Psychopathy is a disorder characterised by affective deficits and an antisocial lifestyle (Hare, 2001). Psychopathic individuals present as callous, dominant and manipulative and they exhibit a propensity to ignore or break societal rules (Hare, 2001). Although it only affects 1% of the general population, it can be seen in up to 25% of prison inmates (Hare, 1996). Hence, it is important for clinicians to understand what leads to the development of psychopathy and what interventions need to be implemented to reduce violent crime. This paper will examine what factors are associated with the development of psychopathy and how clinical intervention should be influenced by these factors. It will first examine how affective deficits may be due to an inability to attend to relevant stimuli and discuss Mindfulness as a relevant therapy. It will discuss how a psychopath’s antisocial lifestyle is influenced by an interaction between genetics and sociocultural childhood influences. Finally, this paper will examine prevention strategies and how these may be able to attenuate the risk of anti-social behaviour.
Empathy and Attention
It is well documented that psychopaths show emotional detachment and an inability to express empathy (Bennett, 2011): they struggle to process emotional information, leading to a lack of understanding and dismissal of emotions in others. This lack of empathy is thought to be due to cognitive deficiencies rather than an anti-social motivation (Newman, 1998). Research has repeatedly shown that criminal psychopaths lack the ability to use selective attention effectively compared to control prisoners and non-prisoners (Pham et al., 2003), and are unable to move their attention to other stimuli after beginning to engage in a “goal-relevant task” (Larson et al, 2013). When emotional cues are deliberately attended to, a psychopath’s behaviour on neuropsychological tasks is similar to non-psychopaths (Zeier, Maxwell & Newman, 2009). Newman and colleagues found that psychopaths display a normal fear response if specifically paying attention to the threat cues, but a much smaller response if they have already allocated their attention to another stimulus (Newman et al., 2010). Psychopaths react in a normal way to affective stimuli unless their attention is already focused on other cues (Newman & Baskin-Sommers, 2012), because psychopaths can’t monitor the environment for cues if already attending to something (Tang, Posner & Rothbart, 2014).
Early selective attention leads to an inability to process peripheral emotion-related, sensory stimuli (Baskin-Sommers et al., 2012). The physical feelings that are associated with emotions help to guide our future behaviour (Damasio, Tranel & Damasio, 1991). If an individual is unable to attend to these important cues, e.g. threat cues, it is likely that they are either unaware of the consequences of their behaviour for themselves and for other people, or they cannot focus on the consequences at that moment in time (Brito et al., 2013). If one cannot attend to, and therefore process, emotion-relevant cues, it is likely that one will be unable to learn from punishment, change behaviour or make good quality decisions, resulting in reckless and aggressive anti-social behaviour (Yang et al., 2005). Is it possible that we can decrease dysfunctional affective personality traits and therefore anti-social behaviour by training attention?
Mindfulness and Meditation
Mindfulness is the bringing of attention to internal and external stimuli that occur in the present moment (Kabat-Zinn, 2003). The technique has been used in prison to successfully reduce stress, mood disturbance and hostility amongst inmates (Samuelson et al., 2007) and can reduce anger and aggression (Peters et al, 2015).
To date, no research has been conducted on Mindfulness and its effectiveness with psychopaths. However, there is research around the effects of Mindfulness that relate to the factors that contribute to the development of psychopathy, suggesting that it could be a viable treatment. There is now research to suggest that Mindfulness techniques could prove important when tackling attention. Merely 15 minutes of a Mindfulness technique known as Attention-to-Breath Practice can increase connectivity between the amygdala and the prefrontal cortex (Doll et al., 2016). These brain areas are both important in attention and emotional regulation: the amygdala provides input to the prefrontal cortex about negative emotions like fear and the prefrontal cortex then assesses the consequences of decisions (Cummings, 2016). MRI and fMRI studies have shown that there is decreased connectivity between the amygdala and the prefrontal cortex in psychopaths (Motzkin et al., 2011) so therapies that can increase connectivity between these brain regions could result in better attention to emotional cues and reduce the callous features of the psychopathic personality. A longitudinal study found that the more time spent practising Compassion-Based Meditation, the more the amygdala was activated in response to stimuli designed to induce compassion and empathy (Desbordes et al, 2012). Increasing activity in the amygdala and prefrontal cortex could aid psychopaths to direct their attention and resources towards stimuli that a person is suffering (Mascaro et al., 2015).
Mindfulness is cost-effective (Halliwell, 2010) and is already available in prisons and forensic services in the UK (Witharana & Adshead, 2013). However, there are several factors to consider when tailoring treatment towards psychopaths. Firstly, psychopaths lack the motivation to change and do not seek treatment (Bennett, 2011). Men with a high score of psychopathic traits are often evasive, resistant to change, non-compliant and are likely to not complete their treatment (Polaschek, 2014). Beck and colleagues (2004) suggested that as psychopaths behave with their own self-interest in mind, therapy should be designed to help them act in a pro-social (or less anti-social) way with in these limits. Therapists could try to encourage individuals to engage in treatment as it could reduce their anti-social behaviour which is not always in their own best interest (e.g. incarceration) (Beck et al., 2004); and Mindfulness has been linked to improvements in mood, a reduction in stress hormones and even a better immune response to foreign antibodies (Tang, Posner & Rothbart, 2014). Framing therapy as something that will benefit the individual’s life could provide the motivation needed to take part in treatment.
Secondly, as there is currently no research on Mindfulness and psychopathy, it is important that the effectiveness of the treatment is measured properly. Self-report and behavioural measures should not be relied on, as psychopathic individuals have a propensity to manipulate and lie (Bennett, 2011). Psychopathic individuals may be able to learn and simulate “correct” responses so that therapists will regard them as having made progress (Seto & Barbaree, 1999). Following treatment, psychopaths should be continually monitored and given follow-up “booster” sessions (NICE guidelines, 2009). As research has suggested that Mindfulness can alter brain connectivity and executive functioning (Tang, Posner & Rothbart, 2014), clinicians should monitor change using neuroimaging and neuropsychological tests, pre- and post-treatment. It is appropriate to use a battery of outcome measures (Hare & Neumann, 2009). This battery could include self-reports (e.g. The Agression Questionnaire, Buss & Perry, 1992), staff and family views (e.g. the Staff Observation Aggression Scale-Revised, Nijman et al., 1999), neuroimaging whilst viewing emotional stimuli (e.g. Cummings, 2016), and neuropsychological tests examining selective attention and ability to attend to emotional cues (e.g. Newman & Baskin-Sommers, 2012). When combining all these outcome measures, it may be possible to ascertain whether Mindfulness is a viable treatment for psychopathy.
A caveat: although most research suggests that Mindfulness can increase compassion, kindness and attention (Desbordes et al., 2012; Tang, Posner & Rothbart, 2011), a few studies have suggested that Mindfulness may reduce activation of the amygdala when exposed to emotional stimuli (Goldin & Gross, 2010). This poses a problem when treating psychopaths, as a decrease in amygdala activation is associated with a lack of empathy and emotional detachment (Blair, 2007). It is therefore important for future research to examine what specific Mindfulness techniques will be the most appropriate when treating psychopaths. An increase in neuroimaging techniques such as Optogenetics and Transcranial Magnetic Stimulation should help researchers to understand how specific socio-affective training techniques affects brain plasticity and structure (Cavanagh, 2014).
Interactions between Genetics and the Environment
While the cognitive deficiencies and underlying neurological mechanisms discussed previously are likely partially due to genetic factors, there is some debate about how heritable psychopathic traits are and how much influence the environment has in the development of psychopathy (Bennett, 2011). Twin and adoption studies suggest that antisocial behaviour and callous-unemotional traits (all seen in adult psychopathy) are highly heritable at around 80% (Plomin et al, 2013) with little environmental influence. There was no relationship between parenting style and anti-social behaviour for children with callous-unemotional traits but there was for children without these traits (Wootton et al., 1997). However, a meta-analysis found evidence of an interaction between MAOA genotype and childhood adversity on anti-social behaviour in adult males (Byrd & Manuck, 2014), suggesting that there is an environmental influence. Raine (1996) noted that not all children who exhibited the attentional difficulties and reduced amygdala activation in response to affective stimuli that is seen in adults, went on to lead criminal lifestyles (some became police officers!). Plenty of research has suggested different environmental factors can account for the variance not attributed to genetic factors including prenatal exposure to smoking (Beaver et al., 2010), witnessing violence as a child (Howard et al., 2012) and victimisation from peers (Barker & Salekin, 2012). A review found that, contrary to Wootton et al.’s findings, styles of parentings are related to callous-unemotional traits and antisocial behaviour, and parenting focused interventions can reduce antisocial behaviour in young people (Waller, Gardner & Hyde, 2013). The picture is mixed but it appears possible to inhibit the antisocial lifestyle associated with psychopathy, using preventative interventions.
Prevention is Better than Cure
Bourduin (1999) described an approach that could target families and their immediate environment, combating the precursors to antisocial behaviour. His multi-systemic therapy (MST) approach involves increasing supportive parenting e.g. monitoring and rewarding good behaviour, encouraging friendships with prosocial peers, and Cognitive Behavioural Therapy to help teach social skills and problem-solving abilities. This approach is intensive and designed to combat antisocial behaviour rather than specifically Anti-Social Personality Disorder or psychopathy (Bennett, 2011). There is a large amount of support from research in the US and UK: there was a reduction in recorded offences at 18 month follow up compared to participants in a control intervention (Butler et al., 2011); family functioning was better for participants in the MST group than 70% of a control treatment group (Curtis, Ronan & Borduin, 2004); both meta-analysis and longitudinal studies report that there are fewer arrests and less time spent in institutions for young people in a MST group compared to those in standard treatment groups (Schaeffer & Bourduin, 2005; Woolfenden, Williams & Peat, 2002). Woolfenden and colleagues (2002) also noted that the approach could save money for society in the long run due to a potential drop in crime rates and lost parental work days.
These results are promising for tackling antisocial behaviour and criminal lifestyle. However, as research has not specifically targeted children with traits that predict psychopathy (Frick et al., 2014), it is unclear whether MST would be successful with this group. One study found that boys with conduct problems and a high number of callous-unemotional traits were less responsive to a parenting intervention than those without callous-unemotional traits (Hawes & Dadds, 2005). Frick and colleagues (2014) conducted a review and found that children high in callous-unemotional traits could be treated with MST, but the intervention must be tailored to the unique emotional and cognitive deficiencies that children with high levels of callous-unemotional traits exhibit. There was a reduced rate in anti-social behaviour for children with callous-unemotional traits when MST was combined with medication for hyperactivity and training in perception and interpretation of others’ emotions (Frick et al., 2014). As children with callous-unemotional traits show similar attentional impairments as adult psychopaths do (Blair, et al., 2001), it might be possible to integrate some Mindfulness therapies into the MST approach as well, aiding young people’s executive functioning and emotional processing (Semple et al., 2010).
Conclusion
Psychopathy is a complex personality disorder, with many aetiologies and is difficult to treat (Bennett, 2011). The lack of empathy characteristic of psychopathy appears to be due to an inability to attended to stimuli (Newman, 1998). The antisocial lifestyle most psychopaths pursue appears to be a complex interaction between inherited characteristics and childhood experiences (Plomin et al., 2013). Despite what many have stated, treating psychopathy and preventing criminal behaviour is not impossible (Polaschek, 2014). Clinicians should attempt to train attention through Mindfulness (Tang, Posner & Rothbart, 2014). Policymakers should implement preventative psychological interventions so that children who possess the traits of a psychopath do not commit crimes and live more prosocial lives (Frick et al., 2014). It is important that clinicians and researchers work together to develop the best therapies to curb and prevent the harms that psychopaths pose to themselves, their families and society as a whole.