With reference to current research, evaluate the efficacy of treatment for Anti-Social Personality Disorder Essay

Anti social personality disorder is listed in the DSM IV criteria as to have at least three of the following, Repeated law breaking, deceitfulness, impulsivity, irritableness and aggression, disregard for own and others safety, irresponsibility as seen through unstable employment, or lack of remorse. The individuals must also be at least 18 years of age, have evidence of a conduct disorder before the age of 15 and have antisocial behaviour not occurring exclusively during episodes of schizophrenia or mania. The term is often used in conjunction with that of Psychopathy, as the two are closely related and there is an argument over diagnosis (Davidson et al 2004; Reid 2000; Kendall et al 1998).

Within psychopathy there are different criteria of diagnosis, Cleckley 1976 (cited in Davidson et al 2004; Sutker 2001) developed a set of criteria mainly based on thoughts and feeling rather then behaviour. The key characteristics of this are their lack of emotion, anxiety and continued manipulation for personal gain. Hare et al 1990 (cited in Davidson et al 2004;Black 1999) also developed a checklist for the psychopathic personality which contain two clusters, firstly is emotional detachment characterised by selfishness and a lack of remorse and the second is the antisocial lifestyle characterised by impulsivity and irresponsibility (Davidson et al 2004; Hare 1971).

‘Some researchers have argued that the DSM diagnostic criteria of Antisocial personality Disorder should be altered to include more of the traits of psychopathy’ (Kendall 1998). Other research questions the stability of the Antisocial Personality Disorder criteria, the requirement for the individual to have conduct disorder in childhood may overlook those individuals who develop antisocial characteristics in later life (Alterman et al, 1998, cited in Blackburn, 2000). The range of diagnostic tools has caused problems for examining the efficacy of treatment for both Antisocial Personality Disorder and Psychopathy which in turn has regularly caused them to be considered together, which will also be the case in this essay(Reid 2000; Salekin 2002; Sue et al 1997;).

The prevalence of anti social personality disorder and psychopathy are the highest of all personality disorders, and form approximately 3% of the population (Blugass 1999; Kendall 1998; Davidson et al 2004; .Sue et al 1997; Sutker 2001) This is extremely high in the penal system at 38% (Office of National Statistics, 1998 cited in Pilgram 2001).The cause of antisocial disorders are unknown however they have been linked to child abuse and genetic factors.

The family and other biological factors have also been put forward as explanations (Website 1; Sue et al 1997; Hare 1971; Davidson 2004; Sutker 2001). This lack of understanding has had problems in the treatment of the disorder, this however in only one of many problems. The individual is unlikely to see themselves as having an illness which in turn inhibits any willingness to change, (Gask 2000) also the traits of the illness such as the lack of honesty, inability to build a relationship and the constant manipulation of situations for personal gain can all have an effect on treatment. Antisocial Personality Disorder has also been associated with substance abuse which can cause problems in some treatments such as medicalisation (Reid et al 2000).

More often than not intervention takes the form of incarceration, or imprisonment as the punishment for a crime. ‘Criteria for diagnosing Antisocial Personality Disorder emphasize overt violations of social rules; it is not surprising that Antisocial Personality Disorder is commonly found in criminal populations’ (Kendall 1998). Psychopathy however is ‘thought to define a much narrower range of criminals in prison…. Than does Antisocial Personality Disorder’ (Hare, Hart and Harpur 1991, Widiger et al 1996, Cited in Kendall 1998). The need for lack of remorse in the diagnosis of psychopathy is one suggestion for this difference. The prison situation also creates problems for treatment as it is either compulsory or the individual may see it as an easy option (Doren 1987).Treatments such as psycho analysis, medicalisation, group therapy/therapeutic communities, Cognitive interventions and experimental programmes have all been used to combat the disorder, with a range of results. The results of therapy are usually measured through reoffending rates, however improvement in relationships, reduced violence and reduced substance abuse have all been used to measure effectiveness in each of the therapies.

Psychoanalysis has continually failed to create any lasting effects on the psychopath, Reid (2000) points out that the ‘ lack of discomfort with their disorder, their virtually universal intolerance for the anxiety necessary to benefit from intensive work and the ease with which they can escape treatment both literally and figuratively all work against any probability of success’ (Reid 2000) Those that have reported success have mainly been case histories which clinicians only tend to publicise if successful ( Bennet 2003).

There is also the problem of manipulation of the therapist by the patient. The amount of effort that a therapist exerts in treatment can also be frustrating causing burnout. Medication has been used in both Antisocial Personality Disorder and Psychopathy to combat aggressiveness and impulsivity. ‘Lithium has been shown to reduce the number of impulsive aggressive episodes among offenders in n American correction centre’ (Bennet 2002) However these were young offenders and only a quarter were affected. There is also the problem of abuse of medication and the individual may even sell the product for their own personal gain rather then taking it themselves. Substance abuse programmes also tend to focus on the reduction of use rather then the Antisocial Personality Disorder as a whole.

Therapeutic communities were first developed by Maxwell Jones in the late 1940’s (Bennet 2003) and are an intense 24 – 7 community responsible for the physical and emotional care of the rest of the group. When on its own this treatment does not seem to have a positive effect. For example Rice et al (1992); Seto and Barbaree (1999 Cited in Bennet 2003) found that psychopathic individuals in such a programme were more likely to reoffend when discharged from prison. The problem in this kind of treatment is that as with prison being a school for crime therapeutic communities, if not monitored correctly can be a school for the psychopath. This criticism has also been taken up with group therapy; Reid (2000) suggests that there is no symptom orientated groups which categorically antisocial behaviour.

This is also seen in some cognitive therapies. Hare et al (2002) examined the outcome of short term, prison based cognitive behaviours programmes finding that ‘intervention had little effect on reoffending rates, the courses included anger management and social skills training however they seemed to teach the individuals how to be ‘better psychopaths’ (Hare et al 2002 cited in Bennet 2003). Beck et al (1990) however, rather then trying to completely change behaviour, looked at the realistic goals of this kind of intervention, suggesting that psychopaths will primarily act out of self interest and therefore the goal of therapy should be to help them act in ways which are functional within these limits, for example, believing one is always right will cause interpersonal friction inhibiting the psychopaths individual goal. (Beck et al 1990 cited in Bennet 2003; Sue et al 1997)

Recent research has produced more promising results. Wong and Hare (2002 cited in Bennet 2003) have developed a cognitive behavioural approach that involves both the institution, i.e. the prison and the individual. This programme however has not yet been empirically tested. (Bennet 2003) Changing the whole environment of the individual is difficult however some institutions have produced encouraging results. The patuxent institute in Maryland U.S.A is a good example of this (Reid 2000; Website 11; Website 2). Family intervention is another therapy that has shown effective. Borduin (1999 cited in Bennet 2003) cited in Bennet (2003)

Developed a multi systematic approach to treatment involving parenting skills, coping strategies for parents, peer orientated interventions and cognitive behavioural interventions. This approach has achieved significant success rates in relation to reoffending; however the groups involved appear to be of a younger age, suggesting prevention rather then treatment. There is also the argument of natural course; this is due to the decreased activity of those with Psychopathy and Antisocial Personality Disorder over the age of 40. ‘Cross sectional studies indicate that later life changes may relate to things such as decreased energy rather then characterlogic change (Hare 1971 cited in Reid 2000). However this is not a suitable treatment as the government need to be seen to be doing something and there is a real danger from these individuals.

Each therapy has particular pros and cons; however there is still an underlying pessimism within the psychological profession as to the success of any one treatment. The most comprehensive study into whether treatment for psychopathy works is that of Salekin (2002). He reviewed 42 treatment studies on psychopathy discovering that there is little evidence for the belief that psychopathy is an untreatable disorder. Three problems are suggested which cast doubt on this suggestion, firstly the inconsistency in the defining characteristics of psychopathy. Secondly the aetiology of psychopathy is not well understood and thirdly that there are very few efforts empirical investigations into the psychopathy – treatment relationship (Salekin 2002).

Most of the studies he analysed used a Clecklian approach to psychopathy and he used a meta -analysis to discover the effectiveness of each treatment. The treatments he examined were psychoanalytic, cognitive -behavioural, therapeutic communities, actional procedures, eclectic, pharmacotherapy, ECT, personal construct, rational therapy, psychodrama, not specified and a control. He found that cognitive behavioural treatments (0.62 mean success rate over 246 cases) and eclectic treatments (0.86 mean success rate over 62 cases) were the most successful treatments. This suggests that treatment for Psychopathy and Antisocial Personality Disorder do make a significant difference in some cases.

However although this study is promising there is still a multitude of problems in treating the disorder, the most significant of these is that psychopaths and those with Antisocial Personality Disorder are unwilling to assume personal responsibility because they tend to blame others or circumstances for their behaviours – a situation that creates little motivation for self exploration (Kendall 1998);(Bennet 2003).

Because of the ‘difficulties involved in treating or modifying adult Antisocial Personality Disorder and conduct disorder, investigations have focused more directly on prevention of Antisocial Personality Disorder, largely by treating children’s anti social behaviour symptoms early in life before they become severe or chronic.’ Kendall 1998) Prevention has become a major issue and a renewed interest in personality disorders as a whole has come about in both practioners and policy makers along with renewed interest in treatment ‘Perennial concerns about the treatability of psychopaths are currently reflected in Britain in a recent government discussion document on the management of ‘dangerous severe personality disorders’ (Home Office/ Department of Health, 1999 cited in Blackburn 2000).

Salekin’s study (2002) emphasizes the major issue in Psychopathy and Antisocial Personality Disorder which is the pessimism surrounding treatment. This may well influence the individual being treated and effect the outcome, ‘there continues to be debate about whether psychopaths or antisocial personalities should be treated. One argument is that psychopaths are not ‘mad’ or mentally ill, and are hence responsible for their ‘bad’ moral choices’ (Blackburn 2000). Treatment does continue never the less and the range of treatments all have problems when used individually however eclectic treatments seem to have a greater effect.

The multi systematic approaches of Borduin (1999 cited in Bennet 2003) and the behavioural approach of Wong and Hare (2002 cited in Bennet 2003) have shown promising results along with the range of institutes which have been developed. As Black points out Antisocial Personality Disorder may never be curable but the symptoms may be controllable ‘Even some of those patients who show the greatest change seem unable to comprehend the degree to which their actions affected those around them’ (Black 1999 pp 143). As the essay has discussed the range of treatments needs to be evaluated further with emphasis on multi systematic approaches. This along with further research into prevention could correct the pessimism currently surrounding the disorders and give greater insight into the best forms of treatment.