Can psychopaths change?

Psychopaths might account for only about 1% of the general population, but they account for a disproportionate share of violent crime.

Distinct from other conditions like sociopathy and antisocial personality disorder, psychopaths tend to show traits such as an absence of remorse or guilt, a lack of empathy and a charming and manipulative interpersonal style.

You may find it hard to imagine how someone without much empathy can change. And early psychological treatments were not successful. But advances in research are showing that a deeper understanding of psychopathy may help to create more effective interventions.

People with psychopathy typically show problems in responding to other people’s suffering, including difficulty recognising facial expressions of fear and sadness. If you have ever seen someone badly hurt themselves, then you probably had an averse response.

Your brain will have reacted to their pain and your body will probably have shown signs of physiological arousal. Your heart rate might have gone up, or you might have sweated.

These are common signs of physiological arousal in response to someone else’s suffering. But they are often lacking in psychopaths.

When my colleagues and I asked people in prison with a history of violence to view pictures of others’ emotional facial expressions, those who reported more of the characteristic features of psychopathy also showed blunted physiological arousal. Our 2019 study found that the pupil (the small black hole in the centre of the eye that lets in light but also increases in size during physiological arousal) did not change much in size among people higher in psychopathic traits when they looked at pictures of people who were afraid.

These differences mean that some people with these traits might struggle to learn about how their actions cause other people to feel distressed or afraid.

Prisons and secure forensic hospitals are where people with psychopathic traits are often entered into treatment programmes designed to reduce their risk of reoffending. Modest reductions in general reoffending have been reported following cognitive behavioural programmes that are offered to people in prison with or without psychopathy or another personality disorder.

But not all criminal behaviour programs have been marked by success. For example, in the UK in 2017 the failure of the Core Sexual Offender Treatment Programme designed by His Majesty’s Prison and Probation Service (HMPPS) and approved for use in 1992, to lower reoffending was highly publicised.

HMPPS has since introduced a new programme, Building Choices. It adopts a strengths-based, skill focused approach to improve emotion management, healthy relationships and sense of purpose. Unlike the previous course, the programme is not designed to address particular offence types, and it has shown some signs of promise.

Historically, researchers have considered such programmes less effective at reducing reoffending when offered to people with psychopathy. Indeed, some studies even suggest that people with psychopathy worsened following treatment.

One of these programmes, offered from around 1965 to 1978 at the maximum-security Oak Ridge Division of the Mental Health Centre in Penetanguishene, Ontario, Canada, made use of a so called “total encounter capsule.”

These results made for a high degree of pessimism among scientists and practitioners alike. But that pessimism might be misplaced.

It is perhaps unsurprising that the “total encounter capsule” did not prove effective. The capsule was “a tiny self-contained chamber where sustenance was supplied through tubes in the walls and from which no group members would leave during sessions that lasted up to two weeks”.

Participants were reported to be nude and did not participate voluntarily. There were few professional therapists, and the use of force and humiliation was permitted.

Historically, there has been a lot of pessimism around treatment for other personality disorders, too.

This is in part a reflection of stigma attached to these disorders. But it is also because personality difficulties can make it harder for people to build relationships, including with the people responsible for their treatment.

Yet a form of therapy known as dialectical behaviour therapy has shown success in reducing self-harm in people with borderline personality disorder. This type of therapy is designed to help people cope with intense emotions and to learn interpersonal skills.

In another recent study, mentalisation-based treatment, which targets the person’s ability to understand and regulate the negative effects of thoughts and feelings, led to reductions in aggressive behaviour in people with antisocial personality disorder. Findings like these suggest tailored interventions are more effective when it comes to personality disorders.

Capable of empathy?

One important consideration when treating psychopaths is that they are often assumed to be incapable of empathy. But this assumption has been challenged by some intriguing studies, which suggests that they might instead lack the motivation for empathy.

In a 2013 brain scanning study, a group of scientists at the university of Groningen, the Netherlands, showed that although criminal psychopaths did not automatically feel empathy for other people’s pain depicted in videos, their brains did generate an empathic response similar to that of non-psychopaths when instructed to feel what the people in the videos were feeling.

It could be an important step toward helping people with psychopathy if they could better understand how their actions can hurt other people.

Perhaps the most promising work that suggests people with psychopathy can change has been conducted with young people. Although children and young people under the age of 18 cannot be diagnosed as psychopathic, features of psychopathy referred to as callous unemotional traits can be reliably assessed in children as young as two years of age.

A 2018 study adapted parenting interventions to be more effective for this high-risk group of children, aged three to six years old. Afterwards, the children showed significant reductions in behavioural problems, callous unemotional traits and aggression. The researchers coached parents to show more warmth, sensitivity and responsiveness. Parents were also asked to focus on reward-based rather than punishment-based strategies to encourage the child participants to be more responsive to distress in others.

A 2022 study also reported positive outcomes, showing improvements in behaviour and personal relationships in adolescents after an intervention with a focus on strength-based (helping children understand what they’re good at) rather than punishment-based parenting strategies.

So recent work is offering a glimpse of a more optimistic future for reducing aggressive and antisocial behaviour associated with psychopathy. Perhaps the question is not can psychopaths change now, but can we get better at helping them to change.

Steven Gillespie has consulted for Ministry of Justice. He receives funding from Economic and Social Research Council.