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We aimed to evaluate critically the evidence behind the perceived inverse association between the degree of psychopathy as reflected by a high score on the Hare Psychopathy Checklist-Revised (PCL-R) and treatment response. A literature search with the key identifiers of PCL-R (or its derivatives) and treatment response produced 24 studies that were then systematically evaluated. This showed that only three studies were of an appropriate research design to answer the question and of these, none met our standard for an acceptable study. We conclude therefore that the commonly held belief of an inverse relationship between high-scores on the PCL-R and treatment response has not been established.
Very occasionally, a paper appears in the literature that has a significant impact on both policy and practice. An example is the Rice, Harris, and Cormier (1992) evaluation of the impact of a therapeutic community on the recidivism rate of "criminal psychopaths." This showed that although the program was effective in reducing violent recidivism among nonpsychopaths, it had the reverse effect on psychopaths.
As the assessment of psychopathy is becoming increasingly routine in both health and criminal justice settings, the conclusion from this and other studies has begun to influence service delivery for this subgroup of mentally disordered offenders. It implies, for instance, that there may be some psychopathic individuals from whom interventions ought to be withheld as these are likely, not merely to be ineffective, but even to have the reverse effect from that which is intended. This influence is already evident within correctional settings where some inmates find themselves in a Catch 22 situation. They are told, on the one hand, that they cannot be considered for release or parole if they do not complete certain treatment programs while, on the other, they are refused entry into these programs on the grounds of their high PCL-R score.
The new services currently under development in England for the treatment of personality-disordered offenders (Department of Health/Home Office, 1999), brings this issue into sharp relief as their remit will be to assess compulsorily and treat individuals who have both a severe personality disorder (defined mainly by a high PCL-R score) and who also present a high degree of risk to the public. How are such individuals to be treated...