Your readings asks a very controversial question, “Are Psychopaths Treatable?” Using your assigned readings for the week, provide a 5 page paper distinguishing the characteristics that make psycho

Theoretical Medicine & Bioethics, 35, 31-42.

To Treat a Psychopath

Heidi L. Maibom

Recent successes in manipulating the activity of the brain more or less directly—e.g. through transcranial magnetic stimulation or the administration of drugs that inhibit the production or reuptake of certain neurotransmitters—promise that one day soon it may be possible to treat a range of hitherto treatment resistant disorders [1-4]. Conventional treatment is typically unsuccessful with psychopaths [5-6]. Some people, however, are now quite optimistic about the possibility of treating psychopathy with drugs that directly modulate brain function [2]. Does the recent evidence support the idea that we will soon be able to treat psychopathy? I shall argue that it does not. Psychopathy is a global disorder in an individual’s worldview, including his social and moral outlook. Because of the unity of this Weltanschauung, it is unlikely to be treatable in a piecemeal fashion. But recent neuroscientific methods do not give us much hope that we can replace, in a wholesale manner, problematic views of the world with more socially desirable ones. There are, therefore, principled reasons that psychopathy is so singularly treatment resistant.

1. The Trouble with Psychopaths

By contrast to depression, which can often be treated by the administration of mood-enhancing drugs (SSRIs or SNRIs)1 and/or psychotherapy, psychopathy is a disorder involving a wide variety of symptoms that, on the face of it, have little in common except for their moral and social undesirability. Depressive symptoms typically form a unified picture of a certain type of affective disorder. Psychopathy has been called a moral or an antisocial disorder [7, 8]. Where it seems relatively obvious, at least in theory, that to treat depression one must help elevate the subject’s mood and alleviate her despair, how to treat amoral or antisocial tendencies is less clear. And since we have experience of ingesting substances that are mood-elevators, at least in the short term, such as champagne or chocolate, it is not too far-fetched to suppose that other substances may produce a longer-term effect on a person’s mood. But what of amorality or antisociality?

On closer inspection, depression and psychopathy have more in common than it might seem at first. The two disorders represent more global divergences of cognitive and emotional functioning compared to the statistical norm. Depressed individuals tend to have a rather dark view of themselves and existence in general, associated with social withdrawal and lack of interest in activities, even those that were previously of great importance to them. Georg Northoff has suggested that depressed individuals may experience difficulties projecting themselves into the future or, if you like, imagining a future different from their current reality.2 Psychopaths’ divergence from the statistical norm is also of a more global sort. For the moral and social issues that psychopaths have are not limited to a certain domain. They characterize not a weakness or a lacuna in an otherwise intact socio-moral outlook, but a global socio-moral deficit or dysfunction. It is no coincidence that psychopaths are known to be ‘amoral’ or ‘without conscience’. Let us rehearse, briefly, the main features of the condition. Psychopaths experience relatively little empathy or sympathy and they may be unable to truly love others [10]; they experience little guilt and shame [10], are relatively fearless [11], and experience mainly unstable and shallow emotions.3 They can experience an emotion very strongly one minute—great anger for instance—but not at all the next. Their emotional impairments extend to deficits in recognizing certain emotions.4 It is often that it is the lack of empathic orientation towards others that allows the psychopath to manipulate, exploit, and parasitize those around him. However that may be, he seems to lack basic respect for others.

Generalizing, we may say that the psychopath tends to regard others as tools or means to his own ends. Being able to lie without compunction no doubt makes it easier for him to use other people. Seeing others as in some sense worthy of respect in their own right appears to be beyond him [18]. The problem is not that he has a tenuous regard for humanity, say, but that he lacks respect even for friends and family. Robert Hare notes that criminal psychopaths distinguish themselves from other career criminals by being as likely to cheat, steal from, mistreat, harm, and generally act irresponsibly towards members of their own family as they are towards others [19, 20]. Psychopathy is par excellence a problem of living with others in organized social groups. More universally, they appear to regard the world and everything in it in terms of its use for their own purposes without being able to see animals, nature, works of art, etc. as having intrinsic value [18]. Famously, all traditional methods of treatment have failed to show results, though some recent treatment programs have shown some progress for adolescents with psychopathic tendencies [21].

There may be principled, as opposed to more practical, reasons treatments have failed. First, there are those that argue that psychopathy is not a disorder at all, but an evolved strategy. It is, if you like, a human psychological subtype, which either was adaptive in ancestral environments or is currently adaptive in a strictly evolutionary sense. If it is an adaptive strategy, it may be much harder to resolve, if it is resolvable at all, than illnesses or diseases that can be understood as a dysfunction of a system relative to a statistical norm [22]. Second, one might suppose that as a personality disorder, psychopathy is tremendously resistant to treatment. A version of this argument is that it is a special type of mental disorder, i.e. a Cluster B personality disorder, which requires moral commitment for treatment to work. Ultimately, I shall argue (in section 2) for a variation of this position, but where it focuses on commitment, my main concern is the unity of a subject’s moral outlook or, as I shall argue, her Weltanschauung. But first, let us examine the two positions, because the ways in which they fall short is instructive.

There is much evidence of genetic variation within humans. For instance, lactose tolerance or the sickle cell trait are chronic genetic conditions, which confer significant advantages on their bearers, i.e. resistance to parasitization of the red blood cells by the plasmodium falciparum parasite (one of the more serious forms of malaria) and the ability to digest lactose throughout life. In parallel to such genetic variations in physical traits, Linda Mealey argues that psychopathy should be regarded as its own special genotype, adaptive if it occurs relatively infrequently in the group in which it occurs. It is the cheater, defector, or free rider genotype [23].5 In the words of Mealey, psychopaths:

are designed for the successful execution of social deception and […] they are the product of evolutionary pressures which, through a complex interaction of environmental and genetic factors, lead some individuals to pursue a life strategy of manipulative and predatory social interactions.

Lee Dugatkin [24] has suggested something similar, providing a detailed game theoretic model of the viability of the ‘con artist’. The idea behind these suggestions is relatively simple. Being devoid of the emotions that ordinarily curtail immoral actions of various kinds, psychopaths have an adaptive advantage over people who come fully equipped with empathy, guilt, and shame. Psychopaths are able to break their promises, cheat, lie, steal, and otherwise coerce others into doing their will without experiencing negative emotions as a result. Relative fearlessness and impulsivity may add to such abilities/tendencies. In other words, the psychopath’s presumed deficits enhance his ability to con, manipulate, and coerce others. From a certain perspective, what we call deficits are advantages. Mealey focuses on the emotional deficit, but it is equally likely that their practical reasoning deficit facilitates this type of behavior, perhaps by being undeterred by temporary setbacks in manipulative strategies.

Other defenders of such selectionist accounts of psychopathy stress psychopaths’ sexual strategy. Grant Harris and Marnie Rice [5] point out that not only are psychopaths very promiscuous, but they are also quite willing to use deception and coercion in order to have sex. Sex offenders who “preferentially target “reproductively viable” victims (i.e., postpubertal females) have significantly higher PCL-R scores than those who target all other classes of people” [5, pg. 564].6 Michael Seto and Vernon Quinsey [6] point out that from a Darwinian perspective at least, to talk of a condition as pathological (i.e. an illness or a disorder) which leads to increased reproductive success would be nonsensical. Whether to call such conditions diseases or dysfunctions or not, is not relevant to the project at hand. What matters is that there is a difference between conditions that reflect a genotypic variation, and thus an abnormality or a deviation from the statistical norm [cf. 25, 23], and conditions that constitute an abnormality or deviation from the ordinary functioning of the individual. In the latter cases, treatment can be aimed at bringing the subject back to their ‘normal’ state (some state that is within the statistical norm of functioning for that person). But in cases where the deviation is due to genetic variation, treatment aims to change the subject from his or her own norm. And this may be what the obstacle is to ‘treating’ psychopathy.

The trouble with this line of thinking is that there are, indeed, evolutionary accounts of other mental disorders, such as depression [e.g. 26, 27] and anxiety syndromes [e.g. 28, 29], and yet there are decent treatment options available for both. So it cannot simply be in virtue of being an adaptation that a condition remains untreatable. It must be something more specific about the condition—whether or not we believe it is technically a disorder or an adaptation—that makes it resistant to treatment. One possibility is that psychopathy is really a disorder of the personality or character of a person rather than being an episodic condition, which depression typically is. This is the second position mentioned above. Though psychopathy is not in the DSM-IV, its closest living cousin in that reference work is Antisocial Personality Disorder. Personality disorders are life-long conditions, which affects the very character of the people who suffer from them. Because they affect character as a whole, some people have been very skeptical about the possibility of treating such disorders [31]. Even if treatment is possible, it cannot be aimed at restoring a character that has been overcome by illness—as in depression, for instance—because their illness is, in an important sense, part of who these people are. If one treats the disorder, one changes the personality or character of the individual. This is, perhaps, most dramatic in the case of Dissociative Personality Disorder, where one can argue that by treating the individual, one actually kills off some of her personalities [32].

Some of these personality disorders are disorders in living with others. Louis Chartrand [33] calls Cluster B Personality Disorders—Narcissistic, Histrionic, Borderline, and Antisocial Personality Disorder—“moral” disorders. These are disorders where “it is impossible to imagine a successful “treatment” or “cure” […] that does not involve some sort of conversion or change in moral character.” [33, pg. 71] In the cases of Narcissistic and Histrionic Personality Disorders “the “excessive attention seeking” and “inappropriate sexually seductive and provocative behavior” […] is flatly inconsistent with a pattern of empathy and regard for others.” [33, pg. 71] Any treatment of Antisocial Personality Disorder would have to address and alter the “pervasive pattern of disregard for and violation of the rights of others” [33, pg. 71].7 Indeed, such disorders are only treatable if the person shows moral willingness or moral commitment to therapy and change [33, pgs. 71-72].

If Cluster B Personality Disorders prove difficult to treat because of the need to ensure the subject’s moral commitment, we should expect psychopathy to be even more treatment resistant given that it is, more than any other, a moral disorder. My point is not that psychopathy is reducible to Antisocial Personality Disorder. Rather, if the latter is a moral disorder, psychopathy is even more so given that “the formal criteria of ASP place more emphasis on antisocial and criminal behaviors, and less emphasis on personality traits, than do traditional conceptions of psychopathy and the PCL-R” [34, pg. 5].8 Chartrand is a bit cagey about why he thinks that therapy or treatment of Cluster B Personality Disorders requires moral commitment on the part of the subject, other than for the obvious reason that therapy in general requires commitment. What he seems to have in mind is that Cluster B Personality Disorders are moral, not medical, disorders, and that they therefore require moral, not medical, treatment. But moral treatment requires commitment to moral change. At the core of moral treatment for all Cluster B Personality Disorders is “[w]illingness and commitment to developing the capacity for empathy” [34, pg. 71]. Lack of empathy is at the core of Narcissistic Personality Disorder, Antisocial Personality Disorder, and Psychopathy.

It is often suggested that the psychopath’s more or less complete disregard for the wellbeing of others is at the core of their disorder [14, 35]. Many studies report a negative relation between empathy and aggression [36, 37]. So it would seem that if we could only increase empathy in violent offenders, we would reduce their violent tendencies.9 Psychopathy researchers have not been too optimistic about the prospects of increasing empathy in psychopaths. Their emotional deficits are thought to be too wide-ranging [6]. One now rather famous psychotherapeutic program aimed to increase empathy and responsibility lowered violent recidivism in nonpsychopaths, but increased it in psychopaths [38]. In their assessment of the treatment options for psychopaths, David Thornton & Linda Blud argue that: [21, pg. 534]

Motives based on altruism, empathy, deep emotional needs, or long-term self-interest are unlikely to be relevant to psychopathic offenders. Short-term self-interest, excitement, challenges, status, and a sense of power or control are all much more relevant.

This makes it very difficult to see how psychopaths could form a commitment to moral change at all. I take it most moral philosophers would agree that the project of building morality of short-term self-interest is pretty hopeless.

2. Medicating Amorality?

The principled difficulties with treating psychopathy suggested above stems from considerations of traditional treatment techniques. But what about new ones? If empathy cannot be therapeutically induced, perhaps it can be done neuropharmalogically. Molly Crockett and colleagues’ recent success with modulating responses to morally significant situations by means of the administration of SSRIs is very promising [1]. The authors build on evidence that: “prosocial and affiliative behaviors are associated with intact or enhanced serotonin function, whereas antisocial and aggressive behaviors are associated with impaired or reduced serotonin function.” [1, pg. 17433] In their study, they found that increasing a person’s serotonin increased her acceptance of some unfair offers in the Ultimatum Game (but not the really unfair ones).10 It also had the effect of increasing people’s judgment that so-called personal harms are unacceptable, even when such harms are necessary to save the many.11 This is particularly relevant to psychopathy as Koenigs et al. [44] found that some psychopaths—so-called low-anxious psychopaths (also known as ‘primary psychopaths’)—are more willing than nonpsychopaths to endorse such harms to the individual when it is required to save the many.12 Psychopaths have also been found to be more likely to reject moderately unfair offers in Ultimatum Games [46]. Increasing serotonin, then, is a very promising lead in the search for a treatment of psychopathy.

Unfortunately, it turns out that the effects described above are driven by people who are already quite empathetic.13 Increased serotonin has no effect on low-empathy scorers. Since psychopaths are notoriously low in empathy, Crockett and colleagues recognize that the therapy is unlikely to be effective with psychopaths. But why should serotonin not be effective with psychopaths or with people who are not very empathetic if, as the authors claimed, it “directly modifies subjects’ moral judgments and behavior by means of enhancing aversion to personally harming others” [1, pg. 17433]? And why do we see no increased tendency among empathetic subjects with increased serotonin levels to accept quite unfair offers in the Ultimatum Game (18-22% of the stake)? One assumes that this is because the people judge that there is a limit to how much unfairness they should accept. But if this is right, increased serotonin levels do not directly modify moral behavior in this case. If it does not do it in this instance, why should we assume that it does so in the other cases? What is, after all, the difference between the cases that would motivate (justify) such a difference? In short, the fact that increased serotonin has no effect on low empathy subjects and no effect on high empathy subjects once offers are sufficiently unfair together suggest that increased serotonin does not modify moral judgment or behavior directly at all. More likely, the effect is mediated by the subject’s other attitudes, beliefs, propensities, and so on. Increased serotonin levels undergird psychological phenomena that are only some of the pieces of the puzzle of human moral judgment.

It is notable is that according to Crockett and colleagues, serotonin therapy boosts pre-existing tendencies or dispositions. Let us assume, with these authors that high-empathy subjects are already quite reluctant to harm others and are distressed and saddened by the prospects of such harm. Increasing their serotonin level enhances this tendency somewhat (approx. 0.15 on a 0-1 scale). But the concern for the welfare of others is unlikely to be blocked by, or meet much resistance in, the person’s other concerns, tendencies, and attitudes. This points to something that we already surely knew: a subject’s judgment of what is morally acceptable is not reducible to one factor, such as preventing harm to individuals simpliciter. Typically, a moral judgment reflects a wider assessment of the situation, which is the result of a person’s general moral outlook, the neurophysiological underpinnings of which are likely to be considerably complex. We might capture this idea by saying that a subject’s moral beliefs, judgments, attitudes, and behavior are a unified whole. They constitute her outlook on the social world—which, for most of us, simply is the world—and capture her attitude to life with others. One’s view of the world, one’s attitude towards it, is hardly an independent variable that can be modified by direct operation on some of the neurological properties that instantiate it. A Weltanschauung is not merely a matter of having a handful of interconnected ideas, perhaps of a rather lofty nature; it is a diffuse network of beliefs, assumptions, attitudes, and affective dispositions related to a vision of how to live (including how to live with others). Removing a handful of those or replacing them with others is hardly sufficient to change it. For we work at maintaining a relatively coherent worldview, so that if parts of it come into conflict, we must resolve it in a way that coheres, more or less, with our overall view, or with those parts of it that are central and of greatest importance. Therefore, to change a person’s Weltanschauung, one must change it wholesale or change a critical amount, so that the subject can do the rest of the work himself as part of bringing his belief system into a coherent equilibrium. But it does not appear that this can be achieved by means of modulating certain neurotransmitters, as is evidence by the fact that increased serotonin has no effect on low-empathy subjects.

I think we ought to conclude that there are rather formidable difficulties with the project of altering elements of a subject’s moral outlook—such as their tendency to find harmful actions acceptable—because harm-considerations are only one part of a network of closely interrelated beliefs and attitudes. One might increase the salience of harms and the aversion towards them, but if the subject does not generally endorse an outlook on human affairs that places the feelings and wellbeing of others at the very center of what is important, any such influence will be swamped by the other beliefs, attitudes, etc. that constitute their socio-moral outlook. I have suggested that this is due to the dynamic unity of moral, or socio-moral, outlook. If things fall into imbalance, if a person who does not place a high premium on individuals not being harmed compared to the welfare of the many, inducing aversion to harm or empathy will not have the desired effect. For these other ideals of what is of greatest importance will correct the “intruding” thoughts and attitudes.

Nevertheless, it is certainly possible to modify a person’s moral outlook. And if it can be done through other influences, it is not impossible to imagine that it could be done pharmacologically. But it is unlikely to be achievable directly. Such a change would require changes to other parts of a person’s Weltanschauung. That is, the subject would have to complete the work that drugs initiate in her. If this is thought to be problematic in the ordinary individual, the difficulties facing pharmacological intervention in psychopathic populations are formidable indeed. For here we are not talking about enhancing a moral tendency or other; we must implant a tendency that is more or less absent. Furthermore, we require that our “implant” replace their own narrowly self-interested Weltanschauung in its entirety. But everything that we know about the mind, of moral attitudes, of people’s socio-moral outlook suggests that this is impossible. We would not merely have to enhance, reinforce, or even alter their moral outlook, but we would need to give them one in the first place and, by doing so, alter their entire personality.

I have focused on just one new neurotechnology for the possible treatment of psychopathy here, but it illustrates a deeper, more principled difficulty with any treatment options that are targeted at globally immoral and antisocial beliefs, attitudes, and behaviors.14 I suggested that this is partly because of what is involved in moral alteration (given the unity of a person’s socio-moral outlook), and partly due to the particular disorder that psychopathy is. If psychopathy is, at core, the most moral of disorders, then it seems that we must agree with William Reid and Carl Gacono that psychopathy is a disorder that is untreatable in all its aspects [20].

To return to Chartrand’s idea that treatment of Cluster B Personality Disorders requires willingness or commitment to moral change for a moment, I think that the best way to flesh this intuition out is in terms of the unity of a subject’s socio-moral outlook. Because of the relative unity or coherence of a person’s Weltanschauung, one cannot merely fiddle with one part of it and expect it or everything else to stay intact. Type B Personality Disorders are conditions where subjects have a divergent Weltanschauung. In Chartrand’s view these are all conditions whose disease classification is contingent on normative assessment. They constitute disorders insofar as they represent problems that a subject experiences relative to others or to society more generally. Whether or not we agree with this position, we can certainly agree that psychopathy is well conceived as a moral disorder and, for that reason, requires moral commitment on the part of the psychopath to be treatable. But here is the rub, of course. For psychopaths are supposed to be without a conscience [19], to be fundamentally amoral. And since truly making and upholding commitments is plausibly itself a moral activity, we should not expect psychopaths to be able to do so. What would be required is either a wholesale change in moral outlook or, as I have called it, Weltanschauung, or a commitment to moral change. Any current treatment, even of the neuropsychological or neuropharmalogical kind, is so far removed from being able to accomplish anything so fundamental that I don’t think it is premature to conclude that the prospect for treating or curing psychopathy are grim.

3. Concluding Remarks

I have argued that we have little reason to think that psychopathy is treatable, even with new neuro-techniques. There is a principled reason for this. Unless one can change a person’s moral outlook entirely, one will have to work with the outlook a person has. If she already values other’s welfare, one may increase that valuing either through reasoned discourse or even pharmacologically. Whether it is ethical to do so or whether it is desirable to increase a subject’s unwillingness to be physically involved in harming others under all circumstances is another issue, which I cannot address here. However, one must always consider that a person’s moral outlook is a system where the parts mutually affect another. People strive to have reasonably coherent views of the world, and moral considerations must be weighed against each other, and against other considerations. If we were to introduce a change in one set of such considerations, it would still be answerable to all the other beliefs, attitudes, etc. that make up the person’s moral outlook which, I think, we should understand as being inextricably linked to their view of how to live more generally. This is what I have called the subject’s Weltanschauung. If what is introduced is incompatible with or sufficiently in tension with other parts of the subject’s outlook, it will be eliminated. A true change in outlook requires either the subject’s cooperation or extensive, coercive measures of a kind that we have little knowledge of.

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