Clinical Appraisals of Individual Differences in Treatment Responsivity Among Patients With Psychopathy: A Consensual Qualitative Research Study

• Author: Jan H. Kamphuis,Evelyn Klein Haneveld,Kelsey Timmer,Wineke Smid
• DOI: 10.1177/0093854820970597
• Published date: 01 August 2021
• Date: 01 August 2021
• Subject Matter: Articles

CRIMINAL JUSTICE AND BEHAVIOR, 2021, Vol. 48, No. 8, August 2021, 1031 –1051.

DOI: https://doi.org/10.1177/0093854820970597

Article reuse guidelines: sagepub.com/journals-permissions

© 2020 International Association for Correctional and Forensic Psychology

1031

CLINICAL APPRAISALS OF INDIVIDUAL

DIFFERENCES IN TREATMENT RESPONSIVITY

AMONG PATIENTS WITH PSYCHOPATHY

A Consensual Qualitative Research Study

EVELYN KLEIN HANEVELD

Oostvaarderskliniek

WINEKE SMID

Van der Hoeven Kliniek

KELSEY TIMMER

GGZ inGeest

JAN H. KAMPHUIS

University of Amsterdam

This study addressed which factors expert clinicians consider crucial in successful completion versus dropout in the manda-

tory forensic psychiatric treatment of psychopathic patients in the Netherlands. Eleven clinicians were interviewed about

patient characteristics, treatment (provider) characteristics, and other factors they deemed associated with failure (transfer to

another facility) or completion. The interviews were coded using the guidelines of Consensual Qualitative Research (CQR).

Overall, extremely high scores on Psychopathy Checklist–Revised (PCL-R) Facets 1 (Deceitful Interpersonal Style) and 2

(Defective Affective Experience) were thought to impede treatment retention, particularly by its negative impact on motiva-

tion and therapeutic relationship. Older patients, those with a prosocial network, and/or patients with comorbid borderline

traits appeared to fare better. Treatment success was deemed more likely when treatment goals and expectations are stipulated

in a concrete fashion, when an extended and gradual resocialization trajectory is offered, and the treatment team is expert,

cohesive, and stable.

Keywords: psychopathy; forensic psychiatric treatment; qualitative analysis; qualitative methods; responsivity

Both clinical experience and empirical research into inpatient forensic psychiatric

treatment for psychopathic patients to date suggest that these patients are particularly

difficult to treat. In early treatment studies, justice-involved individuals with psychopathy

showed less motivation, less compliance with treatment, and conversely, more often

AUTHORS’ NOTE: We have no conflicts of interests to disclose. Correspondence concerning this article

should be addressed to Evelyn Klein Haneveld, Forensisch Psychiatrisch Centrum Oostvaarderskliniek, Carl

Barksweg 3, Almere 1336 ZL, The Netherlands; e-mail: ekleinhaneveld@ziggo.nl.

970597CJBXXX10.1177/0093854820970597Criminal Justice and BehaviorHaneveld et al. / Individual Differences in Treatment Responsivity

research-article2020

1032 CRIMINAL JUSTICE AND BEHAVIOR

involvement in institutional misconduct, and more drop out as compared to non-psycho-

pathic individuals (Ogloff et al., 1990; Wong & Hare, 2005). However, a handful of more

recent reviews is more encouraging (e.g., Hecht et al., 2018; Polaschek, 2014; Polaschek &

Skeem, 2018; Reidy et al., 2013). Moreover, these early findings do not rule out that for

some subgroups of people with psychopathy, treatment may be effective in reducing crimi-

nal behavior. For example, Olver and Wong (2009) reported on the therapeutic response of

males convicted of a sex offense in a high-risk program. Psychopathy was found to be a

strong predictor of dropout. However, those psychopathic individuals who remained in

treatment and made progress on risk-related treatment targets were less likely to recidivate

violently than the non-completers. In similar vein, a Dutch study (Klein Haneveld et al.,

2018) targeted individual differences in treatability by seeking empirically based subtypes

of male violent patients in a forensic psychiatric hospital. Based on latent profile analysis of

scores on the Psychopathy Checklist–Revised (PCL-R; Hare, 2003), three psychopathic

profiles emerged: one prototypical group, with high PCL-R scores (and thus displaying

virtually all defining features of this composite construct); and two groups with moderate

psychopathic scores on the PCL-R. Dropout was (again) very high in the prototypical psy-

chopathic group (nearly 50%), but those who remained in treatment showed recidivism

rates commensurate with the less severe psychopathic group. Hence, one hurdle to over-

come in the search for effective treatments for psychopathic justice-involved people is the

issue of attrition.

To our knowledge, only a handful of studies have examined treatment attrition in indi-

viduals with psychopathy. These studies (Cullen et al., 2011; Jeandarme et al., 2017; Olver

& Wong, 2011; Sewall & Olver, 2019) reported on the association between non-completion

and the Two-Factor or Four-Facet models of the PCL-R (Hare, 1991, 2003) or the Two-

Factor model of the Screening Version (PCL: SV; Hart et al., 1995). In a group of 154 males

convicted of a sex offense receiving a high-intensity treatment program, Olver and Wong

(2011) found that all Facets were related to non-completion, but that only the Affective

Facet (Facet 2) made a significant unique contribution to the prediction of dropout. Olver

and Wong suggested that shallow affect, callousness, and lack of empathy interfere with the

ability to “connect” with the patient and to form a working alliance in treatment. In a British

study (Cullen et al., 2011) in a group of 84 justice-involved individuals with a mental dis-

order sampled from six medium security forensic hospitals, dropout was studied as part of

a randomized controlled trial of a cognitive skills program. In this group, Factor 2 (impul-

sive and antisocial behavior) was found to predict treatment attrition. A more recent Belgian

study (Jeandarme et al., 2017) also assessed outcome in mentally disordered justice-involved

people receiving medium security treatment (N = 224). Contrary to the British study, Factor

1 predicted dropout after controlling for offense-related and clinical variables (Jeandarme

et al., 2017). Factor 1 encompasses Facet 1 (Interpersonal) and 2 (Affective). Finally, in a

study by Sewall and Olver (2019) in 302 males convicted of sex offenses, only Facet 3

(Lifestyle) made a significant unique contribution to the prediction of dropout, and a trend

was noted for the Affective Facet 2 (p = .081). In sum, although the Affective Facet emerges

as the only replicated predictor, no clear picture emerges from these studies about which

aspects of psychopathy, as measured with the PCL-instruments, are associated with treat-

ment attrition among justice-involved people. Moreover, all studies focused exclusively on

patient characteristics associated with dropout. Clinical experience (Kröger et al., 2014)

strongly suggests that contextual factors may also play a role, such as characteristics of the