Personality Disorder, and now described it as a ...deeply ingrained
maladaptive patterns of behavior that are perceptibly different in quality from
psychotic and neurotic symptoms. Generally these are life-long patterns,
often recognizable by the time of adolescence or earlier (Arrigo & Shipley,
36
2001, p. 337). The DSM-III diagnostic category practically eliminated the
personality traits that Cleckley (1988) described, and instead focused almost
entirely on illegal behaviors. Hare, Hart, and Harpur criticized the diagnostic
criteria as a rather radical break with clinical tradition, with clinical practice,
with earlier versions of the DSM, and excludes...such characteristics as
selfishness, egocentricity, callousness, manipulativeness, lack of empathy,
and so forth" (Hare, Hart, & Harpur, 1991, p. 392). Blackburn (1998) further
argued:
The current equation of psychopathic with antisocial

reflects a transmogrification of the meaning of the adjective
form psychologically damaged (i.e., psychopathological) to
socially damaging... and follows the moral insanity
tradition, insofar as psychological abnormality is inferred
from social deviance (p. 51).
The DSM diagnosis was originally intended to include all of the traits of
psychopaths, but Pitchford (2001) argued that because clinicians were not
thought to be able to assess personality traits competently, the DSM
definition focused instead on the antisocial and criminal behaviors that were
more easily observed and measured. This was a bias toward describing
mental illnesses in terms of their behavioral manifestations rather than the
underlying psychodynamic causes that became increasingly prevalent in later
editions of the DSM. Unfortunately, this emphasis on behavior alone blurred
the distinction between true psychopaths and criminals, and in many ways
effectively reinforced the belief that treatment with these type of offenders
would likely be ineffective (Blackburn, 1998).
37
Hare (1996) argued that this shift in the conceptualization of
psychopathy from dynamic underpinnings to observable behaviors might
have been formulated in the service of greater reliability. Since behaviors are
more easily observed and measured than personality traits, it is easier to
agree on manifest behaviors instead of their complex etiology. However, this
striving for the reliable measurement of behaviors has essentially weakened
the construct validity of psychopathy (Hare et al., 1991; Scogan, 2000).
There was, in fact, much criticism regarding the shift in diagnostic
criteria adopted in the DSM-III and DSM-III-R. For example, Kernberg (1998)
wrote:
The shortcoming of the description of the antisocial

personality disorder in DSM-III-R, where the use of
excessively concrete, behavioral criteria instead of
personality traits - psychological, intrapsychic criteria - and
the heavy emphasis on criminal behavior, all risk coming to
an improper diagnosis...The criteria are certainly broad
enough to include practically all patients with antisocial
personality disorders who present predominantly aggressive
interactional patterns and criminal behavior...In their stress
on childhood antecedents they appropriately direct the
clinician to the childhood origins of this character pathology...
Unfortunately, however, in this very stress on the criminal
aspect of antisocial behavior they include delinquents with
very different personality makeup, and blur the distinction
between sociocultural and economic determinants of
delinquency on the one hand and psychopathology of the
personality on the other, (p. 316)
A particular oversight Kernberg highlighted regarding the DSM-
lll/DSM-lll-R criteria was the exclusion of the non-aggressive variety or the
predominantly inadequate or passive type of antisocial, whom he described
38
as possessing the dominant traits of parasitic and exploitive behaviors, as
opposed to overt behaviors which are more aggressive.
Also new to the DSM-III, and the subsequent revision, was the
requirement for a history of deviant behavior, labeled Conduct Disorder,
before the age of 15 (APA, 1987). For example, some of the deviant
behaviors required for Conduct Disorder were lying, hurting animals or
people, and fighting. Lykken (1995) and others have criticized this
requirement because children might also engage in these behaviors for other
reasons, such as abuse or neglect at home, rather than some biologically
predisposed link to adult psychopathic disorder. I will address these
developmental and biological determinants later in this review.
Hare, Hart, and Harpur (1991) argued that since the criteria for
Antisocial Personality Disorder were not weighted and the frequency or
severity of symptoms was not given serious consideration in the definitional
criteria, there could be little in the way of experimental evidence to support
the validity of the criteria adequately. Further, the researchers also argued
that:
All of those who fulfill the APD criteria may be antisocial, but
they may differ greatly in their motivations for being so and
in significant interpersonal, affective, and psychopathological
features, such as the capacity for empathy, remorse, guilt,
anxiety, or loyalty. Paradoxically, the criteria for APD appear
to define a diagnostic category that is at once too broad,
encompassing criminals and antisocial persons who are
psychologically heterogeneous, and too narrow, excluding
those who have the personality structure of the psychopath
but who have not exhibited some of the specific antisocial
behaviors listed for APD. (p. 393)
39
Hares Psychopathy Checklist - Revised
In response to what Hare believed to be an unacceptable
categorization of the psychopath, he returned to Cleckleys original
psychopathic characteristics (Table 4) and began to address scientific
concerns by focusing his research on the development of more reliable ways
to identify psychopathic individuals. By doing so, Hare hoped that the
psychopathic personality could be identified and characterized more
accurately, and thus minimize the risk psychopaths pose to society.
Part of the early problems with assessing and diagnosing psychopathy
was a lack of research that was replicable and able to identify the traits and
characteristics believed to be psychopathic (Lykken, 1995). Hare ushered in
a dramatic increase in psychopathy research throughout the world (Meloy,
2001, p. 198). However, Hare did more than merely redefine the concept of
psychopathy. Through his years of empirical research, Robert Hare
developed a valid and reliable instrument to assess psychopathy (Arrigo &
Shipley, 2001). The Hare Psychopathy Checklist-Revised (PCL-R) identifies
personality traits of psychopaths based on a cluster of interpersonal and
deviant behaviors. The PCL-R is regarded in the assessment literature as the
instrument of choice for identifying psychopathy (Conoley & Impara, 1995;
Marshall & Cooke, 1999; Woodworth & Porter, 2002), and the gold standard
for operationalizing psychopathy in multiple legal and clinical contexts that
call for assessment of an individuals capacity to benefit from treatment
(Skeem, Monahan, & Mulvey, 2002). Research scientists have also praised
40
the PCL-R and generally regard psychopathy as defined by the PCL-R as the
only reliable and valid construct for research and because it can be
generalized to a variety of populations (Martens, 2000). All the items of the
PCL-R have proven to be both empirically reliable and valid in determining
the degree of psychopathy present in any given person (Meloy, 2001).
The PCL-R is a 20-item scale that employs a two-factor approach to
psychopathy, and identifies both behavioral and affective characteristics by
scores derived from a lengthy, structured clinical interview and a review of
collateral and case history information. The items as described in the PCL-R
rating manual are found in Table 5.
For each of the 20 items, a rating of 0 (definitely does not apply), 1
(applies somewhat or only in a limited sense), or 2 (definitely does apply) is
given based on how present the trait or behavior is in the individuals history
or current presentation as defined by the PCL-R manual (Gacono & Meloy,
1994; Hare, 2003; Hare et al., 1991; Woodworth & Porter, 2002).
According to Hare (Hare et al., 1991), the items consistently fall into
two factors. Factor 1 (aggressive narcissism), or the passive variant,
describes the more affective and interpersonal characteristics, that are more
indicative of the traditional psychopathic traits Cleckley proposed. Factor 1
includes items such as lack of remorse, grandiosity, lying, lack of empathy,
superficial charm, glibness, selfishness, and egocentricity. Generally, the
items loading on this factor are what many typically consider the core
psychopathic traits. The structured clinical interview, direct observation, and
41
collateral information from a review of the persons file provide the
information necessary to score the items in this factor (Westendorf, 2002).
Factor 2 (chronic antisocial behavior), or the active variant, describes
the chronic and versatile antisocial lifestyle, including delinquency as an
adolescent, substance abuse, impulsivity, parasitic lifestyle, and the other
more behavioral aspects of psychopathy. The information required to score
the items loaded on this factor will likely be obtained almost entirely from
records, since there should be extensive historical documentation of these
specific behaviors.
The PCL-R derives a score that represents the extent to which a
person is judged to match the characteristics of psychopathy (Hare et al.,
1991). The score can range from 0 to 40, with a score of the 30 or higher
indicating a severe psychopath. For research purposes, the scale can be
viewed as a continuum to define a degree of disturbance: mild (10-19),
moderate (20-29), and severe (30-40) (Meloy, 2001). Using this scale,
research has linked the severity of psychopathy with treatment failure,
violence and recidivism (Meloy, 2001; Millon et al., 1998). Interestingly,
Factor 1 scores have been found to be relatively static across the lifespan,
while Factor 2 items see a decline with age and seemingly correlate with the
Antisocial Personality Disorder (Hare, 1996). Thus, the psychopath does not
burn out as the typical Antisocial Personality Disordered criminal might.
The two-factor model has generated the most research and empirical
studies using the PCL-R, and has enhanced the assessment, management,
42
and treatment of psychopathy (Cooke & Michie, 2001). There is evidence
that Factor 2 is a robust predictor of recidivism, with both factors playing an
equally important role in predicting violent recidivism (Hemphill, Hare, &
Wong, 1998). Factor 1 has been linked with planned predatory violence,
while factor 2 is linked with impulsive violent behavior (Hart & Dempster,
1997).
The PCL-R also has predictive value and has enabled researchers to
distinguish between the behavioral patterns of psychopaths and other
criminal offenders. Individuals who obtain high scores on the PCL-R and are
classified a psychopaths will begin their criminal careers sooner than non
psychopaths, commit a wider variety of crimes, and commit offenses at a
much higher rate than non-psychopaths (Shipley, 2001). Williamson, Hare,
and Wong (1987) studied the difference in the types of victims between
psychopaths and non-psychopaths, as defined by the PCL-R, and found that
non-psychopaths were more likely to commit homicide during a domestic
dispute, while psychopaths tended to kill unknown male victims. In addition,
Westendorf (2002) reported that the motivation for the cold-blooded crimes of
the violent psychopath was usually revenge, or at other times occurred under
the influence of substances. Hobson (2000) stated that disruptive behavior
during treatment groups was surprisingly correlated to a higher Factor 1
score, not Factor 2 as might be expected, as well as the efficacy of treatment
response.
43
Limitations of the PLC-R
The PCL-R is not, however, without its skeptics or limitations. For
example, Salekin et. al., (2001) stated that despite over 60 years of research
of on psychopathy, including PCL-R investigations, most studies have
focused primarily on forensic patients with little emphasis on the
manifestation of psychopathy in the general public. Cooke and Michie (2001)
believed that while psychopathy as defined by the PCL-R, was a good
predictor of violent criminal behavior, failure on conditional release,
recidivism, and poor treatment response, the two-factor model developed by
Hare cold not be substantiated statistically. Instead, they proposed a 3-
factor, hierarchical model in which psychopathy is subordinate to 3 factors:
Arrogant and Deceitful Interpersonal Style, Deficient Affective Experience,
and Impulsive and Irresponsible Behavioral Style.
In response to the plethora of research using the PCL-R, and
undoubtedly the criticisms of the instrument as well, Hare (2003) released the
PCL-R Second Edition, which included normative data on both male and
female offenders, substance abusers, forensic patients, and African
Americans. In addition, it introduced four facets - two within each factor -
of psychopathy: Factor 1 was broken down into Interpersonal and Affective
facets while factor 2 was divided into Lifestyle and Antisocial facets. These
additions lend themselves to a much finer characterization of the overall
score, and are better able to capture the complexity of the disorder.
44
Despite the utility of the revised PCL-R and the research it generated
regarding the correlation of the items with various psychopathic
characteristics, the DSM-IV, like its predecessor the DSM lll-R, chose to
abandon the theoretical assumptions on which the PCL-R was based.
DSM-IV Antisocial Personality Disorder vs. Psychopathy
Mounting criticisms of the DSM-III notwithstanding, there were only
slight changes made to the Antisocial Personality Disorder made in the DSM-
IV (1994), and the essential features that defined the disorder continued to
remain focused on antisocial behavior.
Pitchford (2001) stated that DSM has blurred the distinction
between psychopaths and criminals, and of course most of the latter are not
psychopaths (P. 29). By focusing on behavioral features which were easier
to determine than motivations, the characteristic which so clearly defined the
psychopath was removed as a diagnostic criteria. Typically, a psychopathic
individuals motivation for being psychopathic may be quite different, and with
varying degrees of features of the disorder (Hare et al., 1991). But if
motivations are disregarded the difference in behaviors between psychopaths
and other criminal offenders is often difficult to distinguish.
Antisocial Personality Disorder is described in the DSM-IV as:
A pervasive pattern of disregard for, and violation of, the

rights of others that begins in childhood or early
adolescence and continues into adulthood...This pattern
has also been referred to as psychopathy, sociopathy, or
dyssocial personality disorder. Individuals...fail to
conform to social norms with respect to lawful behavior.
They may repeatedly perform acts that are grounds for
arrest...such as destroying property, harassing others,
45
stealing...They are frequently deceitful and manipulative

in order to gain personal profit or pleasure...They may
repeatedly lie, con others, or malinger...frequently lack
empathy and tend to be callous, cynical and
contemptuous of the rights of others (American
Psychiatric Association, 1994, p. 645).
The prevalence rate for the DSM-IV Antisocial Personality Disorder are
different than the rates of psychopaths, as identified by the Hare
Psychopathy Checklist-Revised (Arrigo & Shipley, 2001).
In the general population, approximately 5% of adult American males
will meet the criteria (Meloy, 2001). 50% - 80% of offenders and forensic
patients are diagnosed with ASPD, but only 15% - 30% of those same
individuals met the criteria for psychopathy (Arrigo & Shipley, 2001; Hare et
al., 1991; Hart & Hare, 1997). Thus, many people diagnosed with Antisocial
Personality Disorder may not be psychopathic at all (Hare, 1996; Pitchford,
2001). Psychopaths are a special population among those classified with an
ASPD. They are more likely to commit violent crime when compared with the
general population (Arrigo & Shipley, 2001; Hare, 1993; Monahan, 1998), and
are responsible for more than 50% of all serious crimes committed (Hare,
1993).
Pitchford (2001) thought that this confusion of terminology was
particularly troublesome from a research perspective, because the DSM-IV
associates Antisocial Personality Disorder with low socio-economic status,
while psychopathy did not appear to be linked to social disadvantage. Also,
the tendency to use the term Antisocial Personality Disorder interchangeably
with psychopathy in clinical discussions confused the distinction between the
46
two disorders and created diagnostic problems for clinical practitioners and
those social scientists who were studying the disorder.
Arrigo and Shipley (2001) noted that identifying a true psychopath by
means of their being given an Antisocial Personality Disorder diagnosis was
quite different from identifying them using the traditional criteria for being
psychopathic. This definitional ambiguity has consequences more far
reaching than merely a desire for greater precision in clinical terminology. The
consequences of incorrectly diagnosing someone as a psychopath, or
alternatively failing to identify someone who is a psychopath, could cause
serious errors when deciding the most appropriate course of treatment or the
decision to withhold certain types of treatment.
While there have been many criticisms of the DSM diagnostic criteria
for psychopathy, few researchers have suggested a cogent alternative. Hare,
Hart, and Harpur (Hare et al., 1991) recommended the development of a
separate diagnostic category, Psychopathic Personality Disorder, which was
based on the PCL-R criteria. Meloy (1996) recommended the inclusion of
mild, moderate, or severe psychopathy and the PCL-R score after the ASPD
diagnosis on Axis II as a way to provide better diagnostic clarification. Yet,
the most comprehensive and plausible recommendation was made by Arrigo
and Shipley (2001):
W e maintain that psychopathy should be included as a

separate personality disorder, along with specific guidelines
on how it can be assessed. Furthermore, we suggest that
ASPD function on a continuum of mild, moderate, and
severe. Mild ASPD would reflect the current understanding
of ASPD, primarily with a behavioral orientation. It could be
47
assessed by clinical interviewing and a criminal history

alone. However, if the PCL-R were given, it would indicate
a score of no more than 15. Moderate ASPD would
suggest a cluster of symptoms, including both personality
traits and behavioral symptoms as presented in both factors
1 and 2 of the PCL-R. The PCL-R score should range
between 16 and 29. Finally, a diagnosis of severe ASPD or
psychopathy would be obtained if an individual had a PCL-
R score of 30 or higher, and met the behavioral criteria
necessary for ASPD. This designation would be the most
cogent for evaluating the risk of violence to other offenders
and staff, likelihood of recidivism, and prognosis of
treatment (p. 411).
It is not clear what ramifications the current research and writings will
have on the next version of the DSM, however, support for revision of the
diagnosis becomes more widespread and is better substantiated by research
with each passing year. Despite the abundance of research, however, most
clinicians continue to define, assess, and treat psychopathy according to the
DSM-IV cookbook approach, and remain confused about what psychopathy
is and how it differs from Antisocial Personality Disorder (Arrigo & Shipley,
2001; Hare, 1996).
Review of the Historical Changes to the Psychopathy Construct
This review has provided a brief overview the development of the
construct of psychopathy from its first inception to its contemporary
interpretation. Over time the construct has undergone many changes as
societal norms, morality, religion, and research have separately and conjointly
helped to shape the evolution of psychopathy. According to Arrigo and
Shipley (2001), only two features of the psychopathy construct have
remained static over the years. First, the psychopath is not psychotic and
48
has intact reality testing. Second, sadly, the psychopath has always been
considered untreatable.
Psychoanalytic theory, possibly more than any other, has consistently
produced plausible hypotheses about the etiology of the psychopathic
disorder. The next chapter will discuss the more prominent analytic writings
on the psychopathic disorder.
Leaff (1978) considered the psychodynamics of the psychopath to be
an area in which there have been varied and differing opinions as to the
etiology, in which sociology, criminology, and psychiatry interface, and in
which the role of hereditary and organic factors must be considered (p. 79).
This occurs because of a number of factors. The differences of opinion
concerning the etiology of this disorder stem not only from the different
theoretical orientations of the clinicians who have offered causative
explanations, but also from the complexity of the illness itself. The disorder
has a large number of symptoms and behavioral manifestations which do not
fall into easily related groupings and manifest at quite different levels of
intensity depending on the severity of the pathology. This variety has caused
considerable difficulty throughout the history of the development of the
psychopathy construct. The complexity of defining this illness leads even
clinicians with the same theoretical orientation to different conclusions
regarding its etiology depend on the symptoms of behavioral manifestations
that they consider most significant. In the next chapter, I will review
49
alternative psychoanalytic theories that have attempted to explain the origins
of the severe personality disorder known as psychopathy.
Table 5
Hare Psychopathy Checklist-R Factor Items and Descriptions

Item_______________________________ Description________
Factor 1: Interpersonal/Affective
1. Glibness/Superficial Charm A glib and facile individual who exudes

an insincere and superficial sort of
charm. Often an amusing and
entertaining conversationalist, is always
ready with a quick and clever
comeback, and is able to present
himself well.
2. Grandiose senses of self-worth An individual with a grossly inflated view

of his abilities and self-worth. Often
appears self-assured, opinionated, and
cocky.
4. Pathological Lying For this person, lying and deceit are a

characteristic part of his interactions
with others. He often lies for obvious
reasons, but deceiving others also has
some value.
5. Conning/Manipulative This item is more focused on the use of

deceit and deception to cheat, defraud,
or manipulate others. They use
schemes and scams for personal gain,
with disregard for their effects on
victims.
6. Lack of remorse or guilt No concern about what affect his

actions might have had on others. In
fact, may even be so bold as to outright
state that he/she has no guilt about
what they have done, and may blame
the victim for what has happened to
them.
50
Table 5 (continued).
Characteristic Description
7. Shallow affect There is not the normal range of affect

that individuals usually display. Appears
as unemotional, or the emotions are
incongruent with actions.
8. Callous/Lack of empathy They totally disregard the rights of

others, and selfishly manipulate people
to get what they want.
9. Failure to accept responsibility Does not accept responsibility for what

They for their own actions do, and
rationalize behavior away. They may
blame the victim for their plight, but
always have an excuse for their deeds
Factor 2: Antisocial Behavior
3. Need for stimulation/ An individual that has a chronic and

proneness to boredom and excessive need for novel and
exciting stimulation, and in doing things
that are exciting, risky, or challenging.
9. Parasitic Lifestyle Avoids employment, and get what they

want from family, friends, or government
assistance. This stems from a belief that
they are supposed to have their needs
meet, no matter what.
10. Poor behavioral controls Often short-tempered, is unable to

tolerate frustration and may become
violent. Outbursts are usually short
lived, and out of proportion to the
context.
12. Early behavior problems Before the age of 12, these individuals
have already been caught lying,
stealing, setting fires, fighting, and
perhaps sexual activity.
13. Lack of realistic, long-term goals These individuals have no long-term

goals. They live day-to-day and dont
worry about the future very much.
51
Characteristic Description
14. Impulsivity They do not think about what they are

doing, and do things because they feel
like it. They do not consider the
consequences of their actions.
15. Irresponsibility Habitually fails to follow through on

word, has no loyalty to friends or family,
defaults on loans and credit obligations
and exhibits behavior that may cause
risk to others (i.e. drunk driving).
16. Juvenile Delinquency History of antisocial behavior before the

age of 18, including criminal convictions.
19. Revocation of conditional release A violation of conditional release,

incurring new charges while on
conditional release, or an escape from
an institution.
Additional Items that do not load on either factor:
11. Promiscuous sexual behavior Engages in casual, impersonal sexual

encounters, with many of these types of
relationships at the same time. In fact,
may force themselves on victims and
have a history of sexual offenses.
17. Many short-term marital relationships These individuals have many marital or
live-in relationships that have some kind
of commitment.
20. Criminal versatility Charges or convictions for a variety of

criminal offenses such as theft, fraud,
drug offenses, sexual offenses,
kidnapping, etc.
a/_!_ H i
TU-. i i_n*.ii__ _i_i: /nad ed.), by R.
1
. n . JII J \
Note. From The Hare Psychopathy Checklist - Revised, (2n
Hare, 2003. Ontario: Multi-Health Systems, Inc.
52
Chapter IV
Psychoanalytic Theories about Psychopathy
Among adult criminals, we must no doubt accept those

who commit crimes without any sense of guilt, who have
either developed no moral inhibitions or who, in their
conflict with society, consider themselves justified in
their actions (S. Freud, 1916, p. 333).
Beyond this brief statement, Sigmund Freud did not specifically
address the development of the diagnostic category now called psychopathy.
Generally, he described criminal behavior as the result of unconscious
Oedipal guilt which was relieved by projecting the guilt onto something real
and immediate, with the secondary benefit of serving as a mechanism for
punishing the self (Yochelson & Samenow, 1976). Freud (1916) further
wrote:
Analytic work then afforded the surprising conclusion that

such deeds are done precisely because they are
forbidden, and because by carrying them out the doer
enjoys a sense of mental relief. He suffered an
oppressive feeling of guilt, of which he did not know the
origin, and after he had committed a misdeed the
oppression was mitigated (p. 342)
As psychoanalysis began to coalesce in the United States during the
1920s, other theorists began to describe and publish writings from an
analytic orientation about their various experiences working with psychopathic
patients (Millon & Davis, 1998). What distinguishes these writings from those
discussed in Chapter II, is their attempt to not merely identify those with the
disorder and describe its characteristics, but instead to go beyond this in
order to understand psychopathy based on psychodynamic, biological,
developmental, the structural dynamic considerations. By providing an
53
account of the origins of psychopathy, it is hoped that insight could be gained
in the prevention and amelioration of the disorder. Futhermore,
psychoanalytic theory allows the complexity of the distorted mind of the
psychopath to be understood more fully, as there is a distinct focus the
developmental sequellae that are rooted in childhood experiences. Other
theories, such as cognitive behavioral theory, which is far too behaviorally
focused, lack the depth in which the psychopathic disorder must reach (i.e.
the unconscious, disturbed attachments, and defense mechanisms).
Early studies of the psychopathic personality centered on ego
deficiencies. Inadequate superego formation (the conscience) was seen as
the primary cause of psychopathy. Wilhelm Reich (1925/1972) believed that
the superegos functions were somehow unavailable because the ego was
over controlling, thus neither the ego nor superego could restrain powerful
impulses from the id. Door and Woodhall (1986) supported Reichs position
and believed that the earlier analytic understanding of psychopathy as a
combination of too much id combined with too little superego was superficial.
Instead, they agreed with Reich that psychopathy was a manifestation of
severe ego deficits. Blatt and Shichman (1981). They argued that the cause
of psychopathy was not an expression of superego deficit, but rather an
impairment of the development of basic ego functions. These analysts
believed that psychopaths cannot observe superego functioning (or their
conscience) because of their deficits in their ego functioning (Beliak,
Chassan, Gediman, & Hurvich, 1973).
54
The belief that the ego and not the superego was the cause of
psychopathy did not go unopposed, however. Other psychoanalytic writers
theorized that psychopathy as developed from a failure on the part of the
individual to adequately introject parental and societal norms, which resulted
in inadequate superego formation (Smith, 1978a). Otto Fenichel (1945)
focused on the deficits of the superego and, in particular, how it was unable
to control id impulses, while Friedlander (1945) thought that psychopathic
expression in youngsters was under the dominance of the pleasure principle,
unguided by an adequately developed superego (Millon et al., 1998, p. 18).
According to Rabin (1979), one of the major criteria for the diagnosis
of psychopathy is a deficit in morality which could be the result of an
inadequate superego and an insufficiently developed acquired conscience.
Specifically, the psychopath has an inability to apply the moral standards of
society to his behavior, thus he cheats, lies, and steals because he has not
incorporated the rules of society and culture. The absence of guilt and
remorse, which are normal functions in a well-developed conscience, permits
the psychopath to continue his behavior indefinitely without experiencing
painful feelings.
Do psychopaths have any superego function at all? Dalmau (1961) did
not believe that psychopaths completely lacked a superego. He insisted that
psychopaths do show some evidence of possessing a superego, although it
would seem as though the ego and the id were joining forces to overpower
the superego despite the threat of punishment. Dalmau hypothesized that
55
parental and societal introjections in the psychopath actually did occur but
were not fully integrated in their personalities. Instead, he thought these
introjects became dissociated or repressed and, through the psychopaths
intrapsychic processes, were then projected in a symbolic attack against the
parents and society via his behavior:
Whether the mechanisms of projection, denial, undoing,

dissociation and reaction formation are all
responsible...is not as relevant as the fact that the
superego is functionally detached from the personality
and projected onto society...The core of the superego is
formed by the parents and what the child believes the
parents expect. Later on society extends the role of the
parents. The functional elimination of the superego then
becomes equated with a symbolic murder of father and
mother; the persistent attack against society also carries
the same symbolism beyond the intrapsychic structure.
(p. 445)
Thus, it was not the absence of a superego, but its continued
presence that was being continually attacked by the psychopath and this
resulted in anti-social behavior which was, at root, a continuing rebellion
against early parental influences. Dalmau (1961) frequently observed that
psychopaths displayed a pattern of getting into trouble due to their criminal
behavior, which often resulted in the loss of their freedom either by
incarceration or hospitalization. He believed this was symbolic behavior that
was representative of guilt feelings:
The psychopath in his symbolic behavior follows a

regressive pattern, from a raping genital sadistic attack
against society to the anal homosexual need to feel
screwed and then back to the oral dependent position
in a hospital, jail, or conditional custody. They use
reality as a vehicle for symbolic behavior, and
56
transference conflicts are acted out in stage-like

representation (p. 446).
In other words, the psychopath was never able and ultimately did not wish to
completely vanquish the superego, but instead always wished to ultimately be
caught and punished to appease superego guilt.
Many authors have recognized the critical role of ego functions, and
subsequent superego development, but Johnson and Szurek (1952)
particularly stressed the deficits in these structures in their frequently cited
studies of antisocial adolescents. These authors observed not a generalized
weakness of the entire superego, but rather a lack of superego functions in
particular areas of behavior, which they described as superego lacunae.
Johnson and Szurek (1952) observed that the parents of these adolescents
transmitted their own poorly integrated id impulses to their children via
conscious or unconscious permissiveness or inconsistent parenting. Thus,
the childs superego lacunae developed in ways similar to the deficits in their
parents superegos. These parents superego lacunae had, in turn, been
derived from the unconscious transmissions of their own parents in an
intergenerational cascade of pathology. Leaff (1978) summarized this
phenomenon by concluding that, The concept of the superego lacunae
developed by Johnson and Szurek states that the identified patient is acting
out the unconscious impulse of the parent or parents. The neurotic needs of
the parent are met vicariously through the childs acting out. The parents
displace any self-punishment to the antisocial child through expression of
57
hostility, and the family is maintained through the scapegoating of the sick
or evil members (p. 95).
Developmental and Object Relations Pathology
Aichorn (1925/1935) studied and delinquency and published
interpretations of the origins of delinquent behaviors from a psychoanalytic
viewpoint. In particular, he stressed the importance of oedipal identifications
and their role in the development of the ego ideal.
Aichorn described conscious and unconscious

struggles which raged within a youth when his efforts at
oedipal rebellion and resolution, as well as his efforts to
hold his father as a love object, failed. Acting out
behaviors were seen as symbolic equivalents.
Delinquency was explained partly by the unconquered
pleasure principle, and also by taking into consideration
the libidinal relationships which had not been dealt with
adequately in earlier childhood. He felt that when a
child was too strictly treated or when enough bad
experiences with reality had occurred too early, he was
unable at that stage of development to make the
necessary adjustments. Regression then occurred and
the pleasure principle achieved mastery (Leaff, 1978, p.
83).
Aichorn also noted that it was unlikely for a person to be born a psychopath.
He identified external factors, such as abusive parents, inconsistent parenting
styles, or separated parents that made adequate superego formation difficult
or impossible to achieve.
Abraham (1925/1935) also referred to several environmental
conditions that could greatly impact the development of antisocial traits in
children, especially those who are deprived of early nurturing or who were
frustrated in their developmental^ appropriate demands for love:
58
Among delinquents (antisocial) we are more likely to

come across a different fate of the libido in early
childhood. It is the absence of love, comparable to
psychological undernourishment, which provides the pre
condition for the establishment of dissocial traits. An
excess of hatred and fury is generated which, first
directed against a small circle of persons, is later directed
against society as a whole (p. 304).
The Traumatic Origin of Psychopathic Impulsivity
A cornerstone trait of psychopathy with roots in ego and superego
development is the manifestation of violent impulsive and aggressive
psychopathic behavior. Shapiro (1965) described impulsive styles, which
Millon (1998) believed could be correlated with the current conceptualization
of Antisocial Personality Disorder. Shapiro wrote:
In many respects, the psychopath is the very model of the

impulsive style. He exhibits in a thorough and pervasive
way what for others is only a direction or tendency. He
acts on a whim, his aim is the quick, concrete gain, and
his interests and talents are in ways and means (Shapiro,
1965, p. 157).
Shapiros description of the impulsiveness of psychopaths was echoed by
Stone (1993) who described his observations of this quality in psychopaths in
the following manner:
Several attributes, personality traits among them, are

noted with unusual frequency in persons who murder.
Rebelliousness and aggressivity are common, as are
mendacity, entitlement, and social isolation.
Murderers are typically beset by surpluses of hatred
and impulsivity. These attributes, especially when
fueled by alcohol, conduce to ragefulness,
characterized by episodic outbursts of violent
behavior directed against others (p. 454).
59
Eissler (1949) explained the development of this malevolent impulsivity
as originating from traumatic experiences perpetrated by a childs parents.
The traumatized child then identified with these abusive parents and this
identification served as the model for an ego ideal that the child would later
attempt to emulate. Trauma during childhood development interferes with the
process of identification by heightening awareness of the aggressive aspects
of the parents behavior so that the other facets of the parents are thrown into
shadow. The power of the traumatizing experience fixates the child on the
task of emulating the abusive parent in his relationships with others. Thus,
the traumatized ego refuses to accept certain behavioral norms, and permits
the expression of id impulses without interference or punishment by the
conscience.
Early Trauma and Its Consequences
What is traumatic for a child depends both on the individual child and
he childs age. Younger children are more susceptible to trauma than older
ones who have developed better skills at communication and self-regulation.
Toddlers and infants are the most sensitive of all. Anna Freud (1949)
stressed the crucial impact of the first year of life and, in particular, the
transition from primary narcissism to object love. In cases where the mother
was absent, neglectful, emotionally unstable, or ambivalent and was unable
to provide reliable emotional support and nurturance, the shift from the
narcissistic libido to object libido resulted in improper or deficient identification
and thus, the aggressive impulses were inadequately bound.
60
Schmideberg (1949) reported clinical observations that suggested the
development of psychopathy was due, in large part, to disturbed object
relations, rather than superego deficit. She described psychopaths as
ambivalent and unstable, and suggested that the defense mechanism of
depersonalization was in important aspect of criminality. Further,
Schmideberg emphasized the role of anxiety in the antisocial activity,
suggesting that adaptation and ego functions were damaged during the
psychopaths childhood development, as were object relationships, as
evidenced by the inability to attach to caregivers.
Once these early developmental missteps had occurred, the pathology
became quickly became firmly entrenched. Dalmau (1961) argued that a
rejecting mother or overly strict father merely reinforce a pre-existing
psychopathy, and that even a psychopath brought up in a nurturing
environment would still be a psychopath because of his impaired intrapsychic
processes. The rejecting attitude of psychopaths parents is likely a
countertransference reaction to the psychopathic child:
The emotional damage in the psychopath may occur

anywhere form birth to Oedipus. It appears that the
true psychopath forms at a very early stage, which
may establish the basic destructive rage pattern
through the diffusion of the life and death instincts.
Any serious disruptive experience occurring at a
prelogical, preverbal level sets the stage for a conflict
of psychotic proportions. The child feels distress and
experiences this as an external attack that gives basis
to the paranoidal ideation and a punitive destructive
superego. The psychopath is afraid of positive
experiences; the fear of loss forces him to deny them
and to reinforce the paranoid position through defiant
provocation, hence the rejecting parents. The
61
psychopath uses parental punishment as justification

for further rage and reinforces the paranoid position
against the parents and later against all authority,
including school, society, and the law. It is invariably
the distortion of a reality situation that gives birth to
the basic feelings of rejection and rage, which then
becomes acted out and set the psychopathic pattern.
Punishment only reinforces the paranoid ideation and
nurses the hatred. The rejection by the parents is
usually well deserved on the basis of this behavior
and it should not be misinterpreted in a causal
relationship to psychopathy (p. 450).
Bender (1947) believed the psychopaths behavior was infantile and,
more specifically, pre-oedipal, pre-superego, and usually pre-narcissistic
citing evidence found in fledgling psychopaths:
There is an imitative, passive as i f quality to the

behavior of older children and adolescents. This is
because there is an inner drive to behave like a
human being. Whereas behavior in the normal child
arises from internal mechanisms, such as identification
process, object relationships, anxieties and symbolic
fantasy life, the psychopathic child has no such inner
life...It, therefore, copies the behavior of other
children, according to its maturation level and ability
(p. 75)
Similarly, Coriat (1927) described what he termed the constitutional
psychopath, who he believed was an antisocial person fixated at infantile
levels, had unresolved Oedipal conflicts, and has never learned to replace
the ego ideals of childhood with the ego ideals of society (quoted in Millon,
et. al 1988, p. 15).
The Role of Childhood Experiences on the Development of Psychopathy
Over the course of analytic investigation into the mind of the violent
psychopath, environmental factors, rather than intrapsychic deficits,
62
contributing to the development of the disorder began to receive increasing
attention. The theory that psychopathy resulted primarily from external,
environmental factors was not without controversy. Theorists who opposed
this suggested there may not be any significant environmental factors that
contribute to psychopathic personality development at all (Marshall & Cooke,
1999). Both Cleckley (1988) and Hare (1993) discounted the significance of
environmental influences by arguing that there is little evidence to support the
claim that psychopathy is the result of any social or environmental factors
(Marshall & Cooke, 1999).
The importance of environmental influences was a matter that could
only be ultimately determined by empirical evidence. As the study of
psychopathy began to be scrutinized more closely, writers such as Meloy
(1988; 2001; 2002), Lykken (1995), McCord and McCord (1956), and others
soon hypothesized that, in fact, there was an inevitable contribution of
developmental sequellae that could be present in the young psychopaths
environment (Table 6). Patterson, DeBaryshe, and Ramsey (1989)
specifically presented evidence of a developmental model of psychopathy in
which a sequence of environmental experiences, beginning early in life and
continuing into adulthood, form the foundation of psychopathy.
Leaff (1978) opined that as the child witnesses continual arguing or
domestic violence between parents, the childs own aggressive impulses
cannot be fully integrated into their emotional life and will likely be acted out
in school:
63
The home environment may present not only continual

battles between the parents but opportunity for sexual
stimulation from the parents and/or observation of
intercourse. The unmitigated aggression, already
difficult to deal with, leads to the conception of
intercourse as a violently aggressive, sadistic act which
is continued until one or both of the partners are
severely damaged...such children may be belligerent,
troublesome, always ready to fight. Their hate
relationships are most important to them, as they
represent love relationships; the hated enemy is their
unconscious representative of the sexual partner. They
may...continue to find direct expression in
characterologic and aggressive behaviors which
represent condensations of masochistic, sadistic,
scopophilic or exhibitionistic fantasies and/or fantasies
of aggressive intercourse (p. 88).
Table 6
Childhood experiences of psychopaths____________________

Author Findings
Lykken (1995) Interaction between biological

predisposition and parental
inadequacy. Inadequate or
incompetent parenting leads to
insecure attachment bonding.
Silverman (1943) Disturbed parent-child relationship is a

causal factor in psychopathy
McCord and McCord (1956) Parental conflict, neglect, and erratic

punishment are linked with subsequent
psychopathy
Cloniger, Reich, and Guze (1975) Marital separation and parental

deprivation often found in the
childhood of psychopaths
Pfiffner, L., McBurnett, K., and Families with fathers at home had
Rathouz, P. (2001) fewer paternal, maternal, and child
antisocial symptoms; antisocial
behavior more likely if the father is
absent or nonparticipating
64
Note: Taken from The Childhood Experiences of Psychopaths: A Retrospective

Study of Familial and Societal Factors by L. Marshall and D. Cooke, 1999,
International Journal of Personality Disorders, 13(3), 211 -225.
Leaff (1978) concluded that as the child witnesses continual arguing or
domestic violence between parents, the childs own aggressive impulses
cannot be fully integrated into their emotional life and will likely be acted out
in school:
The home environment may present not only continual

battles between the parents but opportunity for sexual
stimulation from the parents and/or observation of
intercourse. The unmitigated aggression, already difficult to
deal with, leads to the conception of intercourse as a
violently aggressive, sadistic act which is continued until
one or both of the partners are severely damaged...such
children may be belligerent, troublesome, always ready to
fight. Their hate relationships are most important to them,
as they represent love relationships; the hated enemy is
their unconscious representative of the sexual partner.
They may...continue to find direct expression in
characterologic and aggressive behaviors which represent
condensations of masochistic, sadistic, scopophilic or
exhibitionistic fantasies and/or fantasies of aggressive
intercourse (p. 88).
Marshall and Cooke (1999) compared childhood experiences of both
psychopaths and non-psychopaths, and found two factors to be highly
correlated with higher psychopathy scores on the PCL-R as described below:
The societal influences factor has a linear relationship,

suggesting that as the PCL-R score increases so does
the influence of societal experiences. In contrast, the
familial factor has a negative curvilinear relationship,
indicating that as the score on the PCL-R increased the
effect of the childhood variable decreases. This
suggests that low to moderate scores on the PCL-R are
strongly related to experiences within the family, while
high scores are less influenced by this factor. In other
words, the negative curvilinear effect suggests that the
biological influence may be stronger at the upper end of
the trait (p. 221).
65
These familial factors included parental discipline, antipathy, discord, neglect,
and lack of supervision; physical, sexual, or emotional abuse; scapegoating;
negative school experience, performance; or negative social experience as
likely variables contributing to the childhood experience (p. 218).
Lykken (1995) suggested the interaction between biological factors,
(such as those described in the next chapter), and inadequate parenting may
lead to the development of psychopathy. He reasoned that inadequate or
incompetent parenting leads to insecure attachment bonding that forecasts
low levels of empathy, compliance, cooperation and self-control (p. 199).
From an analytic perspective, McWilliams (1994) described the
backgrounds of psychopaths as often rife with insecurity and chaos and
wrote:
One can find virtually no consistent, loving, adequately

protective family influences. Weak, depressed, or
masochistic mothers and explosive, inconsistent, or
sadistic fathers have been linked with psychopathy, as
have alcoholism and other substance abuse in the family
origin. Patterns of moves, losses, and family breakups
are also common (p. 156).
Patterson et al. (1989) agreed that family disruption could be an
important causal factor that promoted the development of psychopathic
behaviors. They initially studied antisocial behavior in juveniles and
hypothesized that traits associated with this disorder begin early in life and
continue into adulthood. Their research described how disrupted family
processes might produce antisocial behavior in a childs early years, which
later contributed to the childs becoming involved with a deviant peer group.
66
Further, the study found evidence suggesting there are specific phenomena,
rooted in the home and social environment of the budding psychopath, that
influence the development of psychopathic personality in adolescence and
into adulthood. The factors that Patterson et al. (1989) suggested, are: (a)
basic training in the home, (b) social rejection and school failure, and (c)
deviant peer group membership. These factors, whose influence was
confirmed by other researchers, are described below.
Basic training in the home. Several studies have identified family
dynamics as a contributing external factor to early antisocial behavior. Both
Marshall and Cooke (1999) and Patterson (1989) found that families with
children who were considered antisocial could be described as having harsh
and inconsistent discipline, little parental involvement, and inadequate
monitoring and supervision of the childs activities. Additional factors were
also described by, Frodi et al., (2001) who emphasized the importance of
coercive parent-child interactions, a damaged or absent parent-child bond,
inconsistent parenting, neglect, and severe punishments as likely causes of
the development of psychopathy. Not surprisingly, Frodi also discovered that
higher scores on the PCL-R seemed to associate highly with a greater
number of convictions, more violent crime, and a higher likelihood of
childhood abuse.
Social rejection and school failure. Patterson et. al. (1989) believed
the childs behavior is likely to elicit reactions from his/her environment, which
may manifest as rejection by the childs peer group or by performing poorly in
67
academic endeavors. This was later confirmed by Marshall and Cooke
(1999) who studied both adult psychopathic and non-psychopathic individuals
and found that poor school experience in childhood was associated with
psychopathy as an adult.
Deviant peer group membership. Patterson (1989) found that poor
parental supervision and peer group rejection were correlated positively with
the childs identification with a deviant peer group, which ultimately led to
delinquent acts and substance use. The deviant peer group then supports the
antisocial behavior. In essence, this can be thought of as a positive feedback
loop that maintains and amplifies the ongoing negative process.
A Psychodynamic Understanding of Childhood Influences on Psychopaths
While an identification of the external factors contributing to the
development of psychopathy are is important, in order to appreciate why
these factors are so influential requires an understanding of the
psychodynamics and internal world of the psychopath.
The importance of early parent-child interaction and bonding has been
examined extensively by psychoanalytic theory and empirical investigations.
Marshall and Cooke (1999) credit Bowlby as being the first psychiatrist to
suggest that early separations from attachment figures, or absence of
attachment figures, would predispose a person toward the development of
emotional coldness, or the affectionless character (p. 270), which resembles
could be a precursor to psychopathy.
68
Bowlby (1944) attributed psychopathy, or what he termed the
Affectionless Character, to prolonged separation of a child from his mother.
Such a childs ability to sustain object-relationships is impaired and that child
has very limited control of his or her libidinal and aggressive impulses.
Bowlby observed that:
A child separated from his mother comes to crave both

for her love and for its accompanying symbols and this
craving, if unsatisfied, later presents itself as
stealing...the part played by aggression must not be
forgotten, for stealing not only enriches oneself, but
impoverishes and hurts others...If one has suffered great
deprivation oneself, one will feel inclined to inflict equal
suffering on someone else (p. 36).
The analytic understanding of psychopathy also offers an explanation
of how early attachment experiences influence how a psychopath manages
anxiety. In normal development, anxiety manifests in interpersonal
relationships to ensure the safety of a child when a stranger is introduced, or
during an actual or perceived separation of the maternal object (John Bowlby,
1988). For psychopaths, however, this anxiety is minimal or completely
absent (Meloy, 1988). Is this universally true?
The lack of anxiety appears in psychopaths appears to be a matter of
degree with a lower levels of anxiety corresponding to more serious forms of
the illness. Empirical research (Blackburn, 1998; Lykken, 1957; Ogloff et al.,
1990) has found that the presence of anxiety differentiates secondary
(anxious) psychopaths from primary (non-anxious) psychopaths, and is
considered a factor in children at risk for becoming psychopaths. Lynam
(1996) coined the term fledgling psychopath to describe the biological deficit
69
of the adolescent with features of callousness, lack of emotions, and the
minimal anxiety previously mentioned.
The lack of early attachment to an adequate primary caregiver
causes in the best cases an unbalanced, distorted, or conflicted ego ideal to
which the child relates only with extreme difficulty. Frodi et al., (2001) studied
24 psychopathic criminal offenders assessed with the PCL-R and found an
extensive over-representation of individuals who were dismissing of
attachment and attachment-related experiences, no secure individuals, and
an association between a higher psychopathy score and a family
constellation of a rejecting father and an emotionally very warm (idealized)
mother (p. 269).
In the worst cases, the child is left with a core of resentment that is
defended against by a reaction formation denying the value of the attachment
figure and hence temporarily reducing anxiety. Brody and Rosenfeld (2002)
described the development of psychopathy in terms of object relational
deficits, which resulted in the harboring of profound underlying psychosocial
damage including intense anxiety, anger, bitterness, and resentment (p.
408).
Bender (1947) argued that the main deficiency of the psychopath is an
inability to form relationships, identify empathically, and share in the
experiences of others. In her view, the developmental process in
psychopaths appears to be fixated at an early age (p.100). Benjamin (1993)
70
characterized the interpersonal aspects of the antisocial personality
disordered individuals noting that:
There is a pattern of inappropriate and unmodulated

desire to control others, implemented in a detached
manner. There is a strong need to be independent, to
resist being controlled by others, who are usually held in
contempt. There is a willingness to use untamed
aggression to back up the need for control or
independence. The antisocial personality usually
presents in a friendly, sociable manner, but that
friendliness is always accompanied by a baseline position
of detachment. He or she doesnt care what happens to
self or others (p. 203).
Rabin (1979) confirmed this analysis. In his work, he identified certain
characteristics he believed to be present in the psychopaths object relational
life such as emotional immaturity, egocentricity, and impulsivity, and a
stunted capacity for love and emotional involvement.
Emotional immaturity, egocentricity, and Impulsivity. According to
Rabin, the young infants are only concerned with themselves and their own
wants and needs. They are egocentric, placing themselves in the center of
their own world. Their primary goal is the satisfaction and gratification of their
desires. Should the caretaker fail to satiate these immediate wishes, the
infant may become angry and lash out at the caretaker. As children mature
they become socialized and learn to delay gratification, to consider other
feelings, and to obey societal rules. In other words, they become socio-
centric.
The psychopath grows up physically and is often well

developed and attractive in appearance. He/she also
matures as far as formal intellectual functions are
concerned, and acquires many of the perceptual, motor,
71
and cognitive skills necessary for the manipulation of the

environment. However, (s)he remains immature
emotionally and continues to be egocentric and impulsive,
being solely concerned with the immediate fulfillment of his
needs. As they can tolerate no delay or postponement and
cannot tolerate frustration when thwarted by the
environment, they remain rather childish in this respect.
As a rule, he/she proceeds to get what he wants when he
wants it, without consideration of others (Rabin, 1979, p.
327).
This characterization is similar to Shapiros (1965) description of what
he called the impulsive style. The distinctive quality of this subjective
experience revolves around an impairment of normal feelings of
deliberateness and intention. It is manifested in the nature of the experience
for these people of impulse or irresistible impulse, and of the significance of
whim in their mental lives (p 134). The psychopath does not learn or profit
from past experience because the capacity for self-control has never been
developed and he cannot inhibit his own behavior. Immediate and infantile
needs remain strong while control remains weak.
Stunted capacity for love and emotional Involvement. Rabin (1979)
referred to the affective life of the psychopath as an emotional poverty,
because of the lack of insight into the emotional state of others (and thus
ultimately themselves). Lacking an awareness of others feelings, the
psychopaths attention is directed inward rather than outward. Accordingly,
the psychopath suffers a genuine lack of empathy, and other people are
important only to the extent that they can be of use to the psychopaths own
self-gratifying ends. Generally, the psychopath is callous and insensitive other
people, and thus has no genuine intimate relationship aside from sexual
72
involvement with promiscuity as the rule and physical discharges that is very
detached from his partners.
Rabin ultimately concurred with his predecessors regarding the role of
the identification process in early personality development. According to
Rabin, the child begins this process by imitating the behavior of his parents
and by adhering to their demands which Rabin described as modeling
behavior. To the child, his parents are all-powerful. The child attempts to act
and become like them because this makes the child feel secure. The
behavioral expectations the parents try to instill in their child are usually the
standards of the community, society, and their culture. Traditionally, the child
internalizes these parental standards in order to avoid punishment and gain
the parents love and affection. As these standards become part of the childs
personality, the child learns to identify with society and humankind.
The unconscious, defensive operations, and affect. Franz Alexander
(1930b) was the first influential analyst to spend a great deal of time studying
and extensively writing about antisocial behavior. He developed the first
description of criminal behavior from a purely psychoanalytic perspective.
His publications, Psychoanalysis of the Total Personality (1930b) and The
Neurotic Character (1930a) described four levels of pathology: neurosis,
neurotic character, psychosis, and true criminality (Millon et al., 1998).
Alexander believed that one of these types, the neurotic character, was
equivalent to the psychopath because both tended to manifest their
unconscious conflicts behaviorally rather than trying to understand or
73
overcome them. Describing these types of character structures Alexander
stated:
Their conduct arises from unconscious motives which are

not directly accessible to their conscious
personality...Admonition, encouragement or punishment
coming from the environment is as useless as his own
resolution...A large proportion of such individuals, are
neurotically driven by unconscious motives, now to commit
a transgression, then to seek punishment, sooner or later
fall foul of the law...(quoted in Millon, et. al., 1988, p. 16).
In his later work, Alexander (1935) became aware of the effects that
the interplay between the environment, genetic predisposition, and
intrapsychic forces had on the development of psychopathy and set the
groundwork:
The emotional conflicts and deprivations of childhood, the

resentments of parents and siblings, find a powerful ally in
resentment against the social situation, and this combined
emotional tension seeks a realistic expression in criminal
acts and cannot be relieved by mere fantasy products that
are exhibited in neurotic symptoms...criminality in some
cases is a direct expression of protest against certain
depravations, a reaction of spite against certain members
of the family, the expression of jealously, envy, hostile
competition, all of which are strengthened by early
sufferings or the lack of love and support on the part of
adults...intense hostilities in such cases frequently create
strong guilt feelings, which in turn lead to an unconscious
need for punishment (p. 278).
In a reaction to anger at early or abusive caregivers, the psychopath is thus
torn between an aggressive emulation of them and unconscious feelings of
guilt which can manifest in a need to be caught and punished. If this is the
primary conflict of a psychopath, how is it defended against? Analytic authors
have offered several suggestions.
74
Dalmau (1961) argued that the defense of projection predominated in
the psychopath, and that the instinctual behavior of the psychopath is quite
possibly a reaction formation against a massive, repressive superego. It is
the threat of this overwhelming superego that forces the psychopath to deny
its existence and project it symbolically onto society but even then he is not
free from it.
The so-called true psychopath shows little or no

manifestation of anxiety, guilt, remorse, or other superego
feelings. If there is a breakdown in ego defenses, it is
usually a brief psychotic episode with rapid reintegration of
defenses when deprived by hospitalization or jail of its
basic opportunity for acting-out operations...the
pathological defenses are so sturdily constructed that they
present the invulnerable, unassailable ego structure (p.
443).
McWilliams (1994), on the other hand, believed the primary defensive
operations in psychopaths were omnipotent control, projective identification,
acting out, and subtle dissociative processes. Of omnipotent control
McWilliams wrote, The need to exert power takes precedence over all other
aims. It defends against shame and, especially in brutal psychopaths,
distracts others from seeing the sexual perversions that often underlie
criminality (p. 153).
One way the defense of omnipotent control manifests in psychopaths
is via their flagrant bragging about their crimes and conquests, which is an
attempt to impress others with their abilities and power. Kernberg (1984)
referred to this as malignant grandiosity. Projective identification in the
psychopath may reflect a type of developmental arrest, and an inability to
75
articulate his own thoughts and feelings thus forcing others to feel what he
himself cannot. Gacono and Meloy (1994) found similar defensive operations
such as devaluation, splitting, projective identification, and denial, and
Kernberg (1975) viewed these type of pre-oedipal defenses as part of the
borderline personality organization as well. The next to the last of the
defenses McWilliams identified, acting out, is virtually definitional of
psychopathy...they do feel anxiety, but act so fast to relieve themselves of
such a toxic feeling that the observer has no chance to see it (McWilliams,
1994, p. 155).
McWilliams (1994) also suggested that there is some type of
dissociative phenomenon that occurs in psychopaths which includes
minimizing mistakes or, in severe cases, amnesia for a particular crime. The
extent to which this occurs remains unclear however since psychopaths may
deny memory of an incident in order to manipulatively shirk responsibility for
it. Meloy (1988) saw disparities of this type as an interrelationship between
conscious choice and an unconscious defensive process in itself. For
example, there is a different internal and/or external goal sought between
conscious malingering and unconscious dissociative defenses as described
below in Table 7.
Many authors (Bender, 1947; Kernberg, 1998; Meloy, 1988) have
observed that, affectively, psychopaths function at the toddler stage, with the
only emotions available in their repartee being shame, envy, rage, frustration,
76
or excitement. Meloy (2001) termed this phenomenon as part-object
emotions, which are quickly felt and just as quickly dispelled:
Once again, what is absent is most important. The

psychopath...will not evidence the more mature feelings
that necessitate whole-object relatedness and a capacity
for attachment. These emotions include anger, guilt, fear,
depression, sympathy, empathy, remorse, gratitude,
sadness, loneliness, and reciprocal joy - a range of feeling
that is broad, deep, and complex (p. 17).
It is difficult to imagine a way of looking at the world in which these
emotions, that seem so familiar to almost everyone, are not at all present.
Without, the world of the psychopath must be very strange indeed. There
remains some question as to the purpose of the psychopaths affective and
defensive positions; on one hand, they are adaptive and on the other,
defensive. Clearly more research is needed in this area.
Table 7
Meloys Defensive Structuring of the Psychopath

Conscious choice Unconscious Description
Defense
Deception Denial Deception is intentional, goal
directed, and gives false
information used to deceive.
Denial is a primitive mechanism
used against internal and/or
external reality.
Imitation Simulation Imitation is the intentional,

conscious mimicking of another
persons attitudes or behaviors.
Simulation is a magical and
omnipotent fusion between the
self- an' object percept; as-if
personalities.
77
Object Control Projective Object control is the actual

Identification controlling of another person or
attempting to do so (usually via
projective identification).
Projective identification is a
process in which affective and
ideational components of the
individual are attributed to
another person.
Splitting Dissociation Dissociation is a defensive

process that expresses the
operation of splitting._____
Note. From The Psychopathic Mind: Origins, Dynamics, and Treatment,
1998, by J. Reid Meloy, p. 117-181. New Jersey: Jason Aronson, Inc.
Freedman, Kaplan, and Sadock (1975) underscored the interplay
between the developmental, psychodynamic, and genetic forces that
combine in the psychopath:
The evidence currently suggests that a predisposition to the

disorder is inherited. This implicates a constitutional
diatheses...in addition to biologic factors, the evidence also
points to environmental influences interacting with the
biological predisposition. The presence of certain forms of
parental deviance in the home clearly facilitates the
development of antisocial personality. Although this
influence may be partly genetic, the adoption work has
demonstrated that nongenetic parental influence is important
also (p. 1290).
Despite the many published works attempting to describe the etiology
and development of the violent psychopath from an analytic perspective, only
Meloy (1988; 2001) and Kernberg (1989) have been truly successful in both
thoroughly describing the disorder and generating a substantial following of
their theories in this area. Since their psychoanalytic paradigm is the
78
foundation of much of the current thinking on the subject, their theoretical
postulates will be described in detail, and the breadth of their contributions,
particularly those aspects rooted in psychoanalytic theory, are fundamental to
this presentation.
Kernberg
Kernberg (1975) stated that psychopathy was at the severe end of the
continuum of the narcissistic personality disorder, and referred to the
development of a malignant narcissism (Geberth & Turco, 1997) which
involved five essential features of pathology in psychopaths: (a) narcissistic
personality structure, (b) overt antisocial behavior, (c) sadistic cruelty, (d)
egosyntonic aggression, and (e) reintrojection of primitive persecutory
superego features.
Arising from a belief that there had been an overemphasis in the
psychoanalytic literature on Freuds (1916) theory of criminality stemming
from unconscious guilt, Kernberg (1989) reinterpreted psychopathic behavior
as a reaction formation against unconscious guilt rather than the expression
of deficient superego development. Kernberg, perhaps more than any other
analyst, integrated the existing analytic literature in a way that formulated a
rich, detailed theory of psychopathic personality development. Kernberg
credited Johnsons (1949) and Johnson and Szureks (1952) description of
superego lacunae as influencing his own views, and began to focus on the
structural and dynamic aspects of antisocial personalities.
79
Kernberg (1989) stated that the features of narcissistic personality
disorder are present in almost all patients diagnosed with psychopathy, plus
"a specific pathology of their internalized systems of morality (i.e. superego
functions) and a deterioration of their world of internalized object relations" (p.
315).
Kernberg also defined the predominantly aggressive aspects of the
psychopathic personality disorder from an analytic perspective:
These patients typically present a narcissistic personality

disorder. The typical symptoms of the narcissistic
personalities are in the area of pathological self-love:
excessive self reference and self-centered ness; grandiosity
and the derived characteristics of exhibitionism, an attitude
of superiority, recklessness, and overambitiousness;
overdependency on admiration; emotional
shallowness...these patients predominant symptoms are
inordinate envy (both conscious and unconscious);
devaluation of others as a defense against envy;
exploitativeness reflected in greediness, appropriation of
others ideas or property, and entitlement...the basic ego
state of these patients is characterized by a chronic sense of
emptiness, evidence of an incapacity to learn, a sense of
aloneness, stimulus hunger, and a diffuse sense of
meaningless of life. In addition, all of these patients present
some degree of superego pathology. Ordinary superego
pathology of narcissistic personalities includes the incapacity
to experience mournful, self-reflective sadness; the
presence of severe mood swings; and a predominance of
shame as contrasted to guilt in their intrapsychic regulation
of social behavior (p. 323).
Kernberg believed that psychopathy was the most severe disorder along the
continuum of narcissistic personality disorders (Table 8), since these
individuals possessed severe narcissistic features as well as an antisocial
orientation. According to Kernberg, psychopaths have a severe superego
pathology. They manifest symptoms as evidence of this which are
80
characterized by the combination of (a) a narcissistic personality disorder; (b)
antisocial behavior; (c) ego-syntonic aggression or sadism directed toward
others or toward oneself, the latter producing a perverse sense of triumph in
self-mutilation or suicide; and (d) a strong paranoid orientation (Millon et al.,
1998, p. 24). When the antisocial personality disordered individuals also
have a narcissistic personality disorder (Table 8), the more ego-syntonic
aggression, and the more the personality structure shifts from the narcissistic
into the antisocial, the more such aggressive behavior may become life-
threatening, and a subgroup of aggressive antisocial personalities may center
their criminal behavior on sexual assaults and murder (Meloy, 2002, p. 322).
Kernberg (1989) added that the most striking central feature of the disorder is
the absence of a capacity for remorse and authentic guilt feelings, and the
inability to imagine an ethical dimension in others. Even domesticated
animals sometimes seem to be exhibit manifestations of such guilt when they
transgress a known boundary.
81
Table 8
Kernbergs Classification o f Personality Disorders

in which Antisocial Features are Prominent
Disorder Description
The Antisocial Personality Disorder The Psychopath; typical

symptoms of narcissistic personality,
with severe superego pathology; no
capacity for remorse or guilt feelings
Malignant Narcissism Narcissistic, but still have the

capacity for loyalty to and concern
for others or for feeling guilty
Narcissistic Personality Disorders Antisocial behaviors, but no ego-

with Antisocial Behavior syntonic sadism or overt paranoia;
have capacity for guilt,
can plan for the future; lack of
capacity for commitment to long
term relationships
Other Severe Personality Disorders Less negative prognosis; these

with Antisocial Features are patients with borderline
personality organization and non-
pathological narcissism
Neurotic Personality Disorders Freuds criminals from an

with Antisocial Features unconscious sense of guilt;
antisocial behavior occurs with in the
context of a neurotic personality
organization; excellent prognosis
Antisocial Behavior as Part of a Symptomatic Occasional antisocial behavior

Neurosis as a symptomatic neurosis part of
adolescence or in adjustment
disorder; social environment may be
fostering antisocial behavior
Dyssocial Reaction Normal and/or neurotic adjustment

to an abnormal social environment
or subgroup.
Note: From The Narcissistic Personality Disorder and the Differential Diagnosis of Antisocial
Behavior, by O. Kernberg, 1989, In: J. Reid Meloy, (Ed.), The Mark o f Cain: Psychoanalytic
Insight and the Psychopath, 2001, p. 315-337. New Jersey: The Analytic Press.
82
Table 9
Kernbergs Antisocial Personality Disorder Symptoms

Symptom Description
Pathological Self-Love Excessive self-reference and self-

centeredness; grandiosity and the
derived characteristics of
exhibitionism, an attitude of
superiority, recklessness, and
overambitiousness; overdependency
on admiration; emotional
shallowness; and severe bouts of
insecurity alternating with a
predominant grandiosity.
Pathological Object Relations Inordinate envy (both conscious and

unconscious); devaluation of others
as a defense against envy;
exploitativeness reflected in
greediness, appropriation of others
ideas or property, and entitlement;
an incapacity to truly depend on
others in a mutual relationship; and
a remarkable lack of the capacity for
empathy with and commitment to
others.
Basic Ego State Characterized by a chronic sense of

emptiness, evidence of an
incapacity to learn, a sense of
aloneness, stimulus hunger, and a
diffuse sense of the
meaninglessness of life.
Superego Pathology The incapacity to experience

mournful, self-reflective sadness;
the presence of severe mood
swings; a predominance of shame
as contrasted to guilt in their
intrapsychic regulation of social
behavior; and a lack of an integrated
adult value system, reflected in the
persistence of childlike values.
Their self esteem depends on
physical beauty, power, wealth, and
admiration from others, in contrast
to such adult values as personal
capabilities, achievements,
responsibility, and relation to ideals.
Note: From The Narcissistic Personality Disorder and the Differential Diagnosis of
Antisocial Behavior, by O. Kernberg, 1989, In: J. Reid Meloy, (Ed.;, The M ark o f
Cain: Psychoanalytic Insight and the Psychopath, 2001, p. 315-337. New Jersey:
The Analytic Press.
83
Kernberg also theorized about the likely psychodynamic
developmental origins of psychopaths as a result of their childhood
experiences:
These patients convey past experiences of savage

aggression from their parental objects, and frequently report
violence both observed and experienced in their early
childhood. They also convey a dramatic conviction of the
impotent weakness of any good object relation: the good are
weak and unreliable by definition, and the patient shows
rage, devaluation, and contempt against those vaguely
perceived as potentially good objects. The powerful, in
contrast, are needed to survive, but are unreliable in turn;
and they are invariably sadistic. The pain experienced in
having to depend upon powerful, desperately needed but
sadistic parental objects is transformed into rage, and
expressed as rage mostly projected, thus worsening the
sadistic image of powerful bad objects who become towering
sadistic tyrants. In this world...aggression is prevalent but
unpredictable, and this unpredictability precludes even a
secure submission to the sadistic tyrant and prevents the
patient from idealizing the sadistic value system of the
aggressor. This failure to achieve any idealization of
objects...prevents the antisocial patient from attempting a
masochistic submission to a predictable although sadistic
authority. The patient is deeply and totally convinced that
only his own power itself is reliable, and the pleasure of
sadistic control the only alternative to the suffering and
destruction of the weak (quoted in Meloy, 2001, p. 333).
Meloy
Meloy (1988; 2001) is, perhaps, the leading contemporary authority on
the psychoanalytic psychology of the psychopath, and has authored many
books and articles on the subject. Meloy built upon the seminal work of
Kernberg, by proposing a psychobiological understanding of the psychopath
(i.e., how nature and nurture interact to shape each other over time), which
consists of an inability of attachment, underarousal, and minimal anxiety.
84
Like Kernberg, Meloy (1988) also believed that the psychopath suffered from
a pathological narcissism, and further distinguished the psychopathic
personality organization from the narcissistic personality, as shown in Table
8. Meloy (2001) defined the psychopathic disorder as:
A deviant developmental disturbance characterized by an

inordinate amount of instinctual aggression and the absence
of an object relational capacity to bond...psychopathy is a
process: a continuous interplay of factors and operations
that are implicitly progressing or regressing toward a
particular end point, a fundamental disidentification with
humanity...that can be understood as an aggressive
subcategory of narcissistic personality disorder (p. xvii).
Meloy cultivated significant support for the notion that there is both a
genetic predisposition to psychopathy, as well as intrapsychic factors that, in
combination, are related to the absence of empathy and sadomasochistic
qualities of the mind, emotion, and behavior.
Meloy (2001) combined these various dimensions and developed a
working definition of psychopathy from a psychobiological view that describes
the characteristics of psychopathy as:
No attachment, underarousal, and minimal anxiety

biologically anchor the foundation of the psychopath. As we
see later in adulthood, these substrates manifest in a
fearless and sensation-seeking lifestyle, one that is
unfettered by the constraints of an affectional bond,
excitability or worry, or fear of violating the rules of others (p.
8).
Meloy suggested that, from an analytic perspective, certain of the
psychological failures of the psychopath also involve biological deficits.
85
Table 10
Meloys Psychopathic Personality Organization__________________________
1. The predominance of aggressive drive derivatives and the gratification of

aggression as the only significant mode of relating to others.
2. The absence of more passive and independent modes of narcissistic
repair.
3. The presence of sadistic or cruel behavior, implying the activation of
primitive persecutory introjects, or sadistic superego precursors.
4. The presence of a malignant ego ideal with developmental roots in a cruel
and aggressive primary parental object.
5. The absence of a desire to morally justify ones behavior, which would
imply the presence of superego precursors of a more socially acceptable
ego ideal.
6. The presence of both anal-eliminative and phallic exhibitionistic libidinal
themes in the repetitive interpersonal cycles of goal conflict with others,
the intent to deceive, the carrying out of the deceptive act, and the
contemptuous delight when victory is perceived.
7. The emergence of paranoid ideation when under stress, rather than a
vulnerability to depressive affect.
Note: From The Psychopathic Mind: Origins, Dynamics, and Treatment,

1998, p. 19. New Jersey: Jason Aronson, Inc.
Specifically, these are the failures of internalization, grandiose self and
omnipotent fantasies, primitive internalized object relations, and superego
abnormalities. I will briefly consider each of these.
Failures of internalization. As previously described, the psychopathic
individual has extreme difficulties with identifications and introjections.
Identifications are behaviors that are done to model after the object, while
86
introjections are internalized aspects of the object. For psychopaths, these
internalizations are completely absent, not available when wanted, or harsh
and unpleasant...the child may come to anticipate hard, aggressive objects
and may identify with such objects for both adaptive and defensive reasons
(Meloy, 2001, p. 10). Both Meloy (2001) and Kernberg (1984) referred to this
fantasy as the predator part-object, which becomes evident in the way
psychopaths take pleasure in dominating others. McWilliams (1994) referred
to this phenomena as being under the thumb of the psychopath.
Grandiose self and omnipotent fantasy. As previously stated, a
psychopathology of narcissism is the functional and affective core of
psychopathy upon which the house of psychopath is built (Meloy, 2001, p.
12). Meloy (2001) also said that:
The grandiose self-structure, a pathological formation rather

than a developmental fixation, has three fused, or
condensed, components: a real self, the actual specialness
of the child; an ideal self, a fantasized self-concept, which
compensates for severe oral frustration, rage, and envy; and
an ideal object, a fantasized image in the childs mind of a
completely loving and accepting parent, often at odds with
the actual behavior of the real parent (p. 11).
In other words, while reality testing remains intact for psychopaths, people
are merely objects designed to gratify their sexual or aggressive impulses
and have no other purpose. Psychopaths devalue others in order to feed
their own narcissism and to satisfy this omnipotent fantasy that they will not
be abused or criticized but rather will do that to others.
Primitive internalized object relations. Meloy (1988; 2001) described
developmental themes that distinguish psychopathy from Kernbergs (1984)
87
narcissistic disturbance. Meloy believed that psychopathy should be thought
of as part of the borderline personality organization:
The developmental origins of the psychopathic personality

are characterized by a precocious separation from the
primary parent during the symbiotic phase of maturation;
failures of internalization that begin with an organismic
distrust of the sensory-perceptual environment; a
predominate, archetypal identification with the stranger self
object that is central to the conceptual self and object fusions
within the grandiose self-structure during the period of
separation-individuation; a failure of object constancy and a
primary narcissistic attachment to the grandiose self; and
states of relatedness that are aggressively and
sadomasochistically pursued with actual objects. This
coexistence of benign detachment and aggressively pursued,
sadistically toned attempts to bond is pathognomonic of the
psychopathic process (Meloy, 1988, p. 59).
Because the psychopath is organized at the borderline level, the self is
either all good or all bad, as are other people. However, given their
narcissism, usually they are all good and others are all bad. This goes for
their feelings as well so their own feelings are completely good while others
are totally bad. This dyadic structure, as opposed to the more mature
development of an id, ego, and superego, is classically psychopathic:
Repression must activate if there is to be a differentiated ego

and id, and ideal self-representations must integrate with
ideal object representations as an ego ideal if the
differentiation between ego and superego is to begin. In the
pre-Oedipal personality of the fledgling psychopath, which
continues into adulthood, there are only dyadic self- and
object representations, which are either condensed or
displaced somewhere else, usually outside the self (Meloy,
2001, p. 14).
Superego abnormalities. For the psychopath internalizations largely
fail so the ability to internalize the values, mores, and societal expectations
88
are also impaired. The adult psychopath is a valueless person...morals
responsibility is a moot question in psychopathy (Meloy, 2001, p. 15).
Further, there may be a process of identifying with badness or evil. When
this occurs, a sadistic quality emerges that is evident behaviorally, for
example, in the torturing of animals.
Although a psychoanalytic formulation of the development of
psychopathy is integral to the premise of this review, the importance of
biological aspects contributing to this paradigm warrants further investigation.
The following chapter summarizes the more poignant biological findings of
the psychopathic disorder.
89
Chapter V
Biological Contributions to Psychopathy

Are psychopaths born or made? The house of psychopath
is built on a psychobiological foundation of no attachment,
underarousal and minimal anxiety (Meloy, 2001, p. 3)
Contemporary models, based on emerging research findings and
technological advances, incorporate not only a psychological basis of
psychopathy but also include a complex interplay between biological, social,
and developmental factors as well. Freuds drive theory is built upon the
notion that psychological processes have roots in biological functions, and
Hare (1993) observed there is evidence of genetic factors influencing brain
functions and personality structure. This impacts the way individuals interact
with the social environment.
Alexander (1935) believed that psychopathy had both psychological
and biological origins, which, when they converged, created a continuum of
psychopathy that he labeled neurosis, neurotic character, psychosis, and
criminality (p. 279). Kraepelin (1887/1904) also suspected a biological or
constitutional etiology of psychopathy, as evidenced by deficits in
psychopaths inability to enjoy a full range of affect and their lack of
adherence to moral values. These are characteristics that are quite
consistent over the course of a psychopaths lifespan.
Siever et. al., (1985) observed that psychopaths may demonstrate
lowered cortical arousal and more disinhibited motoric responses to a variety
of stimuli. Thus, persons with antisocial personality disorder are more likely
90
to act immediately than to reflect prior to their taking action, so that
internalization of societally sanctioned controls may be more problematic (p.
43). In persons identified as psychopaths, there appears to be a complex
interaction between psychological, environmental, and biological
predispositions to develop the full disorder. Psychopathy has already been
linked to family difficulties, such as physical punishment, inconsistent
discipline, and broken homes (Mitchell & Blair, 2000). Meloy (1988)
suggested there was a biological influence on psychological processes, and
by examining empirical research in this area he postulated two assumptions
about the biology of psychopaths. First, there seems to be a significant
relationship between criminality and psychopathy. Second, there also seems
to be a significant relationship between psychopathy and aggression,
whereby psychopaths generally commit more crimes than non-psychopaths.
Meloy hypothesized that the positive correlation between psychopathy,
criminality, and aggression are due, in part, to (a) neuroanatomical structure,
(b) genetic predisposition, (c) neurochemical sets, (d) hormonal influences,
and (e) autonomic reactivity. Each of these is considered below.
Neuroanatomical structures. Meloy cites Mednicks (1982) study in
which abnormal electroencephalogram measures were found in 25 to 50
percent of psychopathic individuals studied, while the incidence of these
abnormal readings in the normal population ranged from 5 to 20 percent.
Meloy also referred to Yeudalls (1977) research in which he discovered that
91
about 91 percent of psychopaths exhibited significant neuropsychological
impairment...implicating frontal and temporal area brain dysfunction (p. 22).
Genetic predispositions. Christiansen (1977) hypothesized that there
was a genetic influence in criminal behavior by studying monozygotic and
dizygotic twins, where he discovered a .69 concordance to criminality in
monozygotic twins, and a .33 concordance in dizygotic twins. An adoption
study by Schulsinger (1977)) discovered that psychopathic adoptees
relatives, who were unknown to the adoptee, as compared to non-
psychopathic adoptees, manifested more psychopathy than the normal
population (p. 23). This supports a biological influence for psychopathy which
may have a stronger influence than environmental factors.
Neurochemical Factors. Certain brain functions and physical
responses are different in psychopathic individuals than in non-psychopathic
individuals and this may provide a link between psychopathy to aggression
(Meloy, 1988). Meloy defined aggressive behaviors as falling into two
different categories: affective aggression that is the result of external or
internal threatening stimuli that evoke an intense and patterned activation of
the autonomic nervous system accompanied by threatening vocalizations and
attacking or defending postures (p. 25). The second form of aggression,
predatory aggression is directed toward the destruction of prey, usually for
food gathering in subhuman species (p. 410). Meloy (1988; 2001)
suggested that psychopaths are more apt to be predatorily aggressive, or
display primitive acts of violence. He cited this as a possible biological
92
source of the disorder, with increased levels the neurotransmitters of
serotonin, norepinephrine, dopamine, and acetylcholine as physiological
correlates of aggressive behavior.
Meloy found a strong and positive correlational relationship among
the psychopaths aggression, social dominance, and testosterone levels (p.
27) as well as evidence of reduced androgen levels that seem to increase
aggression.
Autonomic reactivity. Meloy hypothesized that psychopaths are
autonomically hyporeactive, at an electrical level (p. 31) and suggested that:
...The psychopathic individuals anticipation or experience of

unpleasant, negative affect will have little or no behavioral
consequence...insight may be imitated and quickly learned,
but will exist without an affective dimension such as shame,
guilt, or remorse...predominant aggressive-drive derivatives
will be less inhibited by the psychopathic personality despite
their aversive consequences for the individual and
others...and subsequent positive affect may strongly
reinforce these aggressive-drive derivatives. Punishment of
the psychopathic criminal exists only as a public projection (p.
33).
Hare (1970) reached similar conclusion through work he demonstrated
autonomic irregularities using skin conductance measures. These measures
send an electrical current through the fingers. If a subject is perspiring, thus
more nervous, the skin conductivity will increase, thus indicating increased
autonomic activity.
There are two structures in the brain that have been thought to play a
part in the development of psychopathy. Mitchell (2000) identified the
orbitofrontal cortex and the amygdala as possible candidates for links to
93
psychopathy. According to Mitchell, damage to the orbitofrontal cortex,
located in the frontal lobe below the center of the forehead, has been linked
to severe behavioral problems, including aggression and rage reactions.
Lesions in this area have been known to cause increased anger and
aggressive behaviors in previously normal people. Damasio (1994) termed
individuals affected in this way acquired sociopaths. The amygdala, located
in the forebrain, is central to the processing of emotions and is critical to
mediating the fear response. From an early age, this region functions
differently in individuals with psychopathy (Mitchell, 2000). Blair and Frith
(2000) discussed possible impairments in neural substates that might cause
psychopathy. They concluded that the development of psychopathy is
associated with impairment in emotional processing, and that the
development of this kind impairment may be due to dysfunction within the
amygdala. When the amygdala is damaged, a person will not show fear or
startle responses. Mitchell (2000) further suggested that these findings might
provide evidence of a link between impaired fear and empathy responses
typical of a psychopath and amygdala functioning.
Physiological examinations of psychopaths have revealed other
biological abnormalities. For example, Patrick (1994) reported that
psychopaths have smaller heart rate changes and skin conduction in
response to fear-provoking sentences than non-psychopaths. Martens (2000)
suggested that psychopaths have dysfunctions in the limbic system that
affect the ability to inhibit behavior, even when it will lead to punishment.
94
Further, he noted a marked negative relationship between monoamine
oxidase (MAO) activity on one hand and sensation seeking and impulsivity on
the other (p. 3), which are core features of the psychopathic disorder. He
concluded that psychopathy could be linked to a number of biochemical
abnormalities (which he defines as serotonin, monoamine oxidase, and
hormone dysfunctions), genetic and environmental influences, and
psychological and social manifestations (p. 406). In a review article of
research in this area to date, Martens summarized the salient findings,
presented in Table 11 below. Further, he described some brain injuries and
cerebrovascular disorders that can cause psychopathic personality changes,
as well as frontal lobe lesions or other disturbances in prefrontal functioning,
which may in psychopaths be related to the core features of impulsivity and
disinhibition (p. 410).
In total, these various measures of cortical underarousal (slow EEG
activity, low resting heart rate, and the skin conductance abnormalities)
appear to correlate with criminality (Marshall & Cooke, 1999; Meloy, 2001;
Raine, 1988). When taken together, they have a predictive power that can
override the influence of the environment, especially when the latter is what
we would consider normal, nurturing, and good enough (Meloy, 2001, p. 6).
Although there has been an abundance of research examining possible
biological causes for psychopathy, it should be noted that there has yet to be
a single or group of specifically identified biological underpinnings
consistently related to the psychopathic disorder. Lynam (1996) suggested
95
that both environmental difficulties and genetic factors play a role in the
development of psychopathy. Other contemporary researchers agree with
this position (Lykken, 1995; Marshall & Cooke, 1999). Understand the
mechanisms and the extent to which biological factors predispose an
individual toward psychopathy is essential to address the disorder. Blair and
Frith (2000) believe that until there is a complete understanding, on an
anatomical level, of what the psychopath is doing wrong, there is no way to
truly treat the psychopath.
Table 11
M a rte n s B iological, Psych o log ical, a n d S o c ia l D e te rm in a n ts o f P s y c h o p a th y

Cause Description
Brain Injuries and Dysfunctions Brain injuries, frontal lobe
lesions, disturbances in
prefrontal functioning,
dysfunctions in the limbic system
(affects the ability to inhibit or
disrupt ongoing behavior; cannot
learn from consequences).
MAO, 5-HIAA, and Hormone Dysfunctions Marked negative relationship

between MAO activity on one
hand and sensation seeking and
impulsivity on the other;
Association between low
serotonin function and
aggressive behavior; Inverse
relationship between 5-HIAA on
one hand and impulsivity,
irritability, hostility, and
aggression on the other.
Electroencephalogram (EEG) Abnormalities Association between

psychopathy and abnormal EEG
readings; stimulation seeking
behavior as a consequence of
pathological underarousal.
Low Autonomic Activity-Reactivity Low adrenaline excretion

strongly associate with persistent
antisocial behavior; Resting skin
96
Table 11 (continued)
conductance and heart rate -
characterized in psychopaths as
_________________________________________ underarousal._______________
N o te: From Antisocial and Psychopathic Personality Disorders: Causes,
Course, and Remission - A Review Article, by W. Martens, 2000, In te rn a tio n a l
J o u rn a l o f O ffe n d e r T h e ra p y a n d C o m p a ra tiv e C rim inology, 44(4), 406-430.
97
Chapter VI
Treatment of Psychopathy
Dont forget these people. They have no one, yet they are
people. They are desperately lacking and in terrible pain.
Those who understand this are so rare; you must not turn
your back on them (Sturup (1951), quoted in Millon, 1998, p.
29)
Rabin (1979) some time ago asked, What can be done to prevent
this sort of disorder to begin with, and what can be done to modify and
change its course and continued path of destructiveness? Can the condition
be cured? (p. 342). In other words, how can psychopathy be prevented
from occurring or cured or partially ameliorated when it does occur?
Unfortunately, psychologists do not have much better answers to these vital
questions than the answers that were available at the time Rabin posed
them.
According to Lee (1999), at least some of the confusion and
controversy about treatment interventions stems from a lack of agreement
among clinical professionals regarding three critical issues:
The first issue concerns the nature of the psychopathic

condition and the specific class of persons to whom it applies.
The second issue relates to the most appropriate goals and
targets for the clinical management of the disorder, the form
treatment should take, and how successful treatment outcome
should be evaluated by the clinicians involved. The third issue
concerns the extent to which psychopathic behaviors are
treatable and to whether evidence of psychological change
during treatment implies reduced risk of re-engaging in such
behavior once treatment has culminated (p. 1).
The psychopath is often the least loved of patients (Strasburger,
1986) and traditionally, the psychopath has been deemed untreatable and
98
incurable (Arrigo & Shipley, 2001; Carney, 1978; Cleckley, 1988; Hare, 1993;
Rabin, 1979; Strasburger, 1986), with the prognosis for effective
psychotherapeutic intervention as practically non-existent. Suedfled and
Landon (1978), for example, ironically noted that even a quick review of the
literature suggests that a chapter on effective treatment should be the
shortest in any book concerned with the psychopath. In fact, it has been
suggested that one sentence would suffice: No demonstrably effective
treatment has been found (Suedfeld & Landon, 1978, p. 347). In part, this
widespread consensus that treatment is ineffective may reflect a general
aversion for the psychopathic personality and therefore a reluctance to
engage it. Vaillants (1975) once observed that, The defense mechanisms
that underlie sociopathy seem...as unbearably gross to the observer as a
strong cigar in a crowded elevator (p. 75).
Nevertheless, it surprising that so little progress has been made
regarding the treatment of psychopaths since Rabin (1979) summed up the
matter almost twenty five years ago. Rabin observed that:
Imprisonment of the psychopathic criminal has not aided

much in his rehabilitation. Violation of parole and recidivism
are the rule rather than the exception, according to the
evidence we have. Modes of temporary segregation from
the community other than imprisonment have been similarly
unsuccessful in the long range. Hospitalization in psychiatric
institutions is usually of brief duration, frequently on an
emergency basis. Quite often, psychopaths shuttle back
and forth from penal to psychiatric institutions until paroled
or discharged, to resume the antisocial behavior for which
they were originally incarcerated. Quite often, prison
authorities feel that these prisoners have psychological
problems which should be treated in a hospital setting, but
psychiatric institutions return the men to prison, for past
99
experience has shown that the ordinary hospital regime,

including individual counseling or group therapy as well as
various other ancillary methods of treatment, is of little value
in attempting to change the psychopath (p. 343).
Efforts to treat this misunderstood and often dangerous population
have been quite frustrating, and traditional interventions have almost always
proven ineffectual (Frodi et al., 2001). The psychopath has a tendency to
attribute his problems to the external environment making thus
psychotherapy with this population challenging (Doren, 1987). Hare (1993)
reported another major problem in treating psychopaths is that psychopaths
do not consider themselves to have psychological or emotional problems,
and subsequently they see no reason to change their behavior to adhere to
societal norms. Similarly, McCord and McCord (1964) stated, ...the typical
psychopathic personality seems singularly resistant to change. He lacks a
desire for change and the anxiety, which most therapists believe is a
prerequisite for treatment. Most psychopaths see nothing wrong with
themselves and, therefore, no reason to change (p. 118). Karpman (1946)
agreed with this calling the psychopath a virtually incurable case, requiring
indefinite institutionalization rather than temporary punishment (p. 285).
Clearly, there are numerous challenges facing the mental health
professional treating psychopathically disturbed individuals, and many
differing views about the efficacy of different techniques and treatment
approaches. This is not to say that all psychopaths are completely immune to
psychotherapy, however, treatment efficacy has been difficult and
problematic to measure since psychopaths generally see treatment as a way
100
to secure particular goals such as discharge or early release from prison and
are prone to feign improvement.
Taking a more pessimistic stance than some of his contemporaries,
Meloy (2001) cites the lack of analytic writings on therapeutic techniques for
the treatment of psychopathy as a lack of clinical or empirical evidence that
psychopaths will benefit from any form of psychodynamic therapy, including
the expressive or supportive psychotherapies, psychoanalysis, or various
psychodynamically oriented group psychotherapies (p. 183).
Although this paper attempts to understand the psychological and
interpersonal dynamics underlying psychopathy, there is little
empirical research that combines both what is already known about
psychopathy and how to treat the disorder effectively. Psychoanalytic
models seem to provide the greatest hope of shedding light on the poor
prognosis and lack of suitable treatment models and, minimally, play a
large part in the development of future clinical interventions.
Psychoanalytic Treatment
Analytic knowing has charted the expectable but invariably

malignant course of transference and countertransference
and also contributed to empirical diagnosis to discern the
patient for whom psychoanalysis offers no hope (Meloy,
2001, p. 202).
Among the first to focus on the treatment of psychopaths was Aichorn
(1935), who described three types of antisocial behavior, each warranting
different methods of treatment. First, he recommended that psychopaths
who were driven by guilt originating in the superego have a wish to be
101
punished to alleviate the guilt feelings could be benefit from psychoanalytic
treatment. Second, therapists treating individuals who identified with their
antisocial parents needed to encourage a strong positive transference to the
therapist, who should use a variety of incentives including unconditional
forgiveness and admiration, and even gifts (Wolman, 1980). Aichorns third
type was the primitive delinquent, who had no superego. He suggested a
structured environment and non-psychoanalytic psychotherapy for these
individuals.
According to Toch (1979) there are several determinants of patient
responsiveness to psychoanalytic treatment modality: (a) the dominant role
of irrational motives, pressures of which the individual may not be aware,
which can manifest themselves in devious or indirect ways; (b) deficits that
can occur in the egos mediation of reality, or the egos capacity to control
affects or drives; (c) the presence of several layers of motivation; (d)
problems with values which can be tenuous or tyrannical; (e) the complexity
that is produced by internal conflicts; and (f) cues that the persons past is
alive in his reactions to present circumstances (p. 191).
Kernberg believed it is crucial, from a diagnostic, prognostic, and
therapeutic viewpoint to carefully evaluate (a) the presence or absence of
some form of pathological narcissism; (b) the extent to which superego
pathology dominates - that is, where the patient falls in the continuum from
the narcissistic to the antisocial personality disorders; (c) the intensity of ego-
syntonic aggression, whether directed toward the self (in the form of suicidal,
102
parasuicidal, and/or self-mutilating and self-destructive behavior) or against
others (in the form of physical violence, homicidal tendencies, or a life-
endangering sadistic perversion); (d) the severity of paranoid trends; and
finally (e) the stability of reality testing (Kernberg, 1998, p. 376). This careful
assessment, which Kernberg cautioned to not attempt to carry out alone in a
closed room (p. 378), has been used by clinicians to determine the degree of
a persons antisocial tendencies in order to make predictions about the
quality of their object relations and their ability to benefit from
psychotherapeutic treatment (Kernberg, 1998; McWilliams, 1994).
Kernberg (1989) believed the most important feature to assess for
treatability was the extent to which lives were at stake; either the patients life,
the lives of other people, or the therapists life. Despite this attempt to
identify those individuals with antisocial tendencies who might benefit from
psychotherapy, Kernberg even suggested the prognosis for psychopathic
patients to be practically zero. He stated:
It is important to keep in mind that some patients cannot be

helped (at least in the concrete situation of any particular
psychotherapeutic engagement), and that, in the end, it
cannot be only the therapist who wishes to help patients
whose major gratification in life is the destruction of those
who are attempting to help them (p. 391).
On the other hand, to say that psychopaths never recover at all
flies in the face of change that occurs with some.
While the more extreme psychopaths are unlikely to benefit from
therapy, those who are less disturbed may find some benefit. Meloy believed
there is an inverse relationship between level of psychopathic disturbance
103
and treatment efficacy, i.e., the greater the psychopathic disturbance in the
individual, the more likely psychotherapy will have no effect:
Treatment should not proceed if the patient is a primary

psychopath. Interpersonal and intrapsychic features that
contraindicate any form of treatment include sadistic behavior
in the patients history that resulted in serious injury, maiming,
or death of a victim; the need to justify or rationalize such
behavior or a complete absence of any remorse; intelligence
greater or less than two standard deviations from the mean; a
historical absence of attachment without depression; and the
presence of an atavistic fear of predation felt by clinicians
when with the patient (Meloy, 2001, p. 188).
The degree of damage that a psychopath has sustained is determined
by the extent of ego or superego dysfunction. Severe damage to these
faculties occurs most frequently when individuals are quite young. Bender
believed there was a certain point in the normal development of the
personality after which analytic treatment could not be used to:
repair the infantile deprivation because the psychopath was

not able to engage in a transferrential relationship that was
required for successful education and treatment. Once the
early childhood has been passed without the adequate
opportunity for normal relationships and personality
development, the organization of the personality permits no
modification (Bender, 1947, p. 76).
Strasburger (1986) suggested that degree of insight and openness
required for analytic treatment is unrealistic for the psychopathic personality,
and because their behavior is characteristically callous and without empathy
there would inevitably be an incapacity to maintain the therapeutic
relationship:
These people are impulsive, unable to tolerate frustration

and delay, and have problems with trusting. They take a
paranoid position or externalize their emotional experience.
104
They have little ability to form a working alliance and poor

capacity for self-observation. Their anger is frightening.
Frequently they take flight. Their relations with others are
highly problematic. When close to another person they fear
engulfment or fusion and loss of self. At the same time,
paradoxically, they desire closeness; frustration of their
entitled wishes to be nourished, cared for, and assisted
often leads to rage. They are capable of a childs primitive
fury enacted with an adults physical capabilities, and action
is always in the offing (Strasburger, 1986, p 191).
Transference
It is only in psychoanalytic treatment that reliving distorted or disturbed
has a curative effect, and thus the psychopath will have to relive, through
transference and countertransference, these early conflicts. Meloy (2001)
stated that psychopaths would adopt one of four transference positions in
treatment that were originally characterized by Kohut (1971). This stems from
their core narcissism. The patient will either seek to idealize (I want to
worship), or to mirror (I want to be worshiped), or to twin (I want to imitate), or
to merge (I want to control) (p. 184). In a traditional therapeutic situation it is
likely, that the primitive need to control the analyst will emerge and the
discomfort is experienced as being under his thumb (McWilliams, 1994). In
response to this threatening hostility the therapist will likely feel that working
with the psychopath is like walking on eggshells to avoid what is
catastrophically imagined as rageful, explosive, and potentially violent affect,
perhaps a complimentary and fearful identification with how the psychopath
felt as a child (Meloy, 2001, p. 184). Vaillant (1975) suggested that from the
very beginning of the treatment the therapist must aggressively take control
105
of the relationship, structure it, and define its limitations in order to establish
adequate boundaries on the therapeutic frame.
Meloy (1988, 2001) also identified other predictable resistances that
would likely occur when working with a psychopath. These included
manipulative cycling, deceptive practices, malignant pseudo-identification,
and sadistic control. He described manipulative cycling as:
A goal conflict, an intent to deceive, a successfully carried

out deceptive act, and a subsequent feeling of
contemptuous delight...the process of which unconsciously
defends against envy and oral rage, which is likely felt when
the analyst is initially idealized; it purges devalued introjects
that are then projectively identified into the analyst and thus
retain the homeostasis of the grandiose self-structure
(Meloy, 2001, p. 184).
Deceptive practices, or manipulation, are to be expected when working with
psychopaths, and Kernberg (1992a) wrote:
I have coined the term psychopathic transference to refer to

periods in the treatment when...conditions of deceptiveness
and their projection prevail. In my view, it is essential to
explore such transferences in great detail, and to resolve
them interpretatively before proceeding with other materials
(p. 18).
The psychopath uses deception in an attempt to devalue the therapist, which
wards off anxiety, and leaves the therapist feeling suspicious. Malignant
pseudo-identification is used to control the therapist and appeals to the
psychopaths own narcissistic tendencies. An example of this would be when
the psychopath attempts to imitate certain emotions during treatment, using
all the right words about certain feelings, but without any actual insight about
what they actually feel like or mean. The analyst is left feeling distant and
106
skeptical, yet confused by the absence of any true empathic responses in
himself (Kernberg, 1992b). Sadistic control, a component of malignant
narcissism was first discussed by Kernberg (1984) and later described in
more detail by Meloy (2001) as:
...ranging from verbal devaluation of the process to blatant

forms of psychological and physical aggression. It is a
clinical manifestation of the prey-predator dynamic in which
all relationships, including the one with the analyst, are
defined by dominance and submission. The analytic
question is the degree to which the desire for sadistic control
by the patient is ego syntonic, or riddled with conflicts and
dependencies (p. 185).
When the analyst attempts to treat this syntonic sadism, it can have serious
implications for the therapy including actually physical danger. McWilliams
(1994) stated that the psychopaths transference to the therapist is a
projection of his or her internal predation, the assumption that the clinician
intends to use the patient for selfish purposes (p. 159). According to
McWilliams, this was the result of not being able to understand the interest or
generosity of the therapist, having been deprived any kind of gratifying
emotional experiences as a child.
Countertransference
The clinical treatment of psychopathy can elicit a variety of responses
from the therapist, including anger, empathy, hatred, fear and other intense
negative emotions (Weiss, 1988). Kernberg (1989) suggested that therapists
working with psychopathic patients might be tempted to either just accept the
patients statements, or fully reject them in what he called a protective
pseudoneutrality, which may be a way to devalue the patient. Kernberg
107
recommended taking a true ambivalent stance; moral but not moralizing, fair
but not naive, and confronting but not aggressive.
Strasburger (1986) wrote a great deal about countertransference
reactions in therapists working with psychopaths, and described six typical
responses: fear of assault or harm, helplessness and guilt, loss of
professional identity, denial of danger, rejection of the patient, and the rageful
wish to destroy (Table 12). Strasburger discussed the therapeutic
pessimism that may be evoked in the therapist during treatment:
It is difficult to be sympathetic toward delinquent, substance

abusing, and sometimes violent individuals...Clinical staff do
not like their repeated demands for help, coupled with their
insistence that their troubles always originate outside
themselves. Their infantile manner, omnipotent demands,
and lack of introspection cause them to be rejected. Their
hedonism and requirements for instant gratification often
clash head-on with the personal values of the clinical staff
(quoted in Meloy, 2002, p. 298).
Because the behavior of these types of clients can be so disgusting
and undesirable, they are often dismissed as just psychopaths, and their
inner world can be ignored by the clinician in a dehumanizing fashion - just
as the psychopath does to the therapist. Vaillant (1975) stated the pejorative
term, psychopath, is accurate only insofar as it describes the back of a
patient fleeing therapy. If a psychiatrist sees the same patient in a prison
hospital, he may doubt that such a disorder exists (p. 75).
Meloy (2001) and McWilliams (1994) described a therapeutic
nihilism, or a certain cynicism in the analyst which can occur when working
with clients who have even mild antisocial histories. This countertransference
108
manifests as a dismissive or derogatory attitude toward any patient who
reports an illegal act or has been accused, or convicted, of a crime (Meloy,
2001, p. 185). Conversely, the therapist may believe, mistakenly, that there
is a therapeutic alliance or attachment to them when what is occurring is
simply faking on the part of the psychopath This type of countertransference
usually stems from the therapists wish to believe that the psychopath does
have some ability to form a bond (Lion, 1978). McWilliams (1994), with great
insight, described the therapists reaction to this as:
Shock and resistance to the sense that ones essential

identity as a helper is being eradicated. The naive
practitioner may succumb to the temptation to try to prove
helpful intent. When that fails, hostility, contempt, and
moralistic outrage toward the psychopathic person are
common reactions. These unempathic feelings in
ordinarily compassionate people should be understood,
paradoxically, as a kind of empathy with psychopathic
psychology: The client is unable to care about the therapist,
and the therapist finds it almost as hard to care about the
client...if one can tolerate the experience of internal
coldness and even hatred, one will get a unpleasant but
useful glimpse of what it is like to be a psychopathically
organized person (p. 159).
Often, clinicians describe having a physical sensation when meeting
with psychopathic patients as a fear of physical harm that manifests as
goose bumps, piloerection, or the skin crawling. Meloy (2001) specifically
noted that:
These are phylogenetically old, biologically based autonomic signals of

impending predatory danger. They may prompt a variety of systemic
disturbances in the analyst, including gastrointestinal and
cardiopulmonary reactivity, and may be signaling an actual future
threat (p. 186).
109
Melloy surveyed mental health and criminal justice professionals, and
found this countertransference response occurred in a majority of the
respondents. Its universality suggested that it reflected an important and
perhaps primitive survival mechanism. McWilliams (1994) thought it
important to tolerate these reactions and avoid minimization of the actual
threats these patients pose.
Table 12
S tra s b u rg e rs C o u n te rtra n s fe re n c e R e s p o n s e s in W o rkin g with P s y c h o p a th s

Response Description
Fear of assault or harm The therapists frustration can produce anger,

which is projected as a fear of ambush. Fear
can lead to the abandonment of talking in favor
of seclusion, restraint, or medication. Fears of
assault usually diminish with experience.
Helplessness and guilt The therapist may feel his efforts to help
rejected while he himself is devalued. It is a
difficult, slow-moving task. Helplessness and
guilt about the
patients lack of improvement, manifest as
either emotional withdrawal or as over
responsibility for what happens to the patient.
Loss of professional identity The patient disowns his problems and ascribes
them to the therapist, and the therapist may
come to feel that he owns them. Unwilling to
experience the dysphoria, the therapist
attempts to wriggle free of the patients
attributions. Devaluation by the patient can
evoke feelings of worthlessness, fear,
depression, rage, guilt, shame, and envy.
Denial of danger It may lead to a failure to elicit information

about weapons, lethal skills, past criminal or
violent acts and the therapist may counter-
phobically place himself in a dangerous
position.
110
Rejection of the patient The therapist must maintain a delicate balance

between a talion rejection of the patient and a
masochistic submission to unreasonable
demands. Rejection might be a lack of
emotional investment, boredom, hatred, or
emotional withdrawal.
The rageful wish to destroy May be reactively mirroring the emotion of the
patient, or via identification with the aggressor.
The patients defiant, remorseless, threatening
attitude provokes its punitive reaction.
Note. From The Treatment of Antisocial Syndromes, by L. Strasburger, 1986, In W. Reid,

D. Dorr, J. Walker, and J. Bonner (Eds.), Unmasking the psychopath: Antisocial personality
and related syndromes. New York: W. W. Norton and company.
Successful psychotherapy requires the therapist to show acceptance
of the subject, yet the necessary focus on the patients destructiveness may
generate an intense countertransference reaction that can sometimes
develop into a fear of the patient (Blackburn, 1993).
Leaff (1978) observed that while treatment demands with psychopathic
patients are many, these patients actually might be treatable if they had at
least some adequate developmental history. By treatment, Leaff meant any
interventions from psychoanalysis to supportive counseling as well as the use
of institutionalization, whether in a hospital or prison setting, as well as
medication:
The therapist is buffeted by demands from the patient and

the external world, as well as by intense transference and
countertransference reactions. The patent, as well as his
family, may subvert treatment; provocativeness and acting
out may bring extreme pressure to bear from the
environment, or evoke inner feelings of discouragement and
failure in the therapist. The patients devaluation of the
therapist may lead to feelings of depletion. Covert and overt
hostility may engender counterhostility. Repeated use of
externalization and hostile expectations may make engaging
the patient difficult; the patients constant conscious and
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unconscious rage toward the therapist may lead to

termination of treatment, increased acting out or even
assault of the therapist. Alternatively, the therapists values
are threatened. He may attempt to become the patients
superego or his own instinctual drives may be so
stimulated by the patient that the therapist becomes
anxious, does not function effectively, and/or withdraws from
the treatment situation (Leaff, 1978, p. 115).
Dalmau (1961) was a bit more optimistic, and a perhaps a bit naive, in
recommending a psychoanalytic approach for the treatment of psychopathy
with specific focus on the interpretation of psychopathic behavior in symbolic
terms. He believed that one of the greatest difficulties in treating the
psychopath is understanding the symbolic meaning of his behavior and
managing the overwhelming malignant transference.
The true psychopath is more difficult to reach because the

prelogical level of trauma makes the defenses almost
impregnable. The psychotic intensity of the conflict is too much
of a threat to the ego and analysis is avoided realistically. If the
premise of the massive overwhelming superego directly
proportional to the instinctual forces is correct, then therapy
poses the threat of internalization and acceptance of psychic pain
(Dalmau, 1961, p. 451).
Skeem et al (2002) cited the emotional detachment of psychopaths as
an obstacle preventing them from establishing a therapeutic alliance with the
therapist as a reason for treatment failure, ...interpersonal and affective
features of psychopathy like manipulativeness, pathological lying, shallow
affect, and denial of responsibility are obstacles in accomplishing empirically
validated characteristics of effective psychotherapy such as therapeutic
cooperation, self-exploration, cognitive confrontation, affective intimacy,
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patient engagement, reciprocal attachment, and openness (Skeem et al.,
2002, p. 578).
Current Research and Treatment Modalities
Salekin (2002) reviewed 42 treatment studies on psychopathy and
concluded that there is little scientific basis for the belief that psychopathy is
an untreatable disorder (p. 79). Salekin found several problems with the
existing research in this area. First is widespread disagreement concerning
the definition and characteristics of psychopathy. Second, the etiology of
psychopathy is not well understood. Finally, there are too few empirical
studies of the treatment of psychopaths with little follow up investigations
after treatment (p. 79).
The results of Salekins meta-analysis (Table 13) found that
psychoanalytic therapy was, in fact, an effective modality in the treatment of
psychopathy. Salekin (2002) reported that the average success rate was
59% based on 17 studies and 88 psychopaths, and found that after
psychoanalytic treatment these individuals (between 8 and 55 years old)
improved. By improved he means a decrease in lying, an increase in
remorse and empathy, and improved relations with others (p. 105). He
added, this finding indicates that insight-oriented therapies may decrease
psychopathic traits and that psychopathic individuals gained some awareness
of their general approach to life through this therapeutic approach (p. 101).
Further, Salekin added for the most effective programs the treatment
consisted of an average of four sessions of individual therapy per week for at
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least one year, and when augmented with group psychotherapy was
preliminarily beneficial. Salekins research has challenged the prevailing
consensus in psychology that treatment for the psychopath is a lost cause
(Skeem et al., 2002). Agreeing with Salekin, Frodi et. al. (2001) asserted that
when a psychopath has regular sessions over an extended period, this can
provide a secure base from which psychopaths can access different
aspects of their internal world, address transference and countertransference
issues, and eventually facilitate their development of empathy for others.
(Frodi etal., 2001, p. 281)
Aside from Salekins meta-analysis, an extensive literature search did
not produce many studies on using analytic group psychotherapy with
psychopaths. Cox (1998) described a small (6 member), modified group-
analytic psychotherapy approach to treating psychopaths at Broadmoor
Hospital, where about 25% of the entire patient population have been
diagnosed as psychopathic. Interestingly, patients there are hospitalized
without limit of time, which implies that it is only when patients are
considered psychodynamically integrated, socially stable, and safe that they
are transferred to less secure conditions (p. 395). Because the participants
have violent histories, Cox stated that the only place to work analytically in
groups with these patients is in the secure setting of prisons or hospitals.
Some research indicates that insight-oriented therapies actually make
psychopaths (but not non-psychopaths) more likely to recidivate, possibly
because psychopaths can use psychotherapy sessions to develop their skills
114
in psychological manipulation, and because they see no need to change their
personalities. (Hare, 1993; McCord & McCord, 1964).
It appears that the least effective modality for treating psychopaths is
the therapeutic community. Despite this therapeutic communities have been
and continue to be used quite often with this population. Salekin believes that
the reason for the low level of success is that therapeutic community
programs are not designed to target the symptoms of the psychopath and do
not have sufficient contact with psychologists as part of their design (Salekin,
2002, p. 101). Without the psychological insight of mental health
professionals, therapeutic communities can be easily manipulated. Harris,
Rice, and Cormier (1992) reported that psychopaths tended to exploit
unstructured programs such as therapeutic communities. This can be easily
done since many psychopaths are often quite verbally facile.
Ogloff et al. (1990) speculated that the therapeutic communities may
fail to provide effective treatment for psychopaths because often psychopaths
initially seek treatment for secondary gain, such as conditional release, but
once treatment has begun they tend to be less motivated, put less effort into
the program, and are eventually removed - either for lack of motivation or
behavioral and security concerns. The psychopath starts to become more
aware of the impact of his self-destructive and irresponsible behaviors.
These insights may be alien and uncomfortable to him, and he escapes this
difficult environment by acting up, (p. 187)
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Lee (1999) described other problems with the therapeutic community
approach to the treatment of psychopathy:
On closer look at the data, for instance, there are a

noticeably high number of reported incidents of attempted
escape by psychopathic subjects living in this type of
environment, as well as dangerous and life-threatening
group behavior.... psychopathic patients can abuse the
freedoms they are granted within TCs or cliques have
developed among patients which then result in dangerous
behaviour, such as the severe incident that occurred in the
early spring of 1991, in which six unsupervised patients set
fire to a couch and narrowly avoided killing another
patient...(p. 23).
Table 13
Meta-analysis Results for Psychopathy

Intervention Studies
Type of Psychotherapy # of studies Total SampleSuccess Rate
1. Psychoanalytic 17 88 .59
2. Cognitive-Behavioral 5 246 .62
3. Therapeutic Communities 8 371 .25
4. Actional Procedures 1 20 .88
5. Eclectic 2 62 .86
6. Pharmacotherapy 2 10 .70
7. ECT 2 9 .22
8. Personal Construct 1 46 1.0
9. Rational Therapy 1 1 1.0
10. Psychodrama 1 1 1.0
11. Not Specified 1 6 .17
12. Control 8 287 .20
Note: From Psychopathy and Therapeutic Pessimism: Clinical Lore or
Clinical Reality? by R. Salekin, 2002, Clinical Psychology Review, 22, p. 79-
112. Elsevier Science, Inc.
Rice, Harris and Cormier (1992) conducted a retrospective evaluation
of a peer operated, intensive group therapy (80 hours per week), therapeutic
community that ran from 1968 - 1978. They measured the criminal recidivism
of the patients involved in the study and discovered that psychopaths
(defined by Hares PCL-R M = 19) had higher recidivism rates (90%) than
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controls who received no treatment at all (87%) - and, worse yet, those
treated were more likely to recidivate violently.
This surprised the researchers because the program was explicitly
designed to effect positive changes in the psychopathic personality based on
a solid theoretical background provided by the existing literature, and it
provided extensive opportunities for patients to gain insight into their own
behavior and to learn to be caring and empathic (Rice et al., 1992, p. 408).
This is the study that is most typically used to support the statement
previously addressed that therapy may make psychopaths worse (Hare,
1993; Skeem et al., 2002).
Another study of the efficacy of therapeutic communities for
psychopaths was done by Ogloff et al. (1990) with psychopaths (PCL-R > 27)
in a therapeutic community. The authors concluded that psychopaths tend to
show less clinical improvement, they are less motivated in trying to change
their behaviors, and they have a higher attrition rate (p. 186). Overall, it
would seem that therapeutic communities instead of having a beneficial effect
merely facilitate a psychopaths ability to manipulate and exploit others by
placing them in interaction with one another, which fosters criminality,
recidivism, and could be a way for them to learn new ways to commit violent
crimes (Ogloff et al., 1990; Rice et al., 1992).
More recently, Skeem et al., (2002) studied civil psychiatric patients
with psychopathy and found that when these patients received more
treatment sessions (seven or more) during a 10-week period, they were
117
approximately three times less likely to be violent during the subsequent 10-
week period than those who received fewer (six or less) sessions. This is
quite contrary to other studies, and led the authors to conclude that
psychopaths do benefit from adequate treatment regimens.
Rockwell (1978) contends that in the absence of clear understanding
of the etiology of psychopathy, treatment of the antisocial personality is at
best empirical, and stated:
The consistent theme throughout seems to be a focus on

locking the psychopath into a stable milieu in which the
therapists countertransference is looked at in great detail.
The previous pessimism and hopelessness of therapists are
unwarranted, and yet we cannot be sure that what we do can
be shown to be helpful (p. 140).
Virtually all the research on the treatment of psychopathic patients has
suggested that those working with this group of patients will experience a
great deal of difficulty in reducing symptoms and improving the personality
deficiencies of psychopaths. As noted earlier, the research in the area of
analytic intervention is relatively scarce and has overall limited by
methodological deficiencies. Lee (1999) succinctly summarized the
problematic aspects of current research methodologies when he said that in
the research there were very few:
...experiments using controls and adequate follow-up periods

and too many relying upon recidivism statistics as a measure
of success, when these are notoriously inaccurate. It has also
been difficult to make comparisons between the different
studies carried out in this field, because so many of them use
different diagnostic criteria for their subjects and monitor their
progress with incompatible assessment devices (p. 25).
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Despite the recent interest in clinical research of effective treatment
methods for psychopathy, there is still no indication that psychology has
made any important advances in treatment of the psychopathic disorder.
However, even if effective therapeutic techniques are never achieved, the
knowledge that the field of psychology has already amassed or will obtain
in the future through continued research, will greatly assist those working
in the medical, legal, and educational, mental health professions to
develop more effective methods to manage and address the behavior and
internal world of the violent psychopath.
Shortcomings not withstanding, it still remains clear from this review
that psychopathic patients are difficult to treat in psychotherapy. However,
there is currently a growing consensus that not all psychopaths should be
considered untreatable. There are clearly gradations of the disorder that may
be amenable to some therapeutic interventions. One of the most exciting
findings of the research reviewed in this paper was that longer periods of
treatment or more frequent sessions produced better results in psychopathic
patients. Also, with the limited evidence now available, it appears that
psychoanalytic oriented treatment does appear to be effective with
psychopathic patients since they do show improvement in terms of symptom
reduction when they receive the traditional, long term therapy 3 or 4 times per
week.
119
Chapter VII
Conclusion
Historical Overview
This review has considered the historical backdrop and theoretical
efforts that have attempted to provide an understanding of the often violent,
aggressive, and impulsive nature of the psychopath. Although Pinel first
described the psychopath in 1801 over one hundred years ago, there is today
less understanding of psychopathy than any other personality disorder.
Because of this and because of the great harm persons with this illness can
do to society psychopathy present an important and difficult challenge for the
psychological profession.
Over the past 25 years, the fields of psychology, psychiatry, social
science, and the legal professionals have developed and researched a
number of theoretical and practical hypotheses regarding the identification,
assessment, and diagnosis of the psychopathies. Most contemporary
clinicians appear to hold a view of psychopathy, perhaps influenced more by
the media rather than formal training or exposure to this population, that sees
psychopaths as simply untreatable. The psychological research literature that
has been considered in this dissertation suggests that this is not the case.
Treatments with some types of psychopaths do seem to be successful,
though such work is both difficult and expensive. This may be a truth that
society does not want to hear. If psychopathy is indeed a treatable mental
illness, then perhaps it is incumbent upon society which has assumed
custody of many psychopaths and locked them away in prisons, to afford
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them access to this expensive, long term treatment to relieve their continuing
suffering.
Further Research Required
For psychologists, clearly there is a clinical and ethical responsibility to
pursue research focused on treatment interventions with these patients. This
responsibility is not simply to their potential psychopathic patients.
Psychologists also have a responsibility to the public at large, since violent
psychopaths are the most dangerous and have the highest rates of recidivism
(Harris, Rice, & Cormier, 1991). Just as clearly the society at large has a
responsibility to fund the research that will help prevent and treat this disorder
rather than simply accepting the havoc that psychopaths wreck on civil
society and later punishing the offender whose guilt is often mitigated by the
damaging abuse and developmental neglect for he had no responsibility.
Skeem, Monahan, and Mulvey (2002) state that the premise of psychopathy
as untreatable has numerous clinical implications given the scarcity of
mental health care resources, the number of legal contexts that call for
assessment of treatability, and the explosion of research on psychopathy and
violence risk over recent years (p. 577). Obviously, this premise has equally
momentous social implications that are not independent of its clinical
implications.
To this point in time, an enormous amount of resources have been
focused on creating instruments to assess for psychopathy and on clarifying
the diagnostic criteria of this disorder. Without these efforts, successful
121
treatment programs could not be developed. Despite this, it appears that the
current DSM-IV definition of Anti-Social Personality Disorder is rather limited
in its ability to distinguish psychopaths from other social offenders because of
its exclusive focus on behavioral criteria. This problem will hopefully be
corrected in the near future. Once the illness has been given a reliable
definition the next task for psychologists should be to engage in
methodologically sound research and the development of practical
interventions for the treatment of psychopathy.
Research directions in this are numerous. For example, Rockwell
(1978) suggested that research of the following phenomenon related to the
psychopathic disorder required further explanation, and may provide valuable
information on the development of effective treatment modalities:
1. There is a 5:1 to 10:1 preponderance of males to females in diagnosis
of psychopathy. There are close associations among male
psychopathy, female hysteria, and parental psychopathy and
alcoholism.
2. Core or primary psychopathy is a distinct syndrome with no proved
effective treatment.
3. Much of what is written about psychopathy is value-laden description.
4. There appear to be familial and environmental predicates which are
often contradictory in their proposed impact.
5. There is a burn out phenomenon affecting about 1/3 or more of
persons diagnosed as psychopathic, usually between the ages of 30
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and 40.
6. There is failure to explain, in terms of learning theory, the psychopaths
peculiar insensitivity to learning and to generalization.
7. The psychopath is probably neuropsychologically deviant from
normals.
8. One can argue for evidence of significant genetic influence.
9. There seems to be an increased frequency of psychopathic behavior
in Western society as a whole. (Rockwell, 1978, p. 141).
It has been suggested by more than one professional (Kernberg, 1989;
Meloy, 2001, etc.) that the lifelong institutionalization of the psychopath,
either in psychiatric hospitals or prisons should be considered the treatment
of choice for the particularly violent psychopaths. Arguments against this,
however, are based on ethical concerns and highlight the current state of
treatment models in effect. Opposing this position, Lees (1999) argued that:
...it is unethical to keep a psychopathic patient on an indeterminate

hospital sentence, when the condition attached to release is the
amelioration of their disorder. Indeed, the system as it stands has
encouraged a high level of deception among psychopathic patients,
who are aware that if they fail to demonstrate improvement in their
psychiatric symptoms, they will languish in hospital for a far longer time
than would be demanded by legal punishment for their offence (p. 25).
In essence, psychiatric and hospitals by their very nature of treating
the psychopath as untreatable, have encouraged psychopathic patients to lie
about and minimize their behavior and to be deceptive in therapy. Thus,
partially in response to this social policy, psychopaths have developed such
123
an awful reputation in the mental health system that hospitals are refusing to
admit them because they consider psychopathy as untreatable (Lee, 1999).
Evaluating Treatment Options for Psychopaths
Although there is still no clear treatment of choice for psychopaths,
some of the most recent research is decidedly skeptical of the long held
belief that the psychopath is completely untreatable (Blackburn, 2000; Losel,
1998; Salekin, 2002; Skeem et al., 2002). Given all the dogma in the
literature, it is easy to understand the pessimism in treating this population.
However, Skeem, et al. (2002) cite little compelling evidence to support this
blanket assumption (p. 578), and identify two quite problematic flaws in the
research which supports the claim that psychopathy is untreatable: (a) most
studies of treatment outcome and psychopathy focus on heterogeneous
groups of individuals with antisocial personality disorder and are quite
uninformative about those with Cleckleyan traits per se; and (b) of the studies
that specifically focus on psychopathy, few are prospective, include control
groups, and describe their treatment programs (p. 579)
Blackburn also disagreed with the traditional conclusion that
psychopaths are untreatable and stated First, while classical psychopaths
have been shown to respond poorly to some traditional therapeutic
interventions, it has yet to be established that nothing works with this group.
Second, some offenders with personality disorders do appear to change with
psychological treatment (Blackburn, 1993, p. 202).
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Trying to research treatment effectiveness with this population is
difficult for the reasons cited above and due to some contradictory findings.
Skeem, et al. (2002) interestingly have reminded us that existing research
indicates not whether psychopaths are treatable, but how responsive select
groups of psychopaths have been to the treatments we have studied. In
PCL-R based research, the modal treatment studied is a TC and the modal
groups of psychopaths are correctional or forensic inmates (Skeem et al.,
2002, p. 581).
Why do psychopaths not improve with treatment? Perhaps not
because the treatment is inappropriate, but because it is not enough. Are
these patients not improving because they receive insufficient doses of
treatment? It is quite likely that psychopaths actually need more intensive
treatment before results (i.e. change) can be achieved (Skeem et al., 2002).
This is suggested by Salekin (2002) who found a strong correlation between
the amount and duration of treatment and what researchers considered
partially successful. Skeem, et. al. (2002) address this concern quite well
when they note that:
It is possible that psychopaths who drop out of treatment are

more likely to recidivate than those who do not drop out,
regardless of the effects of treatment. Nevertheless, if
intensive treatment is required to effectively alter embedded
personality patterns, two clear pathways to poor outcome for
psychopathy are premature dropout or termination and
provision of inadequate treatment. Identifying whether either
of these pathways characterizes psychopaths relatively poor
outcomes would have crucial implications for designing
standard outpatient care. Given the mental health care
markets emphasis on inexpensive treatment, psychopaths
are unlikely to receive outreach services or long-term
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treatment. This is not a problem if treatment as usual is

ineffective for patients with psychopathy, regardless of
treatment intensity. However, if traditional psychiatric services
are effective for patients with psychopathy, particularly or only
when they are intensive, it would be prudent to provide
increased services to psychopaths to decrease this
syndromes considerable toll on society (p. 583).
Early intervention, too, seems to be a key factor in treating
psychopathy. Although not the focus of this research, Fongay and Target
(1996) inferred that intensive psychoanalytic treatment with children was
somewhat effective. Bender (1947), too, believed that preventative measures
during the early infantile stages, such as avoiding deprivation and maintaining
continuous and close relationships within a family could ameliorate the
development of psychopathy in adulthood. Marshall and Cooke (1999) also
suggested early, targeted interventions for children with both familial and
societal risk factors could reduce the risk of psychopathic development.
Regarding the clear developmental hallmarks of the psychopathy, Lee (1999)
stated:
This implies that psychopathic symptoms are detectable

before the condition gets to the adult stage and that it might
be possible to treat predispositional signs in childhood or
adolescence before they have had a chance to develop.
Indeed, there is a growing amount of evidence that childhood
conduct problems are related to adult psychopathy...it is
surprising, however, that little in the way of preventative
methods have been tried with those suffering from the
disorder (p. 26).
Given that psychoanalytic treatment is rooted in a rich history of
developmental theory, and preferably done with two or more treatment
sessions per week, it seems a likely candidate to succeed where other
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methods have failed. Again, more research in this area is called for before
psychopaths are dismissed as untreatable.
In a personal communication with Salekin (personal communication,
May 13, 2003) regarding the existence of comprehensive research using
intensive psychoanalytic treatment of psychopaths he stated, I do think there
is merit in the analytic approach. I do not know of any other studies on this at
the moment and I think analytic would be hard to find given the lack of
funding for research in this area (2003). In this current environment of
managed care, it is not difficult to imagine the hesitancy in funding such a
lengthy endeavor. Yet without doubt, the victims, and their families, of
Richard Kuklinski, John Wayne Gacy, Jeffrey Dahmer, Ted Bundy, Kenneth
Bianchi, and Angelo Buono would agree there is cause for funding the proper
assessment, diagnosis, and treatment of the violent psychopath.
This study has provided a historical review of the psychological
literature regarding the clinical definition, causative etiology, and therapeutic
treatment of psychopathy. This review indicates that there is a growing
consensus that this disorder is treatable, though the most successful
treatments have required intensive, long term therapy. Because of this, I have
made recommendations for the psychoanalytically informed, long-term
treatment for persons suffering from this disorder. Again, it is only
psychoanalytic treatment that takes a person back to problems rooted in
childhood, through a process of curative experiences via the transference
and countertransference. To be meaningful, these recommendations need to
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be considered in relation to the social context in which they must occur since
it is the larger society that will either support and pay for them or alternatively
pay for the damage that untreated psychopaths will cause.
Is There a Moral Imperative for Treatment?
From a moral viewpoint, I believe that once a treatment is discovered
that will relieve an ailment which causes great suffering or death, it is
inhumane to withhold it. Since workable treatments for psychopathy have
been demonstrated, there exists a social responsibility and moral imperative
to treat those afflicted with disorder in order to relieve their suffering and to
prevent these persons from doing harm to civil society. Clearly, this moral
imperative is not today universally acknowledged. Currently, many millions of
people with AIDS in economically disadvantaged countries are being allowed
to die because wealthy nations choose to profiteer rather than provide life
saving medications to those will die without them. With many more people
dying of this treatable disease than all that have been killed in the wars of the
last century, is it realistic to hope that society will fund expensive treatments
for psychopaths who do not complain that they are suffering? Are not
psychopaths, when they are locked away in institutions, as invisible as the
African children with AIDS are to European and American public awareness?
In contemporary political climate that is guided in large part by
economic considerations and expediency, the more persuasive argument for
treatment is economic advantage rather than a moral imperative. Wealthy
nations began to provide AIDS medications to poorer countries when it was
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recognized that the ongoing loss of population would destabilize the
governments of these nations, causing regional and global disruptions of
trade. Similarly, treatment for psychopaths will likely be funded when the
costs of not treating these individuals are more widely recognized. That this
will happen is inevitable. When it will occur is difficult to predict. However, the
range and severity of the societal problems caused by the psychopaths
behavior is far reaching, with heinous and violent crimes at the severe end of
this disorder. At some point society will recognize that these crimes are too
costly to its order and sense of meaning not to be prevented in every way
possible. That point will occur when society places a significantly greater
value upon itself than at present.
The Range of Psychopathic Behavior and Limits of Psychological Knowledge
While the scope of this problem is broad, the psychological
understanding of psychopaths is really still quite limited. What is known is that
there is an interaction of biological, cognitive, social, and object relational
factors that result in violent psychopathic behaviors. These behaviors range
from a callous disregard for the rights and feelings of others to the most
heinous criminal acts. The dramatic case examples cited in the first chapter -
Kuklinski, Gacy, Dahmer, Bundy, Bianchi and Buono - illustrate the extent of
the pain and suffering that criminal psychopaths may cause. Violent
psychopaths such as these are callous and predatory. They have no
conscience and feel no guilt about their behavior. This makes them
extremely dangerous. Luckily, psychopaths such as those depicted in this
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study represent only a small percentage of criminals, perhaps 15 to 20
percent. Nevertheless these individuals are responsible for more than 50
percent of the serious crimes committed and the majority of violent crimes.
While the legal system has responded to psychopathic behavior with
more restrictive laws and more prisons, Psychology has yet to develop and
operationalize effective treatment or rehabilitation. Advances in this area
have been limited by the inability to integrate all of the knowledge currently
available concerning psychopaths into a cogent, insightful paradigm of the
truly disturbed nature of the psychopathic mind. The work of both social
scientists and clinicians has focused too primarily on the identification and
classification of psychopaths and too little attention has been given to
longitudinal studies that could delineate its etiology or comparative studies of
alternative treatment modalities.
Today, however, this picture is gradually beginning to change. Now,
thanks in large part to psychoanalytic theory, psychopathic clinical study and
research has begun to focus on juvenile delinquency, noting that the
development of adult psychopathic disorder likely has roots in childhood
development and impaired object relations. These manifest as aggressive
childhood behaviors that show a striking callousness and lack of concern for
others.
Contemporary Directions for Defining Psychopathy
In the earlier chapters I have examined how psychopathy evolved from
a morally neutral construct to a pejorative term equated with criminality. For
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the past several decades, contemporary psychologists and social scientists
have struggled to make this construct more precise. Cleckleys (1941) book,
The Mask of Sanity, was a major contribution to this effort that identified
many of the observable behaviors and characteristics of the psychopaths.
Cleckley the first to recognize that psychopathy was not limited to criminals or
psychiatric patients. Successful psychopaths might also be found among
the ranks of successful businessmen or politicians. The damage the
individual may cause to society may make the crimes of typical criminal
psychopaths pale by comparison.
Cleckley provided psychologists with a list of criteria for diagnostic
purposes. This increased the visibility and awareness of psychopaths and led
to an increased number of publications and research. Robert Hare extended
Cleckleys work, confirming that psychopaths are not delusional, psychotic, or
mentally ill in the traditional sense. He demonstrated that, unlike psychotic
individuals, psychopaths are completely rational and fully cognizant of their
behaviors, know why they were engaging in them, and are freely choosing to
do so. Hare operationalized his understanding by creating an instrument to
assess psychopathy, the Psychopathy Checklist - Revised (PCL-R).
Psychopathy vs. Antisocial Personality Disorder
Because of Cleckleys and Hares work, the term psychopath became
popular in both clinical and public domains. However, not all researchers use
Clecklys criteria and, as a result, there is a great deal of literature that is
131
incongruent because they purport to be measuring psychopathy yet when
examined more closely the criteria for inclusion is different across studies.
With the advent of the PCL-R, general agreement was beginning to
coalesce about what characteristics psychopaths displayed, but even today
psychologists and researchers are still far from reaching consensus regarding
the diagnostic criteria which best described the disorder. Despite the
controversy surrounding the Antisocial Personality Disorder construct as it
appears in the DSM-IV, and the suggestions of numerous psychologists
about the psychopathic personality, the APA field study team further
confounded an already disorganized psychological construct by ignoring the
advocates of those calling for separate diagnostic categories for psychopathy
and Antisocial Personality Disorder.
I agree with those (Meloy, 2001; Arrigo & Shipley, 2001) who would
call for the APA field study committee to include psychopathy as a separate
personality disorder, or at least in some way differentiated it from Antisocial
Personality Disorder, in the next version of the DSM. I believe this DSM
definition of psychopathy should include recommendations on how to assess
the disorder by using the PCL-R, with cutoff scores for mild, moderate, and
severe.
In my opinion there are compelling reasons why the next version of the
DSM really needs to address the issue of Antisocial Personality Disorder as
different from psychopathy. This must be done primarily to reduce or
eliminate the diagnostic confusion among clinicians who find it difficult to
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differentiate between the two terms. Unless psychopaths are accurately
identified they cannot be adequately treated. Because criminals, sociopaths,
and antisocial types have all incorrectly received the label of psychopath
confusion is generated regarding what appropriate treatment an individual
should receive. This confusion sometimes extends to treatment efficacy
studies because it confounds the subject inclusion criteria.
Despite the preponderance of research to the contrary, psychopathy is
still used interchangeably with other concepts such as juvenile delinquency,
antisocial behavior, sociopathy and criminality. Many psychologists and
social scientists refer to one of the terms, but are actually describing another.
In forensic settings, Antisocial Personality Disorder is amazingly over
diagnosed by psychologists, particularly when the patient continually acts out.
Thus, while social scientists and select psychologists may have become
familiar with the psychopathy nomenclature, the fact remains that the majority
of clinicians still have little understanding about the etiology of the disorder.
This is an area where psychologists should claim some responsibility, and
begin to educate themselves and other mental health clinicians.
How Better Diagnostic Criteria Can Help Treatment - Primary Prevention
Psychoanalytic theory has much to contribute to the study and
prevention of psychopathy, because it offers a comprehensive theory of
personality development and a rich terminology for describing personality
disorders. For example, Johnson and Szurek (Johnson & Szurek, 1952)
observed that the parents of adolescents transmitted their own poorly
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integrated id impulses to their children thorough conscious or unconscious
permissiveness or inconsistent parenting. Aichorn (Aichorn, 1935) identified
external factors, such as abusive parents, inconsistent parenting styles, or
separated parents that made adequate superego formation difficult or
impossible to achieve. Other contemporary writers have also argued that
there are identifiable developmental sequellae that form the foundation of the
psychopathic disorder which begins early in life. It may also be that there is
some biological predisposition to psychopathy that predisposes some
individuals with a heightened sensitivity to these negative developmental
pressures. If and when such organic correlates are identified they can be
added to the already know social environmental pressures as factors that will
help in the early identification of those predisposed to this disorder.
The problem of psychopathy needs to be addressed at three levels of
prevention. The first is primary prevention. That consists of the early
detection of those predisposed to the disorder and the application of some
treatment to prevent its initial manifestation. To accomplish this some sort of
early screening process is necessary. While the least expensive screening
process would only consider children who have demonstrated behavioral
problems, many of these would be detected only late in development and
those in lower socioeconomic levels would likely be less frequently identified.
A broad and early screening process would likely be more effective in
detecting the ongoing precipitants of this disorder while they have had only a
limited time to deform a childs ability to relate to others. Perhaps all children
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should be tested as part of their regular pediatric care with Mary Ainsworths
Strange Situation (Ainsworth, 1978). Children who are insecurely attached
could be identified and their parents offered parenting classes and individual
psychotherapy if they had attachment issues. The development of these
children could then be closely monitored and those who seem to be
developing early signs of oppositional or conduct disorders could be referred
to caregivers with special training in attachment disorders. At a minimum,
these children who might develop into psychopaths could be identified at an
early age and then be given various interventions that would help them
develop their conscience and feelings for others. Such treatments at an early
age would be much more effective and less expensive than treating
psychopathy and its consequences after it has fully developed. As primary
prevention, early identification and intervention of psychopathy is required in
order to counteract the predisposition and external factors of children in
chaotic families with incompetent parenting. If biological predispositions for
this disorder are eventually demonstrated, then perhaps there may one day a
medical intervention that can supplement psychological treatments.
Hopefully, interventions during childhood may effect change before
permanent adverse personality and behavioral patterns can manifest. If the
known precipitation condition for psychopathic personality disorders can be
reduced or eliminated, particularly in those children who are insecurely
attached, significant progress may be made in the primary prevention of this
disorder. However, implementing these recommendations will require an
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increase the priority American society gives to the care of children. The
chaotic family environment that fosters the development of conduct
disorders, juvenile delinquency, and ultimately psychopathy is difficult to
monitor without unpopular programs such as parental licensure. Yet, the
relationship between parents and children, particularly in infancy, is the most
important and critical to ego and superego development, the ability to
empathize, delay gratification, and modulate anxiety and affect. Societys
response, however, has been to build more prisons rather than address the
problem in its beginning stages of infancy and adolescence. Psychopaths
begin their destructive careers earlier than other offenders, and this behavior
is relatively stable across the lifespan (unlike prototypical antisocial
offenders, who experience a decline, or burn out effect, of their antisocial
behavior in their 30 - 40s), treatment interventions as early as possible are
critical.
Is such a reversal of Americas neglect of its children on the
foreseeable horizon? I believe it is. In terms of many social programs such
as universal health care and child care, the United States currently lags
behind the European democracies, however, in order to compete with them
it must continue to revise its public policies in the direction of their more
progressive stance.
Secondary Prevention
Secondary prevention of psychopathy involves preventing the
reoccurrence of its manifestations once it has initially occurred. This requires
136
gaining greater definitional clarity concerning these manifestations
themselves. The appropriate secondary prevention treatment requires an
intervention that is appropriate to the specific psychopathic behaviors
involved. Because psychopathic behaviors are quite variable, this may be
quite challenging. While the examples of psychopaths I presented in the first
chapter were high profile, dramatic, and extreme, many writers have
suggested that psychopaths may, in fact, exhibit unique symptomology
resistant to identification or classification by current standards of diagnosis.
While this study has focused on what some believe to be the only type of
psychopath (the violent psychopath) there may be and likely are different
kinds of psychopaths with different behavioral manifestation that require
different and specialized treatment interventions.
As an example of this diversity of psychopathic presentation, Millon
and Davis (Millon & Davis, 1998) described ten subtypes of psychopathy,
based on their premise that different people exhibit a wide variety of
psychopathic characteristics that stem from different life experiences.
Although they report many similarities among psychopaths, specifically a
marked self-centeredness and disdain for the needs of others (p. 161),
there are also a number of features that are sufficiently different to justify sub
classification. Mealey (Mealey, 1995) classified these into what he termed
primary and secondary psychopaths:
primary sociopaths are biologically contraprepared to learn

empathy and consequently demonstrate psychopathic
behaviour at an early stage, whereas secondary
sociopaths encounter a combination of risk factors such as
137
a large number of siblings, low socio-economic status,

urban residency, low intelligence and poor social skills.
These variables contribute to the development of
secondary sociopathy in a two-stage process involving
initially parental neglect, abuse, inconsistent discipline, and
punishment as opposed to rewards. In the second stage
children may be at a social disadvantage because of poor
social skills and may therefore interact primarily with a peer
group comprised other unskilled individuals, including
primary sociopaths (p. 534).
The idea that there may be different types of psychopathy may help
explain why there has been such difficulty in the development of the
concept, why there have been persistent problems in reaching agreement
about the assessment and diagnosis of the disorder, and why there has
been continuing difficulty in developing successful treatment programs.
Unlike other personality disorders, psychopathy may require different
treatment regimens depending upon the etiology of the disorder in particular
individuals (i.e. primary or secondary origins), as well as the type,
prominence and potential for danger that various classes of symptoms
present.
Psychoanalytic understanding of psychopathy has definitely been
enhanced by neurobiological research, and the current psychoanalytic
perspective is increasingly open to further neuroscientific evidence. Research
in this area has already led to the identification of brain functions that affect
certain cognitive and affective processes in psychopaths. While some
evidence for a genetic etiology of psychopathy has been postulated, this area
of study remains in its infancy.
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Table 14
Millon and Davis 10 Subtypes of Psychopaths_______

Type Description
The unprincipled psychopath This is similar to the DSM-IV Narcissistic

Personality Disorder. Behavior within
the law, and will not usually present for
clinical treatment. Generally, they exhibit
little integrity, have no social
conscience, and seemingly have no
superego functions. Their interpersonal
and family difficulties are projected onto
others, which makes their interactions
malicious and vindictive.
The disingenuous psychopath Make a superficial good impression, but

are ultimately seen as unreliable,
impulsive, and moody. This group is
similar to Histrionic Personality Disorder
in that they constantly seek attention
and excitement, and can use seductive
means to get what they want. They tend
to have shallow relationships and are
crafty and scheming.
The risk-taking psychopath If one suffers from this disorder, craving

for risk is common. Unlike other sub-
types, risk-taking psychopaths are not
highly motivated by material rewards.
They tend to act before thinking, behave
in an uncontrolled manner, and do not
take the consequences of their actions
into account.
The covetous psychopath This category is very similar to the DSM-

IV Antisocial Personality Disorder.
Those with the disorder feel that life
has not given them their due, so they
take that which they believe they have
been deprived. They exhibit acts of
theft or destruction and violate social
norms to compensate for perceived
inequities.
The spineless psychopath This category is similar to the avoidant

and dependent personality disorders,
being insecure and cowardly, but having
a desire to prove that they are not weak.
139
They become violent in order to
overcome their fear and to psychically
protect themselves against unconscious
fantasies. The view of
self is helplessness, being cornered,

empty, and fragile.
The explosive psychopath These people exhibit sudden,

unpredictable rage, often directed at
family members. They lose control
without provocation at perceived
mistreatment or resentments from
others who then must be destroyed.
The abrasive psychopath The characteristics of this disorder

include the purposeful antagonization of
others, and taking pleasure in the
degradation of them. They claim to be
highly principled, and will fault others for
taking opposing views. These principles,
however, obscure their hostile and
combative character.
The malevolent psychopath This category includes those who are

ruthless, particularly when they perceive
themselves to have been mistreated in
some way. These individuals are
suspicious of others and waste no time
punishing their betrayers without feeling
guilt or remorse. Many murderers are of
this type.
The tyrannical psychopath These individuals attack those they

perceive as weak, and this excites them
a great deal. These attacks are often
brutal, intending to make their victim
fear them. They often show no mercy,
and they seek submission in their
victims who are carefully selected to
ensure compliance.
The malignant psychopath Individuals in this category seek power,

and although they try to abuse other
people, it usually does not work. Their
140
abuse is usually met with retaliation,

which only serves to enrage them and
thus seek retribution.
Note: From "Psychopathy: Antisocial, Criminal, and Violent Behavior," by T. Millon,

E. Simonsen, M. Birket-Smith, and R. Davis, 1998. New York: The Guilford Press.
Nevertheless, it is possible for dynamically oriented formulations to
incorporate these findings into the existing theoretical understanding of the
psychopathic personality structure.
Physiologically Based Treatments for Secondary Prevention
The study of psychopathy, as psychology itself, has been assisted by
emerging technologies that permitted physiological research. Studies of
psychopaths have shown possible genetic and frontal lobe deficits. This work
needs to be expanded to determine if there are physiological causes of
psychopathy that may be treated biologically.
Presently, however, there are pharmacological interventions that might
be used in conjunction with analytic treatment. According to Lee (Lee, 1999),
the most common forms of medication used with personality disordered
patients are neuroleptics, antidepressants, lithium, benzodiazepines,
psychostimulants and anticonvulsants. These medications and their intended
effects are summarized in Table 15 below. Of particular interest, when the
danger of violent behavior is immediate, there seems to be a reduction of
arousal using the neuroleptics (Faulk, 1994; Lee, 1999). I would like to
greatly emphasize, however, that medication is only one possible aspect of
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treating psychopathy, and should be considered complimentary to analytic
psychotherapeutic interventions.
Psychodynamic Treatment Options
The most controversial aspect of psychopathy is whether or not those
with the disorder are amenable to treatment. Although psychopathy
treatment has been viewed as unsuccessful by some (Hare, 1996), other
researchers have found that certain theoretical approaches have been
successful in reducing some of the more flagrant psychopathic
characteristics, as well as a reduction in the rates of recidivism (Salekin,
2002 ).
Psychoanalytic interventions administered in proper doses, (i.e., four
times per week or more) fared much better in achieving those reductions
than other therapies. I would like to suggest that effective treatment is
possible, but given the current limitation of resources, both financial and in
adequately trained staff, administrators need to make a commitment to
address this in order to make any headway in the provision of treatment to
this difficult population. The question of cost inevitably becomes a factor in
developing a model such as this. Given the skewed relationship between
money and psychology, it seem highly unlikely that funding for such a model
will become readily available at any point in the near future; yet, it seems
imperative that attention be focused in this direction. If it is not society will
bear the alternative and inescapable cost of the damage these severely
disturbed individuals will do by the criminal acts.
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Table 15
Psychopharmacological Treatments
Drug Effect
Neuroleptics Tranquilizing effect on disturbed

behavior, tension, anger, and
hostility. Can also be administered
in crisis situations.
Antidepressants MAOIs have been used in

personality disordered Individuals to
reduce anger, impulsivity, and
interpersonal sensitivity. There are
serious side effects from MAOIs,
and they should only be used after a
failed trial of lithium.
Lithium Often used with psychopaths;

reduces impulsive, explosive, and
unstable behavior. Some are neither
impulsive nor undisciplined but they
often appeared well mannered and
socially appropriate, however, they
were inwardly calculating,
manipulative, and self-serving.
Benzodiazepines Helpful during episodes of severe

disturbance or overwhelming
anxiety; also for patients with history
of aggression and/or behavioral
problems.
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Table 15 (continued)
Psychostimulants Reduce feelings of tension and

dysphoria; useful when psychopathic
behavior is related to adult
development of ADHD; even if there
is not a direct relationship between
ADHD and psychopathy, the two
conditions share some overlapping
genetic component.
Anticonvulsants Behavioral dyscontrol exhibited by

psychopaths could be linked to a
disorder of the limbic system;
emerged from
electroencephalography (EEG)
studies of psychopaths. The
incidence of EEG abnormality is
thought to be highest in aggressive
psychopaths with violent histories
and explosive rage.
Note: From "The Treatment of Psychopathic and Antisocial Personality

Disorders: A Review," by J. Lee, 1999. Retrieved on October 23, 2003 from
http://www.ramas.co.uk.
Personal Clinical Experience with Psychopaths
In my experience, psychopaths in most involuntary settings are, for the
most part, unmanageable by the staff of psychiatric institutions. For
example, when asked to recommend treatment interventions for a
behaviorally disruptive psychopath who had coyly been found not guilty by
144
reason of insanity and placed on a ward of patients with profoundly
psychotic disorders, the suggestions offered by this provider was not
encouraging to the staff. I began by noting that the few effective treatment
interventions that had been found to be successful were not likely to work
within the construct of the therapeutic community paradigm and
psychopharmacological treatments available at the institution. The most
important contribution I was able to make was to suggest modalities of
treatment that likely would not work, or might exacerbate his symptoms.
Often when one can be of no positive benefit, one can at least prevent
further harm from being done. That is the point of Hippocrates first principle
of medicine, premium non nocere, first do no harm.
Difficulties Treating Psychopaths in Clinical Settings
Ineffective treatment models are not to be solely blamed for the
inability to cure psychopathy. Provider countertransference reactions to
psychopaths, their acting out behavior, their lack of remorse, and their
manipulative and conning scams also contribute to poor treatment
outcomes. Because of this there is a prejudice against this population within
the mental health field so that even a proper diagnosis of psychopathy is not
always used as a treatment recommendation, but is interpreted pejoratively
by clinicians. In typical clinical settings, psychopaths are generally rare.
Because of this there is staff are often ignorant of the characteristics of
psychopathy, and their implications for treatment and staff interaction.
145
Multidiciplinary teams, in my experience, are wholly unequipped to
handle a true psychopath in their midst. Such a circumstance often results in
arguments, splitting of staff, and staff being manipulated by the psychopath.
Sometimes staff unfamiliar with psychopathic behaviors will suggest
potentially dangerous interventions such as allowing the psychopath to
participate in groups with fragile and easily manipulated patients. Because of
the general lack of understanding of psychopathic behavior by many mental
health professionals who have not worked with them, I believe it is essential
that psychologists play a vital role in the education of other mental health
professionals concerning the characteristics and special treatment needs of
psychopaths in institutional settings. This would be better done through
outreach and direct teaching rather than through journal articles.
Psychologists should also participate more actively in research by applying
clinical case studies to the development of new assessment instruments.
They also have a responsibility both to their patients and to society to
investigate treatment interventions based on empirical and clinical knowledge
and to report these to others both informally and through journal articles.
Tertiary Prevention - A Need for Controlled Treatment Settings
Tertiary prevention is the amelioration of an already chronic condition
so that its ongoing symptoms are significantly reduced. This can occur even
though the underlying illness cannot be cured or eliminated entirely. In terms
of the criminal psychopathic populations who are housed in the prison system
or locked mental facilities, the goal would be reducing the behaviors which
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make them difficult to control by staff and difficult to associate with by fellow
prisoners.
For tertiary prevention, I believe that there should be more
experimental treatment settings. These could be specialized units where
psychopaths can be placed to help further research. They would be located
both in the prison system and in specialized inpatient units in large mental
hospital settings. Having a number of these units in a coordinated and
centrally funded research program under federal sponsorship would go a long
way toward making a beginning to systematically investigating the treatment
options for this illness. Unless such a coordinated effort is established, the
diversity of this population and the complexity and duration of the treatment
they require is likely to frustrate any local or piecemeal attempts to examine
treatment alternatives. Since the goal of tertiary prevention is to allow these
psychopaths to be managed well in confinement thereby reducing staff
problems, there should be ample financial justification for this type of
research. What appears to be needed is some initial evidence that tertiary
prevention has financial benefits, followed by a funding request for a
comprehensive tertiary prevention research program within the federal prison
system.
An example of what might be done in tertiary prevention is Gunns
(1988)(1998) recommended that treatment focus on the select symptoms of
psychopathy such as grandiosity or manipulativeness, within the context of
the specialized units staffed with professionals trained to work with
147
psychopaths. The goal would be to reduce the frequency and severity of
particular symptoms. When enough symptoms were reduced, treatment
could focus on making these individuals aware of their underlying
psychodynamic conflicts.
Certainly developing a experimental therapeutic units such as that
would be costly, require time to establish, and have to recruit and retain train
staff knowledgeable about and dedicated to working with this difficult
population. The impetus for such an experimental program of tertiary
prevention with psychopaths is unlikely to come from the federal prison
management bureaucracy since they lack the confidence that such a
program will be effective. I believe that psychologists who have the expertise
in developing and scientifically validating new treatment alternatives should
be at the forefront of developing effective treatment modalities. In particular,
the American Psychological Association should strongly support this type of
research and lobby for it on a national level. Access to mental health
treatment should be the right not just of those who society favors, but also of
those who are locked away in the prisons because of the consequences of
their mental illness.
Other Psychopathic Populations
Although I mentioned psychopathic females only briefly in this study,
there is limited body of psychological literature that considers this particular
population. The trend seems, at least from my experience and conversations
with other clinicians, to diagnose psychopathic females with Borderline
148
Personality Disorder. This is somewhat an artifact of the present DSM for
Antisocial Personality Disorder which appears biased towards males since it
has as criteria behaviors that are less uncommon among women.
Perhaps the population of psychopaths receives the least attention
from psychologists are those psychopaths that reside in the general public,
individuals who are cunning and manipulative enough to avoid legal
involvement. Cleckley was the first to suggest that psychopathy was often
prevalent in the community and need not manifest as criminal behavior. To
describe this, he coined the term successful psychopath for those people
who achieve positions of power because of their psychopathic personality
traits. Hare (1993) also opined that politicians, doctors, lawyers, and even
university students could be psychopaths. He called these white collar
psychopaths, since they were intelligent and adept at manipulating others
without actually breaking the law. Hare estimated that 1% of the population
are white collar psychopaths, however, my experience suggest this is an
underestimation. It is ironic, then, that Antisocial Personality Disorder is so
heavily behaviorally weighted and used interchangeably with the psychopathy
construct when, in fact, it is least representative of the original concept.
Successful Psychopaths
This widespread misunderstand of the true prevalence of psychopathy
illustrates the need for further research to differentiate the variety and types
of psychopathy. By the 5th edition of his book, The Mask of Sanity, Cleckley
149
(1976) had already envisioned the dichotomy between the obvious and
hidden psychopaths when he said:
The true difference between them (white collar psychopaths)

and the psychopaths who continually go to jails or to
psychiatric hospitals is that (the former) keep up a far better
and more consistent outward appearance of being normal.
This outward appearance may include business or
professional careers that continue in a sense of successful,
and which are truly successful when measured by financial
reward or by the casual observers opinion of real
accomplishment. It must be remembered that even the
most severely and disabled psychopath presents a technical
appearance of sanity, often one of high intellectual
capacities and not infrequently succeeds in business or
professional activities for short periods, sometimes for
considerable periods (p. 191).
There are only a few studies, however, that examine the psychopathic
disorder in the general population. Most research has been done almost
exclusively using forensic samples. While this concentration of focus on the
criminal psychopath has increased psychological knowledge of the extreme
and obvious manifestations of this disorder, it has at the same time limited
our knowledge of the full spectrum of the psychopathic condition. Additional
research is called for on successful psychopaths because the damage they
do, while generally less dramatic, is often just as pernicious and certainly
more widespread than their better known criminal counterparts.
In one of the few studies done on successful psychopaths, Salekin,
Trobst, and Krioukova (2001) found that psychopaths in the community might
be able to delay gratification when it suit them in order to continue their
behavior successfully without legal intervention. In other words, they might
be able to adapt their behavior to avoid legal involvement or even to learn
150
from experience. This would be considerably different from the criminal
psychopath who is generally so impulsive that he is unable to avoid being
captured.
I believe these successfully psychopaths are far more dangerous to
society than the violent psychopaths already incarcerated or in psychiatric
hospitals, since their potential damage to the general public is much greater.
Thus, there is an immediate need to focus more research and clinical
attention on screening for psychopaths in outpatient settings. This may help
detect these dangerous people before their behavior causes harm or
escalates into acts of violence.
Successful psychopaths differ from violent psychopaths in many
ways. First, there is a difference between the type of violence perpetrated by
psychopaths and successful psychopaths or nonpsychopaths (Meloy 1988;
Hare, 2003). Psychopathic violence is more likely to be predatory, or
instrumental, since it is usually motivated by an internal desire to obtain an
object or goal. The act is often callous and calculated with little or no emotion.
Psychopaths of this type often elicit that piloerection response in therapists,
and dynamically, their violent behavior may represent an attempt to dominate
or control.
Second, in contrast to successful psychopaths the victims of violent
psychopaths are usually not friends or family members, since they tend to be
unable to maintain long lasting relationships. Many murders and assaults
committed by nonpsychopaths have occurred during a domestic dispute or in
151
the heat of the moment with females that they knew. By contrast, a violent
psychopaths victims are usually males that they do not know, with revenge or
retribution as the motive. This excites them and makes them feel powerful,
and inflates their self esteem.
Because these types of psychopaths are so different, simply
identifying an individual as a psychopath has limited utility with respect to
treatment. It is necessary to differentiate between the successful or white
collar psychopath and the more violent psychopath. How can this be done?
The white collar psychopath would likely present with higher scores on
Factor 1 of the PCL-R while the violent psychopath would score higher on
factor two. While both would have certain symptoms of psychopathy their
treatment goals would be dramatically different. A problem with previous
research has been a failure to distinguish between these two populations
when setting inclusion criteria for subject participation. Thus, in many of the
studies previously discussed, particularly those relying on PCL-R cutoff
scores for inclusion in treatment groups, an treatment intervention has been
administered to two very different types of psychopaths each of which
required a different treatment approach. I believe that violent psychopaths are
more amenable to cognitive behavioral therapies in which their acting out and
impulsive behavior can be addressed, while the more narcissistic, shallow,
and manipulative psychopath would benefit from psychoanalysis targeting
superego deficits.
152
Considerations for Forensic Psychologists
Forensic psychologists have additional factors to consider in the
assessment, diagnosis, and treatment of psychopathy. Research on
psychopathy and the PCL-R have played a huge role in the assessment of
sexually violent predators (SVPs), have influenced civil commitment laws in
many states, as well as informed public policy. Using the PCL-R has shown
that a high proportion of rapists that are psychopaths. This has been used to
validate the connection between psychopathy and callous, instrumental
violence. Because of this, there is public perception that there is more
diagnostic clarity than is often the case. Psychologists must be sensitive to
this misperception and when necessary try to educate the public and the
professionals who deal with this population on the complexity of both
diagnosis and treatment issues. In particular, extreme care must be accorded
to all diagnoses. As Shipley (2001) recommended:
Forensic psychologists must also be aware of their own biases and
sensitive issues when confronted with this type of client. A diagnosis of
ASPD or psychopathy must not be found arbitrarily based on a therapists
countertransference with a difficult client. This is a label that can have
important and damaging implications that could follow the offender for life. A
psychological evaluation of an offender for a parole hearing that includes
ASPD or psychopathy can decrease the chances of early release (p. 360)
153
Conclusion
Successful treatment interventions will require a collaborative process
between psychologists, social scientists, and policy makers, in order to
implement actual clinical programs that develop from empirical investigations.
To date, there have been few programs developed from theoretical models or
from suggestions made in research studies. For this work to begun
professional organizations of those concerned with this issue must make an
effort to educate the public and lobby lawmakers regarding the need for a
coordinated, sustained program of treatment development for individuals
afflicted with this disorder.
With Meloy (1988) and Kernberg (1989) I am doubtful whether
severely disturbed psychopaths can benefit from the current treatment
approaches. Hopefully new alternatives will become available for this
population at some point in the future. Within the spectrum of psychopathy
there is considerable variability of symptomology with some individuals and
some symptoms being more amenable to interventions. This seems
particularly true of fledgling psychopaths, or delinquent children. Many have
made strong arguments that helping children develop sufficient ego and
superego functions could prevent the later development of psychopathy yet
there is no organized movement toward developing the comprehensive
prevention and treatment programs that are required. Instead, clinical
attention has bee focused largely on the identification and classification of
adult psychopaths.
154
Future research needs to focus on characterizing how non-criminal
psychopaths are different from criminal psychopaths. Comparing these two
groups may provide a better explanation of the disorder and its etiology. Until
this is achieved successful treatment options, however well funded, are likely
to have only marginal success. Treatment is often most effective if it takes
place in either the earlier stages of a disorder or when the disorder has not
developed to its fullest potential. Thus, treatment programs oriented toward
children and program for those successful psychopaths who remain among
us in society at large may provide clues on how to help those most seriously
affected with this disorder. Future research should attempt to determine what
factors distinguish the psychopaths in the community from those in forensic
settings. Knowing this would be the key to successful secondary and tertiary
prevention programs.
This study has identified the large gaps that exist in the psychological
understanding of this disorder. It has reviewed the literature on the genetic,
psychodynamic, neurological, biochemical and sociocultural factors that may
play a role in its development I have argued that there is a compelling and
urgent need for additional research to prevent and ameliorate this disorder
and that such research must be carried out in a comprehensive, systematic
manner. To do this will require a public commitment that hopefully will arise
when there is better understanding of the suffering of both those who are
afflicted by disorder and their victims.
155
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UNDERSTANDING THE CRIMINAL MIND:

PSYCHOANALYTIC PERSPECTIVES REGARDING THE

ETIOLOGY AND TREATMENT OF MALE VIOLENT PSYCHOPATHS

Presented to the Faculty of

The California School of Professional Psychology

San Francisco Bay Campus

ALLIANT INTERNATIONAL UNIVERSITY

Of the Requirements of the Degree

Louis D. Monaco, M.S.

All rights reserved.

ProQuest Information and Learning Company

PSYCHOANALYTIC PERSPECTIVES REGARDING THE

ETIOLOGY AND TREATMENT OF VIOLENT PSYCHOPATHS

Clinical Dissertation Committee:

Christopher D. Tori, Ph.D.

Murray Btfmes, Ph.D.

All Rights Reserved

throughout the years.

cried, and laughed with me.

I thank all of my professors and clinical supervisors at San Francisco State

possibility to achieve all that I aspire to.

this study, and for helping me to create a better dissertation.

psychopaths, and for agreeing to be a part of my dissertation committee. This

dissertation is dedicated to her memory.

through the final phases of the dissertation and defense process.

I. Statement of the Problem.................................................................................... 1

II. Psychopathy: A Brief History.............................................................................. 16

III. Assessment and Diagnosis: Antisocial Personality Disorder

IV. Psychoanalytic Theories about Psychopathy............................................... 52

V. Biological Contributions to Psychopathy...........................................................89

VI. Treatment of Psychopathy.................................................................................97

VII. Conclusion.......................................................................................................... 119

1. Hares ChildhoodSigns of Psychopathic Behavior......................................12

2. Brief History of How Psychopathy has been Understood.......................... 17

3. Kraeplins Psychopathic Categories.............................................................. 28

4. Cleckleys Psychopathic Categories............................................................... 30

5. Hare Psychopathy Checklist-R Factor Items and Descriptions...................49

6. Childhood Experiences of Psychopaths......................................................... 63

7. Meloys Defensive Structuring of the Psychopath......................................... 76

8. Kernbergs Classification of Personality Disorders

9. Kernbergs Antisocial Personality Disorder Symptoms............................... 82

10. Meloys Psychopathic Personality Organization........................................ 85

11. Martens Biological, Psychological, and Social Determinants of

12. Strasburgers Countertransference Responses in Working with

13. Meta-analysis Results for Psychopathy Intervention Studies....................115

14. Millon and Davis Ten Types of Psychopaths.............................................. 138

15. Psychopharmacological Treatments.............................................................142

Statement of the Problem

Why has this man done these terrible things? Because he is a

Psychopathy was the first personality disorder identified and described

and contradictory implications to describe the personality organization and

behavioral characteristics of those who behave impulsively, violently, and

without remorse. The terms psychopath, sociopath, or psychopathic inferior

moral, religious, and behavioral aspects of the disorder demonstrates the

complexity of the historical evolution of this construct.

Regarding the label itself, the diagnostic criteria and classification of

psychopathy has been, and remains to a large degree, uncertain. Today,

there is confusion about the relationship between the D S M -IV Antisocial

Personality Disorder diagnosis and the construct of psychopathy as first

defined in 1941 by Cleckley (Table 4) and later researched and quantitatively

measured by Hare (Arrigo & Shipley, 2001).

societal problems caused by the psychopaths behavior. For example,

prisoners in the United States), it is surprising that an understanding of