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Treatment guidelines for clients with antisocial personality disorder.

The purpose of this article is to present treatment guidelines for mental health counselors who work with clients diagnosed with Antisocial Personality Disorder (ASPD) or characterized as psychopathic. The guidelines use the criteria of both treatment efficacy and clinical utility as recommended by an APA taskforce on treatment guidelines (American Psychological Association, 2002). A review of the literature revealed that psychosocial interventions lack both treatment efficacy and clinical utility in remediating the core characteristics of antisociality or reducing criminal recidivism. However, a strong case can he made for a guideline in which substance abuse treatment is recommended for ASPD clients with comorbid substance use disorders. Slot only have such interventions been shown to possess adequate treatment efficacy, but there is additional evidence that such interventions are cost-effective and feasible for real-world, clinical settings (= clinical utility).

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Persistent antisocial behavior has a tremendous impact on society. Not only are significant financial costs incurred as a result of incarceration and lost productivity but antisocial behavior also leaves in its wake numerous victims (McCollister, French, & Fang, 2010). Historically, chronic antisocial behavior has been considered more the province of the criminal justice system than a treatment specialty area for mental health professionals (e.g., Duggan, 2009). However, the criminal justice system often refers offenders for treatment in the hopes of both reducing recidivism and decreasing the substantial costs of imprisonment. Examples of treatment programs are domestic violence groups, boot camps, therapeutic communities, mental health courts, and substance abuse programs (e.g., Dutton, 2003). Thus many counselors find themselves working with clients who are under court supervision (e.g., Lamb, Weinberger, & Gross, 1999).

One of the challenges in working with such clients is a coexisting diagnosis of Antisocial Personality Disorder (ASPD; American Psychiatric Association, 2013). While ASPD is relatively rare in the general population (2-3% prevalence), in the criminal justice population it is exceedingly common, with a prevalence rate of about 50% (Moran, 1999). These individuals may also enter mental health care through other routes; contrary to popular misconceptions, many individuals who meet diagnostic criteria for ASPD are not recidivist criminals. For example, only about half the participants in the Epidemiologic Catchment Area (ECA) Survey (Robins, Tipp, & Przybeck, 1991) who met diagnostic criteria for ASPD had significant criminal histories. However, the ECA survey did find that over 90% of those who met the criteria had at least one comorbid mental disorder, usually a substance use, mood, or anxiety disorder. These individuals also reported substantial psychosocial impairment, such as unemployment and marital problems, that might prompt them to initiate treatment. While it is rare for these individuals to seek treatment for ASPD itself, those with ASPD and a comorbid mental disorder were just as likely to seek treatment for the disorder as those not meeting the ASPD criteria. For that reason counselors in a variety of settings should be prepared to evaluate treatment options for clients with ASPD.

Psychosocial interventions have generally been considered ineffective for individuals with ASPD. In the opinion of Frances and Ross (2001), "The only effective treatment for Antisocial Personality Disorder appears to be the passage of time. Those individuals who do not get killed or kill themselves and survive into their 40s tend to mellow out and become less impulsive and predatory" (p. 294). However, given both the limitations of past studies and the findings of more recent ones, other clinicians and researchers have argued that such pessimism is not justified. As Skeem, Polaschek, Patrick, and Lilienfeld (2011) remarked, "An increasing number of studies suggest that psychopathic individuals are not uniquely hopeless cases who should be disqualified from treatment, but instead are general high-risk cases who need to be targeted for intensive treatment to maximize public safety" (p. 96). To avoid problems associated with expert opinions or clinical myths, counselors should turn to published studies in considering what treatment interventions, if any, might be feasible for such clients.

Much of the research on ASPD treatment has been concentrated on the basic question of treatment efficacy: Are there any psychosocial interventions that can reliably remediate core antisocial characteristics or reduce recidivism? Though such studies are valuable in their own right, they have limited value for counselors who must make practical, day-to-day treatment decisions. Reports of statistically significant differences between treatment and control groups--even when found--do not provide enough information for front-line counselors; they also need evidence that research discoveries can be readily extended to ordinary practice settings.

Reflecting this concern, the American Psychological Association (2002) formulated criteria for individuals and agencies to use in creating guidelines for treating a mental disorder or health-related condition. The first criterion, treatment efficacy, refers to the extent to which scientific procedures have established that a treatment is actually effective for a given condition. Ideally, evidence for treatment efficacy is obtained from the results of carefully controlled experimental studies. Clinical utility, the second criterion, goes beyond demonstrations of statistically significant changes to practical considerations of program delivery, such as cost-effectiveness and ease of application (APA, 2002). Using the APA criteria as a template, the purpose of this article is to identify guidelines for working with clients who present with significant antisocial characteristics. The guidelines are organized around two common treatment objectives: (1) remediation of core antisocial traits or reducing recidivism, and (2) treatment of comorbid substance use disorders.

But first, let me differentiate ASPD from the more research-oriented construct of psychopathy. This distinction is important because ASPD and psychopathy are likely distinct constructs, and their differences affect both the interpretation of published research and the likely prognosis for treatment (Reid & Thorne, 2006; Wallace, Vitale, & Newman, 1999).

ASPD VS. PSYCHOPATHY

The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V; American Psychiatric Association, 2013) states that the "essential feature of antisocial personality disorder is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood." (p. 659). While the criteria include a few inferential personality traits (e.g., deceitfulness), most of them involve examples of irresponsible or criminal behavior. However, the authors of the DSM-IV consider ASPD to be synonymous with the more inferential construct of psychopathy. Many critics have charged that the diagnostic criteria for ASPD are redundant with criminality and fail to include core personality characteristics--affective and interpersonal impairment--that are fundamental to the psychopathy construct (Blackburn, 2007; Hare, 2007; Ogloff, 2006).

Much of the groundwork in the conceptual development of psychopathy can be traced to the early work of Cleckley (1941), who formulated a comprehensive description of the syndrome based on his clinical experiences, both inpatient and outpatient. The title of his classic work, The Mask of Sanity, derived from his observation that although these individuals did not exhibit any overt signs of psychosis or cognitive impairment, their interpersonal and psychosocial functioning was highly impaired. Cleckley identified 16 personality features that he deemed to be characteristic of psychopathy: (1) superficial charm, intelligence, and adjustment; (2) absence of psychosis; (3) low levels of neuroticism; (4) irresponsibility and undependability; (5) deceit; (6) lack of remorse and shame; (7) recurrent immoral and criminal behavior; (8) poor judgment and difficulty learning from experience; (9) egocentricity and incapacity for love; (10) poverty of affect; (11) poor insight; (12) lack of reciprocity in interpersonal relationships; (13) impulsivity and disinhibition, often heightened by substance use; (14) relative immunity from suicide; (15) superficial and impulsive sexual encounters; and (16) an aimless or shiftless existence.

While Cleckley's 1941 publication made a notable impact on the field, empirical research on the syndrome did not gain a solid foothold until the development of the Hare Psychopathy Checklist (PCL) in the 1990s (Edens, Skeem, & Kennealy, 2009). The revised version of this inventory (PCL-R; Hare, 2003), which reflects Hare's conceptualization of psychopathy, measures two broad factors: Factor 1 (interpersonal/affective) covers such characteristics as grandiosity, shallow affect, and lack of empathy; Factor 2 (lifestyle/antisocial) covers such characteristics as impulsivity, emotional instability, irresponsibility, and history of conduct problems. 1 his differentiation has prognostic implications because Factor I scores tend to be relatively stable over time but Factor 2 scores--along with diagnoses of ASPD-are likely to decline with age (Harpur & Hare, 1994).

From the findings of several studies that have investigated the relationship between psychopathy, as measured by the PCL/PCL-R, and ASPD, as defined by the DSM, it appears that psychopathy is better conceptualized as a general personality factor that cuts across several Cluster B personality disorders than as a synonym for ASPD (Blackburn, 2007). For example, PCL/PCL-R Factor 1 scores have been shown to have a closer correlation with narcissistic and histrionic personality traits than with ASPD, and Factor 2 scores have been shown to converge more with the ASPD diagnostic criteria (Hare & Neumann, 2006; Lykken, 1995; Widiger, 2006). While there is still some debate about the factor structure of psychopathy (e.g., Cooke & Michie, 2001), there seems to be a consensus that psychopathy is qualitatively different from the diagnostic criteria for ASPD (e.g., Herve, 2007; Reid & Thorne, 2006). Because of the differences between ASPD and psychopathy, counselors need to carefully consider how treatment samples have been defined, because the findings obtained with one criterion group cannot simply be generalized to the other (e.g., Ogloff, 2006).

In the next section the treatment literature is considered in terms of the two main problem areas usually targeted for intervention: (1) antisocial characteristics or criminal recidivism, and (2) substance use disorders. For each, I review the treatment literature for ASPD and psychopathy separately and then evaluate the extent to which guidelines can be drawn up for each treatment objective using the APA-recommended criteria of treatment efficacy and clinical utility (APA. 2002).

REMEDIATION OF CORE ANTISOCIAL CHARACTERISTICS

Review of the Literature

As noted, many early treatment studies in this area attempted to evaluate the efficacy of psychosocial interventions in decreasing core antisocial characteristics or reducing recidivism. Most of them, which primarily studied individuals classified as psychopathic, reported that psychosocial interventions are generally ineffective (e.g., Harris & Rice, 2006). Negative results have been reported in a wide array of settings, including psychiatric hospitals (Huchzermeier, Brub, Geiger, Kernbichler, & Aldenhoff, 2008; Morrissey, Mooney, Hogue, Lindsay & Taylor, 2007); therapeutic communities (Hobson, Shine, & Roberts, 2000; Ogloff, Wong, & Greenwood, 1990); and sexual offender treatment programs (Looman, Abracen, Serin, & Marquis, 2005; Olver & Wong, 2011). Though not as well studied as psychopathy, a diagnosis of ASPF) has also been implicated as a negative prognostic indicator. For example, diagnoses of ASPD have been found to predict dropping out of a sexual offender treatment program (Larochelle et al., 2010) and an outpatient psychotherapy program (Hilsenroth, Holdwick, Castlebury, & Blais, 1998). At least one study incorporated measures of both ASPD and psychopathy; Kunz et al. (2004) reported that higher levels of both predicted recidivism after discharge from a psychiatric hospital.

Whereas these studies found only that individuals with antisocial personalities had poor responses to treatment, a few studies have suggested that psychosocial interventions might actually be iatrogenic. In one often-cited example, Rice, Harris, and Cormier (1992) found an interaction effect between psychopathy ratings and treatment participation among offenders in a therapeutic community. Specifically, psychopathic offenders who received this treatment had higher rates of violent recidivism than matched psychopathic offenders who did not receive the treatment. Other researchers, though, have challenged this interaction effect. For example, Skeem, Monahan, and Mulvey (2002) noted that this 1960s-era therapeutic community had several peculiar treatment components, such as the use of nude encounter groups and the administration of LSD to lower psychological defenses. Even if a program of this nature produced iatrogenic effects, it does not follow that more modern and mainstream approaches would have similar results.

Iatrogenic effects have also been reported in other studies. Hare, Clark, Grann, and Thornton (2000) reported an interaction effect between Factor 1 psychopathy, characterized by affective and interpersonal impairment, and offender participation in treatment: prison inmates who scored high on factor 1 and participated in treatment had higher recidivism rates than high-scoring Factor 1 inmates who did not participate in treatment. Seto and Barbaree (1999) described a similar interaction effect in a sexual offender treatment program: participants rated higher in both psychopathy and treatment compliance were more likely to recidivate than comparable participants who were less compliant. They wrote, "Men who behaved better in group sessions, did well on their homework assignments, and were judged to be more motivated and to have made more gains during treatment were significantly more, rather than less, likely to commit a new serious offense" (p. 1242).

Because this later finding generated so much attention, Barbaree (2005) conducted a followup study on this sample to evaluate whether the interaction effect reported held over a longer period of time with a more complete dataset and found that there was no longer an interaction effect between psychopathy and treatment behavior. Consistent with much of the treatment literature on psychopathy, Barbaree found only a main (negative) effect for psychopathy. Additional studies (Langton, Barbaree, Harkins, & Peacock, 2006; Looman et al., 2005) also failed to replicate the interaction effect originally reported by Seto and Barbaree (1999). Thus, there is little if any evidence that modern treatment interventions are iatrogenic for individuals classified as psychopathic.

While these results lend support to the belief that individuals with ASPD or psychopathy are unbeatable, other studies have challenged this conclusion. As one example, Skeem et al. (2002) evaluated the effectiveness of mental health treatment among civil psychiatric patients in the MacArthur Violence Risk Assessment study. After controlling for participant characteristics (e.g., substance abuse, comorbid depression, and employment status) thought to predict treat merit participation, they found that participants who completed 0-6 treatment sessions were three times more likely to commit a violent act during a 10-week assessment period than those who completed 7 or more sessions. While an observational study of this nature cannot provide any direct evidence of treatment efficacy, the results at least provide some evidence that antisocial individuals who persevere in treatment may experience some beneficial outcomes.

Later McKendrick, Sullivan, Banks, and Sacks (2006) compared the effectiveness of treatment-as-usual (TAU) to a modified therapeutic community for prisoners with dual diagnoses, including ASPD. After using a propensity score to statistically control for pre-existing differences between ASPD and non-ASPD offenders, they found that combining the modified therapeutic community with TAU resulted in greater reductions in substance use and recidivism 12 months post-release than TAU alone. Furthermore, the effect was not diminished by a diagnosis of ASPD. Likewise, Davidson et al. (2009) compared the effectiveness of TALI alone to TAU plus cognitive behavior therapy (TAU+CBT) in a sample of 52 men with ASPD and recent aggressive behavior. Aggressive behavior declined in both treatment groups over the course of the study. In the TAU group, reports of verbal aggression declined from 96% at baseline to 81% at 12-month follow-up, and physical aggression declined from 85% to 38%. In the TAU+CBT group, reports of verbal aggression declined from 100% at baseline to 77% at 12-month followup and reported physical aggression declined from 88% to 32%.

Most recently, Olver, Lewis, and Wong (2012) examined the relationships between psychopathy, therapeutic change, and recidivism in a sample of 152 offenders in an intensive violence-reduction treatment program. They found that higher psychopathy ratings, especially Factor 1 ratings, predicted both less therapeutic progress and more violent recidivism. However, they also found some evidence that progress ratings predicted small decreases in violent recidivism, indicating that therapeutic gains, though difficult to obtain, may help reduce recidivism among high-risk, psychopathic offenders.

Probably the most contested study on the potential benefit of treatment for individuals with psychopathy is a meta-analysis conducted by Salekin (2002). Across the 42 studies he analyzed, he reported an overall success rate for treatment of 62%. Success rates were further broken down by type of treatment: 59% for psychoanalytic therapy, 62% for CBT, 86% for interventions that combined CBT and insight-oriented therapy, and 25% for therapeutic communities. He acknowledged that many of the studies in this meta-analysis were methodologically weak (e.g., case studies, pre-post designs), but he justified their inclusion based on the limited number of outcome studies available. Harris and Rice (2006) re-examined the same studies and came to starkly different conclusions about their cumulative meaning. They identified problems in both the studies reviewed and Salekin's analyses of the data. Among their criticisms were the following: inclusion of poorly designed studies with low internal validity; invalid measurements of psychopathy; improvement ratings based almost entirely on therapist judgment; questionable effect size estimates; and mischaracterizations of the findings of the studies analyzed. In addition to methodological problems, the treatment approaches Salekin (2002) identified as successful were very atypical in terms of treatment length and client participation.

Summary and Treatment Guidelines

The studies discussed provide a somewhat complex picture of the benefits of psychosocial treatments in remediating antisociality or reducing recidivism. While most reported negative results, several of the more recent studies found some beneficial outcomes for clients classified with ASPD or psychopathy. In addition, there is no consistent evidence that psychosocial interventions are iatrogenic. Nonetheless, researchers have not yet identified any interventions that clearly meet the standard of treatment efficacy in reducing the core features of antisociality and criminal recidivism. Because treatment efficacy puts a limit on clinical utility, there is no evidentiary base from which to support the clinical utility of any psychosocial interventions.

TREATMENT OF COMORBID SUBSTANCE USE DISORDERS

Review of the Treatment Literature

Even if psychosocial interventions are minimally effective in reducing antisocial traits or recidivism, it does not follow that the ancillary problems these individuals often experience are also unbeatable. As is well-known, substance use disorders are highly comorbid with ASPD (Morgenstern, Langenbucher, Labouvie, & Miller, 1997; Skodol, Oldham, & Gallaher, 1999). As one example, 39% of the participants in a large substance dependence treatment program (N = 7,402) also met diagnostic criteria for ASPD (Flynn, Craddock, Luckey, Hubbard, & Dunteman, 1996). Accordingly, counselors who treat substance abuse, regardless of setting, are likely to encounter many clients who also meet the ASPD diagnostic criteria.

In contrast to the rather pessimistic results related to remediation of core antisocial characteristics, numerous studies have found that individuals with ASPD can benefit from treatment for substance abuse and, more importantly, the therapeutic gains they obtain are often comparable to those obtained by participants without ASPD (Brooner, Kidorf, King, & Stoller, 1998; Cacciola, Alterman, Rutherford, & Snider, 1995; Darke, Finlay-Jones, Kaye, & Blatt, 1996; Easton et al., 2012; Gunter, Black, Zwick, & Arndt, 2004; Longabaugh et ah, 1994; Messina, Wish, Hoffman, & Nemes, 2002; Messina, Wish, & Nemes, 1999; Project MATCH Research Group, 1997). One study actually found that participants with comorbid ASPD were more likely to reduce cocaine use as part of a methadone maintenance treatment program than those without (Messina, Farabee, & Rawson, 2003). Several studies have also found that an additional diagnosis of a depressive disorder may enhance treatment outcomes for individuals with both ASPD and substance use disorders by presumably increasing their motivation to persevere in treatment (e.g., Tomasson & Vaglum, 2000; Woody, McLellan, Luborsky, & O'Brien, 1985). Finally, a meta-analysis by Hesse and Pedersen (2006) revealed that, in general, participants with ASPD were no more likely to drop out of substance abuse treatment than those without. However, not all relevant studies have reported such positive results. A number of research groups have reported that participants with ASPD do not benefit as much from substance abuse treatment as those without (Alterman, Rutherford, Cacciola, McKay, & Woody, 1996; Compton, Cottier, Jacobs, Ben-Abdallah, & Spitznagel, 2003; Galen, Brower, Gillespie, & Zucker, 2000; Grella, Joshi, & Hser, 2003; Hunter et al., 2000; King, Kidorf, Stoller, Carter, & Brooner, 2001; Ross, Dermatis, Levounis, & Galanter, 2003). Yet, even in these studies participants with comorbid ASPD usually benefited to some extent from treatment, though the improvements were not as large as for those without ASPD diagnoses; Hunter et al. (2000) explained, "The association [between ASPD and outcome] is of such a small magnitude that it would have practically no bearing on providing a clinician with predictive value regarding drinking outcome in an individual case" (p. 337). Thus, although treatment benefits might be attenuated, researchers have generally found substance abuse treatment to be beneficial for individuals with comorbid ASPD.

Very few substance abuse treatment studies have incorporated any measure of psychopathy; although one found that participants who scored higher in psychopathy performed as well in substance abuse treatment as those scoring lower (Kalman, Longabaugh, Clifford, Beattie, & Maisto, 2000), two others reported more negative treatment outcomes for participants rated higher in psychopathy (Richards, Casey, & Lucente, 2003; Van Stelle, Blumer, & Moberg, 2004). Finally, a few studies have evaluated the comparative utility of both ASPD and psychopathy in moderating the effectiveness of substance abuse treatment. Neufeld et al. (2008) reported that participants diagnosed with ASPD or psychopathy did almost as well in treatment as those lower in these characteristics, but Alterman et al. (1998) found that both ASPD and higher levels of psychopathy predicted more negative treatment outcomes. However, the latter reported that psychopathy ratings were better predictors of treatment outcome and might be more useful in forecasting treatment difficulties than a diagnosis of ASPD alone.

Summary and Treatment Guidelines

Many well-designed treatment studies have provided convincing evidence that clients with comorbid ASPD can benefit from substance abuse treatment, thus providing strong evidence for treatment efficacy. There is also a significant body of research to support the clinical utility of substance abuse interventions for clients with comorbid ASPD. Substance abuse treatment has been shown to be effective for individuals with comorbid ASPD in a variety of treatment settings, such as contingency management programs (Brooner et al., 1998; Messina et al., 2003; Neufeld et al., 2008); outpatient psychotherapy (Longabaugh et al., 1994; Woody et al., 1985); methadone treatment programs (Darke et al., 1996); and therapeutic communities (Messina et al., 1999; Messina et al., 2002). As further evidence of clinical utility, studies have also documented the cost-effectiveness of substance dependence treatment programs (e.g., Ettner et al., 2006; Godfrey, Stewart, & Gossop, 2004; Wickizer, Krupski, Stark, Mancuso, & Campbell, 2006; Zarkin et al., 2012). Consequently, if the goal of treatment is limited to the remediation of substance abuse disorders, a strong case can be made for a treatment guideline in which substance abuse treatment is recommended for individuals with comorbid ASPD. Because only a few of the studies reviewed incorporated any measure of psychopathy, it is not as clear whether substance abuse treatment will be similarly efficacious and useful for individuals described as psychopathic.

SUMMARY AND CONCLUSIONS

As with any population or presenting problem, mental health counselors have an ethical responsibility to provide counseling interventions that offer a reasonable chance of success (American Mental Health Counselors Association, 2010). Accordingly, they need to be aware of what treatment interventions and objectives are appropriate for clients who present with significant antisocial characteristics. Based on the treatment literature, counselors are justified in recommending substance abuse treatment services for clients with comorbid ASPD. Such interventions have been found to be efficacious, and there is also evidence of clinical utility in multiple practice settings. In contrast, researchers have not yet identified any psychosocial interventions that meet the standards for either treatment efficacy or clinical utility in remediating core antisocial characteristics or reducing recidivism. Consequently, any therapeutic efforts directed toward these outcomes should be considered experimental, and counselors should be fully aware of their ethical responsibilities for ending counseling when it is ineffective (AMHCA, 2010).

Experts and researchers have long debated the viability of developing and delivering psychosocial interventions that will remediate the core features of ASPD or psychopathy. As this review has illustrated, the basic question of treatment efficacy has yet to be answered satisfactorily. Nevertheless, McGauley, Yakeley, Williams, and Bateman (2011) recommended that researchers continue to search for interventions that might reduce antisociality because of the tremendous impact it has on both those diagnosed and society at large. For researchers, this is a worthwhile endeavor; yet for those delivering service directly, the important question is not whether a given treatment can technically reduce the severity of ASPD or psychopathy in a random clinical trial. Given large enough sample sizes, it is conceivable that researchers will occasionally report statistically significant improvements among individuals who actually complete intensive treatment programs. The more important question for counselors and administrators is whether any of the treatment benefits reported (treatment efficacy) can be realistically obtained in real-world settings (clinical utility).

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Gregory T. Hatchett is affiliated with Northern Kentucky University. Correspondence about this article should be addressed to Gregory T. Hatchett. Department of Counseling. Social Work, & Leadership, Northern Kentucky University, MEP 203E, Highland Heights, KY 41099. Email: hatchettg@nku.edu.
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Title Annotation:THEORY
Author:Hatchett, Gregory T.
Publication:Journal of Mental Health Counseling
Geographic Code:1U2NY
Date:Jan 1, 2015
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