Are psychopaths evil, or broken?

kw: book reviews, nonfiction, psychology, psychopaths, autobiographies, fmri

Psychopaths and psychopathy have been of growing interest for about thirty years. Amazon currently lists 96 hardbacks with "psychopath" (singular or plural) in the title, and more than 600 if paperbacks and Kindle editions are counted. Perhaps a quarter of these books delve into the science to some extent. The rest are more sensational treatments or contain advice about dealing with a troublesome boss, co-worker, lover, child or parent, who may or may not actually be psychopathic.

Of books on the subject with a more scientific or investigatory aim, I suspect most are at least partly based on the work of Kent Kiehl, who has just published The Psychopath Whisperer: The Science of Those Without Conscience. Beginning with the work of Drs. Hervey Cleckley and Robert Hare, and based very much on the PCL-R (Psychopathy Check List – Revised), he initiated the study of brain structure and function in psychopaths using fMRI (functional Magnetic Resonance Imaging).

While he was a graduate student Dr. Kiehl began working with prisoners convicted of the most violent crimes, learning to apply the PCL (I'll leave the R off; it is understood these days). To properly use the PCL, interviews lasting a few hours, conducted by a well trained clinician, are needed. The score ranges up to 40, with 30 being the cutoff. The average for all inmates in maximum-security prisons is 11. The average for the general population is 4. The average for serial killers is 35, but not all serial killers have been found to be psychopaths.

Throughout the book the chapters each begin with a mini-fact. The first is

One in four maximum-security inmates is a psychopath

So if you have a bunch of inmates whose average score is 11, but a quarter of them have an average score of about 32 (this assumes that higher scores are more scarce), then the rest will average 4, the same as the general population of the non-incarcerated!

Psychopathy is a primarily male affliction. While about one man in 150 is a psychopath, the rate for women is closer to one in 1500, so about 90% of psychopaths are male. If we confine our concern to those between the ages of 18 and 50, in the U.S. population about half a million men and 50,000 women are psychopaths, as measured by PCL-R.

I wondered about the 30-point cutoff. Its utility depends on the distribution of scores. For example, if someone is rated by a trained clinician, for whatever reason, and is scored a 29, is he considered "almost a psychopath" or a non-psychopath? Having dug around some, I didn't find much on score distributions, and nothing for the "general population". But I did find a few histograms compiled for psychiatric populations. They showed a bimodal distribution with a pronounced low region in the range 20-30. Curiously, among many articles that mention score distribution, most treat the scores as a normal (that is, Gaussian) distribution, which introduces serious errors if the true distribution is bimodal (think of a camel with two humps; the Gaussian curve has one hump only).

It is a terrible pity that so many scientists, psychologists in particular, try to shoehorn all distributions into the Gaussian model, when so few natural phenomena are truly Gaussian! Sure, height in males or females tends to be normally distributed ("normally" meaning "according to the Gaussian model"). So do a small number of other measurable things. But consider this question:

What is the average number of digits (fingers plus thumbs) possessed by persons the day of their birth...or death?

Neither question can be answered "exactly ten". On the day of birth, some babies are born deformed and have fewer than ten, and in rare cases, no digits or even hands at all. Also, ten is not the maximum number because some are born with twelve, and sometimes more. The internet abounds with pictures of babies born with 14 digits or more. And at the end of life, a significant number of folks have lost one digit or more to accident or disease. So while the mode (greatest frequency) of the distribution curve is right at ten, the number ranges from zero to at least 16, and is strongly skewed, numbers smaller than ten predominating. To analyze frequencies of digit quantity using Gaussian statistics would be a serious error.

The difficulty of labeling is also discussed. Young people can also display psychopathic tendencies, and there is a PCL for juveniles, but it is a breach to tell a youngster the result. In one case in the book, a young man with some emotional problems was told by a doctor that he was a psychopath, whereas it turned out later he was not one at all! But he believed the doctor and decided he'd live a life of crime, including killing.

Dr. Kiehl's work has been primarily with serious criminals. A significant focus of his work has been predicting rates of recidivism, or re-offending, after a prisoner is released. Psychopaths are six times as likely as others to re-offend. Does that mean that we ought to give the PCL to a freshly incarcerated person and, if he "fails", lock him up and throw away the key? Not so fast. The author spends a chapter discussing the Mendota Juvenile Treatment Center (MJTC) in Wisconsin, where a different approach has been used to ameliorate the antisocial traits of the least-manageable juveniles, who are termed "callous and unemotional" to avoid labeling them "psychopaths" at too early an age.

Psychopaths in general do not learn from punishment or other negative consequences. They seem immune to correction, and many are proud of it. At MJTC, as I understand it, the juvenile offenders are trained in a way similar to performing animals. Every slightest "good behavior" is rewarded, and while serious misbehavior may be sanctioned for the safety of the staff, most misbehavior is simply ignored. Everyone there is trained in the method, from clinicians to cleaning staff. The results have been spectacular. For example, among juveniles not treated who were released at age 18, a certain number became adult criminals and several committed murder. Among an equal number of those who completed the MJTC program, fewer than half as many committed any crimes, and none were murders. Some went on to get more education and were able to hold jobs. Getting such results is neither quick nor cheap, but considering that crime in America costs at least a trillion dollars yearly, not doing anything is even more costly!

I find it interesting that Dr. James Fallon has studied psychopaths, using tools developed by Dr. Kiehl, and found that he is himself a psychopath, as are a number of people, such as Niel Armstrong, who are not in any way in trouble with the law. It seems one's fMRI scan can show the suppressed emotional brain activity characteristic of a psychopath, and one can score 30 or more on the PCL, while still having respect for law. Dr. Fallon believes such psychopaths outnumber the criminal ones. Let's hope so!

A "horse whisperer" is one who has a special rapport with horses and can train them quickly and effectively. The book's title points not so much to the author as to the originator of the program at MJTC. I hope the work there leads to follow-on programs that can take the fangs out of  the most dangerous young persons and, one might fondly hope, gradually depopulate our prisons. It is a national shame that America has such a large number of prisoners.