Journal of Forensic Psychology Practice

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14 Ways to Disturb the Treatment of Psychopaths

Willem H. J. Martens MD and PhD

To cite this article: Willem H. J. Martens MD and PhD (2004) 14 Ways to Disturb the Treatment of
Psychopaths, Journal of Forensic Psychology Practice, 4:3, 51-60, DOI: 10.1300/J158v04n03_03

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 PRACTICE UPDATE

14 Ways to Disturb the Treatment

of Psychopaths
Willem H. J. Martens, MD, PhD

ABSTRACT. Unsuccessful treatment of psychopaths might be deter-

mined by factors that vary from engagements of inexperienced and in-
different therapists to limited supply of therapeutic diversity and dull,
non-stimulating hospital environment. Awareness of these risk factors
should be increased, and the most actual criteria of and guidelines on
therapeutic affectivity should be provided to all professionals who are
involved in the treatment of psychopaths. More research is needed into
various risk factors and adequate prevention of treatment distortions in
psychopaths. [Article copies available for a fee from The Haworth Document De-
livery Service: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.
com> Website: <http://www.HaworthPress.com> © 2004 by The Haworth Press,
Inc. All rights reserved.]

KEYWORDS. Psychopathy, psychotherapy, therapeutic community,

treatment efficacy, risk factors

Willem H. J. Martens is Director of the W. Kahn Institute of Theoretical Psychiatry

and Neuroscience, Beatrxisraat 45, 3921BN Elst (Utrecht), The Netherlands (E-mail:
WimmartensW@netscape.net). He received his MD in 1975 from Amsterdam Univer-
sity and his PhD in Forensic Psychiatry in 1995 from Tilburg University. He conducts
his research on theoretical explanation models for personality disorders.
Journal of Forensic Psychology Practice, Vol. 4(3) 2004
http://www.haworthpress.com/web/JFPP
© 2004 by The Haworth Press, Inc. All rights reserved.
Digital Object Identifier: 10.1300/J158v04n03_03 51
52 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE

INTRODUCTION

Many therapists consider psychopaths as untreatable or very difficult to

treat (Martens, 2000a, 2000b). According to Hare (1998a) and Hare and col-
leagues (2000), the received wisdom on the subject is that psychopaths not
only do not improve with psychotherapeutic treatment, but they may actually
get worse. In current treatment models, they learn better ways to manipulate
the system to their advantage and to play “head games” with the clinicians.
O’Neill et al. (2003) suggest that psychopathic characteristics (Psychopathy
Checklist–Revised, PCL-R, see Hare, 1998a) were negatively related to treat-
ment process and outcome variables, including attrition, participation, sub-
stance use, and clinical improvement. Psychopathic characteristics were
positively related to the number of arrests in the 12 months following treat-
ment completion (O’Neill et al., 2003). The results of Reiss et al. (2000), how-
ever, showed (n = 89), in contrast to previous North American research (Hare
et al., 2000; O’Neill et al., 2003), that the PCL-R did not predict any of the out-
come factors. Because the PCL-R was able to identify psychopaths in this pop-
ulation (English high security hospital) but failed to predict their prognosis, it
is possible that their outcome may have been improved by the treatment they
received in hospital (Reiss et al., 2000). Furthermore, a review of 42 treatment
studies on psychopathy revealed that there is little scientific basis for the belief
that psychopathy is an untreatable disorder (Salekin, 2002). Psychopaths can
be treated successfully (Kernberg, 1984, 1992; Martens, 1997, 1999, 2002a;
van Marle, 1995; Skeem et al., 2002), mostly as a consequence of (a) very
capable therapists (who understand the problems of psychopaths), (b) a com-
bination of psychotherapy, neurologic treatment, and psychosocial guid-
ance/counseling, (c) favorable circumstances (friendship, impressive events,
confrontation, maturation and so on), and/or (d) as a function of age (Martens,
1997, 1999, 2003a, 2003b, 2003c, 2003d). A lack of successful treatment in
psychopaths might be linked to factors that lay behind the responsibility and
capacities of the patient (Martens, 2000a, 2000b). In this paper the possible
correlates of lack of treatment success in adult psychopaths will be investi-
gated in order to enhance critical awareness in therapist that might lead to
more adequate treatment.

Diagnostic Features of Psychopathic Personality Disorder

Psychopathy is characterized by features like irritability and aggressive-

ness; impulsivity or planning ahead; reckless disregard for the safety of self
and others; pathological egocentricity; lack of guilt or remorse; social malad-
justment; poor development of relationships; deceitfulness; inadequate motivated
 Practice Update 53

antisocial behavior; lack of nervousness and psychoneurotic manifestations; ab-

sence of delusions and other signs of irrational thinking; superficial charm and
good intelligence; incapacity for love; specific loss of insight; unresponsive-
ness in general interpersonal relations; fantastic and uninviting behavior
with drinking and sometimes without; suicide rarely carried out; sex life im-
personal, trivial, and poorly integrated; poor judgment and failure to learn
from experiences (Cleckley, 1984); manipulative behavior; conning; patho-
logical lying; grandiose sense of self-worth; need for stimulation/proneness
to boredom; shallow affect and/or callousness and lack of empathy; parasitic
life-style; poor self-control; promiscuous sexual behavior; many short-term
marital relationships; early behavioral problems juvenile criminality and
versatility among others (Hare, 1998b); poor fear conditioning (lack of fear)
(Lykken, 1995) and sensation seeking (Zuckerman, 1994).

Therapeutic Effects upon Psychopaths

Studies of the treatment efficacy in adult psychopaths indicate that:

• There is mixed evidence that therapeutic communities (TC) are effec-

tive in psychopaths. Some recent research has indicated that treatment
of psychopaths in therapeutic communities is problematic in terms of
high rates of attrition, low levels of motivation, and increased
reconviction (Shine and Hobson, 2000). Harris et al. (1991) found that
psychopaths who completed treatment therapy recidivated even at a
higher rate than non-psychopathic controls and psychopaths who had
not received any therapy. Ogloff et al. (1990) and Harris and Rice
(1994) also concluded that TC programs might be inappropriate for
psychopaths. However, Doren (1996), Kennard (2001), Leuw (2000),
Martens (1997, 1999, 2002a), Van Marle (1995), and Theys (1995) re-
vealed that Therapeutic Communities may be effective in the treatment
of psychopaths. During 3 to 8 years follow-up of released adult foren-
sic psychiatric patients (n = 315; nearly one third of them suffered from
psychopathy) who underwent TC treatment (only) 15% to 20%
reoffended (committed serious crime and stayed 6 months or longer in
prison) (Leuw, 2000). Differences in the (a) personal schemes of treat-
ment, (b) treatment diversity, (c) presence or absence of experimental
attitudes of staff members (see Martens, 1999, 2002a), (d) manage-
ment, (e) selection, and (f) availability of high qualified and motivated
therapists and staff members might be (partly) responsible for distinc-
tions in treatment outcome between various studies.
54 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE

• It was discussed earlier that some investigators such as Hare (1998),

Hare et al. (2000), and O’Neill et al. (2003) showed very skeptical
views on the psychotherapeutic effects upon psychopaths. Nevertheless,
psychotherapeutic (especially cognitive, behavioral, and psychodynamic
psychotherapy) treatment seems effective in the long run (mostly at least
5 years from treatment), in so far that psychopathic personality traits di-
minish or become less extreme (Dolan and Coid, 1995; Martens, 1997,
1999; Dolan, 1998; Sanislow and McGlashan, 1998). Psychoanalytical
treatment might be effective (Cleckley, 1984; Kernberg, 1984, 1992;
Martens, 1997, 1999; Van Marle, 1995). Although the evidence is
sparse, it is fair to conclude that therapy programs that are based on cog-
nitive-behavioral theories have been found to be effective in sexual psy-
chopaths (Wood et al., 2000). Here again, differences in treatment
outcome studies may be explained by distinctions in personal schemes
of treatment, availability of highly qualified and motivated therapists,
management, and selection.
• Short-term behavioral therapy and group psychotherapy seem not to be
effective in psychopaths (Doren, 1996; Martens, 1997; Vailliant et al.,
1998).
• Since many psychopathic traits such as aggression, impulsivity, sensa-
tion seeking, incapacity to learn from experiences, lack of social-emo-
tional and moral capacities are neurobiologically determined (Martens,
2000c, 2001c, 2002a, 2002b, Raine, 1996) it may be possible to diminish
these traits with the help of psychopharmacological (Bloom and Kupfer,
1994; Hollander, 1999; Sanislow and McGlashan, 1998; Sheard et al.,
1976; Tupin et al., 1973), or neurofeedback (Martens, 2001, 2002a;
Raine, 1996) treatment, eventually in combination with psychotherapy
(Martens, 1997, 2002a).

Remarkable Shortcomings in the Treatment of Psychopaths

The author observed the following failures in the approach to and treatment
of psychopaths, which might lead to lack of therapeutic success:

1. Engagements of psychotherapists who are inexperienced, immodest,

not interested, or who do not understand the problems of psychopaths.
This happens in all kinds of forensic psychiatric psychotherapeutic
settings. Especially in Therapeutic Communities (forensic psychiatric
hospitals, high security hospitals, forensic psychotherapeutic hospi-
tals, prison treatment departments) such engagement might be the
consequence of a shortage of therapists or lack of high qualified thera-
 Practice Update 55

pist (eventually) as a consequence of financial limitation, mismanage-

ment, and/or numbed and grind attitude of therapists and other staff
members (as a result of a lack therapeutic progress in this category of
patients).
2. Lack of click between therapist and patient that may happen in all kind
of therapeutic settings, whereas there is no opportunity or readiness to
exchange therapists because of rigid division of tasks, lack of avail-
ability of substitute therapists (or readiness to change therapist since
this has adverse consequences such as increased planning activities
and difficulties, change of schedules, increased energy consuming,
flexibility, and correlated insecure and chaotic effects on the task of
therapists), rigid treatment programs (particularly in Therapeutic
Communities and private outpatient’s psychotherapeutic facilities),
and reasons that are mentioned in 1 above.
3. Limited treatment diversity and lack of knowledge of alternative
(combinations of) treatment. Most prison therapeutic departments,
high security psychiatric hospitals, forensic psychiatric hospitals, and
outpatient psychotherapeutic practices are specialized in one or only
one or a few psychotherapeutic approaches, whereas only a few forensic
psychiatric hospitals are able to offer patients a large variety of
psychotherapeutic approaches and eventually balanced combinations of
specific psychotherapy, neurologic and neurofeedback treatment and
psychosocial guidance. In some cases of ineffective treatment of psycho-
paths, the origins may lay in unavailability of suitable psychotherapeutic
treatment (eventually in combination with), neurobiological, and
psychosocial treatment (Martens, 2002a, 2003a, 2003b).
4. Lack of respect, ignorance, and even humiliating approach, particularly
in high security psychiatric hospitals and forensic psychiatric hospitals
(Winkels, 1989). Especially difficult and/or aggressive acting out pa-
tients run an increased risk of such approach, because staff members
may become very nervous and/or fed up of such patients.
5. Continuous suspicious treatment (this may happen in all kind of
psychotherapeutic settings), because of the unreliable attitude of the
psychopath. Such continuous suspicious treatment may easily rein-
force the patient’s indifferent attitude (because he or she experiences it
as rejection and lack of positive attention) and some if his or her psy-
chopathic features such as hostility, impulsivity, lack of empathy
and/or immorality (Martens, 1997).
6. Lack of patient’s personal freedom and privacy that may correlate
with lack of possibility of self-reflection and lack of development of
new activities and capacities. The author observed in most forensic
56 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE

psychiatric hospitals, high security psychiatric hospitals, and (psychi-

atric departments of) prisons a lack of privacy, whereas for every psy-
chiatric patient privacy is a basic need and requirement according the
international rules of psychiatric ethics (Martens, 2001a).
7. Lack of useful selection (and associated criteria) of fellow-patients of
psychopaths in Therapeutic Communities that may lead to chaotic,
dangerous situations and environment, which interfere with treatment
progress. Adequate selection of patients in a ward might be a useful
component in therapeutic progress and motivation (Martens, 2001b).
8. Dull, non-stimulating environment and lack of possibilities for devel-
opment in all kinds of Therapeutic Communities. Psychopaths are
characterized by excessive need of stimulation (Martens, 1997,
Zuckerman, 1994), and lack of opportunities of stimulation in a social
and structural manner may increase the psychopath’s tendency to seek
thrill in an undesirable way.
9. Harsh and/or rigid regimes in high security hospitals, psychiatric de-
partments of prisons, and forensic psychiatric hospitals. The etiology
of psychopathy is often linked to negative experiences and harsh treat-
ment in childhood and adolescence that is characterized by rejection;
neglect; physical abuse and severe punishment; lack of love, guid-
ance, support, and/or emotional warmth (Martens, 1997; Martens,
2003d). As a consequence, harsh treatment of psychopaths may result
in (a) associations with negative experiences in the past and related ag-
gressive impulses, (b) reinforcement of specific psychopathic traits
such as hostility, violence, impulsivity, recklessness, immoral and in-
different behavior, and resistance to change (Martens, 1997). Lack of
flexibility of staff and program might also lead to inflexible attitudes
in psychopathic patients.
10. Lack of evaluation studies and/or experimental research in most out-
patient’s psychotherapeutic practices, prison psychiatric departments,
and some forensic psychiatric clinics and high security psychiatric
hospitals. Without results of such investigation there is no profound
basis of necessary self-critic, therapeutic insight, refreshment, and
continuing professional enthusiasm.
11. Unresolved transference and countertransference problems in all
kinds of treatment settings. For example, therapist’s hate for and jeal-
ousy of the psychopathic character. The therapist may suppress his or
her feeling of disgust that might be evoked by a particular psycho-
pathic or he or she may suppress feelings of jealousy because of the
psychopath’s lack of internal conflicts, lack of nervousness, and free-
dom to do what she or he likes and lack of social obligations and asso-
 Practice Update 57

ciated absence of suffocating feelings of responsibility and

adjustment.
12. Lack of financial means that may result in severe limitation in treat-
ment supply, employment of high qualified psychotherapists and staff
members, quality of residence, and special facilities that may contrib-
ute to therapeutic progress in all kinds of therapeutic settings. Particu-
larly, expensive but necessary neurologic assessment and treatment is
sometimes left out of assessment and treatment package.
13. Bad influence of friends or partner that interferes with patient’s moti-
vation for treatment and that may lead to obstruction of treatment
progress. In some Therapeutic Communities there is a policy to re-
strict or even prevent such harmful external contacts in order to give
adequate treatment a chance.
14. Lack of positive perspective (especially) in prisons and high security
psychiatric hospitals for the patient that might lead to lack of motiva-
tion for treatment and to change attitude.

CONCLUSIONS

As with much of the treatment outcome research for psychopaths, most of

the studies conducted with TC models are plagued with methodological short-
comings, including the inadequate use of controls, a lack of uniform criteria
for improvement, short follow-up periods and an over reliance on the use of re-
cidivism as a measure of long-term success. It is also important to note that be-
cause most Therapeutic Communities have developed their own personal
schemes of treatment, management, and selections, it is difficult to make com-
parison between these models or to generalize from the findings of one setting.
There are many shortcomings in psychotherapists that might be linked to
unsuccessful treatment of psychopaths. Martens (2000a, 2000b) observed that
such treatment failure is often not (solely) due to patient’s attitude, but it can
frequently be attributed to inadequate treatment programs, lack of experienced
and well motivated therapists and other staff members (as a result of burn-out),
financial limitations, lack of evaluation studies, and so on. Awareness of
psychosocial, environmental, and neurobiological correlates of unsuccessful
treatment should be systematically enhanced in all professionals who work
with psychopaths. A complete list of criteria and risk factors should be distrib-
uted to all the forensic psychiatric hospitals and professionals who work with
psychopaths. The author discovered that many forensic psychiatric profes-
sionals are unaware of or indifferent to (because they felt that they were unable
to change conditions in order to improve treatment) most of these risk factors.
58 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE

Because of working pressure and blunted attitude (as a consequence of many

disillusions in the work with psychopaths) most therapists and other staff
members are unable or not willing to be continuously alert for all possible risk
factors. It would be helpful to give psychotherapists who work with psycho-
paths episodically other, less exhausting, and more satisfying work (therapy of
patients with other mental disorders) in order to prevent burn-out and fatal
failures. Independent, external inspection of the mental and professional con-
ditions of psychotherapists and other staff members in Therapeutic Communi-
ties as well as outpatient’s psychotherapeutic practices might be necessary to
obtain and maintain an optimal standard of treatment. Until now, such inspec-
tions happen only by concrete complaints.

REFERENCES

Bloom, F.E., & Kupfer, D.J. (1994). The fourth generation in progress. New York: Ra-
ven Press.
Cleckley, H.M. (1984). The mask of sanity. St. Louis, MS: Mosby.
Dolan, B. (1998). Therapeutic community treatment for severe personality disorders.
In T. Millon, E. Simonsen, M. Birket-Smith, & R.D. Davis (Eds), Psychopathy: An-
tisocial, criminal, and violent behavior (pp. 407-438). New York: The Guilford
Press.
Dolan, B., & Coid, J. (1995). Psychopathic and antisocial personality disorders:
Treatment and research issues. London: Gaskell.
Doren D. (1996). Understanding and treating the psychopath. Northvale, NJ: Jason
Aronson.
Hare, R.D. (1998). The PCL-R assessment of psychopathy: Some issues and concerns.
Legal and Criminological Psychology, 3, 100-122.
Hare, R.D. (1998). Without conscience: The disturbing world of the psychopaths
among us. New York: Guilford Press.
Hare, R.D., Clark, D., Grann, M., & Thornton D. (2000). Psychopathy and the predic-
tive validity of the PCL-R: an international perspective. Behavioral Sciences and
the Law, 18(5), 623-45
Harris, G.T., & Rice, M.E. (1994). Psychopaths: Is a therapeutic community therapeu-
tic? Therapeutic Communities: International Journal for Therapeutic and Support-
ive Organizations, 15, 283-299.
Harris, G.T., Rice, M.E., & Cormier, C.A. (1991). Psychopathy and violent recidivism.
Law and Human Behavior, 15, 623-637.
Hollander, E. (1999). Managing aggressive behavior in patients with obsessive-com-
pulsive and borderline personality disorders. Journal of Clinical Psychiatry, 60,
38-44.
Kennard, D. (2001). Therapeutic communities. In M. Gelder, R. Mayon, & P. Cowen
(Eds), The Oxford textbook of psychiatry. Oxford: Oxford University Press.
Kernberg, O.F. (1984). Severe personality disorders: Psychotherapeutic strate-
gies. New York: Jason Aronson.
 Practice Update 59

Kernberg, O.F. (1992). Aggression in personality disorders and perversions. New

Haven, CT: Yale University Press.
Leuw, E. (2000). Reoffending after forensic psychiatric treatment: Patterns, pro-
cesses and predicting of dangerness. The Hague: Ministry of Justice, WODC,
Research and Policy, Publication, p.182.
Lykken, D. (1995). The antisocial personalities. Hillsdale, NJ: Lawrence Erlbaum.
Martens, W.H.J. (1997) Psychopathy and Remission. PhD thesis, Tilburg Univer-
sity, The Netherlands. Maastricht: Shaker Publishing, 1997.
Martens, W.H.J. (1999). Marcel-A case report of a violent sexual psychopath in re-
mission. International Journal of Offender Therapy and Comparative Criminol-
ogy, 43, 391-399.
Martens, W.H.J. (2000a). How treatable are “untreatable” forensic psychiatric pa-
tients? International. Journal of Offender Therapy and Comparative Criminol-
ogy, 44, 367-369.
Martens, W.H.J. (2000b). What shall we do with untreatable forensic psychiatric
patients? Medicine and Law, 20, 389-396.
Martens,W.H.J. (2000c). Antisocial and psychopathic personality disorders:
Causes, course, and remission–A review article. International Journal of Of-
fender Therapy and Comparative Criminology, 44, 406-430.
Martens, W.H.J. (2001a). Necessity to adapt psychiatric treatment to relevant ethi-
cal guidelines. Medicine and Law, 20, 393-403.
Martens, W.H.J. (2001b). Agitation therapy for antisocial and psychopathic per-
sonalities. American Journal of Psychotherapy, 55, 234-250.
Martens, W.H.J. (2001c) Effects of antisocial or social attitudes on neurobiological
functions. Medical Hypotheses, 56, 664-771.
Martens, W.H.J. (2002a). The hidden suffering of the psychopath. Psychiatric
Times, 19, 1-7.
Martens, W.H.J. (2002b). Criminality and moral dysfunctions: neurologic, bio-
chemical, and genetic dimensions. International Journal of Offender Therapy
and Comparative Criminology, 46, 170-182.
Martens, W.H.J. (2003a). Constructive functions of aggression in psychopaths. Fo-
rensic Psychiatry On-line, April 18, 1-20.
Martens, W.H.J. (2003b). A case report of an extremely violent serial rapist with
borderline personality disorder in remission. Acta Psychiatrica Scandinavica,
107, 465-567.
Martens, W.H.J. (2003c). Multisystemic therapy for antisocial juveniles: suggestions
for improvement. Manuscript under review, Acta Psychiatrica Scandinavica.
Martens, W.H.J. (2003d). Multisystemic therapy for antisocial juveniles: A critical
comment. Manuscript under review, International Journal of Offender Therapy
and Comparative Criminology.
Ogloff, J.R., Wong, S., & Greenwood, A. (1990). Treating adult psychopaths in a
therapeutic community program. Behavioral Sciences and the Law, 8, 181-190.
O’Neill, M. L., Lidz, V., & Heilbrun, K. (2003). Adolescents with psychopathic char-
acteristics in a substance abusing cohort: Treatment process and outcomes. Law and
Human Behavior, 27, 299-313.
60 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE

Raine, A. (1996). Autonomic nervous system factors underlying disinhibited, antiso-

cial, and violent behaviour: Biosocial perspective and treatment implications. An-
nals of the New York Academy of Sciences, 794, 46-59.
Reiss, D., Meux, C., & Grubin, D. (2000). The effect of psychopathy on outcome in
high security patients. Journal of the American Academy of Psychiatry and the Law,
28, 309-14.
Salekin, R.T. (2002). Psychopathy and therapeutic pessimism: Clinical lore or clinical
pessimism? Clinical Psychology Review, 22, 79-112.
Sanislow, C.A., & McGlashan, T.H. (1998). Treatment outcome of personality disor-
ders. Canadian Journal of Psychiatry, 43, 237-50.
Sheard, M., Marini, J., Bridges, C., & Wapner, A. (1976). The effect of lithium on im-
pulsive aggressive behavior in man. American Journal of Psychiatry, 133, 409-413.
Shine, J., & Hobson, J. (2000). Institutional behavior and time in treatment among psy-
chopaths admitted to a prison-based therapeutic community. Medicine, Science,
and the Law, 40, 327-335.
Skeem, J.L., Monahan, J., & Mulvey, E.P. (2002). Psychopathy, treatment involve-
ment, and subsequent violence among civil psychiatric patients. Law and Human
Behavior, 26, 577-603.
Theys, J.M. (1995). Psychopathie et toxicomanie. [Psychopathy and drug addiction].
Acta Psychiatrica Belgica, 95, 82-90.
Tupin, J., Smith, D., Clinton, T., Kim, L.I., Nugent, A., & Groupe, A. (1973). The long
term use of lithium in aggressive prisoners. Comprehensive Psychiatry, 14,
311-317.
Valliant, P.M., Hawkins, T.J., & Pottier, D.C. (1998). Comparison of psychopathic and
general offenders in cognitive behavioral therapy. Psychological Reports, 82,
753-754.
Van Marle, H.J.C. (1995). A closed system: A psychoanalytic framework of forensic
psychiatric community treatment. PhD thesis, Utrecht University. Arnhem: Gouda
Quint.
Winkels, M.J. (1989). The internal cage: a study into the utilization and check of forced
measures in forensic psychiatric patients. PhD thesis, Groningen University.
Wolters Publishing: Groningen.
Wood, R.M., Grossman, L.S., & Fichtner, C.G. (2000). Psychological assessment,
treatment, and outcome with sex offenders. Behavioral Science and the Law, 18,
23-41.
Zuckerman, M. (1994). Behavioral expressions and biosocial bases of sensation seek-
ing. New York: Cambridge University Press.

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REVISED: 11/06/03
ACCEPTED: 11/06/03