One argument in support of a public policy of not subjecting persons with psychopathic disorders to civil or criminal commitment is that these disorders do not improve with treatment. This article examines the relationship between the assumption of untreatability of psychopathic disorders and outpatient civil commitment, inpatient civil commitment, and insanity acquittee commitment. Research on the treatability of psychopathy is reviewed and the treatment of conditions co-morbid with psychopathy is considered. Research evidence is insufficient to support the conclusion that psychopathy is improved, worsened or not affected by treatment. Evidence does support effective treatments for conditions that can be co-morbid with psychopathic disorders including impulsive aggression which can be interpreted as a manifestation of psychopathic disorder.
The absence of evidence based treatment efficacy for psychopathic disorders is a logical reason for not subjecting individuals with only a psychopathic disorder to involuntary hospitalization. This assumption should not becloud the possibility of treatable co-morbid conditions which may or may not qualify for involuntary hospitalization. Where the primary mental disorder, for which an individual is involuntarily hospitalized, results in behavioral improvement, the continued presence of a psychopathic disorder itself, should not be sufficient reason to continue coerced confinement. Even so, where the primary disorder is incompletely treated, psychopathy can be considered a risk factor when deciding upon the appropriate time for discharge and when formulating a safe and effective after care plan.
Psychopathic disorders,1 a spectrum of character pathology ranging from Antisocial Personality Disorder of DSM IV-TR (American Psychiatric Association, 2004) to Clecklian Psychopathy (Cleckley, 1976) and Hare Psychopathy (Hare, 1991 and Hare, 2007), are widely assumed to be untreatable conditions. The presumption of “untreatability”2 appears to have been a decisive factor in formulating public policy in the United States that disfavors civil and criminal commitment of individuals with only a psychopathic disorder. Because psychopathic disorders represent psychopathology, they warrant treatment, or therapeutic research if evidence based treatments are lacking. The future DSM V will revise the taxonomy of personality disorders which could remain as categorical disorders and traits, to designate lesser degrees of anomaly, or the nomenclature could be transformed into one of pathological dimensions rather than disorders with arbitrary thresholds. More likely, the revised nomenclature will consist of a hybrid of disorders and dimensions (Regier, Narrow, Kuhl, & Kupfer, 2009). In any case, whether disorders or dimensions, psychopathic psychopathology will remain and will remain in need of effective treatments.
The presumption of “untreatability” of psychopathic disorders argues against the treatment of psychopathically disordered individuals and especially their legally coerced treatment. If psychopathic disorders are untreatable, it makes little sense to subject individuals with psychopathic disorders to outpatient civil commitment, let alone inpatient civil commitment. If hospital commitment is inappropriate for psychopathically disordered individuals, it is equally inappropriate regardless whether the commitment is civil or criminal. If an NGRI acquittee cannot be hospitalized for public safety reasons, allowing an NGRI defense in the first place would seem to be imprudent public policy, putting aside in this discussion other arguments for and against NGRI acquittal based only upon psychopathy.
Are psychopathic disorders as untreatable as received wisdom would suggest? After examining the relationship between the presumption of untreatability and civil and NGRI commitments in the United States, this analysis will review the evidence that Hare psychopathy is or is not treatable. Regardless whether the core psychopathology of psychopathic disorders is amenable to treatment, other treatment considerations are appropriate and must be considered. Psychopathically disordered individuals may not be as categorically and absolutely untreatable as is so widely assumed, but what does this mean for their civil commitment and criminal commitment?
The untreatability assumption is overly pessimistic. More accurately put, evidence for treatment amenability or non-amenability of psychopathic disorders has yet to be proven by research. Even so, many conditions that can be co-morbid with psychopathic disorders, including some conditions that can be regarded as manifestation of the psychopathic disorder, show improvement with specific treatments. Future research could conceivably lead to discoveries of specific treatments for psychopathic disorders that today are only hypothetical. Whether psychopathic disorders should qualify or disqualify for mental defenses against criminal charges has nothing to do with treatability. The lack of demonstrated treatability of psychopathic disorders remains an important consideration in whether psychopathic disorders should qualify for coercive hospital detention and treatment.
Importantly, any serious attempt to treat psychopathic disorders presupposes, beyond adequate assessment of the psychopathic disorder, an attempt to assess co-morbid conditions for which evidence of treatment effectiveness exists. It is unrealistic for chronic disorders in general to show lasting improvement after a time limited intramural treatment program: treatment must continue after the individual has reentered the community. Future research on the effectiveness of treatment for psychopathic disorders should satisfy the quality standards identified by D'Silva and colleagues. If obvious Axis I disorders like schizophrenia are to be ruled out for purity of research, the nature of aggression should not disqualify. Rather assessment of the type of aggression should also be made and corresponding treatments with demonstrated efficacy implemented
