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Mental Disorders

by Carl B. Gacono (editor)
Lawrence Erlbaum Associates, 2000
Review by Susan Dwyer, Ph.D. on Jul 12th 2002

The Clinical and Forensic Assessment of Psychopathy

This is an excellent collection of essays, remarkably consistent in tone and quality, that presents comprehensive coverage of the latest work on psychopathy.  While the book is aimed at practitioners – psychologists and psychiatrists in both forensic and non-forensic settings – it is readily accessible to philosophers with an interest in the moral psychological implications of psychopathy.  All the authors presume a basic familiarity with Cleckley’s seminal treatise on psychopaths (The Mask of Sanity [1942]), but there are plenty of useful references for catch-up reading.  Indeed, the last of four Appendices is a wonderful, topically organized Bibliography.

Seventeen chapters are organized into three main sections.  The first focuses on conceptual issues, the second on clinical issues, and the third on applications of the construct of psychopathy in a wide variety of areas, including the treatment and management of substance abusers and sex offenders, hostage negotiation, and industrial-organizational psychology.  There is not a dull paper here.  And without repetition or awkwardness, each paper speaks to one or both of the book’s two main themes.

The first of these is to correct the common misunderstanding that psychopathy and antisocial personality disorder (ASPD) are identical.  ASPD appears as a Personality Disorder in DSM-IV, while psychopathy does not.  This is more than a mere terminological matter.  A diagnosis of ASPD is warranted on the basis of a series of predominantly behavioral criteria, whereas psychopathy, now reliably measured by Hare’s Psychopathy Checklist (revised), is composed of two stable factors.   Factor 1 captures personality traits of callousness, lack of remorse, low empathy and low anxiety (among others).  Factor 2 captures behavioral traits such as thrill-seeking, irresponsible and impulsive actions, and unconventional and antisocial lifestyle.  Of course, it is Factor I that has drawn the attention of moral philosophers: psychopaths’ moral motivation appears to be radically at odds with their moral knowledge.  They have no difficulty recognizing moral transgressions, they just don’t seem to care much about them.  The distinction between ASPD and psychopathy is empirically borne out by the relative frequencies of the conditions in forensic populations: “In forensic populations, baserates for ASPD are 50% to 80%, compared with only 15% to 25% meeting criteria for diagnosis of psychopathy (60).”

One might wonder what hangs on this distinction, since psychopathy appears to be a type of  ASPD.  The second main theme of the book speaks to this question.  Because of their particular personality psychopaths present unique challenges to the clinician.  Exquisite abilities for deception and manipulation make therapeutic relations difficult and, in some cases, risky for the clinician.  Clinicians need to understand who they are dealing with; Chapter 8 offers useful guidelines for navigating these troubles.  In addition, while psychopaths can feign improvement, the condition appears not to be treatable.  A diagnosis of psychopathy, especially in adolescents, can result in clinical abandonment. Chapters 1, 2, 3 are relevant here.  And Chapter 6 provides a good account of the ways in which the construct of psychopathy has been deployed in both civil and criminal legal cases.  The take home message is that while effective and safe dealings with psychopaths requires our recognizing psychopathy as distinct from ASPD, caution must be exercised in labeling individuals as psychopaths.  In particular, a finding of psychopathy must not be allowed to muscle out other clinically relevant factors.


Addressing questions about the treatment and management of psychopaths will be facilitated by a better understanding of the mechanisms of psychopathy, and in particular, of the natural history of the condition.  All the papers the first conceptual section of the book are helpful here.  There is excellent discussion of the developmental dimensions of psychopathy and of the latest empirical work bearing on hypotheses about the centrality to psychopathy of various affective and information-processing deficits.  No one theory about the underlying mechanisms of psychopathy is endorsed, rather the research is laid out in ways that allow the reader to make her own assessments.

It is impossible to do justice to all that is interesting, convincing and important in this book. But one further feature bears mention.  For the most part, what we know about psychopathy has emerged from work with incarcerated populations.  However, not all psychopaths are criminals, and those who live among us cause substantial damage to their families, acquaintances, and coworkers.  The editor is to be applauded, then, for including several contributions which report on work with psychopaths in the general community.  This research is in its infancy, yet as chapter 12, “Psychopathic Manipulation at Work,” makes abundantly clear, it is vitally important.

In sum, this book is an outstanding contribution to the field.  Practicing clinicians and researchers will find it useful, and, for philosophers interested in psychopathy, it is an indispensable resource.

 

© 2002 Susan Dwyer

Susan Dwyer,Ph.D. is Associate Professor of Philosophy at UMBC (Baltimore, Maryland) where she directs the Masters Program in Applied and Professional Ethics.