The Psychopath Whisperer: The Science of Those Without Conscience (7 page)

Koch was also one of the first to insist that to assess psychopathic traits one has to consider the entire life history and all facets of an individual’s life in order to get a complete picture of how the symptoms manifest themselves. This critical piece of the puzzle has shaped much of how we currently assess psychopathic traits in
forensic settings. Koch’s diagnostic criteria were very popular and were included in the eighth edition of Emil Kraepelin’s classic textbook on clinical psychiatry.
¹⁴

Even though Koch’s
psychopastiche
narrowed the term from the vast population of those criminals with moral insanity, it was still a broad construct that was indicative of a generic label for all personality disorders. The so-called German School of psychopathy expanded the category to include people who hurt themselves as well as others, and in the process of broadening the definition seemed to lose sight of the moral disability that was central to the condition.

By the 1920s, psychiatry was using the word
psychopath
to include people who were depressed, weak willed, excessively shy, and insecure—in other words, almost anyone deemed abnormal. For example, in one of my favorite movies,
Changeling
, a tragic true story set in 1928, Christine Collins (played by Angelina Jolie) is incarcerated in the “psychopathic ward” for her emotionality associated with repetitive challenging of the police’s treatment of the case of her missing son.

Up to this point in time, the construct of psychopathy had been grounded in Koch’s physical or biological basis. This view soon collided with the emerging behaviorist era in psychology. Behaviorists believed the human brain was a blank slate at birth and all processes, even psychopathic traits, were formed through social forces.
¹⁵
The term
sociopathy
was introduced in the 1930s and signified the origin of psychopathic traits from social causes. One of the problems with the diagnosis of sociopathy was that it was too broad and encompassed far too many individuals. Literally every criminal met criteria for the condition. Another unfortunate consequence has been that the term
sociopathy
has been confused with
psychopathy
ever since.

Sociopathy and psychopathy are very different. Sociopathy includes a broad, heterogeneous category of individuals who act antisocially, the causes of which are believed to be social and environmental
in nature.
Psychopathy
is a term grounded in biology and genetics and is truly agnostic to causes or etiology. In other words, genetics and the makeup of the brain, as well as environment, contribute to the construct of psychopathy. Although the term
sociopathy
is
not
used in modern academic circles to mean “psychopathy” anymore, some people continue to confuse the terms.

The first formal meeting on psychopathy was organized by forensic psychiatrist Ben Karpman (1886–1962) and held at St. Elizabeth Hospital in Washington in 1923. Karpman felt that because of psychologists’ general lack of knowledge of the field, the question of psychopathy’s origins (nature vs. nurture) should be held open until the exact symptoms of the condition were clarified. German, English, Italian, and American scientists came together at the meeting to develop the first comprehensive set of symptoms to characterize psychopathy.
¹⁶
One central theme was that psychiatrists were constantly surprised by the behavior of psychopaths. Psychopaths were smart, and it baffled psychiatrists that they are unable to use that intelligence to control their behavior.

I often refer to psychopaths as a
walking oxymoron
: they say one thing and do another. Clinicians in the early days of psychiatry were mystified, confused, even stymied by the repetitive self-defeating behavior of psychopaths once they left the confines of the psychiatrist’s office, mental ward, or prison cell. Psychiatrists felt that psychopaths should simply learn from their bad outcomes (divorce, bankruptcy, arrests, conflicts with parents, siblings, and friends) and not repeat their poor decision making. But, to the chagrin of those conducting psychotherapy, psychopaths rarely if ever changed their pattern of behavior once they left the psychiatrists’ couches.

The psychoanalytic school of thought, founded by Sigmund Freud (1856–1939), dominated much of the early twentieth century. Freud argued the psyche could be divided into the id, the ego, and the superego. The superego is supposed to develop as a result of the Oedipal conflict—a conflict that arises in a boy’s unconscious desire to sexually possess his mother and kill his father. A normal superego puts the brakes on impulses and aberrant sexual behavior. If the psyche is damaged or poorly developed, it lacks the ability to suppress the id (instinctual drives), and antisocial behavior is the result.

Psychodynamic thinkers wrote that psychoanalytic treatment of psychopaths was never successful. Indeed, the psychopath’s ego was fed by the therapist’s interest in him. Thus, while trying to treat the psychopath, many psychodynamic therapists found the psychopath only got worse and more egocentric.

This belief carries through to popular culture today. For example, after years of performing psychotherapy on the fictional mafia figure Tony Soprano (portrayed by James Gandolfini) on the American HBO hit television show
The Sopranos
, his therapist declared that she had finally figured out that Tony was an incurable psychopath and so she quit treating him.

Psychopaths are resistant to psychodynamic treatment, in part because they typically don’t feel there is anything wrong with them; they are rarely interested in participating in therapy or changing. Consequently, psychodynamic therapy was not very successful with psychopaths, and that led to the pervasive view that persists today that psychopaths are untreatable.
¹⁷

Freud’s psychodynamic theory in general and psychoanalytic treatment in particular quickly fell under heavy criticism when it was pointed out that it was not a theory at all; that is, psychodynamic theory does not make any predictions, and hence does not have any testable hypotheses.

It was American psychiatrist Hervey Cleckley (1903–1984) who changed the face of psychopathy research with his masterpiece
The Mask of Sanity
, first published in 1941.
¹⁸
Cleckley sought to clarify
the construct of psychopathy from other incantations of the disorder and to provide the psychiatric community with a treatise on the condition using a plethora of case studies. From these case studies, Cleckley gleaned sixteen criteria that formed the basis for the modern assessment of the condition. In elegant, magnificent prose, Cleckley educates the reader about the symptoms and makeup of psychopathy. Cleckley’s criteria, listed in Box 1, are consistent with the historical traits identified by his predecessors but contain much more detailed analyses and refinement. In four subsequent editions of
The Mask of Sanity
, covering nearly fifty years of clinical experience, Cleckley continued to refine and illustrate psychopathy as we know it today.

It is impossible to overstate the value of Cleckley’s contribution to the field of psychopathy. The multiple editions of
The Mask of
Sanity
revolutionized our understanding and classification of the disorder.

Beginning in the mid-1970s, some clinicians began to rethink a working clinical definition of
psychopathy
. Based on Cleckley’s published criteria, Dr. Robert D. Hare (1934–) and his students developed a clinical rating scale for the assessment of psychopathy.

The first version of the Psychopathy Checklist (PCL) was published in 1980.
¹⁹
In 1991, the PCL was revised by consolidating a few items and updating and optimizing the scoring criteria.
²⁰
Since the publication of the Psychopathy Checklist-Revised in 1991, the numbers of items and scoring criteria have not changed. The manual was revised again in 2003, indexing the latest research that had been conducted with the instrument in the prior decade.
²¹

For the first 150 years of studying psychopaths, experts did not have a common diagnostic instrument to assess individuals. But since the development of the Hare Psychopathy Checklist-Revised, we have had more than twenty years of research using the same instrument, and a very large literature has developed in the scientific community confirming its reliability and validity. Many studies have confirmed that psychopathy can be reliably assessed with the Hare Psychopathy Checklist-Revised. However, it should be noted that in the context of an adversarial proceeding in the legal system, the Psychopathy Checklist, like any other psychological instrument, can be distorted. To avoid such problems, the judicial system should avail itself of experts who are hired by the court, and not by one side or the other, to resolve the problems. It is this literature that forms the scientific backbone for the remainder of this book (see
Figure 1
).

For most clinicians and researchers, the Hare Psychopathy Checklist-Revised (henceforth referred to as the Psychopathy Checklist) has become the “gold standard” diagnostic tool for psychopathy. It is the single most commonly used tool to assess psychopathy in general, and forensic populations in particular. It has been translated into sixteen different languages and distributed around the world.

Figure 1
. Google scholar results for number of published papers per year from 1970 to 2012 in the scientific literature with the keyword search “psychopathy.” There is a massive burst of activity beginning about 1993—an effect likely due to the development of the assessment for psychopathy known as the Hare Psychopathy Checklist-Revised (PCL-R), published in 1991. (From Google scholar search completed 12/7/11; years 2011 and 2012 added on 6/11/13).

As outlined in Box 2, the Psychopathy Checklist includes nearly all the traits that Cleckley and his predecessors developed, as well as additional traits that assess socially deviant behavior.

To complete the Psychopathy Checklist, a trained clinician needs to do both a detailed semistructured interview of the client that lasts approximately two hours and a collateral file review. Files typically include police reports, social worker assessments, details on family
dynamics, employment history, education, relationships, childhood, adolescence, and criminal history.
²²
From these sources of information, the interview and files, trained experts then rate the client on the twenty items, following the scoring criteria in the Psychopathy Checklist manual.

I’ve trained hundreds of people to score the Psychopathy Checklist, including undergraduates, clinical and research graduate students, psychiatric residents, and psychiatrists and psychologists.
²³
With about a week of intensive training and scoring of practice cases, nearly all the trainees are able to achieve reliable scores on the Psychopathy Checklist.

Dr. Robert D. Hare is now known as the modern father of the field of psychopathy. In 2010, he was awarded the Order of Canada, one of the highest civilian honors bestowed by the country, for his scientific and community efforts developing the Psychopathy Checklist.