Psychopathy ≠ untreatable: Comorbid psychopathy in forensic psychiatric patients

Psychopathy is associated with greater therapy-interfering behavior, with PCL-R Factor 2 predicting institutional misconduct and PLC-R Factor 1 predicting dropout from treatment. This is the bottom line of a recently published article in the International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | International Journal of Forensic Mental Health | 2017, Vol. 16, No. 2, 149-160

Forensic Psychiatric Patients with Comorbid Psychopathy: Double Trouble?

Authors

Inge Jeandarme, Knowledge Center Forensic Psychiatric Care (KeFor)
Claudia Pouls, Knowledge Center Forensic Psychiatric Care (KeFor)
T. I. Oei, Department of Criminal Law, Tilburg University, Tilburg, The Netherlands
Stefan Bogaerts, Forensic Psychiatric Center the Kijvelanden, Rotterdam, The Netherlands

Abstract

Patients with psychopathy need intensive care and supervision. There is however reluctance to treat them because of (supposedly) limited chances of success and risk of therapy-interfering behavior. This study focused on inpatient disruptive behavior in mentally disordered offenders during medium security treatment. Patients (N = 224) were assessed using the Psychopathy Checklist- Revised total, factor and facet scores and divided into three groups depending on the presence of low, medium, and high psychopathy traits. Associations between psychopathy and criminogenic risk and need factors were analyzed. Additionally, the association between psychopathy and therapy-interfering behavior (non-compliance, drop-out, institutional misconduct) was investigated with correlational and logistic regression analyses. The results showed that psychopathy was associated with greater risk, needs, and therapy-interfering behavior. PCL-R Factor 2 predicted institutional misconduct, whereas PCL-R Factor 1 predicted drop-out from treatment. The study highlights the importance of responsive treatment climates in retaining this difficult-to-treat group in treatment.

Keywords

PCL-R, psychopathy, forensic psychiatric patients, internees, therapy-interfering behavior

Summary of the Research

“Under Belgian law, internment is a safety measure for offenders who are found not guilty for reason of insanity (NGRI). As in other countries, this specific legislation allows mentally disordered offenders (MDOs) to be transferred to (forensic) psychiatric facilities for mandatory treatment. In line with research on non-mentally ill offenders, antisocial and/or psychopathic personality traits are also strong risk factors for recidivism in MDOs. Comorbid psychopathic traits in MDOs are associated with more impulsive and coercive and less compliant interpersonal styles, premeditated aggression, and poor criminal outcomes.” (p. 149)

“Furthermore, it is generally believed that high levels of psychopathy guarantee a problematic course of treatment and thus present a serious challenge for therapists. Skeem, Manchak, and Peterson (2011) compared these patients with poor students in the classroom: verbally combative, hostile, prone to break rules, and not motivated to cooperate with treatment. According to Wong, Gordon, and Gu (2007), one of the most daunting responsivity factors in treatment is treating unmotivated, non-adherent and treatment-resistant clients such as many patients with psychopathy or (antisocial) personality disorder.” (p. 149)

“Meta-analytic research findings in different settings— including forensic psychiatric settings—have indicated that the PCL-R total score is associated with broadly defined institutional misconduct (rw = .29) and to a lesser extent, with physical violence (rw = .17). PCL-R Factor 2 was moderately predictive of institutional adjustment, whereas Factor 1 showed a less robust association. Of the PCL-R’s four facet scores, Facet 4 was the strongest and most incrementally valid predictor of institutional aggression in forensic psychiatric settings.” (p. 150)

“Given the abovementioned problems with non-compliance and institutional misconduct and the resulting security concerns, the increased treatment drop-out rates may not be surprising. A meta-analysis performed by Olver, Stockdale, and Wormith (2011) found that having an antisocial personality disorder or psychopathy (both the diagnosis and dimensional PCL-R scores) predicted attrition. In male sex offenders, PCL-R Facet 2 showed significant unique contributions to drop-out, whereas none of the other facets did. In female patients with substance abuse, a shorter treatment stay was associated with PCL-R Factor 1 personality characteristics.” (p. 150)

“The objective of this study was to investigate the relations between psychopathy measured with the PCL-R and indicators of therapy-interfering behavior, namely institutional misconduct, non-compliance and drop-out from treatment. We controlled for other risk/need factors because these may contribute to the associations of interest.” (p. 150)

“The following categorical variables were considered indicators of therapy-interfering behavior (TIB) during inpatient treatment: (1) treatment drop-out, (2) non-compliance, and (3) institutional misconduct. Non-compliance was defined as a report to the CPS that the treatment rules had not been respected (such as the use of alcohol during treatment or failure to cooperate with treatment). Institutional misconduct was defined as (1) absconding (such as escaping from the institution or absconding from supervised or unsupervised leave), (2) violating individually formulated judicial conditions, and (3) engaging in offense related behavior, which was defined as incidents coded under offending categories in the Belgian penal code, regardless of whether they led to further prosecution or sentencing.” (p. 152)

“In the current study, psychopathy was significantly associated with greater risks, needs and TIB. PCL-R Factor 2 predicted institutional misconduct, whereas PCL-R Factor 1 predicted drop-out from treatment.” (p. 155)

“Considered together, our findings support other research stating that treatment should focus on criminogenic PCL-R Factor 2 features while also carefully accounting for PCL-R Factor 1 characteristics to keep patients in treatment.” (p. 156)

“Although it is understandable that clinicians often prefer highly motivated and compliant low-risk patients, the RNR model states that most resources should be deployed to treat more difficult, less compliant patients. Forensic mental health professionals therefore face a great challenge. They must tolerate difficult interpersonal behavior, such as hostility and manipulation, and control their countertransference while still motivating forensic patients who seemingly do not want to change or even stay in treatment. This is clearly not an easy task, but as shown by international research, it is not impossible. Difficult-to-treat should not become synonymous with untreatable.” (p. 158)

Translating Research into Practice

“Therapeutic settings involved in the treatment of MDOs with psychopathic traits face major challenges. Psychopathy is linked to institutional maladjustment, lack of motivation, early drop-out from treatment, and slower progression as well as poor treatment outcomes, for example, in terms of reducing recidivism. The behavioral manifestations of these traits can significantly interfere with treatment, as they impede the formation of a good working alliance and therefore must be appropriately managed. The current study found support for the two-component model proposed by Wong, Gordon, Gu, Lewis, and Olver (2012). The Criminogenic component, or Factor 2, was significantly associated with greater criminogenic need/risk factors and institutional misconduct and reflected an established pat- tern of antisocial behavior and dysfunctional lifestyle both inside and outside the institution. While the Criminogenic component should be the focus of forensic treatment, the Interpersonal component, or Factor 1, is equally important. Factor 1 was significantly associated with drop-out and can thus also contribute to poor out- comes if TIBs are not appropriately managed. As noted by Wong et al. (2012), it is important to distinguish between using risk reduction versus personality change interventions when designing and implementing treatment programs (p. 157).

“[A]s observed, psychopathic and other personality disorder traits in MDOs may be barriers to forensic psychiatric treatment and can lead to premature interruption or discontinuation of treatment. Clinicians are advised to develop a responsive treatment climate with staff and management who are willing to invest time and effort in these personality disordered patients (for good practices, please see Bulten & Decoene, 2015). Instead of viewing poor motivation as a contraindication to treatment, motivation should be evaluated and innovative treatment studies should be designed to enhance individual’s motivation for treatment.” (p. 157)

“A meta-analysis revealed that treatment responsivity indicators such as disruptive behavior during treatment and negative treatment attitudes were among the strongest predictors of increased attrition rates, while higher levels of motivation and treatment engagement predicted decreased attrition. Therefore, it is also important to measure progress in therapy in a uniform manner, with tools specifically developed for thera-peutic measurement, such as the Instrument for Forensic Treatment Evaluation (p. 157).

Other Interesting Tidbits for Researchers and Clinicians

“When comparing the groups with low, medium, and high psychopathic traits, a small significant difference was found, indicating that patients with more psychopathic traits were less compliant. However, when investigating the correlations between the PCL-R total, factor, and facet scores and non-compliance, no significant associations were found, which contradicts other research reporting associations with PCL-R total, Factor 1, and Factor 2 scores. The differences in the operationalization of non-compliance may have contributed to these different findings. Additionally, it should be noted that in the current study, non-compliance might have been underreported.” (p. 156)

“[L]imitations of this study warrant caution when interpreting and generalizing the current findings. First, the PCL-R scores used in the current study were field validity scores with a low IRR. This finding is generally consistent with a growing body of field research that suggests that the high levels of reliability reported in many controlled research studies are not generalizable to practice. However, it calls into question how reliable clinical scores truly are.” (p. 156)

Join the Discussion

As always, please join the discussion below if you have thoughts or comments to add! To read the full article, click here.

Authored by Kenny Gonzalez

Kenny Gonzalez is currently a master’s student in the Forensic Psychology program at John Jay College. His main research interest include forensic assessment, specifically violence risk. In the future, Kenny hopes to obtain a Phd in clinical forensic psychology and pursue a career in academia and practice.

Sex offenders with “deadly combination” of psychopathy and deviant sexual interests are not more likely to reoffend

Research found no evidence that sexual offenders who possess high levels of both psychopathic traits and deviant sexual interests are at a higher risk for reoffending than other sexual offenders. This is the bottom line of a recently published article in Psychological Assessment. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | Psychological Assessment | 2017, Vol. 29, No. 6, 639–651

Field Measures of Psychopathy and Sexual Deviance as Predictors of Recidivism Among Sexual Offenders

Authors

Paige B. Harris, Sam Houston State University
Marcus T. Boccaccini, Sam Houston State University
Amanda K. Rice, Sam Houston State University

Abstract

Offenders with high levels of both psychopathy and deviant sexual interests are often described as being more prone to recidivate than other sexual offenders, and many forensic evaluators report considering this psychopathy and sexual deviance interaction when coming to conclusions about sex offender risk. However, empirical support for the interaction comes from studies using sexual deviance measures that are rarely used in the field. We examined the ability of Psychopathy Checklist-Revised (PCL-R) field scores and possible field measures of sexual deviance (e.g., paraphilia diagnosis, offense characteristics) to predict sexual recidivism among 687 offenders released after being evaluated for postrelease civil commitment (M follow-up = 10.5 years). PCL-R total scores and antisocial personality diagnoses were predictive of a combined category of violent or sexual recidivism, but not sexual recidivism. Paraphilia diagnoses and offense characteristics were not associated with an increased likelihood of reoffending. There was no evidence that those with high levels of both psychopathy and sexual deviance were more likely than others to reoffend. Although the psychopathy and sexual deviance interaction findings from prior studies are large and compelling, our findings highlight the need for research examining the best ways to translate those findings into routine practice.

Keywords

psychopathy, PCL-R, sexual deviance, risk assessment, sexual offenders

Summary of the Research

“Offenders with high levels of both psychopathy and deviant sexual interests—the so called “deadly combination” of sex offender traits (Hare, 1999, p. 189)—are often described as more prone to recidivate than other sexual offenders (Hare, 2003; Witt & Conroy, 2008).” (p. 639)
“A recent survey of sex offender risk assessment practices revealed that the two most commonly used field measures of sexual deviance were a documented history of deviant sexual behavior (96%) and a paraphilia diagnosis (83%; Boccaccini et al., 2017). None of the psychopathy and deviance interaction studies have directly examined these commonly used field measures of sexual deviance.” (p. 639–640).
“Although standardized deviance instruments rely, to varying extents, on some of the same diagnosable and documented behaviors used by clinicians in the field, findings from standardized measures may not generalize to the less structured diagnostic and clinical judgment practices evaluators use in the field.” (p. 640).
“Evaluators in field settings have varying levels of training and experience, and there is often no oversight of their assessment and scoring practices. Research has shown that systematic evaluator differences in psychopathy measure scoring tendencies can lead to higher levels of measurement error in field scores than research scores.” (p. 640)
“There are also reasons to expect a significant amount of measurement error in some field measures of sexual deviance, particularly diagnoses. […] Although diagnoses are widely applied in practice, there is no specific training required for assigning diagnoses and almost certainly a large amount of variability in the practice of assigning them.” (p. 640)
“Although many evaluators report using information about the combined pattern of psychopathy and sexual deviance when coming to conclusions about sex offender risk, the interaction study literature is probably smaller and more variable than many evaluators suspect.” (p. 640–641)
“Our goal was to conduct the first field validity study of the sexual deviance measures that evaluators report using in the field and to examine whether offenders with high levels of deviance and psychopathy were more likely to reoffend than other offenders.” (p. 641)
“We obtained PCL-R scores, diagnoses, and information about postrelease sexual and violent offenses from 687 sexual offenders who were released from custody after being evaluated for civil commitment as sexually violent predators (SVP). […] Participants were 687 male sexual offenders who were evaluated for civil commitment as SVPs, but released (i.e., not committed) after their evaluations.” (p. 641)
“We collected information for this study from evaluator’s behavioral abnormality evaluation reports and a copy of the records that the Texas Department of Criminal Justice (TDCJ) provides to the evaluators. These records include information about index and prior offenses, prison disciplinary infractions, and prior testing conducted by TDCJ staff (e.g., Static-99, Personality Assessment Inventory).” (p. 642)
Measures used: Psychopathy Checklist Revised (PCL-R), Diagnosis, Documented history of deviant sexual behavior, Screening Scale for Pedophilic Interests (SSPI). Postrelease arrest data was used to assess recidivism rates.
“Using 10 possible field measures of sexual deviance, we found little evidence that offenders with higher levels of deviance were more likely to reoffend than others.” (p. 645)
“There was also no evidence that offenders with high levels of both psychopathy and sexual deviance were more likely to reoffend than other offenders.” (p. 646)
“There are at least three possible explanations for our deviance measure findings. First, it may be that our field measures of sexual deviance do not measure sexual deviance, or do not measure sexual deviance adequately enough for there to be an interaction effect. […] A second possible explanation for our findings is the questionable field reliability of our psychopathy and deviance measures. […] A third possible explanation is that there is something unique about our sample.” (p. 646–648)
“It seems more likely that evaluators rely on paraphilia diagnoses and offense characteristics when coming to conclusions about deviance. […] However, none of these deviance indicators were predictors of recidivism in this study.” (p. 648)
“PCL-R scores and antisocial personality disorder diagnoses were predictive of the combined category of violent or sexual recidivism, but not sexual recidivism. […] Although some have argued that this combined category of violent and sexual arrests may be a better indicator of true sexual recidivism than sexual arrests alone (Rice, Harris, Lang, & Cormier, 2006), the small negative effect for post-release sexual arrests in our sample argues against using antisocial personality disorder diagnoses for predicting sexual recidivism.” (p. 648)

Translating Research into Practice

“This study found that the types of offender and offense characteristics that field evaluators report using as indicators of sexual deviance were not predictive of postrelease sexual offending among a large sample of sexual offenders who underwent risk assessments before release from prison. In this field study, there was no evidence that offenders with high levels of both psychopathic traits and deviant sexual interests—the so called “deadly combination” of sex offender traits—were more likely to reoffend than other sexual offenders.” (p. 639)
“Although evaluators report using paraphilia diagnoses and documented incidents of deviant sexual behavior as their primary field measures of sexual deviance, we found that no field measure produced the same type of interaction effect documented in prior studies. Thus, at this point, there does not appear to be sufficient empirical support for using the combination of PCL-R scores and these field measures for coming to conclusions about offender risk, at least in the context of SVP evaluations. Evaluators who wish to base their risk assessment practices on documented empirical support should look to studies reporting significant interaction effects (e.g., Harris et al., 2003; Olver & Wong, 2006; Seto et al., 2004), and the deviance measures used in those studies, such as plethysmography or the Violence Risk Scale: Sex Offender version (Wong, Olver, Nicholaichuk, & Gordon, 2004).” (p. 649)

Other Interesting Tidbits for Researchers and Clinicians

“The average age at the time of the evaluation was 42.82 years (SD = 11.44). The number of sexual offense victims ranged from one to eight (M = 2.54, SD = 1.08). Although offenders eligible for SVP civil commitment must have been convicted of at least two contact sexual offenses and be serving a sentence for a sex offense at the time of evaluation (Texas Health & Safety Code, Title 11, Chapter 841, 2000), the qualifying sexual offenses can be against the same victim.” (p. 641)
“We did not include offenders who had been civilly committed because of the intensive monitoring and supervision within the SVP program. […] There is no doubt that the exclusion of committed offenders affected the study sample, but the extent to which their exclusion might explain the difference between our findings and prior studies is less clear. […] Although there would have been more variability in our sample if we had been able to study recidivism among the committed offenders, there was no evidence that our sample differed dramatically from the samples used in other psychopathy and sexual deviance studies. […] We also have no information about participation in sexual offender treatment or postrelease supervision, factors which may help explain the low base rate of recidivism in this study.” (p. 648)
“Although we did not find any evidence of an interaction between antisocial personality diagnoses and sexual deviance for predicting recidivism, this is clearly an area in need of more research.” (p. 648)
“Although our findings add to a growing body of research suggesting weaker reliability and validity in field settings, they also highlight possible areas for growth. Nonfield studies show us that instruments and assessment practices can attain desired levels of reliability and validity, and it is possible for field practices to improve. […] Documenting the current performance of field practices allows us to better understand where we are underperforming, helps us to identify areas in need of improvement, and provides a baseline for future studies aimed at improving in field performance.” (p. 649)

Join the Discussion

As always, please join the discussion below if you have thoughts or comments to add!

Authored by Kseniya Katsman

Kseniya Katsman is a Master’s student in Forensic Psychology program at John Jay College of Criminal Justice. Her interests include forensic application of dialectical behavior therapy, cultural competence in forensic assessment, and risk assessment, specifically suicide risk. She plans to continue her education and pursue a doctoral degree in clinical psychology.

Psychopathy Associated with Witnessing Domestic Violence as a Child

Witnessing domestic violence as a child is associated with overall psychopathy levels. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | Law and Human Behavior | 2017, Vol. 41, No. 2, 173-179

Witnessing Domestic Violence During Childhood Is Associated With Psychopathic Traits in Adult Male Criminal Offenders

Authors

Monika Dargis, University of Wisconsin-Madison
Michael Koenigs, University of Wisconsin-Madison

Abstract

While there is growing evidence that suffering physical abuse during childhood is subsequently associated with psychopathic traits in both juvenile and adult offenders, there is considerably less research on whether exposure to domestic violence as a witness, rather than as a direct victim, influences the subsequent presentation of psychopathic traits in adulthood. Accordingly, the current study examined the relationship between witnessing domestic violence during childhood (i.e., witnessing, hearing, or intervening in abuse against a parent/sibling) and psychopathic traits in adulthood in a sample of n 127 incarcerated male offenders. As predicted, witnessing domestic violence was significantly associated with overall level of psychopathy, with a particularly strong relationship to the interpersonal/affective features of psychopathy. Importantly, this relationship held when controlling for the experience of domestic violence as a direct victim. These results add to the growing body of literature linking adverse and traumatic events during childhood with psychopathic traits later in life, and suggest that domestic violence exposure may be one factor contributing to the manipulative, interpersonal style exhibited by individuals high in psychopathy.

Keywords

psychopathy, childhood maltreatment, domestic violence, PCL-R

Summary of the Research

“Despite growing evidence that the direct experience of childhood maltreatment is associated with psychopathic traits in both juvenile and adult offenders, there is considerably less research on whether exposure to domestic violence as a witness, rather than as a direct victim (i.e., witnessing, hearing, or intervening in abuse against a parent/sibling), influences the subsequent presentation of psychopathic traits later in life. This is a critical gap in the literature given that an estimated one in 15 children in the United States witness domestic violence every year. Furthermore, there is a substantial body of work suggesting that witnessing domestic violence, even in the absence of direct victimization, puts children at a greater risk for developing both internalizing and externalizing symptomology.” (p. 173)

“Thus, while there are well-documented relationships between psychopathy and childhood maltreatment as well as between domestic violence exposure and externalizing symptomology, and emerging evidence on the relationship between community violence and psychopathy, the link between witnessing domestic violence and psychopathy has not been directly investigated. This may be an important distinction to make as some authors have suggested that the degree to which exposure to violence affects long-term emotion processing and traumatization may relate not only to the intensity of the violence, but also the relationship the child has with the victim of the violence. Furthermore, if there is indeed a relationship between psychopathy and domestic violence exposure, it is important to distinguish which features of psychopathy most strongly relate to domestic violence exposure. There is substantial evidence that divergent relationships emerge among the interpersonal/affective and lifestyle/antisocial traits of psychopathy.” (p. 174)

“Participants included n=127 adult males incarcerated at medium-security state prisons in Wisconsin. All participants were selected from a larger database of eligible participants. Individuals were eligible for participation if they were between the ages of 18 and 55, had no documented diagnosis of a psychotic disorder, and were not currently taking psychotropic medications. Additionally, participants were eligible if they had a fourth grade reading level or above and scored a 70 or above on a standardized measure of intelligence. Individuals meeting inclusion criteria were asked to participate in an ongoing study on the causes of incarceration and informed that participation was completely voluntary and would have no impact on their incarceration status.” (p. 174)

The Maltreatment and Chronology of Exposure (MACE) scale was used to separately assess childhood exposure to domestic violence as a direct victim and as a witness. The MACE is a 52-item scale comprised of 10 subscales which assess different types of trauma experienced during childhood (i.e., 18 years and younger), including witnessing parental domestic violence (e.g., “Saw adults living in household push, slap, or throw something at mother”), witnessing domestic violence against a sibling (e.g., “Parents or adults living in house hit your sibling so hard that it left marks”), and directly experiencing physical abuse (e.g., “Parent hit you so hard it left marks for more than a few minutes”).” (p. 175)

“In a sample of incarcerated male offenders, we have shown a significant association between witnessing domestic violence during childhood and psychopathy in adulthood. More specifically, we found that witnessing domestic violence was individually associated with both factors and all facets of the PCL-R, but when controlling for the unique variance of the factors and facets, a

specific relationship between witnessing domestic violence and the interpersonal/affective features of psychopathy emerged. This relationship was driven predominantly by the relationship between the interpersonal features of psychopathy (Facet 1) and witnessing domestic violence. Finally, we showed that although the effect sizes decreased, these results largely remained unchanged when controlling for direct experience of physical abuse.” (p. 176)

Translating Research into Practice

“Given the consistency of these cross sectional findings, further longitudinal research is needed in order to better parse how environmental experiences contribute to, or exacerbate, the development of psychopathic traits. A firmer understanding of environmental contributions to severe emotional and behavioral pathology, like psychopathy, would not only provide a better understanding of etiological factors of psychopathy, but would also help guide intervention efforts for children living in violent homes. For example, recent efforts have been made to design randomized, controlled studies to treat children exposed to domestic violence. It is possible that these specific interventions could influence the presentation or development of psychopathic traits. The current findings also suggest that the presence of psychopathic or callous/unemotional traits should be taken into consideration when developing domestic-violence focused interventions for youth.” (p. 176)

Other Interesting Tidbits for Researchers and Clinicians

“An alternate explanation for the specific relationship between domestic violence exposure and the interpersonal features of psychopathy may be rooted in social learning theory, which highlights the role of the environment in shaping children’s future behavior. Following this framework, it is possible that witnessing domestic violence in the home models a maladaptive interpersonal style that is then adopted by the abuse exposed child.” (p. 177)

“An alternative possibility regarding the relationship between Facet 1 of psychopathy and domestic violence exposure is that children exposed to violence against their caregiver(s) and sibling(s) may learn to develop a manipulative interpersonal style in an effort to avoid direct victimization. Although further research is needed in order to examine this prospect, researchers have suggested that attentional abnormalities exhibited by maltreated children may be adaptive given the hostile environment in which they are raised.” (p.177)

Join the Discussion

As always, please join the discussion below if you have thoughts or comments to add!

Authored by Kenny Gonzalez

Kenny Gonzalez is currently a master’s student in the Forensic Psychology program at John Jay College. His main research interest include forensic assessment, specifically violence risk. In the future, Kenny hopes to obtain a Phd in clinical forensic psychology and pursue a career in academia and practice.

Mental Health’s Role in Juvenile Justice Rehabilitation

Justice involved youth whose mental health needs were treated, also had their criminogenic need met. However, more research is needed to understand how mental health treatment affects intervention targeting criminogenic needs. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

Feature Article | Law and Human Behavior | 2017, Vol. 41, No. 1, 55-67

The Role of Mental Health and Specific Responsivity in Juvenile Justice Rehabilitation

Authors

Sarah McCormick, University of Toronto
Michele Peterson-Badali, University of Toronto
Tracey A. Skilling, Centre for Addiction and Mental Health, Toronto, Canada and University of Toronto

Abstract

Understanding the role that mental health issues play in justice-involved youth poses challenges for research, policy, and practice. While mental health problems are generally not risk factors for criminal behavior according to the risk-needs-responsivity (RNR) framework of correctional psychology practice, prevalence rates are very high and RNR principles suggest that mental health as a responsivity variable may moderate the success of interventions targeted to criminogenic needs. In this study we investigated the relationships among mental health status, criminogenic needs treatment, and recidivism in a sample of 232 youth referred for court-ordered assessments and followed through their community supervision sentence (probation). Youth with mental health needs were no more likely than youth without these needs to reoffend, regardless of whether those needs were treated. Youth who received mental health treatment also more frequently had their criminogenic needs matched across several domains, suggesting an association between mental health treatment and intermediate treatment targets. However, mental health did not moderate the effect of criminogenic needs treatment: youth who had a greater proportion of criminogenic needs targeted through appropriate services were less likely to reoffend, regardless of mental health status. Findings are consistent with the RNR stance that, within a correctional context in which the primary goal of intervention is preventing recidivism, treatment for mental health needs should be in addition to criminogenic needs treatment, not in replacement of it. They also point to the need for continued research to understand precisely how mental health treatment interacts with intervention targeting criminogenic needs.

Keywords

Mental health, psychopathology, youth, risk-need responsivity, recidivism

Summary of the Research

“Despite a higher likelihood of having mental health problems, justice-involved youth are less likely than nonoffending youth to have had these problems identified previously or to have received services. Mental health problems also pose considerable challenges to frontline staff (e.g., probation officers); mental health issues may be perceived as a barrier to youths’ engagement with rehabilitative programming, with treatment of mental health needs often taking precedence over other issues, including those known to be directly related to risk to reoffend.” (p. 55)

“In the adult literature, mental health symptomatology has emerged as a weak predictor of reoffending for offenders in general but also for most offenders with mental illness; the strongest predictors of recidivism are criminogenic needs shared by those with and without mental disorder. To our knowledge, only one study of youth focused explicitly on the role of mental health in reoffending has also considered criminogenic needs, so it remains unclear whether mental health status relates to reoffending.” (p. 56)

“Within the corrections and criminal justice context, studies of offender populations that have identified mental health as a risk factor for subsequent criminal behavior have been challenged by research on forensic risk prediction that firmly asserts that mental health is not a risk factor for recidivism when examined alongside empirically validated risk factors—termed “criminogenic needs” in the risk-need- responsivity (RNR) literature.” (p. 56)

“In the current study we investigated the role of mental health needs and mental health treatment among youth in the context of criminogenic needs treatment. In keeping with the RNR framework, we defined mental health needs as those that are not captured within the RNR risk/needs tools. We also sought to differentiate between mental health symptomatology as an initial status variable—the presence or absence of mental health needs—and mental health treatment as a dynamic variable—whether or not youth received treatment for their mental health needs. Mental health treatment alone has rarely been found to reduce recidivism. However, it remains unclear whether the treatment of mental health problems, in addition to treatment targeting criminogenic needs, may improve reoffending outcomes.” (p. 56)

Methods

“The sample consisted of 232 youth referred by youth court judge between January 2002 and January 2010 to a mental health agency in a large urban center in Canada for an assessment to inform sentencing, and who provided consent for use of their information for research. The sample was predominantly male (n=187; 80.6%) and was ethnically diverse: 35.6% Black, 34.8% White, 9.8% Asian, and 19.7% other ethnicities. Youth ranged in age from 12 to 20 years, (M=16.12, SD=1.63). The youths’ most serious charges precipitating referral for assessment included violent offenses (e.g., assault, robbery; 59.1%), sexual offenses (16.8%) and nonviolent, nonsexual offenses (e.g., breach of probation, theft, drug-related offenses; 19.4%); offense information was missing for 4.7% of the sample.” (p. 57)

Results

“In preparation for addressing our primary study questions, we divided the sample into two groups: those who had mental health needs identified by clinicians (57.8%; n=134) and those with no identified mental health needs (42.2%; n =98); as noted above, “mental health needs” included diagnoses and subthreshold issues relating to mood, anxiety, thought disorders, trauma, and noncriminogenic personality features. We further divided the “identified mental health needs” group into “treated” and “untreated” mental health needs subgroups and compared the three groups to determine whether they differed in terms of demographic variables, offense characteristics, overall risk, identified criminogenic needs, and receipt of service for their identified needs.” (p. 58)

“Youth with mental health needs tended to have more criminogenic needs identified by clinicians than those without mental health needs and youth with untreated mental health needs had higher total risk scores than youth without mental health needs. These findings suggest that youth with mental health problems are characterized by greater criminogenic risk than those without, which is consistent with findings from the adult literature. This relationship between mental health needs and criminogenic needs suggests that, while a common set of risk factors may be sufficient for predicting reoffending, individuals with mental illness may present with more of these risk factors. When examined in terms of specific criminogenic need domains, youth identified with mental health needs were comparable with other youth in the areas of criminal history, family, peers, and attitudes, but they had higher risk/ need scores in education/employment, substance abuse, leisure, and personality/behavior.” (p. 62)

“The “good news” in our findings is that treatment of mental health needs was associated with increased likelihood that criminogenic needs would be addressed; in turn, intervention addressing youths’ criminogenic needs was associated with reduced likelihood of reoffending. The “bad news” is that—although, as expected, youths’ identified criminogenic needs increased with risk level—contrary to the risk principle, the number of needs addressed during probation did not change as risk increased.” (p. 63)

Translating Research into Practice

“Together, these findings suggest several implications for service. First is the need for services to be provided in a manner consistent with the risk principle: High-risk youth have more criminogenic needs and these needs should be addressed regardless of mental health status. Further, the present results do not support treatment of noncriminogenic mental health needs alone as an effective way to reduce reoffending; service providers must also attend to criminogenic needs in order to meet the goal of reduced involvement in the justice system. The finding that youth with treated mental health needs also had more of their criminogenic needs treated suggests that these youth may experience a better standard of care. It may be that youth have better outcomes with wraparound services than with referral to several siloed programs. Alternatively, youth receiving mental health treatment may have had an additional source of intervention targeting domains such as education, family functioning, and behavior, which may be targets for improved functioning from both mental health and criminogenic needs perspectives, and which correspond to the domains in which we found that more youth had both needs met.” (p. 64)

Other Interesting Tidbits for Researchers and Clinicians

“The conclusion that treatment of mental health problems was not associated with reoffending may be conservative given the findings on intermediate treatment targets; the great majority of youth across most criminogenic need domains had either both or neither of their criminogenic and mental health needs matched, while comparatively few had only one or the other need matched. Accordingly, while there was not a complete separation in the data, there was limited power to differentiate between groups to detect an effect between youth with only criminogenic needs matched and youth with both types of needs matched. Until the reasons for the association with intermediate treatment targets are better understood we may be limited in the analysis of mental health treatment as a moderator of criminogenic needs treatment.” (p. 64)

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Authored by Kenny Gonzalez

Kenny Gonzalez is currently a master’s student in the Forensic Psychology program at John Jay College. His main research interest include forensic assessment, specifically violence risk. In the future, Kenny hopes to obtain a Phd in clinical forensic psychology and pursue a career in academia and practice.

PCL-R Demonstrates Inadequate Field Reliability and Validity

The PCL-R demonstrates low rater agreement and inadequate field reliability and validity for predictions of recidivism in prison and hospital settings. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | Law and Human Behavior | 2017, Vol. 41, No. 1, 29-43

PCL-R Field Validity in Prison and Hospital Settings

 

Authors

Inge Jeandarme, Knowledge Center Forensic Psychiatric Care
John Edens, Texas A&M University
Petra Habets, Knowledge Center Forensic Psychiatric Care
Liesbeth Bruckers, University of Hasselt
Karel Oei, Tilburg University
Stefan Bogaerts, Tilburg University and The Kijvelanden

Abstract

Recent field studies have questioned the interrater reliability (IRR) and predictive validity regarding (violent) recidivism of the Psychopathy Checklist-Revised (PCL-R). Using a forensic psychiatric sample, the current study investigated discrepancies in scoring between hospital and prison settings, as well as differences in predictive validity across these two settings. PCL-R information was collected from prison and hospital files, resulting in 224 PCL-R total scores and 74 double scores. When examining repeated measurements, large individual differences were found together with an intraclass correlation coefficient (ICCA,1) of .42 for the total score. Discrepant results were found for Factor 2, with repeated scores within the same setting having an ICCA,1 of .28 versus an ICCA,1 of .57 for repeated scores between settings. However, areas under the curve (AUCs) from receiver operating characteristic (ROC) analyses for total, factor and facet scores did not differ between settings. For the whole sample, Factor 2 scores marginally predicted violent and general recidivism after 2 years (AUC .62 and .63), whereas Factor 1 did not predict (violent) recidivism. Consistent with recent studies from other countries, these results suggest inadequate field reliability and validity in prison and hospital settings in Flanders (Belgium).

Keywords

forensic psychiatric patient, PCL-R, field validity, interrater reliability, psychopathy

Summary of the Research

“The Psychopathy Checklist Revised (PCL-R; Hare, 2003) is an extensively used and researched instrument for diagnosing psychopathy. Early factor analyses suggested that the PCL-R consisted of two factors: Factor 1 representing the interpersonal and affective component and Factor 2 capturing the socially deviant and behavioral aspects (Hare, Clark, Grann, & Thornton, 2000). Later, Hare (2003) argued for the existence of a superordinate factor of psychopathy, underpinned by two factors (interpersonal/ affective and social deviance) and four facets (interpersonal, affective, lifestyle, and antisocial; cf. Cooke, Michie, & Hart, 2006).The PCL-R is also frequently introduced in the legal arena to inform violence risk assessment (DeMatteo et al., 2014b), either in isolation or included as an important component within risk assessment instruments, such as the Violence Risk Appraisal Guide (VRAG; Quinsey, Harris, Rice, & Cormier, 2006), and the Historical Clinical Risk Management–20 (HCR-20; Webster, Douglas, Eaves, & Hart, 1997)” (p. 29).

“Although scoring the PCL-R requires at least some subjective judgment, strong interrater reliability (IRR) with good to excellent intraclass correlation coefficients (ICCs) for the total score (.86 to .94), Factor 1 (.69 to .95) and Factor 2 (.74 to .94) have been reported in early validation studies as well as in independent controlled research (e.g., Cooke, Hart, & Michie, 2004; Gacono & Hutton, 1994; Hare, 2003; Ismail & Looman, 2016; Kroner & Mills, 2001; Laurell & Daderman, 2007; Porter, Woodworth, Earle, Drugge, & Boer, 2003)… However, there is growing evidence (e.g., DeMatteo et al., 2014a; Edens, Cox, Smith, DeMatteo, & Sorman, 2015; Lloyd, Clark, & Forth, 2010; Murrie, Boccaccini, Johnson, & Janke, 2008; Murrie et al., 2009) that PCL-R scoring is affected by the evaluation context, with adversarial settings such as contested criminal or civil commitment cases producing scores that diverge much more so than would be expected based on the ICC statistics reported in the professional manual (Hare, 2003)” (p. 30).

“Given the significant role that individual raters seem to play in the PCL-R scores they provide, it is not surprising that reliability across examiners is not particularly high even if those examiners are retained by the same side in a given case” (p. 31)…Although field reliability studies comparing examiners retained by the same side of a case have focused primarily on the PCL-R total score, some of this research has been able to investigate this topic at the factor, facet, and even item level… suggesting that Factor 1 and its two facets are typically significantly less reliable than Factor 2 and its two facets” (p. 31).”

“In summary, the small but accumulating body of literature suggests considerably attenuated reliability and predictive validity when the PCL-R is used in applied forensic settings. Although the first field studies were based on relatively small samples from one jurisdiction (Texas) involving a specific population (sex offenders), other studies have provided further evidence of lower reliability based on larger samples in other U.S. jurisdictions (DeMatteo et al., 2014b; Levenson, 2004; C. S. Miller et al., 2012; Neal et al., 2015) as well as in Canadian and European samples (Edens et al., 2015; Sturup et al., 2014)” (p. 32).

“The current study extends to the existing research concerning the field reliability and validity of the PCL-R by examining this topic in a relatively large sample of Belgian offenders found “not guilty by reason of insanity (NGRI)” (in Belgium referred to as “internees”) who were classified within a medium security risk level. PCL-R assessments were conducted while the patients resided in prison and/or in hospital. For a large minority of the sample, multiple scores were available for analysis…Data regarding level of education, psychiatric diagnosis, criminal history, hospitalization/imprisonment periods, risk assessment scores, and IQ scores were gathered by accessing both CPS files and psychiatric hospital records. Diagnoses were based on the Diagnostic and Statistical Manual of Mental Disorder-IV text revision (DSM–IV–TR; American Psychiatric Association, 2000)” (p. 34).

Results

“The general conclusion of the current study in this sample of forensic psychiatric patients was that the PCL-R in real world settings conducted by real world raters in Belgium is fairly unreliable although there was some evidence of modest to moderate predictive validity for Factor 2 scores” (p. 37).

“The average total PCL-R score found in all patients with a PCL-R score was similar to the mean score for forensic psychiatric patients reported by Hare (2003), and there was not a significant difference found in patients scored within a prison versus a hospital setting. However, when comparing repeated measures for the same offender across settings, mean prison scores were lower than mean hospital scores, suggesting contextual pressure as expected” (p. 37).

Rater agreement was also poor. This could be due to the large sample of non-sexual offenders, an increased number of complex cases, the differences between hospital raters and prison raters, or the differences between criminologists’ ratings and psychologists’ ratings on the PCL-R.

“Overall, the predictive validity was poor, especially for total PCL-R score and Factor 1, which did not predict general or violent recidivism. Factor 2 scores significantly predicted general recidivism for all groups, whereas Factor 2 scores predicted violence only for the combined population (prison and hospital scores). On the facet level, surprisingly, Facet 3 scores were the only significant predictors of general (all and hospital scores) and violent recidivism (all scores)… Although some AUCs reached statistical significance, the level ranged from small to moderate effect sizes, with moderate effect sizes in Factor 2 prison and hospital scores for predicting general recidivism and small effect sizes for all scores (Factor 2 and Facet 3) for predicting general and violent recidivism and for Facet 3 hospital scores for general recidivism.” (p. 39)

Translating Research into Practice

“Field validity studies such as the current one are important for researchers to consider when developing and refining new instruments and for clinicians to be aware of when conducting assessments in practice…When discussing scores, raters and judges should be aware of the fact that potential biases of the rater could have an important impact” (p. 40).

In order to improve rater agreement, the authors suggest either not using the PCL-R if the rater does not frequently use the instrument, or having multiple raters score the PCL-R. Further, “Forensic examiners should provide a comprehensive report of their PCL-R findings, including a discussion on the cut-off used and the profile of the facet scores. Depending on the assessment context, they might also consider not reporting Factor 1 scores at all unless there is some compelling reason for their inclusion” (p. 41).

Overall, the results of the current study suggest “that the high levels of reliability reported in many controlled research studies are not generalizable to practice settings” (p. 37).

Other Interesting Tidbits for Researchers and Clinicians

In the context of future research, the authors were interested to learn if using the PCL-R for violence risk assessment would be more beneficial if the rater scored the offender without conducting an interview, diminishing the potential for individual bias to occur.

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Authored by Sara Hartigan

Sara Hartigan is a second year Forensic Psychology Master’s student at John Jay and hope to obtain a Ph.D. in Clinical Forensic Psychology in the future. My main areas of interest include clinical evaluations and developing treatment interventions within the forensic population.

The Relationships Between Psychopathy, Alcohol Use, and Intimate Partner Violence

Forensic Training AcademyThe following study examines the combined influences of alcohol use and psychopathy on aggressive behavior in the context of intimate partner violence. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

 

Law and Human BehaviorFeatured Article | Law and Human Behavior | 2016, Vol. 40, No. 2, Online First Publication

 

Psychopathy, Alcohol Use, and Intimate Partner Violence: Evidence From Two Samples

 

Authors

Marisa Okano, McGill University
Jennifer Langille, University of British Columbia
Zach Walsh, University of British Columbia

Abstract

Intimate partner violence (IPV) is a substantial public health problem. Psychopathic personality is one of the most important individual difference predictors of violence and has been proposed as a key feature for understanding IPV perpetration. Psychopathy is also associated with alcohol use, a prominent risk factor for IPV. This pattern of interrelationship raises the possibility that psychopathy might mediate the relationship between alcohol use and IPV. However, few studies have examined the combined influences of alcohol use and psychopathy on aggressive behavior, and, to our knowledge, no study has directly examined these interrelationships in the context of IPV. In the present study, we aim to enhance our understanding of risk for IPV perpetration by examining the consistency of the association between psychopathy and violence across levels of alcohol use and gender in 2 samples: a prospective clinical sample (n = 703) and a cross-sectional sample of university students (n = 870). Psychopathy was associated with IPV across both samples independently and, after controlling for gender and alcohol use (R2 = .04–.08), also mediated the relationship between alcohol use and IPV among the nonclinical sample. We found that psychopathy was associated with IPV, that this relationship was consistent despite gender and alcohol use, and was evident across samples. This relationship was small but robust, and appeared to be more prominent than the association between alcohol use and IPV. Future research that examines IPV risk should consider the potential role of psychopathy, particularly when investigating risk associated with alcohol use.

Keywords

partner violence, psychopathy, alcohol abuse, personality, gender

Summary of the Research

“Intimate partner violence (IPV) is a substantial public health problem, as victimization is linked to physical injury, chronic pain, increased substance abuse, and numerous other health problems. A robust literature has examined the individual differences that influence risk for IPV perpetration, with substantial research focusing on alcohol use and personality features as important predictors. Indeed, alcohol use is cited among the most prominent risk factors for IPV, although evidence suggests that this association may vary according to sample type and individual differences in personality” (p. 1).

“With regard to personality, psychopathy has emerged as one of the most important individual difference predictors of violence in general, and has been proposed to be a key feature for understanding IPV perpetration. Several studies have identified an association between psychopathy and domestic violence among male forensic and clinical samples . . . Psychopathic personality features are also associated with alcohol use, which raises the possibility that psychopathic personality might mediate the relationship between alcohol use and IPV. However, few studies have examined the combined influences of alcohol use and psychopathy on aggressive behavior, and, to our knowledge, no study has directly examined this pattern of interrelationships in the context of IPV” (p. 1).

“Despite the considerable evidence showing the independent contributions of both alcohol use and psychopathic personality to IPV perpetration, relatively few studies have examined the patterns of interrelationship among these factors. Evidence from laboratory studies of aggression is equivocal. A study of young adults found that the antisocial facet of psychopathic personality potentiated the exacerbating effects of alcohol on aggressive behavior. However, a study of university students found no moderating relationship between psychopathy and alcohol-related aggression. In sum, further research is required to more definitively determine the extent to which the violence risks associated with both psychopathic personality and alcohol use are distinct, multiplicative, or redundant” (p. 2).

This research first utilized a prospective design with a clinical sample of 703 civil psychiatric patients to “examine the independent and interactive predictive effects of psychopathy and alcohol dependence for IPV perpetration” (p. 2). “Participants were followed for 12 months subsequent to discharge from an inpatient psychiatric facility, during which time they underwent thorough assessments for psychopathology, substance use, and violence every 10 weeks, providing five possible assessment opportunities” (p. 2).

In the first study, “males demonstrated higher rates of psychopathy than females. Males were also more likely than females to meet criteria for a CAD [current alcohol dependence]. Individuals with CAD demonstrated higher levels of psychopathy than did those without CAD. Scores on the PCL:SV predicted IPV, both independently and uniquely after accounting for gender and CAD. Problematic alcohol use was not related to IPV; therefore, criteria for mediation were not met. Females reported significantly higher rates of IPV perpetration than their male counterpart. Further, gender predicted IPV perpetration, such that perpetration was more likely among females. There were no significant two-way or three-way interactions” (p. 3).

“The primary aim for Study 2 was to examine the extent to which relationships identified in Study 1 generalized to a nonclinical sample. Participants were 870 undergraduate students at a Canadian university” (p. 3).

Translating Research into Practice

“This study was designed to examine the relationship between psychopathy and the perpetration of violence toward intimate partners. We found that psychopathy was associated with IPV, and that this relationship was robust across gender and alcohol use, and was evident in both clinical and nonclinical samples. The sizes of the observed effects were in the small range, which is generally consistent with prior findings regarding the predictive power of psychopathy for violence. Relationships of this magnitude are not practically trivial; among the clinical sample in this study, approximately one third of the higher psychopathy participants were arrested for IPV compared with approximately one fifth of the lower psychopathy group, and a discrepancy of a similar size was observed among the university sample. Our identification of a positive relationship between psychopathy and IPV is consistent with prior studies of psychopathy and violence among men and women” (p. 4).

“The relationship between psychopathic personality and IPV appeared to be relatively more robust than the relationship between IPV and problematic alcohol use. Whereas psychopathy was associated with IPV in both samples, problematic alcohol use was not predictive among the clinical sample, and the observed relationship between problematic alcohol use and IPV among the university sample was largely accounted for by covariance with psychopathy. We interpret this finding cautiously in light of the considerable literature that has identified alcohol as an important risk factor for IPV. Nonetheless, the extent to which the relationship between alcohol use and violence may reflect unmeasured psychopathic personality warrants further research, and our findings suggest that psychopathy should be routinely assessed in research on alcohol use and violence” (p. 4).

Other Interesting Tidbits for Researchers and Clinicians

“This study was the first to examine the consistency of the relationship between psychopathy and IPV across gender. The finding that the association between psychopathy and IPV was equivalent for males and females in both samples represents preliminary evidence for the generalizability of the predictive power of psychopathy across gender, and adds to the growing literature on the manifestations of psychopathic personality among females. This apparent symmetry has both practical and theoretical implications” (p. 4).

“From a theoretical perspective, it highlights the relevance of individual differences in personality for understanding risk of IPV perpetration among both men and women. Importantly, this should not be interpreted as diminishing the value of perspectives that foreground structural and social factors. Indeed, the substantial variance in IPV that remained unexplained in both samples highlights the need for a multisystemic approach to elucidating the complex problem of IPV. In addition, our identification of positive associations between psychopathy and IPV despite the relatively low levels of psychopathy in both samples appears to be consistent with assertions that psychopathic personality can be meaningfully characterized as a continuous trait, with meaningful variation even at the low end of the spectrum. From a practical perspective, these findings have the potential to inform risk assessment, and provide further support for the value of including psychopathic personality in actuarial tools. However, evidence of consistent prediction across gender should be considered together with research that has highlighted inconsistent predictive power of psychopathy across ethnicity and socioeconomic status” (p.4).

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Authored By Becca Cheiffetz

Becca Cheiffetz is a master’s student in the Forensic Psychology program at John Jay College of Criminal Justice. She graduated in 2015 from Sam Houston State University with a BS in Psychology and plans to continue her studies in a Clinical/Forensic Psychology PhD program in the near future. Her professional interests include providing clinical evaluations and treatment for individuals in prison as a prison psychologist and conducting forensic assessments for defendants in criminal court.

Strength-based models cannot fully address direct links to future offending in detained girls

Forensic Training AcademyDetained girls’ low quality of life is indirectly linked to future offending through increased mental health problems. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

lhbFeatured Article | Law and Human Behavior | 2016, Vol. 40, No. 3, 285-294

Quality of Life in Relation to Future Mental Health Problems and Offending: Testing the Good Lives Model Among Detained Girls

Authors

Lore Van Damme, Ghent University
Machteld Hoeve, University of Amsterdam
Robert Vermeiren, Curium-Leiden University Medical Center, Leiden, the Netherlands
Wouter Vanderplasschen, Ghent University
Olivier F. Colins, Curium-Leiden University Medical Center, Leiden, the Netherlands

Abstract

Detained girls bear high levels of criminal behavior and mental health problems that are likely to persist into young adulthood. Research with these girls began primarily from a risk management perspective, whereas a strength-based empowering perspective may increase knowledge that could improve rehabilitation. This study examines detained girls’ quality of life (QoL) in relation to future mental health problems and offending, thereby testing the strength-based good lives model of offender rehabilitation (GLM). At baseline, 95 girls ( = 16.25) completed the World Health Organization QoL instrument to assess their QoL prior to detention in the domains of physical health, psychological health, social relationships, and environment. Six months after discharge, mental health problems and offending were assessed by self-report measures. Structural equation models were conducted to test GLM’s proposed (in)direct pathways from QoL (via mental health problems) toward offending Although we could not find support for GLM’s direct negative pathway from QoL to offending, our findings did provide support for GLM’s indirect negative pathway via mental health problems to future offending. In addition, we found a direct positive pathway from detained girls’ satisfaction with their social relationships to offending after discharge. The current findings support the potential relevance of addressing detained girls’ QoL, pursuing the development of new skills, and supporting them to build constructive social contacts. Our findings, however, also show that clinicians should not only focus on strengths but that detecting and modifying mental health problems in this vulnerable group is also warranted.

Keywords

good lives model, psychopathology, young offenders, female adolescents, follow-up studies

Summary of the Research

“Many detained female adolescents are involved in severe criminal behavior, such as robbery and physical violence. In addition, these girls bear high levels of mental health problems, with up to 95% having at least one psychiatric disorder” (p. 285). “It is not well understood why some girls recover from mental health problems or desist from future criminal involvement whereas others do not. This could arise in part because the majority of prospective studies with detained girls has focused on risk factors associated with the persistence of mental health and adjustment problems. These studies, of course, are relevant from a risk management perspective as they help clinicians to develop and provide interventions that are mainly oriented toward solving problems and reducing risk factors. Nevertheless, research that adds the enhancement of one’s quality of life (QoL) to the management of risk is urgently warranted. Studies that apply this strength-based perspective may inform clinicians, for example, how to support offenders in building skills and developing more fulfilling and socially acceptable lifestyles, which is thought to be linked to the reduction of risk. The present study was designed to fill this void by addressing detained girls’ QoL in relation to future mental health problems and offending, thereby testing the strength-based good lives model of offender rehabilitation (GLM)” (pp. 285-286).

“The GLM offers a rehabilitation framework for adult offenders. It forms a theoretical framework to explain relapse and reoffending, introducing QoL as a central concept. According to the GLM, humans want to realize a range of primary goods or basic needs  (e.g., inner peace and relatedness), and achieving these needs contributes to their QoL. The GLM consists of two main assumptions:  that mental health problems are obstacles that hamper the achievement of a good QoL (first GLM assumption) and that individuals who are confronted with a poor QoL may become involved in antisocial activities through either a direct or indirect pathway (second GLM assumption). The direct pathway implies that someone actively commits antisocial behaviors as an alternative strategy to reach a satisfying QoL (e.g., stealing instead of working to obtain material well-being). The indirect pathway implies that an individual’s poor QoL generates a gradual accumulation of negative experiences and deteriorating circumstances that trigger a chain of mental health problems, such as depressed feelings, often followed by alcohol/drug use. Ultimately, he or she loses control of the situation and becomes involved in criminal activities” (p. 286).

“The GLM has been applied to a broad range of offender populations yet only rarely to detained adolescents” (p. 286). “The present study [tested] GLM’s second assumption in a sample of detained girls, focusing on QoL prior to detention in relation to mental health problems and offending 6 months after discharge. We included multiple domains of QoL (i.e., physical health, psychological health, social relationships, environment), different types of mental health problems (i.e., anger-irritability, alcohol/drug use, depression-anxiety), and different types of offenses (i.e., nonviolent and violent)” (p. 286). “The participants were 95 girls who had been placed in an all-girl youth detention center (YDC) in Flanders, Belgium. Girls are referred to this YDC by a juvenile judge when charged with a criminal offense or because of an urgent problematic educational situation” (p. 287).

“Overall, girls with the lowest QoL scores had the highest rates of mental health problems after discharge, but were not at increased risk for future offending.  Although we could not find support for a direct negative pathway from QoL to offending, our findings did provide support for the indirect pathway via mental health problems to offending. This indicates that a low QoL increases the risk of mental health problems, which in turn increases the risk on offending. In addition, our findings revealed a direct positive pathway from detained girls’ satisfaction with their social relationships to offending after discharge. This suggests that the more girls are satisfied with their social relationships the more likely they are to reoffend” (p. 291).

“The results of the current study clearly support the presence of an indirect route to offending, as previously found among adult offenders . A low QoL placed detained girls at risk for mental health problems, which placed them at risk for offending subsequently. Detained girls’ QoL and mental health problems, together with the selected sociodemographic variables, could explain the vast majority of the variance in offending after discharge” (p. 291).

“The results of the current study did not support a direct negative effect of detained girls’ QoL on offending. This contrasts with the scant empirical research among adult offenders suggesting that a low QoL is a risk factor for recidivism” (p. 291).

“The present study found a direct positive effect of detained girls’ satisfaction with their social relationships on offending after discharge. Although this finding does not dovetail with prior work in adult offenders, it indicates that the more girls are satisfied with their social relationships the more likely they are to reoffend. The exclusive direct impact of the social domain of QoL on girls’ offending supports a multidimensional conceptualization of QoL, and converges with the GLM assertion that individuals attach different priorities to the different domains of QoL” (p.292).

Translating Research into Practice

“The prominent appearance of an indirect route from QoL via mental health problems to offending among detained girls yields some interesting insights pertaining to the rehabilitation of this particularly vulnerable group. Recent studies in samples of juvenile offenders have recommended a strength-based empowering approach, over a more traditional, problem-oriented one. For example, starting off by exploring the youngsters’ own perception of QoL, instead of immediately focusing on specific problems, has been shown to be a less threatening and more motivating approach. The current findings acknowledge the potential relevance of addressing one’s QoL. However, they strongly point to a pivotal role of mental health problems in the pathways toward offending, a finding that argues against an exclusive focus on strengths and empowerment. Put differently, and regardless of the importance of a strength-based approach, our findings suggest the need for appropriate methods for detecting and modifying mental health problems in this vulnerable group” (p.291).

“The lack of a direct negative effect in our sample might be because the GLM is developed as a rehabilitation framework for adult, not adolescent, offenders. Although offending among adults might be primarily guided by their own unmet needs and a poor QoL, offending among adolescents might also be to external influences, such as affiliation with deviant peers. Another explanation is that the basic needs of adolescents are generally served by their surroundings, and that these needs therefore may not be the most prominent force guiding one’s behavior.  Yet, when entering adulthood and becoming more and more financially and socially responsible to fulfill their own basic needs, some adolescents may eventually become actively involved in criminality to reach a satisfying QoL. A strength-based empowering approach might pursue the development of new skills and abilities, thereby providing adolescents with desirable and socially acceptable means to obtain a good QoL before they reach adulthood. However, the highly structured and almost artificial nature of detention forms a major challenge, as it restricts the youngsters’ autonomy and hampers the possibility to develop and practice new skills” (p.292).

The “findings regarding the social domain of QoL yield implications for both research and practice. In line with prior work, we suggest that future research regarding the GLM should pay particular attention to negative peer group affiliation and gang membership as inappropriate ways of satisfying detained minors’ primary goods of relatedness and community/ group involvement. In this respect, a qualitative research approach seems useful: for example, asking youngsters about the priority they assigned to different primary goods at the time of offending, and how they operationalized different primary goods at that time. We suggest treatment to support youngsters in building, strengthening, and extending constructive, instead of destructive, social contacts, by offering peer-helping programs, such as EQUIP. In the EQUIP program detained juveniles help each other to decrease self-serving cognitive distortions and to strengthen their moral and social skills” (p. 292).

Other Interesting Tidbits for Researchers and Clinicians

“The indirect pathway from detained girls’ QoL to offending was found for the overall latent QoL variable, as well as for each domain of QoL separately. Only exceptionally  (i.e., for the QoL domain of physical health) a reversed indirect effect was revealed, which suggests that mental health problems are more likely to result in offending than vice versa, when considering the indirect GLM route” (p. 291).

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Authored by Megan Banford

Megan Banford is a master’s student in the Forensic Psychology program at John Jay College. She graduated in 2013 from Simon Fraser University with a B.A. (Honors) and hopes complete a PhD in clinical forensic psychology. Her main research interests include violence risk assessment and management, juvenile offenders and public policy.

Gender Differences on the PCL-R Indicate that Lower Cut-off Scores and Broader Definitions of Violence may Increase Predictive Validity for Females with Psychopathy

Forensic Training Academy

Compared to men, females with psychopathy obtain lower PCL-R scores, are more likely to offend out of relational frustration, and are more manipulative and self-destructive. This is the bottom line of a recently published article in the International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.

International Journal of Forensic Mental HealthFeatured Article | International Journal of Forensic Mental Health | 2016, Vol. 15, No. 1, 97-110

 

Gender Differences in the Assessment and Manifestation of Psychopathy: Results from a Multicenter Study in Forensic Psychiatric Patients

Authors

Vivienne de Vogel, Research Department, De Zorgspecialisten, Utrecht, The Netherlands
Marike Lancel, Research Department, Forensic Psychiatric Hospital, GGZ Drenthe, Assen, The Netherlands

Abstract

Gender differences were explored in PCL-R codings and the manifestation of psychopathy in 197 female and 197 male patients admitted between 1984 and 2013 to one of four Dutch forensic psychiatric hospitals. Four groups were compared with respect to criminological characteristics, historical violence risk factors and psychiatric characteristics including incidents during treatment. The lowered PCL-R cut-off score of 23 as applied in the Female Additional Manual (FAM; de Vogel, de Vries Robbe, van Kalmthout, & Place, 2012) was used to define women with psychopathy. The four groups were: (1) women without psychopathy (PCL-R < 23), (2) women with psychopathy (PCL-R > 23), (3) men without psychopathy (PCL-R < 30), and (4) men with psychopathy (PCL-R > 30). Overall, it was found that women and men with psychopathy show multiple similarities in their personal and criminal histories, but there were also several gender differences. Women with psychopathy compared to men with psychopathy committed more fraud, offended more often out of relational frustration, were more often diagnosed with the Borderline Personality Disorder, and showed less physical violence, but more manipulative and self-destructive behavior during treatment. Overall, women obtained lower scores on the PCL-R than men. Predictive validity of the PCL-R for physical violence during treatment was good for men and moderate for women. When verbal violence was included in the definition of violence, the predictive validity of the PCL-R was good for both the female and male sample. Implications of this study for forensic practice are discussed and several directions for future research are provided.

Keywords

Psychopathy, PCL-R, gender, manifestation, violence risk

Summary of the Research

“Psychopathy is generally considered one of the most serious and potentially harmful personality disorders that can bear severe consequences for victims and high costs for society. Most of the research into psychopathy has been conducted in male samples, but in the past 10 years research into possible gender differences in the assessment and prevalence rate of psychopathy has expanded. This research has yielded several important insights into the assessment of psychopathy in women, mainly with the Psychopathy Checklist-Revised (PCL-R). Overall, lower scores on the PCL-R and lower prevalence rates of psychopathy have been found for women compared to men” (p. 97).

“The PCL-R is assumed to have relevance, for instance, in violence risk assessment in both women and men. However, concerns have been expressed about whether the PCL-R captures the construct of psychopathy satisfactorily in women. It has been suggested that because women demonstrate fewer antisocial behaviors and generally have a later onset of antisocial behavior several PCL-R items are less suitable to assess the core traits of psychopathy in women” (p. 97).

“Although there have been a number of studies on the prevalence and assessment of psychopathy with the PCL-R and on the criminal background in female populations, little is known about gender differences in the etiology and manifestation of psychopathy. Gender-role socialization, psychological and biological sex differences might result in psychopathic traits being expressed differently in women and men” (p.98).

“This study is part of a retrospective multicenter study into gender differences in violence and risk factors in forensic psychiatric patients. The aim of the present study … is twofold: (1) to explore gender differences in several criminological and psychiatric variables in relation to psychopathy, and (2) to examine gender differences in PCL-R scores and predictive validity of the PCL-R. The lowered PCL-R cut-off score of 23 as applied in the Female Additional Manual was used to define women with psychopathy. It should be emphasized that this cut-off score is experimental and mainly for research purposes.” (pp. 98-99). “The present study focuses on gender differences in psychopathy in a sample of 197 women and 197 men. For men, the official PCL-R cut-off score of 30…was used. The relation will be studied between psychopathy and several criminological and psychiatric characteristics, incidents during treatment and historical violence risk factors in four groups: (1) women without psychopathy (PCL-R < 23), (2) women with psychopathy (PCL-R > 23), (3) men without psychopathy (PCL-R < 30), and (4) men with psychopathy (PCL-R > 30)” (p. 99). “The following hypotheses were formulated: (1) women with psychopathy were older at the first conviction compared to men with psychopathy and show less previous convictions; (2) women with psychopathy will differ from men with psychopathy on psychiatric variables, more specifically, they will show more impulsive, emotionally unstable behavior; (3) women will have lower scores on the PCL-R and a lower predictive validity of PCL-R scores for registered incidents during the most recent treatment” (p.99).

“Overall, it was found that women and men with psychopathy show many similarities in their criminal histories. Both women and men with psychopathy had a younger age at first conviction, were more often previously convicted, showed more previous convictions and were more often driven by antisocial motives for offending compared to women and men without psychopathy. In addition, there were also several similarities in their personal and psychiatric histories: they more often grew up without their biological parents, were more often unemployed, more often diagnosed with ASPD, showed more treatment dropout, more manipulative behavior and less self-destructive behavior during treatment compared to women and men without psychopathy. However, there were also several important gender differences and our hypotheses could be confirmed. Compared to men with psychopathy (PCL-R > 30), women with psychopathy (PCL-R > 23): (1) were older at first convictions and showed less previous convictions; (2) differed on several psychiatric variables, for example, they showed more treatment dropout, were more often diagnosed with BPD and less often with ASPD and NPD; and (3) obtained lower scores on the PCL-R and predictive validity for violent incidents was lower for them. Overall, these results are in line with previous studies and conceptual and prototypical analyses into gender differences in psychopathy” (p.105).

“A notable finding was that women with psychopathy compared to men with psychopathy offended more often out of relational frustration motives, like revenge or jealousy. Overall, women with psychopathy seem more often involved in relationships or intimate contacts and it may be that these contacts have a larger impact on them compared to men with psychopathy” (pp. 105-106).

“Furthermore, women with psychopathy were significantly less often reported as being violent during treatment, but they showed more manipulative and self-destructive behavior compared to men with psychopathy. It can be concluded that male patients with psychopathy are more visible during treatment, since they show high levels of violent behavior and are often transferred to other wards because of serious behavioral problems. On the contrary, the female patients with psychopathy are less visible during treatment as they show more subtle, manipulative behavior and less physical violence both compared to their male counterparts and compared to women without psychopathy…Overall, the findings suggest that psychopathy in women is more complex, subtle and less directly visible compared to psychopathy in men” (p.106).

“With respect to the predictive validity of the PCL-R for incidents during treatment, we found lower predictive validity for women compared to men. Interestingly, when verbal violence was included in the definition of violence, the predictive validity of the PCL-R for women was good, while for physical violence it was only moderate. Taken together, the predictive validity of the PCL-R for women is acceptable, but less strong than for men, except when the definition of violence is broader than physical violence alone” (p.106).

Translating Research into Practice

“As many similarities were found between women and men with psychopathy as well as differences between women with psychopathy and women without psychopathy, it could be suggested that this lowered cut-off score may be useful. However, much more research is needed into the accuracy of this lowered PCL-R cutoff score for female offenders, for example with Item Response Theory (IRT) analyses. Research into the factor structure of the PCL-R for women may be highly valuable. Overall, it is still advised to be careful using a lowered cut-off score because it may lead to stigmatization of women with elevated PCL-R scores. Hence, a high PCL-R score should never automatically lead to higher sentences or exclusion of treatment. Furthermore, it is advised that for decision making, for instance, with respect to discharge or treatment admission, the PCL-R should never be used in isolation. For clinical practice however, the lowered cut-off can be helpful, as it may provide more insight and understanding into the more subtle behavior of women with psychopathic traits and may help to be more attentive to manipulative behavior and effects of this behavior on staff and other patients. This may help to better set treatment goals, for instance, not only focus on empathy but focus more on providing insight into the disadvantages of the woman’s maladaptive behavior for herself. Overall, women are more sensitive and aware of their social environment than men, and thus are adept at determining what is socially desirable and they usually have better verbal skills compared to men. Therefore, self-insight and treatment motivation may be more easily overrated for women than for men. Possibly this is even more so for women with psychopathy” (p. 107).

Previous research has had “several good suggestions for the treatment of women with psychopathy, for instance, with respect to one-to-one meetings (e.g., prepare strategy and verify with colleagues), group processes (e.g., structured observation) and the acknowledgment of challenges/burden for staff (being cognizant about the toll on staff, staff needs to have insight in their own behavior and feelings)” (p.107). Other treatment suggestions are to “provide feedback to women about the results of the PCL-R, see psychopathy as a responsivity factor (e.g., emotional bonding and empathy training are not effective), and be alert to signals of psychopathic behavior and the effect on group/climate and intervene when needed. The above described strategies will take highly skilled professionals as well as clear policies in treatment settings, for instance, with respect to intimate relationships. Training staff in recognizing manipulative behavior is important, as well as frequent team interactions, supervision, coaching, and support from managers” (p.107).

Other Interesting Tidbits for Researchers and Clinicians

“Adaptation of the PCL-R for females could possibly be useful, for instance, put less weight on items relating to antisocial behavior, such as Early behavior problems and Juvenile delinquency, and adapt some item descriptions that are very male focused. For example, in the item Glibness/Superficial charm the term ‘macho men’ is applied. Furthermore… the CAPP provides a more gender-sensitive conceptualization of psychopathy and for future studies it would be interesting to further test this instrument” (p. 107).

“Since the present study showed that women with psychopathy demonstrate more manipulative behavior and were more often convicted for fraud, it could be hypothesized that there are female equivalents of these corporate psychopaths in workplaces and that they are just as harmful as their male counterparts. It would be interesting to test this hypothesis in different workplaces, like business organizations, but also in more typical female workplaces, such as health care settings. Furthermore, case studies or qualitative studies could provide valuable insight into the behavioral expression of psychopathy in women. Research into the effects of psychopathic behavior by women on their environment, more specifically their children, partner, or family, but also on treatment staff could be valuable. These types of research are important for theoretical, clinical, and ethical reasons, most importantly, with respect to the prevention of harmful behavior by women and men with psychopathy, especially against vulnerable others, like their children” (p.108).

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Authored by

Megan Banford is a master’s student in the Forensic Psychology program at John Jay College. She graduated in 2013 from Simon Fraser University with a B.A. (Honors) and hopes complete a PhD in clinical forensic psychology. Her main research interests include violence risk assessment and management, juvenile offenders and public policy.

Reevaluated Psychometric Properties of the Psychopathy Checklist-Revised

Forensic Training AcademyNew research elucidates the psychometric properties of the Psychopathy-Checklist Revised (PCLR) while avoiding sampling limitations. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

Law and Human BehaviorPsychometric Properties of the Hare Psychopathy Checklist-Revised (PCL-R) in a Representative Sample of Canadian Federal Offenders | Law and Human Behavior | 2016, Vol. 40, No. 2, 136-146

Psychometric Properties of the Hare Psychopathy Checklist-Revised (PCL-R) in a Representative Sample of Canadian Federal Offenders

Authors

Jennifer E. Storey, Mid Sweden University
Stephen D. Hart, Simon Fraser University and University of Bergen
David J. Cooke and Christine Michie, Glasgow Caledonian University

Abstract

The Hare Psychopathy Checklist-Revised (PCL-R; Hare, 2003) is a commonly used psychological test for assessing traits of psychopathic personality disorder. Despite the abundance of research using the PCL-R, the vast majority of research used samples of convenience rather than systematic methods to minimize sampling bias and maximize the generalizability of findings. This potentially complicates the interpretation of test scores and research findings, including the “norms” for offenders from the United States and Canada included in the PCL-R manual. In the current study, we evaluated the psychometric properties of PCL-R scores for all male offenders admitted to a regional reception center of the Correctional Service of Canada during a 1-year period (n ? 375). Because offenders were admitted for assessment prior to institutional classification, they comprise a sample that was heterogeneous with respect to correctional risks and needs yet representative of all offenders in that region of the service. We examined the distribution of PCL-R scores, classical test theory indices of its structural reliability, the factor structure of test items, and the external correlates of test scores. The findings were highly consistent with those typically reported in previous studies. We interpret these results as indicating it is unlikely any sampling limitations of past research using the PCL-R resulted in findings that were, overall, strongly biased or unrepresentative.

Keywords

PCL-R, cohort sample, psychopathy, PCL-R norms

Summary of the Research

“One of the most widely used psychological tests of PPD [psychopathic personality disorder] is the Hare Psychopathy Checklist-Revised, or PCL-R. Briefly, the PCL-R is a 20-item symptom construct rating scale intended for use in forensic settings. Each item reflects a specific feature of PPD. The lifetime presence and severity of each feature is rated on a 3-point scale (0 = absent, 1 = partially present, 2 = present) on the basis of all available clinical data. Item scores are summed to yield facet, factor, and total scores. Total scores of 30 and higher (out of a maximum possible 40 points) are generally considered diagnostic of PPD. The PCL-R manual summarizes PCL-R ratings for various groups, including male and female correctional offenders and forensic psychiatric patients in Canada, the United States, the United Kingdom, and Sweden. Focusing specifically on correctional offenders in Canada and the United States, the manual presents ratings for a normative sample of 5,408 males who underwent “standard assessments”(p. 136).

“The problem with the PCL-R “standard assessment” and “file review” normative samples for Canada and the United States is that they are not really normative samples at all. They were constructed by pooling samples of convenience, rather than by systematically sampling offenders or patients (e.g., using random, stratified random, or other procedures). For this reason, there is a very real possibility that the norms are not representative of people who may be found in any given setting…Only a handful of published studies have conducted detailed analysis of representative PCL-R ratings, that is, those gathered from offenders or patients selected using systematic sampling procedures” (p. 138).

“Ironically, then, there is a lack of systematic norms for the PCL-R for correctional offenders in Canada and the United States. Pooling samples of convenience—the strategy used in the PCL-R manual—does not necessarily yield results that are representative or unbiased. The lack of systematic norms complicates the interpretation of PCL-R scores in clinical forensic practice and re- search. In clinical forensic practice, the major concern is that the percentile ranks provided in the test manual and the recommended interpretation of score ranges (e.g., very low through very high; see Hare, 2003, p. 33) may be biased. Put simply, the test manual may give an inaccurate picture of what is a relatively high or low score on the PCL-R for male correctional offenders in Canada and the United States. In research, there are at least two major concerns. First, it is difficult to determine the extent to which sampling bias in the norms may have affected analyses of the structural reliability and factor structure of the PCL-R reported in the test manual. Pooled sample may yield a biased or unrepresentative picture of the psychometric properties (e.g., structural reliability, factor structure) of the PCL-R. Second, a pooled sample complicates comparison of PCL-R ratings obtained in Canada and the United States versus other countries for the purpose of cross-cultural validation of the test. To address limitations in past research, in the current study we evaluated the psychometric properties of PCL-R ratings for a sample of serious male offenders selected to be highly representative” (p. 139).

“To address limitations in past research, in the current study we evaluated the psychometric properties of PCL-R ratings for a sample of serious male offenders selected to be highly representative. We studied consecutive admissions to a reception center over a 1-year period. The reception center conducts assessments prior to institutional classification for the entire Pacific region of the Canadian federal prison service. The sample is therefore diverse with respect to correctional risks and needs, yet representative of the population of offenders in the Pacific region. We examined the distribution of PCL-R scores; classical test theory indexes of its structural reliability; the factor structure of test items; and the external correlates of test scores” (p. 139).

“The findings from our study were very similar to those reported in the test manual for offenders assessed via file review. The similarities were observed for PCL-R total, factor, and facet scores. They were also observed with respect to score distribution; Classical Test Theory indexes of structural reliability; factor structure; and external correlates, such as age, correctional risks, violence, and self-harm. Overall, these findings are very reassuring. They suggest two things about the PCL-R manual. First, the pooling of diverse samples in the test manual did, in fact, result in “normative samples” of the United States and Canada that are likely representative of various offender populations in those countries. Second, psychometric evaluations of the “normative sample” are likely generalizable to samples from those same offender populations. In addition, the findings add more general support for the validity of psychopathy as a mental disorder, and the PCL-R as a measure of psychopathy” (p. 144).

Translating Research into Practice

“We interpret these results as indicating it is unlikely any sampling limitations of past research using the PCL-R resulted in findings that were, overall, strongly biased or unrepresentative” (Abstract). Therefore, practitioners might feel more confident utilizing the norms provided in PCL-R manual as well as relying on previous research studies when administering the PCL-R and drawing conclusions. “It will also be important to replicate the current study via standard assessment (i.e., including interviews with offenders and patients), and at various points in time. Only then will we be able to form a more complete picture of the representativeness of the “normative samples” and the generalizability of the psychometric evaluations of the PCL-R presented in the test manual, particularly in light of the fact that the profile of correctional offenders and forensic patients may change in important ways over time” (p. 144).

Other Interesting Tidbits for Researchers and Clinicians

“Notwithstanding the similarities between our findings and those reported in the test manual highlighted in preceding text, we observed a few interesting differences. First, the structural reliabilities of Factor 1 and Facets 1 and 2 scores were somewhat higher in our sample than those reported in the test manual. This may reflect simple sampling variability, but it may also reflect the quantity and quality of file information available at the site where we collected data compared with the file information typically use for assessments via file review.

Second, we observed a better fit for Cooke and Michie’s three- factor hierarchical model with testlets than for Hare’s four-facet, two-factor hierarchical model. This finding is, on the surface, contrary to past research, especially that conducted by Hare and his colleagues. We suspect that the contradictory findings may be the result of the fact that most researchers who evaluate the Cooke and Michie model do not include testlets, which results in significantly worse fit than when testlets are included. Further, differing findings for the four-facet model may arise from confusion regarding which four-facet model is being tested (Cooke et al., 2007). It is important to appreciate that the various 4-facet models proposed have very different conceptual and statistical underpinnings.

Third, we observed higher correlations between PCL-R Factor 1 and Facets 1 and 2 scores and violence that were reported in some past research. This was especially true when examining any documented history of violence as opposed to violent index offenses. Again, sampling variability is one potential explanation for the contradictory findings. But it may also be that when violence is defined in terms of official criminality (e.g., arrest, charge, conviction) it will have higher correlations with scores on Factor 2 and in particular Facet 4, which are themselves heavily saturated with official criminality. For example, 3 of the 10 items that define Factor 2, and 3 of the 5 items that define Facet 4, are scored solely on the basis of official criminality, and official criminality counts heavily toward the scoring of one or two other items that define Factor 2 and Facet 4” (p. 144).

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Authored by Marissa Zappala

Marissa Zappala is currently a second-year Master’s student in the Forensic Psychology program at John Jay College of Criminal Justice in New York. Her main research interests include cognitive biases, forensic assessment, and evaluator training and education. Following her Master’s, Marissa plans to pursue a doctoral degree in clinical psychology and an eventual career in psychological assessment.

Interpersonal-Affective and Antisocial-Impulsive Psychopathic Traits Influence Drug Use Differently in Men and Women

Forensic Training AcademyAntisocial-Impulsive psychopathic traits may serve as a risk factor for drug use while interpersonal-affective psychopathic traits may serve as a protective factor against drug use. However, gender may influence the effect of psychopathic traits on drug use. . This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

 

Law and Human BehaviorFeatured Article | Law and Human Behavior | 2016, Vol. 40, No. 2, 159-168

 

Gender Differences in Psychopathy Links to Drug Use

 

Authors

Nicole Schulz, University of Illinois at Urbana Champaign
Brett Murphy, University of Illinois at Urbana Champaign
Edelyn Verona, University of Illinois at Urbana Champaign

Abstract

Although the relationship between psychopathic personality traits and substance use has received some attention (Hart & Hare, 1989; Smith & Newman, 1990), gender differences have not been thoroughly assessed. The current study examined whether gender modified the relationship between 2 criminally relevant constructs, (a) psychopathy and its factors and (b) drug use. A sample of 318 participants with criminal histories and recent substance use was assessed for psychopathy using the Psychopathy Checklist: Screening Version and for illicit drug use using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. As expected, the impulsive-antisocial traits (Factor 2) of psychopathy were positively related to a number of drug use characteristics (symptoms, age of drug initiation, extent of drug experimentation), whereas the interpersonal-affective traits (Factor 1) showed a negative relationship with drug abuse symptoms and a positive relationship with age of first use. In terms of gender differences, analyses revealed that women showed a stronger association between Factor 1 traits and later age of initiation compared to men, and that Factor 2, and the antisocial facet in particular, were more strongly related to drug abuse in women than men. These findings suggest that psychopathic traits serve as both protective (Factor 1) and risk (Factor 2) correlates of illicit drug use, and Factor 1 may be especially protective in terms of initiation of drug use among women. These conclusions add to the growing literature on potential routes to substance use and incarceration in women.

Keywords

drug use, gender, psychopathy

Summary of the Research

Substance use is strongly related to many other forms of criminal activity within the United States. Although male substance use has received more attention, female substance use appears to be rising, especially among younger cohorts. Moreover, illicit drug use may be an especially relevant pathway to incarceration in women relative to men. For example, a sizably larger proportion of female state prison inmates are incarcerated for drug offenses, relative to males … Because incarcerated women are more likely than incarcerated men to be primary caregivers for their children, women’s substance use and incarceration is especially likely to have negative effects on families and communities, making additional research on female criminality and substance use essential” (p. 159).

“Psychopathic personality is an important criminally relevant construct that has been linked to substance use. The clinical construct of psychopathy encompasses a variety of characteristics, including serious empathy deficits, lack of remorse, impulsivity, and antisocial behavior, which can be characterized in terms of two related but distinguishable dimensions: interpersonal-affective traits and impulsive-antisocial traits . Although relationships between psychopathy and substance use have been evaluated within male samples , and some female samples , research on gender differences in relationships between psychopathic traits and illicit drug use is sparse. This study aims to address this gap in the literature by exploring gender differences in the relationship between the two psychopathy factors (and distinct traits of psychopathy) and illicit drug use, utilizing a community-dwelling sample of participants with a history of substance use and involvement with the justice system.” (p. 159)

“Mainly because of the impulsive-antisocial features of psychopathy, research has consistently shown evidence for a relationship between overall psychopathy scores and substance use behaviors, with persons with psychopathic traits more likely to exhibit serious substance use …. Research has also examined the two main factors of psychopathy. The interpersonal-affective traits (referred to as Factor 1) include deceitfulness, superficial charm, manipulativeness, deficient empathy, and lack of remorse . The impulsive-antisocial traits (referred to as Factor 2) are characterized by impulsivity, irresponsibility, weak behavioral control, and criminal versatility” (p. 160).

“An important consideration in the current psychopathy literature is whether psychopathic traits manifest similarly in women compared to men . For example, although the PCL-R is a good predictor of reoffending (recidivism) within male samples, psychopathy and recidivism are not as closely associated in women . The theoretical perspective informing our examination of gender differences in psychopathy relationships with drug use rests on two considerations. First, drug use appears to be a larger contributor to female incarceration rates , which has implications for how both drug use and psychopathy are assessed in women relative to men… Second, psychopathic traits are generally more inconsistent with cultural gender norms for women than for men” (p.160)

“There is a gap in the knowledge base concerning how gender may moderate the relationship between factors of psychopathy and substance use, especially when examining illicit drug use. In order to investigate illicit drug use reflecting the progression from initiation to addiction, we measured 4 drug use variables: retrospective reports of age of first drug initiation; range of drug experimentation; and clinically rated symptoms of both drug abuse and drug dependence, as per the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM–IV–TR)” (p. 161).

The Present Study

The present study utilized an existing data set from a larger project studying the relationships between drug use, gender, and violence. Participants included 318 community members with histories of drug use within the last 6 months and/or contact with the criminal justice system in the last year.  “The majority of the participants had a history of legal involvement or court supervision, including 70.1% with histories of incarceration or parole/probation and 31.1% mandated to substance use treatment. Slightly fewer than half of the participants were women (n 134, 42.1%), and the participants ranged in age from 18 to 62 with a mean age of 34.75” (p. 161).

Trained staff supervised by a licensed Clinical Psychologist conducted participant interviews for approximately three hours. During that time, “a life history interview for the Psychopathy Checklist: Screening Version , modules from the Personality Disorder Interview (PDI-IV), and modules from the Structured Clinical Interview for DSM–IV–TR Axis I Disorders (SCID-I)” were administered (p. 161).  Each participant received between $35 to $40 compensation for participating in the study.

Results

“The main findings of this study contribute to the literature on female drug use by showing that women demonstrate some similar relationships compared to men between psychopathic traits and various drug use variables, although we found a few notable differences. The two main gender differences revealed in our analyses are (a) the link between drug abuse and antisocial behavior facet in particular appears to be stronger in women than in men and (b) the core interpersonal and affective traits of psychopathy appear to be a modest protective factor in women, in terms of delaying their first use of illicit substances. Both of these findings lend support to the idea that psychopathic traits may be relevant to life trajectories in men and women, such as in terms of drug use” (p. 165).

“In terms of gender, both men and women showed similarly high levels of drug abuse and dependence symptoms, most likely because we recruited persons with drug histories into the study. Our results were somewhat consistent with our predictions, in that women demonstrated a marginally stronger relationship between F2 traits and drug abuse symptoms. More prominently, gender differences were strongest for relationships between substance use variables and the unique variance in the antisocial behavior facet, which to some extent can reflect lifetime incarcerations… Thus, our results indicate that the link between antisocial behavior and drug use is stronger in women than in men. This could either be a reflection of gender differences in underlying psychological characteristics of psychopathy, or it could be a reflection of gendered effects of current drug policy paradigms such as the “War on Drugs” (p. 165-166).

“Importantly, gender served as a moderator of the relationship between F1 and age of drug use initiation. Specifically, F1 traits were associated, albeit at a small effect size, with a later age of first drug use in women compared to men. This finding demonstrates that psychopathic traits in general, and its different features, and not only general antisociality (captured by F2), are important for understanding gender-differentiated manifestations of drug use, most notably in terms of early drug initiation… One explanation for the fact that women’s age of drug use initiation was more affected than men’s by F1 (and to a lesser extent F2) traits involves the idea that psychopathic traits are gender role-inconsistent for women” (p. 166).

Translating Research into Practice

“First, Psychopathy Checklist scores in women may be more heavily linked to incarceration policies of the nation’s “war on drugs.” Given that F2 scores elevate total psychopathy scores, bringing persons closer to potential cut-offs used in clinical or legal agencies, the possibility that a drug use history would confound interpretation of psychopathy scores or labels more so in women than men should be considered in making policy or legal decisions. Second, the fact that F1 traits were shown to have a stronger protective relationship with early drug use for women than men indicates that the interpersonal-affective traits are also important to consider in understanding drug use trajectories in women. Importantly, the fact that F1 traits did not interact with F2 to explain drug use in this study, whereas it has been shown to do so when it comes to BPD and self-harm, suggests that F1 traits may show complex relationships with other forms of disorder in women. This would indicate that researchers should pursue more systematic examinations of the nomological network of F1 traits and their measurement in women” (p. 167).

Other Interesting Tidbits for Researchers and Clinicians

“The current study is the first to directly study gender differences between the factors and facets of psychopathy assessed using the PCL: SV and multiple illicit drug use variables. The outcomes of this study not only add to the growing field of female drug use but can also inform future hypotheses regarding gendered pathways to drug use. For instance, drug use may be more tightly linked to history of criminal involvement in women than men” (p.167).

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Authored by Sara Hartigan

Sara Hartigan is a second year Forensic Psychology Master’s student at John Jay and hope to obtain a Ph.D. in Clinical Forensic Psychology in the future. My main areas of interest include clinical evaluations and developing treatment interventions within the forensic population.