Lying, manipulation, lack of conscience and seductive tendencies are characteristics of the psychopath's personality that makes treatment difficult. In addition, the therapist will often struggle with empathic involvement in the antisocial patient, and that makes psychotherapeutic treatment inadequate. Fact is that psychopaths respond poorly to medication and psychotherapy. When treatment does not succeed, may be prevention is our best choice?
3.2.1. Deep pessimism or light pessimism
There is widespread pessimism concerning rehabilitation of criminal psychopaths. Treatment of psychopaths and criminals seems to be described with more pessimistic prognosis than any other deviant condition in literature. Hare (1999), who has been very much occupied with psychopaths, has stated: “If you are dealing with a true psychopath, it is important to recognize that the current prognosis for significant improvement in his or her attitudes and behavior is poor” (p. 205). Reid and Gacano (2000) are also negative in that they claim, based on research, that neither psychological therapy nor medical treatment has positive effect on antisocial behavior. These viewpoints can also be seen within the writings of Cleckley (1976, pp. 438-443). Ogloff et al. (1990) have in a study found that criminal psychopaths are more likely to become drop-outs in therapy and that they show less motivation and generally less improvements than other patients.
Hare (1999, p. 199) refers to a study of Rice et al. from 1992, where psychological treatment was found to actually make psychopaths worse than they were before the treatment. This was measured by how, after the release, psychopaths, that did not receive treatment were less violent than the psychopaths that had received treatment. Hare (1999, p. 97) and Reid and Gacano (2000), remark one aspect that give rise to optimism of a disappearance of psychopathic traits. This optimism is though, anchored in the evidence there seem to be of a natural “burn-out” of the antisocial symptoms when they reach the age of 40. Hare relates this, among other factors, to the fact that the psychopath gets tired of being in conflicts. However, he does also emphasize that this does not necessarily mean that there has been fundamental changes in the personality of the person.
The presented empirical and clinical based conclusion can be interpreted as an argument that there is no other justifiable way to handle serial killers, than putting them in jail for life and that there is no point in trying to treat them. This is as the negative prognosis might give the impression that serial murderers must be kept in jail as they are not able to change. But is this a proper inferential?
to be a complicated clientele to treat but they also states that “it is difficult, if not impossible to prove that psychopaths cannot be treated.” (p. 188). This is due to the fact that the only way to prove that psychopaths can not be treated is by having tried the possible intervention methods. Dennis M. Doren (1987) who has written a book about psychopaths, from a psychological perspective, also claims that therapy with psychopaths is “not hopeless, just difficult”. (p. 244). He states that many psychopaths can indeed be treated. Also John Gunn, a forensic psychiatrist that states that individuals with serious antisocial problems actually do; “respond to a wide variety of treatment strategies” (Gunn, 2003, p. 38). To take a look into what is of some seen as a meaningless endeavor, though of others as a possibility, the following will be an extension to this.
3.2.2. The preferred prevention
David T. Lykken (1995, p. 230) states, based on his convince that there are no cure for adult sociopathy, that the only useful option is prevention. He emphasizes this by referring to a child psychiatrist, named Jack Westman that in 1994 estimated the costs of a single sociopath in the U.S. to $3 million over 60 years. This is due to destroyed or stolen property and abuses. However, the personal wounds this might cause are also substantial, as has been indicating with the murderers that D.B. committed.
Even though Kohut emphasizes how individuals are dependent on selfobjects throughout the entire life span, he does also claim, as has earlier been mentioned, that a fragmented self is most likely to develop when failures from selfobjcts occur in childhood (before the age 5). This way, it would in his terms, be of importance to intervene as early as possible in life, so that the self does not develop in a fragmented manner.
Potts et al. (1986), states that experience tells us that the younger patient with more recent symptom onset responds better to treatment than does the hardened, psychopathic, criminal adult. In relation to this, D.B. has given the following statement: “It frightens me to look back and see what I was and what I became. It also angers me, for I ask out loud; Why didn’t someone see all the signs?” (Abrahamsen, 1985, p. 201). If this is based on a truthful reveal, it does seem like a quest for early intervention. Could the six young people have been spared, if D.B. had got help? As a matter of fact, D.B.’s adoptive mother did bring him to a psychologist once a week when he was seven. No more details about this is known, but he stated in relation to this, that he “…resented the psychologist’s snooking in his private thoughts and feelings” (p. 37). This way, even though D.B. states that he did not understand how he could do so many negative things as a child and still go unnoticed, early discoveries are not always infallible (Hare, 1999, p. 200). But Hare also states that this situation might change if one manages to find out more about the roots of psychopathy.
Being able to get a hold of potential murderers at a young age would obviously be of great value. If intervention starts at an early age, one might be able to modify antisocial behavioral patterns and possibly reduce aggression and impulsivity by teaching the young one other ways to satisfy their needs than by antisocial acts (p. 200). But it is not to be neglected that it can be a difficult job to predict who would become a serial killer and thereby prevent this from happening. This might look more like an issue of Utopia than real life. So the relevant question is probably more concerned with; what if the damages have already been done? In the shadow of the majority of pessimism of criminal psychopaths’ ability to be treated, the following will discuss what it is that seem to be the reason for the poor prognosis.
3.2.3. What makes criminal psychopaths a difficult clientele to treat?
The contextual circumstances
Generally, persons with antisocial PD do not often search for therapy (Karterud et al., 2001, p. 47). Most of the individuals with psychopathy or antisocial PD are this way found in forensic settings (Rosenquist & Rasmussen, 2001, p. 206). Further, it seems obvious that an individual that has killed multiple others is immediately prevented from doing this again and this way, the serial killer is likely to be found in a maximum security prison. So if therapy is given, it will be in the circumstances of a prison environment. Some American psychologists have even claimed that prison psychotherapy has such a problematic nature, that it is “…a waste of time” (Carney, 1978, p. 273). This claim is due to the form and function of a prison society, “…where violence is encouraged and reason reproved” (p. 273). Doren also claims that therapy in prison is very problematic. This can be due to wrong motivations among the patients/inmates, because they see it as an opportunity to be regarded as involved and conscientious inmate and potentially decrease time behind bars. Also boredom can be a motivation for prisoners to attain therapy. These motivational factors might influence the outcome in therapy, and therapy in prison can such be seen as a rather inadequate setting to meet patients in (Doren, 1987, pp. 149-150).
The serial killers personality
As serial killers are often seen to have the traits of a serial killer; poor behavioral control, shallow affect, callousness, lack of empathy, pathologic/chronic lying, manipulations and lack of remorse and guilt (Beasley, 2004), it is quite obvious that these personality traits can have negative consequences for the therapeutic setting. The pathological lying might disrupt the ability for an honest communication with the therapist and the lack of remorse and guilt, will possible make the offender minimally interested or motivated for changes. Hare (1999) claims in relation to this: “Psychopaths don’t feel they have psychological or emotional problems, and they see no reason to change their behavior to conform to societal standards with which they do not agree.” (p. 195). The shallowness, callousness and the lack of empathy might indicate that it is problematic to work with actual emotions in the therapeutic setting (Lose’, 1998). Their deceiving and manipulative character is potentially giving the patient a feeling of success if they have been able to fool the therapist (Gabbard, 2000, p. 510), and it is said that psychopaths often laugh after therapy because of the credulous therapists who are seeing “improvements” (Rosenquist & Rasmussen, 2001, p. 207). As an example, D.B. wrote in a letter to Abrahamsen (1985) the following about one of the therapists who claimed that he had been psychotic:
“I vividly recall the talks I had with Dr. Daniel Schwartz [one of the Court-appointed psychiatrists who had found Berkowitz to be insane] (Abrahamsen’s remark), for they were to me ecstasy. They were the talks that produced the feedback I wanted. What a pleasure it was back then to hear this man exonerate me of all blame for my sic murders. Oh, the pleasure of hearing this man telling his colleagues how sick I was-how ill- how insane. I knew, that all I had to do was slide “Sam Carr” and the demons into the conversation and I’d have him bending over his chair in my direction. Why he’d practically be wiping tears from my eyes and comforting me, saying, in a sense, don’t fret, don’t cry, you’re a sick, sick boy” (pp. 156-157).
What can here have happened is, what the psychoanalytic, Glen O. Gabbard describes as ordinary behavior of a psychopath; the psychopath simulates tearfulness and remorse, and thereby manipulates the clinician to empathize with them (2003, p. 505).
There is also another important aspect with criminal psychopaths that can have a substantial impact on the therapist and thereby also on the therapeutic process. Jeremy Coid (2003), having written an article about dangerous psychopaths in prison, states that some inmates in prison are psychopaths with such a severe degree of pathology, which, make them dangerous and are hence not safe to have in therapy. This can feel frightening and threatening to the therapist, and thus making him scared of confronting the patient. Safety should always be seen as more important than further analysis (Strasburger, 2001, p. 302; Kernberg, 2003, p. 381).
Another very important aspect that can be seen to influence the effect of therapy with psychopaths is countertransferences. This term refers to the therapist’s feelings and attitudes about the patient (Sandler et al., 1994, p. 100). Because of the personality of a serial killer, and the actions they have made, strong countertransferences are likely to occur in therapy with them. Larry H. Strasburger, with a psychodynamic perspective, has written an article about the therapist’s feelings in relation to treatment of antisocial syndromes, where he writes the following: “The psychopath is the least loved of patients.” (2001, p. 297). The consequence of this, he claims, is that the therapist is doing the exact same thing as the society; “…unconscious rejection of psychopaths.” (p. 298). This rejection might stem from the hatred and aversion that occur in the therapist because of the acts that the patient has done, and the way the patient talks about it (p. 307). An example of what can provoke this aversion in the therapist is statements in therapy like this of the serial killer, Ted Bundy: “What’s one less person on the fact of the earth anyway?” (Online crime library). Further, the psychopaths’ frequent denial of problems and denial of being in need for help might cause the therapist to experience feelings of helplessness, being rejected and also feelings of guilt for not being able to help (Strasburger, 2001, p. 307). Gabbard (2003) claims that the most problematic type of countertransference, that might occur when having antisocial patients in therapy, is “collusion”. This is when one or more of the staff in the institution or prison where the antisocial person potentially stays are corrupted and make illegal or unethical deals with the patient. Gabbard states that this occurs due to a projective identification process, where some of the corrupt aspects of the patient are transformed into the therapist(s) or the staff (p. 505). This can be seen in relation to the fact that it is easy also to be fascinated by a psychopath. This because psychopaths often have a radiance and charisma that sometimes leaves the therapist into feeling seduced by the patient. The manipulative tendency might lead the therapist into viewing the patient as charming and the “daring” behavior of the patient might also cause the therapist to see him as an exciting individual which potentially also can cause unfortunate attraction towards him (Dahl & Dahlsegg, 2000, p. 229). Hare is also marking how there are, in general, especiaty strong attraction towards psychopathic serial killers, in which can be seen in how they receive substantial attention in the terms of groupies, pen pals, supporters and “love-struck fans” (1999, p. 150). There can be seen many reasons for this. As an example Cleckley states that: “Feminine intuition senses that here, concealed beneath an appearance of maturity, is a baby or something very much like a helpless, crying little baby. Her deep instincts to nurse and to protect this winsome little darling are unconsciously called out” (1976, p. 198). If these countertransferences happen in a therapeutic setting, it can potentially cause problematic and unfortunate content in therapy. To avoid this, Dahl and Dahlsegg (2000) suggest that awareness of the countertransferences is essential and that frequent supervision with a qualified professional is of crucial importance (p. 229, 238).
Concluding remark – Treatment of criminal psychopaths
A learning theorist, named Robert Hale, states that serial killers are not deranged but that they rather have behaved in a way that makes sense and is logical for themselves and is derived from “…a perceived wrong” (Hale, 1993, In Ferreira, 2001, p. 15). He also adds that: “You, too, can learn to be a serial killer.” (p. 5). These assumptions seem quit likely and one might, in relation to that wonder if it is not somehow unethical to, like is likely in the US, to punish a serial killer with death penalty. The policy of killing or punish them with up to a lifetime in prison, as a reaction to killing, seems like dismiss of this famous quote from Mohandas (Mahatma) Gandhi: “An eye for eye only ends up making the whole world blind.” (Online quote collection).
Additionally, it does seem likely than an investigation of the potential obstacles in therapy with criminal psychopaths, can improve the possibility to successfully treat these patients. A hypothesis is thus, that the presented potential difficulties in therapy (the patients’ personality and countertransferences) are obstacles that mental health workers have not traditionally been able to overcome, which have influenced the majority of negative views on treatment. This is especially due to how it, because of strong countertransferences, seems difficult to be empathic.
The following statement of D.B. can be seen as a manifestation of the needs there are for improvements in the work with the widespread problematic behavior that he represents:
“Through understanding myself and for learning of my motives for my crimes, which I’ve always consciously known, but which I deliberately suppressed behind a story of demons- rather than openly admitting it-by doing this I hope to be able to better myself to a point in which I don’t need to act out, in reality, my hostilities and frustrations- I won’t have take out my personal revenge on others who have done me no wrong. Hopefully, and with much effort, I will no longer feel the need to act out my childish impulses onto the rest of the human race. Perhaps this all sounds idealistic. It isn’t.” (Abrahamsen, 1985, p. 223).
If this statement of D.B. is true, it is an indication for a need for good- working therapy and thereby improvements in the prognosis for rehabilitation. Reflections upon what is likely to be effective in therapy with a serial killer will be the focus in the following, on the basis of Kohut and his understanding of pathology.