Suddenly, he smashes the bottle down on the table, gets up from his chair and walks over to the stranger who accidentally bumped into him earlier that evening, twisting the broken bottle into his face. A friend of the injured man named Pete reacts aggressively, pushing Tony and lashing out when others try to restrain him, drawing more people into the fight.
When the police arrive, Tony calmly takes charge of the situation, seemingly trying to smooth things over, but in fact blaming Pete. When the police subsequently try to arrest Pete, Pete explodes for a second time – this time punching a policeman in the face.
Though this story is fictional, it serves to illustrate the difference between two types of violent offenders in our prisons. The characteristics that Tony shows are those of a psychopath: cold, calculating, superficially charming, and remorseless. “The violent act is thought through in advance, and the individual may derive much excitement and satisfaction from engaging in it,” says Stephen Blumenthal, a consultant clinical psychologist and psychoanalyst who works with violent offenders at the Portman Clinic, a specialist NHS outpatient psychotherapy clinic in London.
Pete, on the other hand, exhibits symptoms of antisocial personality disorder: a condition characterised by impulsivity and aggression. “The typical violence of the antisocial, non-psychopathic individual is driven by strong emotions and is impulsive or reactive,” Blumenthal says.
Those with antisocial personality disorder are driven by strong emotions and can show impulsive or reactive violence (Credit: Alamy)
Two violent men, two very different motivations – but our criminal justice system often treats them as one and the same. Although both are violent and therefore pose a risk to society, with high rates of reoffending, this may be a mistake. Studies increasingly suggest that their brains work in very different ways. This could mean that they require different types of rehabilitation if they’re to be safely released back onto our streets.
With this in mind, efforts are currently underway to devise new treatments for repeatedly violent offenders.
It was the American psychiatrist Hervey M Cleckley who formalised the concept of the psychopath in his 1941 book The Mask of Sanity, which was based on interviews with inmates in high security prisons.“He identified a group of individuals who seemed very disturbed, but who defied the usual category of mental disorder,” says Blumenthal.
Psychopathy is diagnosed using an assessment tool that scores individuals against a series of criteria. Those above a certain threshold are officially classified as psychopaths – although psychopathy is a spectrum and most psychopaths are not violent criminals (in fact, some are very successful in the business world). However, those that are tend to be criminally versatile.“They often offend in lots of distinct categories,” Blumenthal says.
Among imprisoned violent offenders, a minority are psychopathic. One recent UK study put the prevalence at around 8% of male prisoners and 2% of female ones; another estimated that 31% of violent male offenders and 11% of female ones met the criteria for psychopathy. It’s important to note though that these are already convicted prisoners. It does not mean that the general population – of which less than 1% are classified as psychopathic – are destined to a life of crime.
Among imprisoned violent offenders, only a minority are psychopathic (Credit: Getty Images)
Psychopathy clearly, then, doesn’t explain all violent crime. But once a psychopath is in prison, it is important to figure out how to better rehabilitate them: they are up to four times more likely to reoffend than non-psychopaths.
More prevalent is antisocial personality disorder (ASPD), estimated to affect between 50-80% of the general prison population. “It’s been said that searching for ASPD in prisons is like looking for hay in a haystack,” says Blumenthal.
Although people with ASPD may come across as happy-go-lucky and likeable, in the face of conflict they can quickly snap and become frightening. “They are the hot-headed group,” says Nigel Blackwood, a clinical senior lecturer at Kings College London. “They get frustrated and irritated; see threats where none really exist; and lash out or use reactive aggression to sort out their problems.”
In a minority of cases, violent offenders will meet the diagnostic criteria for both ASPD and psychopathy. Blackwood and his colleagues have identified differences in the brains of such offenders, which set them apart from offenders with only ASPD and from healthy non-offenders. “The differences are in key areas of the social brain that are involved in thinking about our social reputations and using fear to inform our behaviours,” says Blackwood.
Many violent offenders meet the criteria for both antisocial personality disorder and psychopathy (Credit: Getty Images)
Psychopaths seem to process information about punishment and reward differently to ordinary people. Most children go through a phase of hitting or biting other children, but most eventually learn that this is inappropriate behaviour that will be punished.
Psychopaths, though, seem relatively unfazed by punishment, which makes them very difficult to manage. “Our experiments suggest that the key thing that characterises psychopathy is not being able to use punishment information to shape your behaviour,” Blackwood says. “Our study suggests it’s not just that psychopaths are hypo-responsive to punishment, but they are processing it in quite a different way.” He believes this could have important implications for rehabilitation, and that programmes could be tailored for these “separable groups”.
Given their brain’s unusual reward system, one approach might be to consider encouraging other rewarding activities besides reoffending, Blackwood says, such as a hobby or a job. But he cautions “it is still very, very, early days” to know if this would be effective.
More advanced research regards interventions targeting violent offenders with ASPD. Studies have suggested that such individuals struggle to read facial expressions and show other impairments in “mentalisation”: their capacity to understand both their own, and other people’s actions in terms of their thoughts, feelings, wishes, beliefs and desires. Not only could this cause them to misinterpret actions as more threatening than they are; it could also make it harder for them to regulate these emotions, because they struggle to understand their own feelings.
Peter Fonagy, a psychoanalyst and clinical psychologist at University College London, is currently overseeing a trial of mentalisation-based group therapy with violent offenders who have been released on probation – most of whom have ASPD. Each week, they meet and discuss issues that are currently important to them, with the goal of introducing a more nuanced understanding of their own position and those around them.
“We are trying to press a kind of mentalisation pause button: to say okay, hold it right there, what has actually happened here?” Fonagy explains. Mentally unpacking the event often causes the heat of an emotional situation to dissipate, reducing the urge to do something impulsively.
Already, Fonagy and colleagues have successfully used mentalisation to help people with another disorder, borderline personality disorder (BPD), which is characterised by emotional instability and frequent self-harm. One study saw improvements in mood and interpersonal functioningwhich could still be detected eight years later.
“I would not expect that what we have discovered is a panacea and will turn the lives of everyone around,” Fonagy says. But because the risk of reoffending for these individuals is so high, he says, “I think that if you can shift that needle a little bit. Make it easier and safer for even a small minority of these individuals to live in the community, then you will have done something that – certainly from an economic and humanitarian perspective – is rather important.”
Talking is one thing, but researchers in Spain are going a step further and encouraging violent offenders to experience the emotional reactions of their victims for themselves.
The University of Barcelona’s Mel Slater and Mavi Sánchez-Vives have been working with perpetrators of domestic violence who have taken up the offer of a community rehabilitation programme rather than a prison stay (a more lenient sentence is possible because it is their first offence). As part of this, the men undergo a virtual reality session in which they must embody a female avatar and encounter an aggressive male. The male criticises their appearance, throws a telephone against the wall, and then invades their personal space. “It is common to watch videos or to do role-play during treatment programmes, but this is a more intense experience” because it is virtual reality, says Sánchez-Vives.
Before and after the session, the offenders were tested on their ability to recognise emotions such as fear in women’s faces. Their ability to recognise fear improved with the intervention. “We think that expressing that emotion themselves in that situation helps them to understand – in an implicit way – what is actually going on during that kind of confrontation,” says Slater.
Although they haven’t shown that such changes are long-lasting, other virtual reality studies suggest they might be. For instance, Slater previously measured the effect of a white person inhabiting a virtual black body and found that it reduced implicit racial bias – an unconscious, often unintentional form of racism. This reduction remained when participants were tested a week later. “It doesn’t prove that the effect would hold for gender violence, but it at least points in that direction,” Slater says.
Whether such empathy-cultivating approaches would work for psychopaths is less clear. Talking treatments require motivation, collaboration and emotional engagement, but psychopaths don’t experience a normal range of emotions. They may see themselves as superior to their fellow prisoners and therapists, and mock or undermine them in other ways. “If you put them into a group treatment situation there is a risk they will corrupt it,” says Blumenthal. “They are highly problematic to manage.”
In his book Assessing Risk, Blumenthal describes a psychopath, Sid, with a history of preying on vulnerable young women and abusing their children. He was transferred to the probation hostel where Blumenthal worked. “He is one of the most charming and manipulative people I’ve ever met,” Blumenthal says. A month later, Sid absconded with the hostel’s cleaner, “a seemingly stable and reliable woman”. (She had been warned about him).
“I wouldn’t want to write off treatment completely because most current programs are quite basic, and a lot of work is going into this area. But these people need a long time to get better, and they need to choose to do the treatment themselves,” Blumenthal says. “I think one also has to accept that there are some people who are treatment-resistant and are extremely difficult to reach.”
More hope may lie in spotting young people with psychopathic traits in order to change the trajectory of their development. Studies indicate that psychopathy does have an inherited component, and that children with high levels of so-called “callous unemotional” traits are at higher risk of becoming psychopathic adults. The idea that psychopathy can be diagnosed in childhood remains controversial, but evidence shows that there are clear risk factors. Both psychopathy and ASPD are also associated with a history of neglect and abuse in childhood.
And while emotionally reactive children tend to respond well to firm boundaries, unemotional children are less responsive. That’s why interventions could help: recent research suggests that they may be more susceptible to interventions that focus on reinforcing positive behaviour, rather than punishing bad behaviour. This chimes with Blackstock’s findings in adult psychopaths.
Most children go through a phase of hitting or biting other children, but eventually learn that this is inappropriate (Credit: Getty Images)
“If you can build that part of the brain that wants the sorts of rewards you get from pleasing other people, rather than just getting what you want, then you’ve probably got a better chance of success,” says Graham Music, a consultant child and adult psychotherapist who works with Blumenthal at the Portman Clinic. Such children also show deficits in the ability to read others’ emotional states, but Australian research suggests that this skill may be improved by directing them to look at the eyes of others, which may boost empathy and emotional bonding.
That’s why early intervention is key: the brain is more malleable during childhood. This has its own challenges, as these children aren’t necessarily the ones who pass through a child psychologist’s door. “The kids that often get referred are the ones who are reacting, throwing things, kicking people, shouting, getting into fights,” says Music. Callous unemotional children, on the other hand, are sometimes referred to as ‘happy aggressives’ because they seem unfazed by violence.
The growing evidence that violent offenders aren’t one and the same clearly demands a more nuanced approach. Part of the challenge is identifying the individuals who are the most likely to benefit from treatment and channelling resources into supporting their efforts to change.
There may be individuals who are beyond redemption, but many others may be within reach. “I do believe that biology is malleable, and I would rather not give up on people,” Fonagy says.
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