The Clinical and Forensic Assessment of Psychopathy

A Practitioner's Guide

Carl B. Gacono, Carl B. Gacono

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317654391
• Edition: 2
• Topic: Psychology
• Subtopic: Research & Methodology in Psychology
• Index: Psychology

This newly revised edition to The Clinical and Forensic Assessment of Psychopath: A Clinician's Guide brings new chapters on psychopathy in women, brain imaging, assessment and treatment in schools, and more, in addition to the updated original chapters. With its in-depth research on psychopathy, accumulating findings from over the past 40 years and applying them to procedures and methods, it is essential for all of those who face mental health, correctional, or court settings. This edition is an excellent resource for experienced professionals and their trainees, as well as students who need a go-to book between the research and practice on the assessing of psychopathy.

I

Conceptual Contributions

1

Introduction

Carl B. Gacono

Psychopathic disorders have occurred in most societies throughout time, with some cross-cultural variation (Cleckley, 1941/1976; Cooke, 1998). Cleckley (1941/1976) identified the Athenian general of the fifth century BC—Alcibiades—as a prototypical psychopath. He was charming and manipulative, and his behaviors were reckless, impulsive, and violent (Cooke, 1998). In describing antisocial personality disorder, Robins, Tipp, and Przybeck (1991) noted, “it occurs and is recognized by every society, no matter what its economic system, and in all eras, showing that it is not purely an indication of a modern ‘sick’ society” (p. 259). Consequently, labels for psychopaths exist in most cultures (Cooke, 1998; Murphy, 1976). For example, the word Kunlangeta, in the Inuit (Northwest Alaska) community, describes:

a man who … repeatedly lies and cheats and steals things and does not go hunting and, when the other men are out of the village, takes sexual advantage of many women—someone who does not pay attention to reprimands and who is always being brought to the elders for punishment.

(Murphy, 1976, p. 1026)

In rural Nigeria, the term Aranakan describes an individual who, “always goes his own way regardless of others, who is uncooperative, full of malice, and bullheaded” (Murphy, 1976, p. 1026). As noted by Cooke, “Like the poor, psychopaths have always been with us” (1998, p. 13).

The North Atlantic Treaty Organization Advanced Study Institute (NATO ASI) conference in Alvor, Portugal, held from November 27 to December 7, 1995, confirmed the immense international interest in psychopathy. Eighty-five participants from 15 countries met to share research findings on what was then the current state of psychopathy (Cooke, Forth, & Hare, 1998; Gacono, 2000a). Participants were informed of “What we currently know” and challenged concerning “What we yet need to learn” (Gacono, 2000a).

Although it was exciting to discover that the majority of the NATO countries shared similar conceptualizations of psychopathy (Cooke et al., 1998; Cooke, Forth, Newman, & Hare, 1996), this was not always the case. As described by Hare (1998a, p. 1):

The participants at Les Arcs [1975 ASI psychopathy conference, France] … operated from a variety of conceptual frameworks and agendas … The result was a considerable amount of armchair speculation and uniformed debate, but few productive discussions about the nature of psychopathy … like an invitation tennis tournament in which half the participants played ping pong or squash, but who either thought they were playing tennis or argued that it didn’t really matter because everyone was hitting balls.

See Hare and Schalling (1978).

The Alvor ASI research supported the cross-cultural applicability of the construct of psychopathy, suggesting the existence of a personality as distinct and uniform as that of, say, a primary color. Whereas there are, for example, many shades of blue, no shade of blue is likely to be mistaken for red. Likewise, there are many forms of antisocial personality trait and aberrant behavior, but none matches the unique constellation of both traits and behaviors found in psychopathy. The consensus among the NATO countries could be directly attributed to the development of the Psychopathy Checklists (Hare, 1991, 2003) and their ability to measure psychopathy in a reliable and valid manner (Hare, 1998b). By using a PCL-R total score > 30 for assigning a categorical designation of psychopathy, researchers created a common language that allowed for direct comparisons of findings across research groups and across cultures. Barring other methodological errors in their study (Gacono & Gacono, 2006), whenever researchers used this cutoff score, clinicians could be assured that the results related to the same syndrome.

The Hare Psychopathy Checklist—Revised (PCL-R) provided a method for differentiating among individuals based on their level of psychopathy (see Chapter 8).¹ Behaviorally, high PCL-R scores are associated with higher rates of violent and nonviolent offending, a greater variety in the types of offense committed, higher recidivism rates, and poorer treatment response (Ogloff, Wong, & Greenwood, 1990; Rice, Harris, & Cormier, 1992), as well as institutional misbehavior (Gacono, Meloy, Sheppard, Speth, & Roske, 1995; Gacono, Meloy, Speth, & Roske, 1997; also see Chapter 8). These findings remain stable, even when culture, gender, and the presence or absence of a major mental disorder are controlled (Cooke et al., 1998).

Psychopathy, however, is more than a sum of traits and behaviors. Rorschach findings have elucidated the dynamics of the psychopath’s “inner world” (Gacono, Evans, Kaser-Boyd, & Gacono, 2008; Gacono & Meloy, 1994; Meloy & Gacono, 1998). Consistent with Kernberg’s (1975) formulations, male psychopaths emerge as a highly aggressive and emotionally detached variant of a narcissistic personality organized at a borderline level of functioning (Gacono, 1988, 1990; Gacono & Meloy, 1991; Gacono, Meloy, & Heaven, 1990). By contrast, the female psychopath emerges as displaying a malignant form of hysteria organized at a borderline level (see Chapter 9; Cunliffe & Gacono, 2005, 2008; Smith, 2013). Rorschach findings have also contributed to understanding sexual homicide perpetrators (Gacono, Meloy, & Bridges, 2008; Meloy, Gacono, & Kenney, 1994), pedophiles (Bridges, Wilson, & Gacono, 1998; Gacono, Meloy et al., 2008), and schizophrenic psychopaths (Gacono & Meloy, 1994). Equally important, the PCL-R is also much more than a tool for assessing psychopathy or risk assessment: it is also useful for making diagnostic formulations and facilitating treatment planning (Chapter 12).

The publication of the first edition of The Clinical and Forensic Assessment of Psychopathy: A Practitioner’s Guide (Gacono, 2000a) was a direct result of the 1995 Alvor ASI Conference. Prior to that time, its clinical emphasis would not have been possible. Since Alvor, many questions have been answered, and new ones have emerged. Although the past 15 years have witnessed an outpouring of psychopathy research, one disturbing byproduct of this growth has been the publication of many poorly designed studies that, rather than enhancing our understanding of psychopathy, have created confusion. Seemingly discrepant findings are often the product of flawed study design. On the 20-year anniversary of Alvor, this second edition brings readers up to date on the thinking and research of the leading authorities. This introductory chapter discusses key issues essential to understanding psychopathy and in interpreting research findings in this text and elsewhere.

Sociopathy, Antisocial Personality, and Psychopathy

Evolving from Pinel’s first clinical observations, through Cleckley’s refined criteria and the empirical rigor of Hare, the theoretical object relations understanding of the psychopath’s “inner life” (Meloy & Gacono, 1998; Meloy, 1988; Gacono & Meloy, 1994), and the use of empirical measurement to flesh out the inner dynamics of the psychopath (Gacono & Meloy, 1994, 2009), each step has refined, added to, and clarified our understanding of psychopathy. Antisocial syndromes, and particularly psychopathy, have enjoyed more attention and research than any other character disorder. Yet, despite a wealth of published research (Hare, 1966, 1996, 1998a, 1998b), terms such as sociopathy, antisocial personality disorder (ASPD), and psychopathy are often inappropriately viewed as synonymous (Losel, 1998; Millon, Simonsen, Birket-Smith, & Davis, 1998). Originating from separate theoretical lines, these constructs manifest empirically measurable and clinically relevant differences.

Sociopathy (American Psychiatric Association [APA], 1952) and ASPD (APA, 1994, 2013) are terms used in various editions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). Lacking contemporary clinical meaning, sociopathy was used in the first DSM (APA, 1952) to describe a variety of conditions such as sexual deviation, alcoholism, and “dyssocial” and “antisocial” reactions. Characteristics of the Cleckley (1941/1976) psychopath were most visible in the “antisocial reaction” criteria. ASPD replaced sociopathy in the DSM-II (APA, 1968), and many of the traditional psychopathy characteristics disappeared from ASPD in the DSM-III (APA, 1980). Subsequent versions of the DSM (APA, 1980, 1987, 1994, 2013) have reflected the influence of a social deviancy model (Robins, 1966) through their continued reliance on behavioral criteria.²

Unlike ASPD, psychopathy comprises both trait and behavioral criteria (Cleckley, 1941/1976; Hare, 1996; Meloy, 1988; see Table 1.1). As measured by the Psychopathy Checklists (Forth, Kosson, & Hare, 2003; Hare, 1991, 2003; Hart, Cox, & Hare, 1995), psychopathy contains two stable, oblique factors. The first factor, “callous, remorseless use of others” (Factor 1), is characterized by ego centricity, callousness, and remorselessness, and correlates with narcissistic and histrionic personality disorders, low anxiety, low empathy, and self-report measures of Machiavellianism and narcissism (Hare, 2003). The second factor, “antisocial lifestyle” (Factor 2), represents an irresponsible, impulsive, thrill-seeking, unconventional, and antisocial lifestyle and correlates most strongly with criminal behaviors, lower socioeconomic background, lower IQ, less education, self-report measures of antisocial behavior, and the diagnoses of CD and antisocial personality (Hare, 1991, 2003). Although most criminal psychopaths meet criteria for ASPD, the majority of ASPD individuals are not psychopaths.

Table 1.1 Psychopathic Traits and Behaviors (Hare, 1980; Hare, Harpur, Hakstian, Forth, Hart, & Newman, 1990)

*1.	Glibness/superficial charm
*2.	Grandiose sense of self-worth
	+3. Need for stimulation/proneness to boredom
*4.	Pathological lying
*5.	Conning/manipulative
*6.	Lack of remorse or guilt
*7.	Shallow affect
*8.	Callous/lack of empathy
	+9. Parasitic lifestyle
	+10. Poor behavioral controls
11.	Promiscuous sexual behavior
	+12. Early behavioral problems
	+13. Lack of realistic long-term goals
	+14. Impulsivity
	+15. Irresponsibility
*16.	Failure to accept responsibility for own actions
17.	Many short-term marital relationships
	+18. Juvenile delinquency
	+19. Revocation of conditional release
20.	Criminal versatility

Note: * PCL-R Factor 1 Items; + PCL-R Factor 2 Items.

In the past decade, the PCL-R’s two-factor structure has been further divided into four facets—affective, interpersonal, lifestyle, and antisocial—which have important implications for subtyping and treatment planning (see Chapters 2 & 8; Hare, 2003). Similar to the facets, the item clusters and item groups used in the Clinical and Forensic Interview Schedule (CFIS) for the Hare Psychopathy Checklist: Revised and Screening Version (Gacono, 2000b, 2005) and Youth Version (Gacono & Hughes, unpublished) yield interpretative value while aiding in the rapid, accurate administration and scoring of the Psychopathy Checklists.

Caveats for Understanding and Evaluating Psychopathy Research

Understanding that “psychopathy” can be conceptualized in both a dimensional and categorical (taxon; PCL-R ≥ 30) manner is essential to understanding research findings (Gacono, 2013; Gacono & Bodholdt, 2001; Gacono & Gacono, 2006). Research findings can be obscured when authors make categorical inferences (discuss psychopathy; PCL-R ≥ 30) from studies utilizing dimensional research designs (e.g., correlations of behavior with total PCL-R scores; and/or absence of a psychopathic group, > 29 scorers).

Dimensional uses of psychopathy are particularly relevant to clinical usage. Clinically, one is more interested in determining what ranges of PCL-R scores are best at predicting behavior than whether the individual meets the threshold score for a designation of psychopathy (Bodholdt, Richards, & Gacono, 2000; Gacono & Bodholdt, 2001). The VRAG and SORAG (Quinsey, Harris, Rice, & Cormier, 1998) are examples of forensic instruments that use differing PCL-R cutting scores as part of a “weighted” formula for predicting violence and sexual violence risk. In the VRAG and SORAG, PCL-R scores, rather than a diagnosis (category), become one of several factors in decision-making.

For research purposes, our understanding of psychopathy (category) is enhanced when groups of psychopaths (PCL-R ≥ 30) are compared with groups of non-psychopaths (PCL-R < 30) or, at minimum, when there are sufficient numbers of PCL-R ≥ 30 scorers in a given study. What might seem obvious—to make inferences about psychopathy, a study must have psychopaths in it—is frequently overlooked. Two common research procedures that can create samples without psychopaths involve using the PCL:SV or a self-report measure for creating a “psychopathic group,” and/or lowering PCL-R cutoff scores to form a “psychopathic” group (Gacono & Gacono, 2006).

Another potential research error occurs when the PCL:SV is used to designate a subject as psychopathic. It is not a substitute for the PCL-R. Unlike the PCL:SV, the PCL-R allows for a categorical designation of psychopathy (PCL-R ≥ 30). Although the PCL:SV is appropriate for examining relative differences within a given sample, when used as an independent measure for forming “psychopathy groups,” it may tarnish findings, because it can be difficult—or impossible—to determine how many actual psychopaths were in the study.

A similar, yet stronger, argument can be made for the use of self-report measures of psychopathy (Lilienfeld & Andrews, 1996). These instruments suggest that individual traits (dimensional—inherent in any one of a number of disorders and non-disorders) are individually psychopathic (category). In reality, a designation of psychopath is appropriate only when a sufficient number of individual traits are fully present. It is the aggregate of traits, rather than an individual trait, that determines the presence of psychopathy. With some exceptions, self-report measures assess “traits” or dimensions, as opposed to “categories” (presence of a psychopath). Mislabeling traits such as self-centeredness, impulsivity, impaired empathy, and irresponsibility as inherently “psychopathic” returns psychology to the pre-1900s trend of including all personality disorders under the rubric of psychopathy. Even established self-report measures, such as the MMPI-2, are not appropriate for establishing psychopathic groups (Hare, 1991, 2003).

A related concern involves lowering PCL-R cutoff scores to form a “psychopathic” group. Researchers do this for one reason—their samples do not contain sufficient numbers of actual psychopaths (PCL-R ≥ 30). Although this can be part of an acceptable research design, the author(s) must refrain from making inferences about psychopaths (category) when they have few, if any, psychopaths in their sample. When lowered PCL-R cutoff scores are used to establish groups, the best that can be inferred is relative differences among high versus low scorers only within that sample.

Clearly, the methods used for creating a psychopathy group have a direct bearing on the types of inference that can be made; moreover, these methods are critical ...