Mental health articles

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Treating psychopathy by cognitive interventions

Cognitive behavioural interventions may not be immune from this paradoxical outcome. Hare et al. examined the outcome of a number of short-term, prison-based, cognitive behavioural programmes including anger management and social skills training. Their data revealed that the interventions had little effect on re-offence rates of most psychopathic individuals. However, among offenders with particularly high levels of psychopathy, re-offence rates rose following treatment. Again, it seems that these courses taught these people how to be ‘better psychopaths’. Despite these negative results, a number of research groups have considered how the goals and strategies of cognitive behavioural therapy could be adapted to treat psychopathic individuals. Beck et al. attempted to defi ne the realistic goals of such interventions. They noted that the individual will continue to act primarily out of self-interest, and that the goal of therapy should therefore be to help them act in ways that are functional and adaptive within these limits. Cognitive challenge, which lies at the heart of the intervention, may therefore not only address core schemata such as ‘I am always right’, or ‘Other people should see things my way’, but also question whether antisocial behaviour is in the individual’s own interest. Participants in therapy may, for example, be encouraged to question whether behaving in a way that assumes ‘other people should see things my way’ causes interpersonal friction which interferes with their own goals, and to change their behaviour if this is the case. This approach allows client and therapist to work together towards agreed goals. Wong and Hare developed a substantial cognitive behavioural approach to the treatment of psychopathy, involving interventions at both an institutional (prison) and individual level. Their intervention was problem-focused and addressed issues specifi c to psychopathic individuals. Key elements of the programme included the following: Support of pro-social attitudes and behaviour : many psychopathic individuals within an institution seek out others with similar views who will reinforce their own beliefs. To minimize the risk of this happening, Wong and Hare suggest that a ‘pro-social milieu’ is established within the institution. This may be achieved by high-status individuals within the programme modelling positive attitudes and encouraging them in others, and encouraging group reinforcement of pro-social behaviours. Note that the results of Rice et al. suggest that this may not be easy to establish. Changing dysfunctional behaviours – aggression, manipulation, intimidation : strategies to achieve change include self-instruction training to prevent overreacting to situations in which the individual feels inappropriately threatened or angry, and interpersonal skills training where these are lacking and contributing to the use of intimidation or other dysfunctional behaviours. These may be taught through role play and reinforcement of appropriate behaviour. Learning to take responsibility for one’s actions : the intervention here involves a detailed analysis of the factors that lead up to offences, and identifying where the individual made choices that ultimately lead to offending. This also forms the core of relapse prevention training, as information here both encourages the individual to take responsibility for the actions that led to offending behaviour and to identify strategies to avoid them in the future. The programme also examined strategies for minimizing substance misuse and helping participants gain work skills or develop leisure activities to help avoid boredom once discharged, as this may trigger antisocial behaviour. Finally, the programme addressed the social network into which the individual is discharged following their stay in prison. Attempts to maintain or re-establish links with supportive family or other means of social support were recommended, although family contacts may be conducted with some caution, as relationships with family members are frequently poor. Evidence of the effectiveness of these therapeutic approaches has yet to be reported.

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