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Treatment of Sexual Offenders With Psychopathic Traits

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TREATMENT OF SEXUAL OFFENDERS
WITH PSYCHOPATHIC TRAITS
Recent Research Developments and Clinical Implications

JEFFREY ABRACEN
Central District Parole, Correctional Service of Canada

JAN LOOMAN
Regional Treatment Centre (Ontario), Sex Offender Treatment Program

CALVIN M. LANGTON
University of Toronto, Canada; University of Nottingham, UK; Nottinghamshire Healthcare Trust, UK

This article provides a review of recent literature related to the treatment of psy-
chopathy in forensic settings, with particular focus on studies with sexual offend-
ers. The lack of empirical support for the position that psychopaths are untreatable
is noted, and data suggesting optimism is discussed. Research demonstrating an
interaction between psychopathy and substance abuse and between psychopathy
and sexual deviance is also presented. Both substance abuse disorders and inap-
propriate arousal are frequently encountered in high-risk groups of sexual offend-
ers. These topics are of relevance, in that the question of whether treatment is
beneficial with high-risk sexual offenders, including those who are psychopathic,
cannot be answered unless groups presenting with typical concurrent disorders
(paraphilias, substance abuse, dependence) are discussed. It is argued that,
although the evidence is still preliminary, there is reason for optimism with refer-
ence to whether psychopathic sexual offenders are responsive to treatment, includ-
ing offenders presenting with concurrent disorders.

Key words: treatment; psychopath; sexual offender; substance abuse; sexual deviance

ONE OF THE MORE perplexing conundrums produce significant treatment effects (e.g.,
with reference to high-risk offenders is that Andrews & Bonta, 2003), individuals diagnosed
although certain treatment approaches and for- as psychopaths (who pose a high risk of both
mats for high-risk offenders have been shown to general and violent criminal recidivism) appear

AUTHORS’ NOTE: Please address correspondence to Jeffrey Abracen, C/O Correctional Service of Canada, Central District Parole, 330
Keele St., Toronto, ON, Canada M6P 2K7; e-mail: AbracenJA@csc-scc.gc.ca.

TRAUMA, VIOLENCE, & ABUSE, Vol. 9, No. 3, July 2008 144-166

DOI: 10.1177/1524838008319633
© 2008 Sage Publications

144

KEY POINTS OF THE RESEARCH REVIEW
• There is little research that supports the commonly
held view that psychopaths cannot be treated.
• Recent research supports the view that at
least some psychopaths may benefit from
appropriately designed and delivered treatment
interventions.
• Consideration of a history of alcohol abuse
enhances the predictive value of psychopathy in
the prediction of recidivism; however, considera-
tion of other substance abuse does not.
• Consideration of deviant sexual arousal, in combi-
nation with psychopathy, enhances the ability to
predict violent, including sexual, recidivism.
unable to benefit from treatment interventions.
One problem preventing firm conclusions based
on the pertinent literature is the relative dearth
of well-controlled treatment evaluation studies
with individuals diagnosed as psychopathic. In
our earlier review (Abracen & Looman, 2004)
we focused on the treatment of sexual offenders
as a generic group. We concluded that there was
reason for optimism with reference to sexual
offender treatment. Although some authors
remain skeptical about the efficacy of sexual
offender treatment (e.g., Quinsey, Harris, Rice,
& Cormier, 2006), additional studies and meta-
analytic reviews have been conducted since our
last review that are similarly positive, particu-
larly when the efficacy of cognitive-behavioral
treatment is evaluated (e.g., Looman, 2006;
Lösel & Schmucker, 2005; Marshall, Marshall,
Serran, & Fernandez, 2006).
Whether such general conclusions are applic-
able to the highest risk groups of sexual offend-
ers has received somewhat less attention in the
literature. The purpose of this review is to dis-
cuss research related to the assessment and
treatment of high-risk groups of sexual offend-
ers. Specifically, there are a number of studies in
the literature that are concerned with the treat-
ment of sexual offenders exhibiting psy-
chopathic traits as measured by the Hare
Psychopathy Checklist–Revised (PCL-R; Hare,
1991, 2003). This research will be discussed in
the first section of our review. In the second and
third sections, we review research concerning
Abracen et al. / TREATMENT OF PSYCHOPATHY 145
substance abuse problems and deviant arousal
among sexual offenders and explore some of
the implications of these features for assess-
ment and treatment work with high PCL-R
sexual offenders. Both deviant sexual arousal
and substance abuse are frequently encoun-
tered criminogenic risk factors in high-risk
sexual offenders. As well, alcohol abuse
(Firestone et al., 1998, 1999) and deviant sexual
arousal (e.g., Hanson & Bussière, 1998) have
been shown to be significantly associated with
recidivism among sexual offenders. To show
that treatment might be effective with high-risk
groups of sexual offenders, it needs to be
demonstrated that such findings apply to “typ-
ical” psychopathic sexual offenders who fre-
quently present with both substance abuse
disorders and deviant arousal/paraphilia. Data
specifically related to such high-risk groups of
sexual offenders will be discussed with refer-
ence to both substance abuse and deviant
arousal in order to highlight our conclusions.
Such factors as cooperation with supervi-
sion, attitudes supportive of sexual offending,
and intimacy deficits (Hanson, 2006) have
all been associated with sexual offending.
However, there is relatively less research
regarding these factors than with reference to
substance abuse and deviant arousal, at least as
these factors relate to outcome. It is for this rea-
son that we focus our attention on substance
abuse and deviant arousal.
An important distinction to make before pro-
ceeding is that between the construct of psy-
chopathy and antisocial personality disorder
(APD). The criteria for a diagnosis of the latter
listed in the Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV; American
Psychiatric Association, 2000) serves to identify
individuals who have been persistently antiso-
cial. However, many of the individuals who meet
the diagnostic criteria for APD would not meet
the stricter criteria for psychopathy as mea-
sured by the PCL (or its derivatives). With ref-
erence to forensic populations, the base rate for
psychopathy (15% to 25%) is much lower than
the base rate for APD (50% to 80%; Hare, 1998,
2003). As Rogers, Salekin, Sewell, and Cruise
(2000) note, DSM relegates the personality
146 TRAUMA, VIOLENCE, & ABUSE / July 2008
features of psychopathy (e.g., lack of concern
for the suffering caused to others) to associated
features of the disorder. These authors also cau-
tion that it is unlikely that the PCL-R and APD
measure the same construct. Hare (2003)
acknowledges that these constructs are highly
correlated but argues that this does not amount
to saying that they are the same clinical disor-
der. Last, as Hare (2003) discusses, arguments
have been made that question the evidentiary
reliability of APD for forensic evaluations and
testimony. Given the evidence in favor of relia-
bility and validity regarding the PCL-R, as well
as the very clear scoring criteria that exist for the
measure, it is hard to argue with the psychome-
tric properties of the scale (see Hare, 2003, for a
detailed discussion of these matters). With refer-
ence to high-risk sexual offenders, we have
found that, among those offenders treated at
the Regional Treatment Centre Sex Offender
Treatment Program (RTCSOTP), offenders who
scored high on the PCL-R (defined as a score at
or above a cutoff of 25) recidivated at signifi-
cantly higher rates than sexual offenders scoring
low on the PCL-R (Looman, Abracen, Serin, &
Marquis, 2005). However, we have failed to find
significant differences in terms of recidivism
among those with or without a diagnosis of a
personality disorder (Abracen & Looman, 2006).
A recent review (Seto & Quinsey, 2006) of
research on treatment with psychopaths chose
to discuss studies related to both APD and psy-
chopathy. The authors cite Skilling, Harris,
Rice & Quinsey (2002) who demonstrated that
there is a strong correlation between the
number of diagnostic features of APD and
PCL-R scores, in defense of their position.
Nonetheless, these authors suggest that evolu-
tionary perspectives may be best able to
account for psychopathy and argue that psy-
chopaths are a discrete natural class (taxon; see
Harris & Rice, 2006, and Quinsey, Harris, Rice,
& Cormier, 1998, for discussions). In short,
these authors appear to simultaneously adopt
two contradictory positions: namely, that psy-
chopaths are qualitatively different than other
groups of offenders but that research related to
offenders who meet the diagnostic criteria for
APD (i.e., the majority of offenders, as noted
above) is relevant to assessing whether treat-
ment is effective with psychopaths.
Seto and Quinsey (2006) rationalize their
approach by noting that there are few con-
trolled treatment outcome studies and that they
are therefore justified in discussing the litera-
ture on both psychopathy and APD when eval-
uating the research on psychopathy. From our
perspective, it is problematic to argue that psy-
chopathic offenders represent a discrete taxon
and simultaneously take the stance that the
research related to the majority of offenders
(i.e., those with a diagnosis of APD) is relevant
to the assessment of whether psychopathic
offenders can be treated. Perhaps these authors
believe that the majority of offenders fall within
such a taxon. Unfortunately, given that these
authors are rather pessimistic as to treatment
outcome with psychopathic offenders and that
the research on treatment efficacy with refer-
ence to offenders in general has clearly demon-
strated that such groups respond to appropriate
cognitive-behavioral interventions (see Andrews
& Bonta, 1998, 2003, for reviews) it is hard to
understand how these authors would reconcile
this apparent contradiction. In fact, Quinsey
et al. (2006) note that behavioral and cognitive-
behavioral approaches have been found to
reduce criminal recidivism among moderately
high-risk offenders.
These authors (see also Harris & Rice, 2006;
Quinsey et al., 2006) also argue that studies that
do not use randomized designs are methodolog-
ically flawed and of less relevance in the deter-
mination of treatment efficacy. Marshall (2006),
in his excellent critique of the sex offender out-
come literature generally, noted that these
authors “set standards for others that they make
no attempt to meet themselves” (p. 259).
However, Berk (2005) has recently pointed out
some of the difficulties inherent in conducting
randomized controlled studies. He notes that
“randomized experiments rest on more compli-
cated, subtle and fragile foundations than some
researchers appreciate” (p. 431). Abracen &
Looman (2004) have, for example, commented
on the difficulties associated with the series
of studies by Marques et al. (see Marques,
Wiederanders, Day, Nelson & van Ommeren,

2005, for the final results of this research
program). This program has received attention
as it included the use of random assignment pro-
cedures. Marshall (2006; Marshall & Marshall, in
press) discusses the possibility that random
assignment may be the wrong method for
empirically evaluating psychotherapy as it omits
too many elements of what is actually done in
practice. For example, random assignment
designs must involve the use of manuals and
procedures which are rigidly followed by clini-
cians. Data from Marshall et al. (2002) indicating
that the influence of the therapist accounted for
40% to 60% of treatment change with sexual
offenders, highlights the need for therapeutic
interventions that are client centered. Very
highly manualized programs may, at the very
least, make it more difficult for therapists to dis-
play the very features which have been shown to
be related to treatment efficacy.
In jurisdictions such as the Canadian con-
text, where the vast majority, if not all, sex
offenders are offered treatment and there are
significant incentives to attending (i.e., earlier
potential release from prison), it may be diffi-
cult to find sufficient numbers of offenders
who have not received treatment to form a
comparison group. We believe that, based on
the available evidence, there is every reason to
believe that contemporary treatment with
sexual offenders significantly reduces the risk
of sexual recidivism. However, the question of
treatment efficacy with particularly high-risk
groups of sexual offenders remains.
With reference to best practices, as noted
above, it appears that cognitive-behavioral
approaches are the treatment of choice with
sexual offenders. Many of the existing programs
have adopted relapse-prevention-based (also
referred to as self-management-based) tech-
niques that include the development of offence
chains or pathways indicating the factors that
were related to an offence or a series of offences
as well as a list of risk factors that must be
addressed to reduce the risk of future recidi-
vism. Relapse prevention/self-management
plans, which discuss specific strategies to
address these high-risk factors, are then pro-
duced by clients attending the treatment
programs. Ward and his colleagues (e.g., Ward
Abracen et al. / TREATMENT OF PSYCHOPATHY 147
& Brown, 2003; Ward, Vess, Collie, & Gannon,
2006) have recently offered a critical analysis of
these approaches and have suggested the adop-
tion of a good lives model where the focus is not
solely on reducing problematic behaviors but on
also working toward positive goals. They have
argued that these approaches build on, rather
than replace, the principles of self-management.
To discuss the treatment literature with refer-
ence to high-risk sexual offenders, including
those who are psychopathic, the authors have
employed the definition of psychopathy based
on the PCL-R and its derivatives. The original
PCL (Hare, 1985) and later versions were
designed as a measure of particular personality
traits, not as a risk assessment tool. Nonetheless,
meta-analytic reviews have shown that PCL-R
score is among the more robust predictors of
both general and violent recidivism (Hemphill,
Templeman, Wong, & Hare, 1998; Salekin,
Rogers, & Sewell, 1996). The PCL-R is a 20-item
measure, with each item rated between 0 and 2
and total scores ranging from 0 to 40. The PCL-
R items assess two independent but related fac-
tors. The first of these includes the personality
features, which have been historically linked to
psychopathy, such as shallow affect, manipula-
tive behaviors, pathological lying, and lack of
remorse or guilt. The behavioral correlates of
the disorder, such as need for stimulation and
proneness to boredom, parasitic lifestyle, impul-
sivity, juvenile delinquency, and revocation of
conditional release, were described as a second
factor. Hare (1991, 2003) recommends a cut score
of 30+ for diagnosing psychopathy. However,
Quinsey, Harris, et al. (1998) have argued that a
score of more than 25 may be used as a reason-
able cutoff as well. Hare’s (2003) most recent
edition of the PCL-R reports analyses that
separate both Factor 1 and Factor 2 of the PCL-
R into two subcomponents or facets: Facet 1a
(Interpersonal, as evidenced by an arrogant and
deceitful interpersonal style); Facet 1b (Deficient
Affective Experience ); Facet 2a (Impulsive
Lifestyle, including irresponsible behavior); and
Facet 2b (Antisocial Behavior).
Before turning to the research on psycho-
pathic sexual offenders specifically, a brief dis-
cussion related to treatment outcome with
some of the other more pervasive personality
148 TRAUMA, VIOLENCE, & ABUSE / July 2008
disorders seems relevant. We will not review
the research on antisocial personality disorder,
as detailed reviews are already available on the
treatment of offenders in general (e.g., Andrews
& Bonta, 2003). Again, because the majority of
offenders meet the diagnostic criteria for APD,
the research on treatment outcome in general
for incarcerated offenders is perhaps the most
relevant data to discuss in this regard. It is quite
clear, based on the available literature, that cog-
nitive-behaviorally oriented treatment is effec-
tive in the treatment of offender populations
(Andrews & Bonta, 2003). More recently,
Andrews and Dowden (2006) examined
research related to the risk principle established
by Andrews and Bonta (e.g., Andrews & Bonta,
1998). The risk principle simply states that
intensive human service is best delivered to
higher risk cases. Treatment should generally
be restricted with reference to lower risk cases
as there is a relatively low probability of nega-
tive outcome even in the absence of service.
Andrews and Bonta (1998) also argue that treat-
ment should focus on criminogenic needs. By
this, the authors are referring to dynamic risk
factors (i.e., that are subject to change) which
have been empirically linked to recidivism.
Antisocial associates, alcohol/drug problems,
employment, procriminal attitudes, and lack of
organized recreational/leisure activities have
all been linked to recidivism. Best practices sug-
gest that for offender populations generally
these are the factors that should be the focus of
forensic treatment. In the case of sexual offend-
ers, additional dynamic risk factors that have
been identified include intimacy deficits,
deviant arousal, and sexual self-regulation
more generally (see Hanson, 2006; Marshall
et al., 2006, for discussion of these topics).
Sperry (2003) has noted that a number of sig-
nificant developments have evolved in the
assessment and treatment of personality disor-
ders more generally. He notes that there are an
increasing number of effective treatments avail-
able for what were previously thought of as
untreatable conditions. He notes that optimism
exists for even the most recalcitrant of these dis-
orders, including borderline personality disorder,
with newer, more focused treatment strategies.
Linehan (e.g., Linehan, 1993) has developed a
system of treatment, called dialectical behavior
therapy (DBT), for individuals with borderline
personality disorder. The orientation of her
approach is broadly cognitive-behavioral and
positive treatment effects have been noted for
individuals who participate in DBT, which has
been subjected to controlled empirical investiga-
tions. For example, Linehan (1993) discussed
research showing that compared to treatment-as-
usual participants, clients assigned to DBT were
significantly less likely to engage in parasuicidal
behavior and reported fewer parasuicide
episodes at each assessment point. This approach
has now been supported by several randomly
controlled studies (Koerner & Linehan, 2000).
Treatment Outcome With Psychopaths
There have been a number of reviews regard-
ing treatment outcome with psychopaths (e.g.,
D’Silva, Duggan, & McCarthy, 2004; Hare, 1998;
Lösel, 1998; Salekin, 2002; Wong, 2000). The
objective of this section is not to critique these
reviews or focus in detail on the studies
included in them. Rather, the aim here is to take
the tentative conclusions possible from such
work and consider these in light of more recent
research pertinent to the question of treatment
effects with sexual offenders high in psycho-
pathic traits. From these more recent studies, a
number of implications both for study method-
ology and clinical practice will be identified.
Findings From the Extant Research
Two important conclusions can be drawn
from these reviews. First, and quite simply,
there are few well controlled studies, although,
as shall be discussed, several studies have
recently been published that improve on some
of the limitations inherent in the literature. For
example, although Wong (2000) identified 75
studies in the literature that dealt with the treat-
ment of psychopathy in adults, he eliminated all
but 4 of these studies (involving three samples
of participants), as being inadequate based on
the strict criteria he used to determine inclusion
in his review (e.g., inadequate diagnostic criteria

for psychopathy). Second, and more specifically,
based on the methodological limitations of the
larger body of research, it is premature to con-
clude that psychopaths as a group are untreat-
able, whether the evidence weighed concerns
within-treatment gains or lower recidivism rates
after treatment completion (Edens, 2006; Lösel,
1998; cf. Gacono, Nieberding, Owen, Rubel, &
Bodholdt, 1997).
Recently, Skeem, Monahan, and Mulvey
(2002) provided a concise overview of a
number of studies on which the prevailing
clinical pessimism about treatment for psy-
chopaths appears to be based. Among these,
two studies involving the same sample of
offenders (Harris, Rice, & Cormier, 1991; Rice,
Harris, & Cormier, 1992) have been widely
cited as evidence that treatment with psycho-
pathic offenders is ineffective. Given the atten-
tion already paid and critical appraisals of the
implications drawn from these studies, we
limit ourselves here to noting that the program
as described, considered innovative at the time
it was provided, clearly bares little or no
resemblance to contemporary approaches
within forensic contexts. It was peer oriented
with little input from professional staff and
involved such activities as marathon therapy
and the use of nude encounter groups (see
Wong, 2000, for a detailed discussion). Suffice
to say that the program would likely not be
considered ethical by contemporary standards.
Hare, Clark, Grann, and Thornton (2000)
reported on relatively short-term anger manage-
ment and social skills training programs. The
authors compared offenders who had completed
at least one of these programs versus those who
did not. After controlling for age and criminal
history, it appeared that treatment had little
effect on the reconviction rates of offenders in the
high and low PCL-R groups that were com-
pared. However, a somewhat different picture
emerged when offenders were divided into
groups with high and low scores on Factor 1.
The reconviction rate for high Factor 1 offenders
was 58.8% for those who did not participate in
the programs, significantly lower than the 85.7%
reconviction rate for those who had. Importantly
though, the researchers themselves note that
Abracen et al. / TREATMENT OF PSYCHOPATHY 149
these interventions may not have been particu-
larly well conceived or effectively administered.
Parenthetically, Hobson, Shine, and Roberts
(2000) also observed that high Factor 1 scores
were associated with poorer outcome among
offenders who completed treatment.
In contrast to both of these disappointing
findings and the more rigorous inclusion crite-
ria employed by Wong (2000), Salekin (2002)
carried out a meta-analysis from which he
reached notably more positive conclusions
based on 42 studies. To compensate for the fact
that many of these studies did not employ a
control group, for his analysis Salekin used the
mean success rate of untreated psychopaths
from the eight studies that did have a compar-
ison group. He concluded that highly struc-
tured, intensive treatment programs can be
successful in treating psychopaths. However, it
should be noted that Salekin included case
studies. As well, most of the studies presented
in the meta-analysis approached the treatment
of psychopathy from a psychoanalytic orienta-
tion. The average success rate for psychoana-
lytic treatment was 59% based on 17 studies
and 88 psychopathic individuals. Cognitive-
behavioral therapies had a success rate of 62%,
but these data were described as “robust”
given that the results were based on 5 studies
and 246 individuals. It is important to note that
the majority of studies reviewed for the meta-
analysis did not use recidivism as their crite-
rion for success (see Salekin, 2002, Table 2). The
three cognitive-behavioral programs that used
reoffending as their criterion had a success rate
of .62, consistent with the hypothesis that psy-
chopaths can benefit from treatment.
It must be noted that Harris and Rice (2006)
have criticized Salekin’s (2002) review on a
number of grounds, including the fact that only
four studies included used the PCL-R, only
eight employed comparison groups, less that
20% used criminal recidivism as the outcome,
and less than 10% used violence or aggression
as an outcome, whereas more than 70% of the
studies relied on the impressions of treatment
providers to determine effectiveness. These
concerns serve to highlight the methodological
weaknesses of the literature and therefore the
150 TRAUMA, VIOLENCE, & ABUSE / July 2008
difficulties of drawing meaningful conclusions
concerning beneficial or harmful treatment
effects from it.
In a recent study that followed up a sample of
871 civil psychiatric patients with psychopathy
scores assessed in acute inpatient facilities,
Skeem et al. (2002) used a propensity score
approach to control for the effect of nonrandom
assignment to treatment groups and assessed
treatment involvement and violent outcomes
across 10 week intervals over a 1-year period
postdischarge. Among the 121 patients classi-
fied as at least potentially psychopathic (PPP),
these researchers found a significant relation-
ship between treatment involvement at the first
follow-up and violence at the second, with only
6% of those PPP patients who participated in
seven or more treatment sessions committing a
violent act compared with 23% of those PPP
patients who participated in six or fewer treat-
ment sessions (i.e., a dosage effect for treat-
ment). The same pattern of results was observed
across later follow-up times, although the differ-
ences were not significant. As well, the same
patterns of results were found for the 72 psycho-
pathic patients (PSY), although the differences
were again nonsignificant. Average odds ratios
across follow up times indicated that for the PPP
patients, those who participated in six or fewer
treatment sessions were 2.5 times as likely to
commit a future violent act as were PPP patients
who participated in seven or more sessions. The
equivalent figure for the PSY patients was 3.5.
When the propensity scores (generated using
variables associated with treatment attendance
among the sample, such as substance abuse,
race, and employment status) were used to con-
trol for the treatment assignment process, the
association between treatment involvement and
future violence remained, although the odds
ratios were smaller. As Skeem et al. note of their
study, “its results are inconsistent with the pre-
vailing notion that treatment is ineffective or
even iatrogenic for psychopaths . . . patients
with psychopathic traits appeared as likely to
benefit from adequate doses of treatment by
becoming less violent as those without such
traits” (p. 594).
Harris and Rice (2006) consider this con-
clusion highly questionable. They point to the
possible measurement bias that may have
resulted from assessing psychopathy, treatment
involvement, and violence in the same inter-
views, the number of bivariate comparisons rel-
ative to the number of significant findings, and
the particular use of the propensity score
approach. As well, the range of therapies pro-
vided (verbal therapy, medication, drug and
alcohol treatment, group or other, and some
combinations of these) and the lack of detail
given concerning these treatment efforts makes
it hard to be clear about the foci or goals of
these interventions and the mechanisms by
which they might have achieved them.
Certainly, the study’s findings must be repli-
cated before any firm conclusions can be
reached; future research must seek to illuminate
what therapeutic approaches, treatment
models, and program components are actually
effective and demonstrate significant effects
over considerably longer follow-up periods.
Furthermore, although replication results with
nonforensic psychopaths would be both impor-
tant and encouraging, replication with samples
of offenders will be required. Such concerns
notwithstanding, Skeem et al.’s (2002) study
represents an important contribution to a litera-
ture greatly in need of innovative evaluation
efforts.
Harris and Rice’s (2006) criticisms of the
Salekin (2002) review and the Skeem et al.
(2002) study rightly underscore the rigorous
methodological standards to which researchers
should aspire. Nonetheless, we feel that the
note of optimism sounded in such work is in
keeping with the necessary efforts to evaluate
all treatment efforts with the most appropriate
methods that are practically possible. In any
case, sexual offenders present a complex array
of clinical and criminological needs (Marshall,
Anderson, & Fernandez, 1999; Simourd &
Malcolm, 1998), prompting the question of
whether encouraging findings such as those
reported by Skeem et al. (2002) permit opti-
mism about the treatment of sexual offenders
with psychopathic traits. Fortunately, a number
of studies pertinent to this question have been
reported, which inform the debate.
A description of the work completed both at
Warkworth Institution and at the Regional

Treatment Centre (Ontario), both of which offer
comprehensive treatment programs to sexual
offenders under the direction of Correctional
Service of Canada (CSC), is important as these
studies address some of the most significant
concerns regarding treatment with psycho-
pathic sexual offenders noted above. Both of
these programs offer well-defined programs
for sexual offenders employing cognitive-
behavioral techniques. Psychopathy is assessed
by means of the PCL-R and is rated by staff well
versed in the literature on psychopathy and
actuarial assessments more generally. As well,
officially recorded recidivism data are available
on a national basis in the Canadian context and
offenders who have been treated in these
programs have been followed up for extended
periods of time. The reader is referred to
Mailloux et al. (2003) for a more detailed
description of these programs and others
offered in the Ontario region of CSC. These
programs have been subject to a variety of eval-
uations that have demonstrated their efficacy
(e.g., Looman, Abracen, & Nicholaichuk, 2000;
see also Mailloux et al., 2003).
Studies With Sexual Offenders
Seto & Barbaree (1999) examined a sample of
216 sexual offenders who participated in an
institutional treatment program located within a
medium-security Canadian federal penitentiary
and for whom PCL-R scores and treatment
information, as well as recidivism data, were
available. Seto and Barbaree examined the rela-
tionship between serious recidivism (any vio-
lent, including sexual, reoffense) and ratings of
behavior in treatment made by clinicians at the
time of participation as well as by research assis-
tants later using file materials. Importantly, as
noted above, the program meets contemporary
standards for effective correctional treatment
(Andrews & Bonta, 1998, 2003); it was cognitive-
behavioral in orientation and involved daily
group treatment sessions over a period of 5
months. Despite this, the findings appeared to
be quite discouraging. In the absence of a main
effect for treatment behavior ratings on recidi-
vism, the researchers divided their sample into
four groups using the median score on their
Abracen et al. / TREATMENT OF PSYCHOPATHY 151
treatment behavior rating scale and the median
score on the PCL-R for the sample, which was
15 or more. Proportional analyses revealed that
men who were higher in psychopathy and
received more positive ratings of treatment
behavior were almost 3 times as likely to com-
mit a new offense of any kind and 5 times more
likely to commit a new serious offense after
release compared with the other three groups
combined. Such data would seem to justify the
pessimism arising from the treatment evalua-
tions discussed earlier. However, using survival
analysis to control for unequal times at risk, dif-
ferences between the groups’ failure rates fell
short of a conventional level of significance.
Furthermore, in a subsequent study with the
same sample and treatment behavior ratings,
Barbaree and his colleagues (Barbaree, 2005;
Barbaree, Seto, & Langton, 2001) used a more
comprehensive source of recidivism data and
found that for both the follow-up period used in
the 1999 publication and an extended follow-up
period only the PCL-R score was associated
with recidivism, in the expected direction.
More recently, Langton and his colleagues
(Langton, 2003; Langton, Barbaree, Harkins, &
Peacock, 2006) revisited the issue and incorpo-
rated a number of methodological improve-
ments over the Seto and Barbaree (1999) study.
They increased the sample size to 418 sexual
offenders who participated in treatment (202 of
whom had been included in the Seto &
Barbaree, 1999, sample), extended the follow-up
period after release to an average of 5.9 years,
used a more comprehensive source of recidi-
vism data, used a cutoff of 25 on the PCL-R
(likely better capturing the concept of psychopa-
thy than a score of 15 would), and also revised
and then rescored the measure of response to
treatment (because of problems replicating the
interrater reliability coefficients with the origi-
nal treatment behavior scale and cases).
Using Cox regression survival analysis to
control for unequal times at risk and using vio-
lent (including sexual) recidivism and sexual
recidivism as outcomes, Langton et al. (2006)
found no significant interaction between psy-
chopathy and ratings of response to treatment
in the prediction of violent recidivism (although
psychopathy was a significant predictor, as
152 TRAUMA, VIOLENCE, & ABUSE / July 2008
would be expected). However, the converse was
found using the outcome of sexual recidivism,
with no main effect for psychopathy but a sig-
nificant interaction between psychopathy and
treatment ratings; among sexual offenders with
PCL-R scores of 25 or higher, those with ratings
reflecting a more positive response to treatment
recidivated sexually at a slower rate than others.
Following Seto and Barbaree (1999), we also
examined the relationship between psychopa-
thy and treatment behavior using 154 consecu-
tive admissions to a treatment facility located
within the perimeter of a maximum-security
federal penitentiary (Looman et al., 2005). In
our study, we used a treatment behavior rating
scale comprising similar variables (victim harm
awareness, insight into offence cycle, develop-
ment of relapse prevention plan) to those coded
in the Seto and Barbaree (1999) and Langton
(2003) studies. Our ratings were made by the
clinicians conducting the treatment program at
the time it was being provided. As well, the
treatment providers made a global judgment as
to whether each offender’s risk of recidivism
had been reduced following treatment. These
judgments regarding risk were grounded by
knowledge of the actuarial assessments of risk
for each offender and supplemented appraisals
of the offender’s treatment behavior with
observations of his behavior while on the living
unit (given that the program was provided on
an inpatient basis) as well as his interactions
with other staff members not directly associ-
ated with the delivery of treatment.
As was the case with Seto and Barbaree
(1999), a median split for the sample on our
treatment behavior scale and a PCL-R cutoff of
25 produced four groups. Using survival
analysis, and looking first at the PCL-R high
and low groups, Looman et al. (2005) found a
main effect with high PCL-R offenders having
the faster failure rate, as expected. However,
among the four groups, the failure rate for vio-
lent (including sexual) recidivism for the high
PCL-R/good treatment behavior group was
significantly worse than either of the two low
PCL-R/treatment behavior groups (although
not significantly worse than the high PCL-
R/poor treatment behavior group).
The interesting finding from our perspective
was that the high PCL-R/poor treatment rating
group did not differ significantly in terms of
recidivism from either of the low PCL-R groups.
In the published article, we postulated that high
PCL-R offenders who showed resistance (that is,
performed worse on the treatment behavior rat-
ings) to treatment had nevertheless benefited
from treatment, having a similar failure rate to
the low PCL-R groups. We argued that resis-
tance is to be expected in any therapeutic setting
and that a group (such as psychopaths) identi-
fied on the basis of such characteristics as vio-
lent and antisocial behavior would unlikely be
immune from such processes. In fact, one would
expect these offenders to be generally aggres-
sive and confrontational in their presentation.
Psychopathic offenders who were essentially
acquiescing throughout the treatment process
may have received the higher treatment behav-
ior ratings on the basis of conformity but failed
to make any significant gains. This hypothesis
might explain why no differences were found
between the high PCL-R/poor treatment behav-
ior group and either of the low PCL-R groups.
Certainly, psychopathic traits such as manipula-
tiveness and deceitfulness, as well as superficial
charm, would make it hard to gauge genuine
clinical change in the treatment context. As well,
much of the information necessary to complete
the program assignments (on which the treat-
ment behavior ratings were based) were explic-
itly discussed in detail in the individual therapy
component of the program. That is, offenders
were provided with sufficient information to get
reasonably high scores on the rating scale items.
Those high PCL-R participants who chose to be
confrontational, or who received lower scores
on the treatment behavior scales for other idio-
syncratic reasons, may have benefited from the
ensuing discussions with treatment staff. As
Langton et al. (2006) observed, problems assess-
ing change or treatment gains represent a signif-
icant challenge in research of this nature. We
suggest that the therapeutic process, and resis-
tance in particular, represent important foci in
future studies of this kind.
In our Looman et al. (2005) study, the global
ratings of change in risk following treatment

enabled us to incorporate into ratings staff
observations of actual changes in interpersonal
interaction patterns on the living unit (rather
than relying only on the treatment providers’
ratings of behavior in the therapy context); the
findings using this comprehensive index were
more consistent with those reported in the stud-
ies by Langton and his colleagues. We found
that the postrelease violent (including sexual)
recidivism rate of the group of high PCL-R
offenders who were rated as having had their
risk reduced did not differ from either that of
risk-reduced or risk-not-reduced low PCL-R
groups. The fact that a subgroup of high PCL-R
participants recidivated at similar rates to the
low PCL-R participants is certainly of interest
and contradicts statements to the effect that psy-
chopaths are untreatable. These data also rein-
force the findings of Langton et al. (2006) who
found a subgroup of high PCL-R participants
who may have been responsive to treatment.
However, the high PCL-R offenders whose risk
was not rated as having changed showed a sig-
nificantly higher recidivism rate, as one would
expect on the basis of their PCL-R score alone.
Overall, we believe these data suggest that
there is a subgroup of sexual offenders with
psychopathic traits who can benefit (i.e., evi-
dence lower recidivism rates after release) from
specialized cognitive-behavioral-therapy-
based treatment. Although clearly in need of
replication, we believe that the treatment resis-
tance explanation of our data represents an
important avenue for research that should
inform efforts, called for by Langton et al.
(2006), to improve assessment tools and proce-
dures so that reliable and valid appraisals of
treatment gains and risk reduction with highly
psychopathic individuals can be undertaken.
The findings of Langton et al. (2006) and
Looman et al. (2005) appear to be at odds in
terms of which subgroup of psychopathic sexual
offenders benefited from treatment. In the
Langton et al. (2006) investigation it was
observed that those psychopathic offenders who
were rated as having good treatment behavior
recidivated at lower rates, whereas Looman et al.
(2005) observed that it was the psychopathic
offenders who performed worse on the behav-
ioral measures who seemed to benefit from
Abracen et al. / TREATMENT OF PSYCHOPATHY 153
treatment. This may be only an apparent contra-
diction, however, as these studies employed some-
what different measures of treatment behavior.
As well, it is important to emphasize that both of
these studies observed that there was a sub-
group of high PCL-R offenders who recidivated
at lower than expected rates. In future research,
we hope to clarify whether the apparent contra-
diction in the findings observed in these two
studies is simply related to the discrepant opera-
tional definitions of treatment behavior.
Treatment With Adolescent
Offenders With Psychopathic Traits
Caldwell and his colleagues (Caldwell,
McCormick, Umstead, & Van Rybroek, 2007;
Caldwell, Skeem, Salekin, & Van Rybroek;
2006) have conducted several studies on juve-
nile offenders with psychopathic traits. These
authors observed that juveniles with psycho-
pathic features may respond to intensive treat-
ment. Caldwell et al. (2006) compared two
groups of potentially psychopathic offenders—
one group that participated in an intensive
treatment program and another that received
“treatment as usual”—using the Psychopathic
Checklist–Youth Version (PCL-YV). Results
indicated that those attending the treatment as
usual program were more than twice as likely
to violently recidivate in the community dur-
ing a 2 year follow-up when compared to those
attending the intensive treatment program.
Caldwell et al. (2007) also employed the PCL-
YV. Scores on the PCL-YV were computed and
subsequently compared to treatment progress.
Treatment progress was measured by means of a
series of daily behavior rating scales and with
a measure of institutional misconducts that
required security interventions. The authors
note that the program evaluated was specifically
designed for youths who were unmanageable in
conventional programs. The results indicated
significant improvement in both behavioral and
security measures with treatment.
Implications
Few treatment outcome studies with psy-
chopaths or sexual offenders with psychopathic
154 TRAUMA, VIOLENCE, & ABUSE / July 2008
traits have used designs (e.g., use of the PCL-R
to measure psychopathy, appropriate compari-
son groups, criminal recidivism as the depen-
dant variable) that permit strong conclusions
about treatment efficacy for contemporary
programs (see D’Silva et al., 2004, Lösel, 1998;
Wong, 2000). Although random assignment
to treatment and control conditions would be
a useful design strategy in future research, this
clearly is not possible in most settings for
thical reasons. Furthermore, as noted above,
even random assignment studies have their
limitations. Studies employing offenders receiv-
ing programs specifically designed for high-risk
groups and including comparison participants
matched on a variety of relevant criminogenic
factors related to risk (e.g., number of violent
offences, type of sexual offender in the case of
studies involving sexual offenders) are neces-
sary. Furthermore, adequate follow-up times
and relatively large samples of participants are
necessary before any firm conclusions can be
drawn.
Nonetheless, there does appear to be scien-
tific grounds at this stage to justify the hypothe-
sis that contemporary approaches to treatment,
and particularly cognitive-behavioral treatment,
could have a positive effect on the recidivism
rates of high PCL-R sex offenders. Although
there are limitations associated with each of the
studies cited above, the fact that the more rigor-
ously controlled studies (e.g., Langton et al.,
2006; Looman et al., 2005) have demonstrated
that there are subgroups of high PCL-R offend-
ers who recidivate at lower than expected rates
justifies guarded optimism with reference to the
efficacy of treatment with at least some high
PCL-R offenders, including sex offenders. There
remain, however, a variety of empirical ques-
tions that have not received sufficient attention
in the literature: What works, for whom, and
why? Even without the benefit of systematic
research addressing these questions, it is still
possible to identify a number of specific condi-
tions that might reasonably be expected to opti-
mize treatment effects for such groups.
Offenders who have high PCL-R scores
typically have extensive criminal histories and
present with multiple criminogenic needs
(Andrews & Bonta, 2003). The design and
delivery of an integrated, comprehensive treat-
ment program will be crucial (an exemplary
series of evaluation studies, concerning multi-
systemic therapy [MST] for use with juvenile
offender populations, is reported by Henggeler
and his colleagues; see Henggeler & Lee, 2003;
Henggeler, Smith, & Schoenwald, 1994). Wong
and Hare (2005) provide a detailed description
of what a state-of-the-art program for individu-
als with psychopathic traits should include.
Here, we would like to note in particular that
high PCL-R offenders require extensive treat-
ment by skilled clinicians well versed in the liter-
ature on psychopathy, and for sexual offenders
with psychopathic traits, additional expertise in
the area of sexual deviance, as well as in cogni-
tive-behavioral techniques and strategies more
generally. We expect that these requirements will
be demonstrated a necessity for treatment effi-
cacy as research on the responsivity principle
(Andrews & Bonta, 2003) continues to develop.
Such topics as the characteristics of offenders
(with psychopathy an obvious candidate;
Langton & Barbaree, 2006) as well as the therapy
process itself (Beech & Fordham, 1997; Langton,
2007) will require more scrutiny in the literature.
In the remainder of this review, we discuss
two key criminogenic needs areas or domains
we consider important in the treatment of high
PCL-R sexual offenders. We concentrate on
these two domains among a number that are
arguably crucial treatment foci with high PCL-
R sexual offenders for two reasons. First, as
noted above, both have demonstrated robust
associations with recidivism among sexual
offenders. Second, there is empirical evidence
to suggest that these two domains can be suc-
cessfully targeted in treatment and therefore
pay dividends (in the form of lower recidivism
rates as well as advances in the knowledge
base) if focused on in treatment and research
efforts with high PCL-R sexual offenders.
If an argument is to be made that psycho-
pathic sexual offenders are amenable to treat-
ment, we cannot ignore the fact that many suffer
from concurrent disorders, with the paraphilias
and substance abuse disorders being two of the
most frequently encountered in clinical practice.
Only if data are available showing that those
suffering from these additional conditions can

be successfully treated can the guarded opti-
mism noted above be fully justified. Although
attention has been paid in the empirical litera-
ture to the association between deviant arousal,
one of the defining characteristics of the para-
philias, psychopathy, and recidivism (e.g.,
Hanson, & Bussière, 1998), there has been rela-
tively less attention paid to the association
between patterns of substance abuse, psychopa-
thy, and recidivism in convicted sexual offenders.
We believe that, when particular patterns of
substance abuse are investigated, using well
validated measures of substance abuse, alcohol
abuse emerges as a significant predictor of
recidivism for sexual offenders, even when
compared to high-risk groups of violent non-
sexual offenders. Drug abuse, however,
appears to be a significant risk factor for the
majority of offender populations, with sex
offenders being no exception. As there has
been less attention paid in the literature to pat-
terns of substance abuse in sexual offenders
and nonsexual offenders than to the associa-
tion between deviant arousal and psychopathy,
we will consequently spend more time examin-
ing issues associated with the association
between patterns of substance abuse, psy-
chopathy, and recidivism. As some of the
research cited below illustrates, those sexual
offenders who receive both sexual offender
treatment and substance abuse treatment
appear to have better outcomes than those who
only receive sex-offender-specific treatment.
Alcohol Abuse, Drug
Abuse, and Psychopathy
One of the criminogenic needs frequently
associated with psychopathy as well as risk of
recidivism among sexual offenders is that of
substance abuse. There are several authoritative
reviews of psychopathy and substance abuse
(e.g., Knop, Jensen, & Mortensen, 1998; Taylor
& Lang, 2006). As Knop et al. (1998) note, “the
interrelationship of psychopathy and substance
use disorders has been an established fact for
decades. It is based on both clinical experience
and a substantial number of research contribu-
tions on the subject” (p. 321). With reference
to groups of high-risk sex offenders, we have
Abracen et al. / TREATMENT OF PSYCHOPATHY 155
previously demonstrated that 83% of rapists
and 67% of child molesters who were assessed
and/or treated at RTCSOTP, for whom such
information was available, evidenced an alco-
hol abuse history based on a review of file
information (Looman, Abracen, Di Fazio, &
Maillet, 2004). With reference to the group of
violent, nonsexual offenders included in this
study, approximately 28% had an alcohol abuse
history based on a review of file information.
Rates of drug abuse, as indicated by a review of
file information, were relatively similar with
rates varying between 42% for child molesters
and 65% for the rapists with violent nonsexual
offenders demonstrating similar rates of drug
abuse to the child molesters.
A recent review of the link between sexual
offending and substance abuse has been pub-
lished (Testa, 2002). The review by Testa, how-
ever, concerned itself with all of the available
research on the association between alcohol and
sexual offending with only a minority of studies
cited being related to incarcerated sexual
offenders. Reviews of substance abuse in high-
risk, high PCL-R sexual offenders who have had
significant contact with the criminal justice sys-
tem have not received particular attention. To
assume that the population in general is similar
to offenders included in the forensic literature is
ill-advised. Incarcerated offenders appear to be
different than the general population with refer-
ence to a number of parameters (e.g., proportion
suffering from substance abuse disorders; see
Boland, Henderson, & Baker, 1998, for details
related to offender populations).
From their review, Taylor and Lang (2006)
conclude that the empirical literature supports
a moderate association between psychopathic
personality traits and substance abuse disor-
ders. They note that the rate of substance abuse
disorders is high in criminal samples in general
and even higher for psychopathic offenders,
but that the association between drug abuse
and psychopathy is stronger than is the associ-
ation between psychopathy and alcohol abuse.
Unfortunately, much of the research they cite
does not involve comparisons between differ-
ent groups of violent offenders and they
acknowledge that there is much less research
concerning psychopathy (as measured by the
156 TRAUMA, VIOLENCE, & ABUSE / July 2008
PCL or its derivatives) and substance abuse
disorders than there is concerning antisocial
personality disorder and substance abuse dis-
orders.
As well, Iacono, Carlson, Taylor, Elkins, and
McGue (1999) note the important distinction
among subtypes of alcoholism that has consis-
tently emerged in the literature between an
early-onset form of alcoholism, associated with
polysubstance abuse and other antisocial
behavior, and a late-onset form, with little evi-
dence of antisocial behavior. The implications
for treatment of the early-onset form among
sexual offenders, especially those with psycho-
pathic traits, are considerable, and suggest
careful attention to onset and history of alcohol
and drug abuse with this group.
Unfortunately, the extant literature is charac-
terized by numerous methodological short-
comings. In particular, the failure to control for
type of substance abuse and the use of diag-
nostic classifications rather than well-validated
measures of substance abuse have been notable
problems. Recent advances in the area of sub-
stance abuse have indicated that alcohol abuse
is primarily associated with negative emotion-
ality, whereas drug abuse is more closely
related to disinhibited behavior; however,
these associations only become obvious when
the effects of each type of abuse are statistically
controlled (McGue, Slutske, & Iacono, 1999). If
alcohol abuse is primarily associated with neg-
ative emotionality, a theoretical link between
alcohol abuse and issues of etiological signifi-
cance to sexual offending can be made.
Marshall (1989, 1993) has persuasively
argued that issues associated with intimacy
deficits and negative emotionality are relevant
to the onset of sexual offending. Marshall (1989)
has suggested that insecure patterns of attach-
ment might be related to the development of a
number of difficulties as an adult, including
problems associated with intimacy and the con-
sequent feelings of loneliness. Difficulties asso-
ciated with the development and maintenance
of intimate relationships are central to
Marshall’s perspective. Research conducted by
Marshall and his colleagues has largely sup-
ported the theory (see Mulloy & Marshall,
1999). One corollary of Marshall’s theory, that
sexual offenders are more likely to experience
negative emotionality as a consequence of inse-
cure attachment patterns and the consequent
intimacy deficits, has also received support in
research conducted both by Marshall and our
group. Sexual offenders were found to be more
likely to use emotionally focused coping strate-
gies compared with comparison groups and to
respond to stressful situations with negative
emotionality (Looman, Abracen, et al., 2004;
Marshall, Serran, & Cortoni, 2000).
Although negative emotionality may serve
as a link between theories of sexual offending
and alcohol abuse, this does not imply that
other theories as to the influence of alcohol use
on behavior are irrelevant. For example, alcohol
myopia theory (Steele & Josephs, 1990), which
has gained influence in the substance abuse
field, may offer additional pathways by which
alcohol is related to sexual behavior. Alcohol
myopia theory suggests that the reduction in
information processing ability, which is caused
by drinking alcohol, results in an increased
probability of engaging in risky sexual encoun-
ters compared to when no alcohol is consumed.
In support of this theory, Maisto et al. (2004)
observed that participants who drank alcohol
(as opposed to those in placebo and control
conditions) were less able to negotiate safer sex
and more willing to engage in “unsafe” sexual
behavior in response to taped vignettes.
More generally, self-regulation theory offers
additional insights into the role that alcohol
may play in sexual offending. For example,
Hull and Slone (2004), in reviewing the litera-
ture on alcohol and self-regulation, cite research
indicating that individuals may drink to avoid
negative affect and to enhance positive experi-
ences. In fact, as Hull and Slone note, loneliness
has been specifically linked to alcohol use. Such
insights, rather than contradicting an associa-
tion between alcohol and sexual offending, sim-
ply reinforce the perspective noted above. It is
interesting in this regard that Hull and Slone
conclude that negative states that are a conse-
quence of interpersonal difficulties appear to be
especially likely to motivate alcohol use. We
have previously argued that alcohol abuse and
intimacy deficits may act synergistically with
reference to sexual offending (Abracen &

Looman, 2004). Data related to sexual offenders
specifically and from the substance abuse liter-
ature more generally appears to reinforce this
perspective. The question, however, remains as
to how intimacy deficits, psychopathy, and sub-
stance abuse patterns interact in terms of the
prediction of recidivism.
Given that alcohol abuse is associated with
negative emotionality and negative emotionality
is also associated with sexual offending, it fol-
lows that the presence of alcohol abuse among
sexual offenders might exacerbate the difficulties
these offenders have in this domain. Certainly,
substance abuse has been identified as a possible
trigger to sexual offending behavior (Beech &
Ward, 2004), and as an important component in
the assessment of dynamic (i.e., changeable) risk
among sexual offenders (Hanson, 2006).
The pattern of results in three studies con-
ducted by our team demonstrate these associa-
tions with high-risk (high PCL-R) incarcerated
sexual offenders (Abracen, Looman, & Anderson,
2000; Abracen, Looman, Di Fazio, Kelly, &
Stirpe, 2006; Looman, Abracen, et al., 2004).
These studies, each using different samples of
high-risk, incarcerated sexual offenders, and
comparison groups consisting of high-risk, vio-
lent, nonsexual offenders, have all yielded the
same basic finding. That is, sexual offenders
have significantly higher scores on the
Michigan Alcohol Screening Test1 (MAST;
Selzer, 1971) than do comparison participants.
A very different pattern of results is in evi-
dence with reference to the scores on the Drug
Abuse Screening Test (DAST; Skinner, 1982).
We have either found that violent nonsexual
offenders report significantly higher levels of
drug abuse as measured by the DAST (Abracen
et al., 2000) or that there were no differences
between sexual offenders and comparison par-
ticipants on measures of drug abuse (Abracen
et al., 2006; Looman, Abracen, et al., 2004). Both
the MAST and the DAST are well validated
measures of substance abuse.
At first glance, our findings appear some-
what at odds with the broader literature. In her
recent review of the association between alcohol
consumption and sexual offending, Testa (2002)
concluded that studies report modest correla-
tions between typical alcohol consumption and
Abracen et al. / TREATMENT OF PSYCHOPATHY 157
history of sexual offence perpetration but that
spurious effects may account for much of the
relationship. Testa also noted that the research
indicates that offenders arrested for nonviolent
sexual crimes and violent nonsexual crimes
are as likely as rapists to abuse alcohol (citing
studies by Allnutt, Bradford, Greenberg, &
Curry, 1996, Kouri, Pope, Powell, Oliva, &
Campbell, 1997, and Langevin & Lang, 1990, in
support of this).
In the study by Kouri et al. (1997), no signifi-
cant correlation was found between the type of
substance abuse diagnosis and the type of
crime committed. However, the diagnoses used
in this study were based on a 15 to 30 min inter-
view regarding history of substance abuse
rather than psychometric assessment. Further-
more, only half of the inmates invited to partic-
ipate agreed to the interview. It is difficult to
interpret results based on a study where the
possibility of self-selection exists. Although the
structured clinical interview for DSM-III was
used in this study, it would have been useful to
provide data based on a quantitative measure
of substance abuse with demonstrated psycho-
metric properties. It may be that degree of sub-
stance abuse is related to type of offending and
that studies using interview data (particularly
when a relatively short interview is used) may
obscure such patterns if they, in fact, exist.
The results reported by Allnutt et al. (1996)
and Langevin and Lang (1990) are actually con-
sistent with our findings of an association
between alcohol abuse and sexual offending.
Allnutt et al. administered the MAST as part of
their assessment and found differences between
groups of sexual offenders with reference to lev-
els of alcohol abuse, suggesting a more compli-
cated pattern of associations according to type
of sexual offence behavior. Such data highlight
the complicated nature of research related to
substance abuse with offender populations but
do not contradict the findings above. Langevin
and Lang observed that less than one fifth of
their sample of sexual offenders had a drug
abuse problem as measured by the DAST, in
marked contrast to the finding that more than
half of their sample was alcoholic based on the
MAST data. Unfortunately, a limitation of
Langevin and Lang’s study was that the
158 TRAUMA, VIOLENCE, & ABUSE / July 2008
researchers did not provide data for comparison
groups (see Abracen et al., 2000, for further dis-
cussion of this study).
To further our understanding of such matters,
and given that there is relatively little controlled
research examining patterns of substance abuse
in high-risk incarcerated offenders, we exam-
ined the association between alcohol and drug
abuse, PCL-R score, and recidivism among a
sample of 380 high-risk incarcerated sexual
offenders followed up for between 5 and 8 years
(Abracen, Looman, & Maillet, 2005). The mean
PCL-R score for the sample was 22. Mean
number of convictions for sexual offences was
3.4 and for nonviolent convictions it was 12.3.
Mean age at time of the index offence was 31.
Median follow-up time varied from more than 5
years to approximately 8 years depending on
the analysis. The sample was divided first into 3
groups, based on their MAST/DAST scores.
The first group consisted of high MAST scorers
(i.e., over 10) who scored in the mild or moder-
ate categories on the DAST (i.e., below 11). The
second group consisted of clients who scored 11
and above on the DAST but who scored in the
mild or moderate categories on the MAST. For
simplicity sake, we refer here to these two
groups as the Alcohol and Drug groups. A third
group, the Sober group, consisted of those who
scored in the low or moderate ranges on both
the MAST and the DAST and served as the com-
parison group. In dividing the groups based on
a combination of MAST and DAST scores, we
were able to effectively control for type of sub-
stance abuse. As noted above, few studies have
controlled for type of substance abuse and this
failure may serve to obscure otherwise impor-
tant patterns of abuse in groups of sexual and
nonsexual offenders. Each of these three groups
were then subdivided into high and low PCL-R
subgroups (using a cutoff of 25 on the PCL-R).
Any recidivism (an inclusive outcome combin-
ing both violent and nonviolent convictions,
dichotomously coded) was used as the depen-
dent measure.
Looking first at substance abuse, a categori-
cal analysis on the MAST and DAST revealed
that 21.5% of the sample had elevated scores on
the DAST, whereas 38.4 % of the sample had
elevated scores on the MAST. There were
significantly fewer high DAST/low MAST
participants and significantly more high
MAST/high DAST participants than would be
expected by chance. These results are consistent
with the findings noted above that sexual
offenders appear to have more difficulties with
alcohol than drug abuse.
Turning to the subgroups of high and low
PCL-R offenders, for the Sober group, results
were exactly as would be expected based on
PCL-R score alone, with high PCL-R partici-
pants failing at a significantly faster rate than
low PCL-R participants. A different pattern of
results emerged when the Alcohol group was
used. No significant difference in terms of
recidivism was observed between the high and
low PCL-R offenders within the Alcohol group.
It is interesting to note that there were too few
participants in the Drug group for the analysis
to be meaningful.
Two points are clear from these data: First, it
is only when drug abuse is controlled that this
pattern becomes clear. As there were so few par-
ticipants in the high DAST groups, the addition
of these participants to an analysis of “substance
abuse patterns” would have obscured the pat-
tern of results that were observed. Second, the
problems sexual offenders have with alcohol
abuse are serious enough to remove the
expected significant difference in failure rates
between high and low PCL-R subgroups.
The findings cited above would suggest that
treatment that focuses on both sexual-offender-
specific issues and alcohol abuse should reduce
the rate of recidivism in high-risk sexual offend-
ers. This is precisely what we observed in one of
two recent studies reported by our team
(Abracen et al., 2006). In this study, we examined
the RTCSOTP database. Abracen et al. (2006)
observed that sex offenders who received both
substance abuse and sexual offender specific
treatment programs evidenced significantly
lower rates of general recidivism than those who
only completed sex offender specific treatment.
Consistent with our data, Hildebrand, de
Ruiter, and de Vogel (2004) found that sub-
stance abuse/dependence remained a signifi-
cant predictor for violent nonsexual offending
even after controlling for psychopathy. More
generally, Långström, Sjöstedt, and Grann

(2004) found that alcohol abuse more than dou-
bled the risk of recidivism among their sample
of sexual offenders. These researchers observed
that drug abuse was also a significant predictor
of sexual recidivism but only alcohol abuse was
a significant predictor of violent recidivism as
well. Taken together, these sets of data indicate
that the targeting alcohol abuse as a crimino-
genic need in treatment with high PCL-R sexual
offenders represents a promising focus in both
clinical work and further research.
In contrast to these findings with sexual
offenders are those reported by Rice and Harris
(1995) in their series of analyses with a total
sample of 685 individuals comprising mentally
disordered offenders and matched convicted
offenders. Although their sample could not be
considered representative of offenders more
generally, it is one of only a few described in
the literature that clearly focuses on serious
(more than 80% were found to have one or
more violent offences on record) and relatively
high-risk (22% were classified as psychopaths
using a cutoff score of 25) offenders.
For both psychopathy and alcohol abuse, these
researchers reported the expected positive rela-
tionships with violent recidivism. As well, psy-
chopaths were more likely to abuse alcohol.
However, using the subset of 457 with the rele-
vant data, only among the nonpsychopaths was
alcohol abuse related to violent recidivism. Rice
and Harris (1995) postulated that the behavioral
controls of psychopaths may have been so poor
that alcohol abuse did not have a disinhibiting
effect as it might have had for the nonpsycho-
pathic alcohol abusing offenders. Clearly, more
research is needed to clarify the situation, given
the practical implications for treatment planning.
Recommendations
We have elsewhere (e.g., Abracen & Looman,
2004) argued for the use of well-validated mea-
sures of substance abuse in research related to
this topic, as have others (Marshall, 1996).
Unfortunately, few studies on incarcerated
sexual offenders have adopted this approach.
As well, appropriate comparison groups need
to be employed. As offender populations tend
to have higher rates of substance abuse than
Abracen et al. / TREATMENT OF PSYCHOPATHY 159
community samples, the use of incarcerated
nonsexual offenders would appear to be a more
informative choice for comparison than com-
munity participants. As well, data from mea-
sures that provide quantitative data are clearly
preferable. Although interview data may allow
researchers to make distinctions between sub-
stance abuse and dependence diagnoses (see
DSM-IV-TR, American Psychiatric Association,
2000, for a discussion of these diagnoses) such
dichotomous data precludes more finely tuned
distinctions between groups of offenders. For
example, Peugh and Belenko (2001) found that
two thirds of their sample of 13,986 incarcerated
offenders was “substance-involved.” The find-
ing that offenders may meet diagnostic criteria
for a substance abuse disorder may say little,
other than that they are typical of offender pop-
ulations. A recent review of the relationship
between substance abuse and violence by Boles
and Miotto (2003) noted that, in the case of alco-
hol, evidence from both laboratory studies and
empirical investigations supports the possibility
of a causal role in violent behavior. This conclu-
sion differs from that of Testa’s (2002) review
with reference to the association between alco-
hol and sexual offending. What both articles do
agree on is that the complexity of the relation-
ship between alcohol or drug abuse and sexual
offending is likely moderated by a variety of
variables. Psychopathy, and in the case of sexual
offenders, intimacy deficits, may be two such
moderating variables.
Psychopathy and Deviant
Arousal in Sexual Offenders
In addition to psychopathy, one of the most
consistently identified risk factors for sexual
recidivism has been deviant sexual arousal,
particularly toward children (Hanson & Bussière,
1998; Hanson & Morton, 2003). For example,
Hanson and Morton (2003) reported an effect
size of .32 for phallometrically assessed arousal
to children, and .23 for antisocial orientation,
which was coded for indicators of antisocial
personality or persistent rule violation, includ-
ing the PCL-R and Minnesota Multiphasic
Personality Inventory–Psychopathic Deviate
scale scores.
160 TRAUMA, VIOLENCE, & ABUSE / July 2008
A number of researchers have reported an
interaction between psychopathy and sexual
deviance. In general, those offenders who are
both high on psychopathy and high on sexual
deviance indices reoffend at higher rates than
other groups. For example, Rice and Harris
(1997) found that sexually deviant psy-
chopaths reoffended sexually at a faster rate
than nondeviant psychopaths and deviant and
nondeviant nonpsychopaths.
More recently, Harris et al. (2003) examined
the relationship between psychopathy and
deviant arousal (determined using phallometric
assessment) in 396 sexual offenders from four
samples gathered at various sites across
Canada. These researchers reported that both
deviant sexual arousal and psychopathy indi-
vidually were associated with both sexual and
violent (including sexual) recidivism. When the
interaction between psychopathy and deviant
sexual arousal was examined using logistic
regression a significant effect was found for vio-
lent recidivism, and a marginal effect for sexual
recidivism. A significant interaction between
psychopathy and deviant arousal was not found
for either outcome using survival analyses (to
control for unequal time at risk), however, leav-
ing only a main effect for psychopathy.
Hildebrand et al. (2004) used the Sexual
Deviance rating from the Sexual Violence Risk-
20 (Boer, Hart, Kropp, & Webster, 1997) as a
proxy measure of sexual deviance, and
observed that the sexual offence failure rate for
psychopathic deviant offenders was 82%,
whereas the sexual failure rate for the psycho-
pathic/nondeviant group was 25%.
A similar study was conducted by Seto,
Harris, Rice, and Barbaree (2004) using the
Screening Scale for Pedophilic Interests (SSPI)
as a proxy for sexual deviance, in combination
with the PCL-R in a sample of 130 released
sexual offenders with child victims. After form-
ing four groups based on high/low psychopa-
thy and high/low SSPI scores, they found that
the interaction between the SSPI and psychopa-
thy was significantly associated with sexual
recidivism, with the offenders scoring high on
psychopathy and high on the SSPI reoffending
at a faster rate than the other groups.
Data from our own program (Looman,
Maillet, & Abracen, 2004) also indicate a signifi-
cant interaction. However, we observed that
psychopathy alone accounted for virtually all of
the variance; the addition of deviant phallomet-
ric data to the analyses added minimally to the
prediction of recidivism (but it is possible that
the fact that more than half of the sample were
found to be sexually deviant reduced the pre-
dictive utility of the index of sexual deviance).
More recent analyses (Morphett, 2007) of these
data indicated that for child molesters, when
treated separately, the psychopathy/sexual
deviance interaction was significant when pre-
dicting violent (including sexual) recidivism.
Implications for
Assessment and Treatment
Given the findings summarized above, it is
clear that deviant sexual arousal must be
addressed in the assessment and treatment of
sexual offenders, especially when dealing with
high-risk populations, and when dealing with
offenders with child victims. Despite reserva-
tions some have noted regarding the psycho-
metric properties of current methods of
assessment (e.g., Marshall & Fernandez, 2000),
direct measurement of sexual arousal patterns
through phallometric technology appear to be
the best method to make these assessments.
When deviant arousal is detected, several
methods can be used to assist the offender in
managing this treatment target. Note that the
current authors do not endorse the idea that
deviant arousal patterns can be “recondi-
tioned” or changed in any meaningful fashion.
The strategy is to teach the offender techniques
to assist him to manage what will be a long-
term, ongoing risk factor. The methods
described below have been used with some
success in the RTCSOTP.
The simplest procedure for addressing
deviant arousal is the use of the ACT model to
address distorted thinking that contributes to
deviant sexual thoughts (Looman, 2002). For
example, the man who thinks “Women who
come to bars alone are looking for sex” could
challenge this thought by saying “No, that’s

distorted thinking (Awareness). I need to change
the way I’m thinking (Chose to think rationally).
Lots of people come to bars simply to socialize
and have a good time. And if she is looking for
sex, she is the one who chooses who she has sex
with. If she doesn’t want me, that’s fine (Take
action).” In our treatment program, the use of
the ACT model to manage thoughts related
to sexual offending is explored with every
offender, as even if they do not display deviant
arousal in the lab, the majority exhibit distorted
thinking that, from a clinical perspective, is a
prominent feature of their offence cycles
(Langton & Marshall, 2000).
Arousal modification procedures employed
in the RTCSOTP include covert sensitization
(Cautela, 1967), which involves pairing images
associated with sexual offending with images
of highly negative consequences (e.g., arrest,
incarceration). An alternative procedure, which
appears to be effective with some offenders,
especially child molesters, is to have them focus
on the negative consequences of sexual offend-
ing for the victim. In those cases where the
deviant arousal is especially resistant to change,
aversion therapy (noxious odor) may be used.
This procedure is based on the assumption that
to some extent sexual preferences are classically
conditioned phenomena (i.e., arousal and
orgasm have become paired with deviant
sexual stimuli). Treatment thus involves pairing
the aversive stimulus with the deviant respond-
ing in the laboratory. In this procedure, the
offender is exposed to a deviant stimulus in the
laboratory. When he becomes aroused he is sig-
naled to inhale the noxious smell (typically
ammonia). The offender is also provided with a
small bottle of ammonia that he can carry with
him so that if he experiences arousal to inappro-
priate images over the course of the day he can
use the ammonia to stop the arousal.
For clients who have elevated scores on the
PCL-R, strategies, such as those described
above, that rely on client motivation may be
problematic. Motivation to use such techniques
is encouraged by helping the offender to realize
the benefits to himself of learning to manage
deviant arousal. For offenders with psycho-
pathic traits, this may principally concern stay-
ing out of jail; for other offenders, benefits
Abracen et al. / TREATMENT OF PSYCHOPATHY 161
might include improved adult sexual relation-
ships and increased feelings of self-worth.
However, in some cases (e.g., preferential
pedophiles, particularly with psychopathic
traits), motivation to use these techniques will
remain low.
In some cases, antiandrogen medication is
indicated. These medications function primarily
by reducing the level of serum testosterone and,
although the link between testosterone and
sexual arousal remains to be conclusively proven
(Prentky, 1997), there is support in the literature
for the effectiveness of such medications as an
adjunct to other treatment procedures in manag-
ing sexual offenders (Bradford, 1997).
The psychopathic, sexually deviant offender
presents a considerable challenge in terms of
management and treatment, both in the institu-
tion and the community. Although some
authors present skepticism concerning the wis-
dom of treating and releasing such offenders
(e.g., Hildebrand et al., 2004), we do not sup-
port the idea that such offenders present an
unmanageable risk. What is needed is further
research in key areas such as those discussed
above to permit clearer interpretation of results
and so better inform the development and
implementation of treatment efforts and super-
vision practices. Techniques to address features
must include an awareness of the offender’s
offence pattern, close monitoring, use of sex-
drive reducing medications, and motivational
interviewing techniques.
General Conclusions
Based on this review of the pertinent litera-
ture, it seems fair to conclude that the available
research does not support the perspective that
“nothing works” with psychopaths, and that
there is mounting evidence that at least some
subgroups of high PCL-R offenders can
respond to treatment and show lower recidi-
vism rates. It is important to emphasize, how-
ever, that for treatment to be effective with
high-risk groups of offenders, including psy-
chopaths, an intensive program lasting many
months and involving the use of well estab-
lished cognitive-behavioral treatment princi-
ples (e.g., relapse prevention) would appear to
162 TRAUMA, VIOLENCE, & ABUSE / July 2008
be the most effective option (Andrews & Bonta,
2003; Wong & Hare, 2005). As well, it seems
likely that high PCL-R sex offender groups will
recidivate at higher rates than low PCL-R
sexual offenders, regardless of treatment. The
question of interest is whether treated high
PCL-R offenders recidivate at lower rates than
matched untreated offenders. Here, it is impor-
tant to keep in mind that, as noted by Wong and
Hare (2005), “even modest reductions in the use
of aggression and violence by psychopaths
would be of enormous benefit to society”
(p. 13). Within the Canadian context, the vast
majority of high-risk participants are serving
determinate sentences. These offenders will be
released into the community. To refuse treatment
IMPLICATIONS FOR PRACTICE, POLICY, AND RESEARCH
• Legal proceedings that incarcerate offenders for poten-
tially indefinite periods based in large measure on a
diagnosis of psychopathy alone should be questioned.
The hypothesis that psychopathic offenders as a group
do not respond to treatment does not appear to be sup-
ported by the available research.
• Research is needed as to whether there are groups of
high PCL-R offenders who may be more responsive to
cognitive-behaviorally based treatment programs.
• Treatment programs for moderate- and high-risk
sexual offenders should incorporate elements related
NOTE
1. It should be noted that the Correctional Service of Canada
has adopted a scoring method for the Michigan Alcohol
Screening Test (MAST) that is different from that originally
described by Selzer (1971). The MAST used in our treatment
program has 24 items (vs. 25 in the original scale), and each item
is scored one point (see Looman, Abracen et al., 2004, for details),
which represents a much more conservative approach than that
adopted in the original scoring.
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SUGGESTED FUTURE READINGS
Abracen, J., Looman, J., Di Fazio, R., Kelly, T., & Stirpe, T.
(2006). Patterns of attachment and alcohol abuse in
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Jeffrey Abracen, PhD, is cur-
rently the clinical director of the
Central District (community)
National Maintenance Sex
Offender Treatment Program
operated by Correctional Service
of Canada (CSC). Prior to work-
ing at the Central District Parole
Office, beginning in 2002, he had
worked in the Regional Treatment
Centre Sex Offender Treatment Program operated by
CSC between 1995 and 2001 and as a research manager
at the national headquarters of CSC in 2002. He has been
employed by CSC since 1995. His research interests are
related to the assessment and treatment of sexual offend-
ers as well as patterns of substance abuse in different
groups of high-risk offenders. He has published a number
of articles on these topics.
Jan Looman completed his
PhD in clinical/forensic psychol-
ogy at Queen’s University in
Kingston, Ontario, in 2000. He
has been working in the area of
assessment and treatment of
sexual offenders since 1987 and
has been working for Correctional
Service of Canada since 1992. He
has been the program director of
the High Intensity Sexual Offender Treatment Program
at the Regional Treatment Centre (Ontario) since 1997,
and was responsible for that program’s accreditation in
2002. He is also been involved in the development of the
National High Intensity Sexual Offender Program,
which is ongoing. His research interests include risk
assessment, treatment outcome, and psychopathy in
sexual offender populations. He has published numerous
articles in peer-reviewed journals on these topics.
Calvin M. Langton, PhD, was
an assistant professor at the
Department of Psychiatry,
University of Toronto, Canada, at
the time this article was written. He
is currently a special lecturer in
forensic mental health in the
Division of Psychiatry at the School
of Community Health Sciences,
University of Nottingham,
England, and a senior fellow at the Institute of Mental
Health, Nottinghamshire Health Care Trust, England. His
research interests include assessment and treatment issues
with sexual offenders, personality disordered individuals,
and children with emotional and behavioral problems.