Episode 116: Interview on Psychopathy with Expert Carl Bruce Gacono, PhD, ABAP
By listening to this episode, you can earn 1.75 Psychiatry CME Credits.
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Article Authors: Eleanor McDaniel, Carl Gacono, PhD, David Puder, MD
There are no conflicts of interest for this episode.
On this week's podcast, I interviewed Carl B. Gacono, PhD, who maintains a consulting private practice in Asheville, NC. He is an expert in the areas of criminal psychopathology, behavior, and treatment. Dr. Gacono has honed these skills through twenty years of hands-on research and experience in the correctional and forensic psychiatric institutions. Throughout his career, he has authored or edited a plethora of books and scientific articles. These include Understanding Female Offenders, The Clinical and Forensic Assessment of Psychopathy, The Handbook for Forensic Rorschach Assessment and The Rorschach Assessment of Aggressive and Psychopathic Personalities. He has worked as a clinical and forensics psychologist utilizing the Rorschach Test and Psychopathy Checklist (PCL-R) as relevant research tools.
In this episode, we dive into understanding and acknowledging the distinct differences between psychopathic and non-psychopathic patients and how their assessment with the PCL-R and Rorschach aid in their management and treatment. We also discuss how understanding transference and countertransference is essential when interacting with these difficult patients.
What is Psychopathy?
Psychiatry and psychology has long struggled with the concepts of psychopathy. The evolution of the construct can be traced through the 1941 work of Hervey Cleckley to its empirical assessment by Robert Hare with the Hare Psychopathy Checklist-Revised (PCL-R). As measured by the PCL-R, psychopathy consists of two primary factors that combine character traits (pathological narcissism in males and malignant hysteria in females) with antisocial behaviors.
By contrast, the antisocial personality disorder (ASPD) traces its roots to sociopathy in the first DSM. ASPD is composed mainly of behaviors and forms a more heterogeneous group than what is captured by the two-factor structure of psychopathy (Gacono, 2016).
Most psychopaths meet the criteria for ASPD, while most ASPDs are not psychopathic.
What are the Tells of a Psychopath?
Psychopaths thrive in situations where there is chaos. They avoid detection as they fly under the radar, while others struggle with the chaos. This pattern translates to societal settings, work settings (Babiak, 2010), or even personal situations (where the individual is vulnerable for any number of personality or situational factors). If one looks deeper, they discover inconsistencies within the lives of these individuals. Investigate their references and you will discover fabrications. There will be unexplained gaps in their history. Find the right person to interview and you will discover a trail of interpersonal problems that reflect their exploitation of others.
When interacting in person, it is important to not ignore their inconsistencies, their lapses in personal empathy, the fact that you have never met their family, their strange behavior in situations where empathy is common sense to responsible people. Rather, see these situations as the tip of the iceberg related to their personality deficits. Do not accept their excuses or give them the benefit of the doubt. Trust your gut when things don’t seem quite right. If not, you leave yourself vulnerable to exploitation. This can be difficult, as most people view others through their own biases and tend to see others as basically good, with good intentions. Consider that for these individuals, kindness is weakness, an opening for exploitation.
Psychotherapy vs. Forensic Assessment
There are practical and ethical differences between treatment and assessment. Evaluators are neutral examiners whose purpose is to objectively evaluate an issue related to a referral question. In the process they routinely utilize documented accounts of the examinees' history. Treaters focus on the relationship aspects of the patient/professional relationship; mostly relying on the patients self-report. Their purpose is to help.
In court those who treat are limited as to the types of questions they can address. They have not conducted a comprehensive evaluation of issues such as parenting. It is unethical to offer opinions about certain forensic issues as a therapist. Not only has the therapist not used the proper methodology but in many cases it is a conflict of interest to serve the dual role of forensic evaluator and therapist.
It is also important to understand that psychopathy is not a diagnosis. It becomes relevant as part of an assessment battery within the context of a referral question (Gacono, 2016). For example, what is this individual's risk of reoffending?
Predicting the risk of a patient involves considering both can be static (age, history) and dynamic (changeable) factors. Some factors such as alcohol dependence can be modified with intervention. Other factors, such as age and history of violence, are set. While the PCL-R does not predict if someone will be violent, high scorers fall within a group that is at higher risk for violent reoffense. Consequently “psychopathy” becomes one factor in predicting future risk.
Assessing Psychopathy
Assessing psychopathy with the PCL-R is based on an analysis of the individual’s history (behaviors) and attitudes. A semi-structured interview schedule is utilized in order to quantify this data (Gacono, 2005). Administering the PCL-R requires considerable training and supervision.
The PCL-R is a twenty-item scale, with each item rated 0, 1, or 2 (meets criteria in most essential aspects) dependent on how well the individual meets the items criteria. For example, someone scoring high on an item related to long-term goals is likely to be unrealistic and grandiose. They may present with a plausible sounding goal, but their plan would lack practical details related to the feasibility of the plan or how they might make these goals achievable.
For example, a psychopath was asked about his long-term goals upon release from the institution and he stated that he wanted to be a corporate lawyer. However, his background included gang affiliation, multiple arrests and convictions, an unfinished GED, never holding a job for more than a week, and never being out of prison for more than a few months during his adult life. Additionally he could not articulate how one goes about becoming a lawyer, if his criminal record would impact this process, etc.
Is Psychopathy Treatable?
While the ASPD group is very heterogeneous and consequently some individuals within it can be treated, those who meet the criteria for psychopathy are less amenable to treatment. In fact, those that score high on the PCL-R tend to cause more problems in treatment, drop out sooner, or are discharged much more frequently than those who are “non-psychopathic.” Treatability, however, must be determined on a case-by-case basis considering many factors.
For psychopaths, some of their behaviors may lessen with age; however, their narcissism remains high. This results in their propensity for violence remaining high. Most of us learn that we have nothing coming without hard work. A psychopath feels entitled and believes the world owes them something; they are prone to feeling frustrated and angry.
Severe narcissism, in itself, represents a difficult treatment prospect.
Management vs. Treatment of Psychopathy
Management is not changing the personality structure of the patient, but helping them modify/control behavior. At times it is ensuring an individual patient's behavior does not disrupt the milieu and the provision of services to the other patients.
In treatments, you must be thoughtful regarding the timing of interventions and the choice of words. For example, psychopaths view kindness as a weakness that can be exploited. If you show kindness and take a traditional therapeutic approach, they feel as though they can take advantage of you because of your naivety. It is most important to evaluate every request for a psychopathic patient. Why are they asking you this now? It is an example of splitting, where you are the third person they are making the request of? Failure to prepare for splitting can destroy the functioning of the milleu.
When attempting to manage or treat a psychopath, you must be aware of transference and countertransference in order to manage strong reactions such as splitting. Without this structure, the integrity of the milieu is threatened.
How Criminals Think Differently
A criminal will say whatever is necessary to make you believe what they are saying. You must compare their stories with their behavior. One aspect of the male psychopaths style is described as a manipulative cycle whereby they attempt to pull one over on you in order to bolster their grandiosity.
Once during a criminal thinking group, participants were asked, “What are you thinking?” One mentioned he was thinking about the therapist's office and whether the drawers had anything he could steal. Another was wondering if the back door was unlocked and whether he would be able to get out of the institution. Another was daydreaming about strong arming another patient.
They frequently tell you what they think you want to hear. As a clinician, you cannot be gullible and fall for what they are saying. They are able to give plausible explanations for their irresponsible behavior that will deflect blame. Examining factual accounts or asking what did the police report say will often provide a more realistic picture.
As noted by Smith, Gacono & Cunliffe (2021), men and women are different in this presentation. Female psychopaths need the people surrounding them to manage their emotions and bolster their damaged sense-of-self. Male psychopaths are able to bask in their own grandiosity.
Is Psychopathy Due to Trauma?
Understanding character pathology is the first key to understanding that, over time, trauma may play a considerable role in shaping one's personality. But it should not be misinterpreted as the main factor operating within an established personality structure. While neurotically organized patients can be directly helped by interventions that uncover and impact specific events, characterological issues have developed over the course of a lifetime and require a more comprehensive and thoughtful approach. If you don’t address the character pathology first, then there will be problems because the underlying thoughts are still there.
Looking for simple solutions will also take the clinician off course. Problems with authority and attachment issues are often misguidedly associated with not having a good role model to look up to. This is false for many of the psychopaths. They often chose to go along with the more exciting people in their life that were doing illegal things because they already had a propensity for getting in trouble. There is no single approach or simple fix for impacting characterological issues (personality disorders).
Antisocial and psychopathic patients require the highest skill levels within the treating assessors and clinicians. Unfortunately, most graduate academic programs no longer prepare individuals for interacting with severe mental disorders such as psychotic and personality-disordered patients.
Dr. Gacono’s Experience With Youth
Youth will dismiss you if you are unable to show them that you understand them. A connection is made when you can prove that you understand their world and thinking. Otherwise, they will dismiss any technique you try with them. As noted by Aichhorn in his classic book involving Wayward Youth, when the clinician can demonstrate understanding of how the youth thinks (worldview), but even a more sophisticated understanding of them, the youth becomes intrigued with the possibility that the therapist may have something to offer. The youth looks up to you, with an idealizing transference, that becomes the basis to the clinical work.
Conduct-disordered youth can readily identify how they differ from responsible peers. These traits relate 100% to their criminal thinking which must be a focus of their treatment.
The Problem of Therapist Projecting
Mental health workers are vulnerable to projecting their own worldview onto their patients. By contrast it is best to adopt an old Rogerian premise of entering the client’s world and seeing things from their perspective. This is critical for all personality-disordered patients and especially so for antisocial and psychopathic ones. You cannot gain their respect without showing them that you understand them. Their way of thinking is different from yours and by not acknowledging that difference there is a divide between standard treatment and the treatment needed for this specific individual. As demonstrated by Yochelson and Samenow (1977), the way the criminal views the world differs from responsible people (e.g., they view kindness as weakness).
Empathy begins with not putting your own worldview onto the patient. Empathy is achieved when one intervenes based on who the patient is, not based on what the therapist wants the patient to be.
Self-awareness is essential when working with personality disorders. Unresolved personality issues within the therapist can create multiple countertransference issues that impact or shut down treatment.
Everyone is different in many ways including their basic levels of personality functioning. A patient's level of personality organization and specific issues must guide the formation of any treatment intervention.
What is the Rorschach Test?
Ironically, both the Rorschach and the PCL-R were not initially developed as clinical tools. Rorschach referred to his test as an experiment. The PCL-R was developed as a research tool for differentiating among offenders. However their robustness quickly resulted in clinical applications.
The Rorschach is a performance-based measure that provides a template for understanding how an individual functions within their world. It assesses personality issues, how they solve problems, along with many other issues. The ten blots are presented to the examinee who is asked, “What might this be?” Based on responses that are already coded, it allows for variables and ratios to be compared to various patient and non-patient groups. For example, a pattern of response coding might be compared to a group of depressed patients or to thinking difficulties in a schizophrenic sample. This aids in determining the presence of clinical issues.
It is standardized so that it is always administered in the same way. It is reliable in that two people will agree upon how responses are scored. It is valid in that variables are tested on people that have those qualities that are purported to be measured by the indice. For example, variables associated with anxiety being validated by comparing anxious people or people in stressful situations to people who are non-anxious.
The Rorschach has been thoroughly researched. Each variable has specific bases for each score. With studying and proper training it can be an accurate test.
The Rorschach also shows us how an individual reacts to a novel, unstructured stimulus. The image pictured below is the first of ten different cards shown on the test.
Scoring involves many factors, such as if the whole image or only a part of it was utilized in forming the percept. You also have to be aware throughout the test what kind of patterns there are in the patient's response.
In the case of a psychopath, they produce many whole responses as a template for understanding the manner in which they scan the environment looking for prey, or scan to avoid being preyed upon. One might ask, is the overproduction of whole responses reflective of their grandiosity, how they overextend what psychological resources they have? The answers to these questions rest in evaluating the entire Rorschach.
The use of color, movement, etc. are also part of the rorschach scoring.
Texture Relates to Affectional Relatedness
Texture is an interesting Rorschach variable. It is scored when the card is seen as soft or furry and associated with affectional relatedness. With texture response, female psychopaths saw more texture whereas the males did not (indicative of their severe detachment) (Smith, Gacono, & Cunliffe, 2021). Texture is associated with relationships and the desire to connect.
Within a relationship, this is an important variable. If both partners don’t see texture, they work well because both are cold and detached. If a high-texture person is coupled with a zero-texture person, there will likely be conflict. The non-texture person is likely to experience the multi-texture person as very needy.
How do Psychopaths Score on the Rorschach Test?
While one does not determine whether someone is psychopathic based on the Rorschach, it does add to our understanding of the individual.
Psychopaths produce Rorschach patterns consistent with their self-centeredness, borderline or psychotic personality organization (primitive defenses, etc.) and impaired interpersonal relationships.
The Rorschach can score primitive defenses such as projective identification, splitting, devaluation, and idealization. The difference between emotional projection and projective identification is that in projective identification there is a cycle created in reacting to the card. It is not only an angry monster (projection) but an angry monster with a club coming after me (not only is the aggression projected onto the blot but it returns to haunt the person). This defense operates in cases of stalking behavior and becomes a key process that must be addressed in all treatment.
For example, a prisoner said to Carl, “You would like to be there when I get to the gas chamber and watch it,” as the prisoner has a one-sided smile. He was projecting a sadistic persona onto Carl, in that he would enjoy watching a person suffer. Carl would confront the defense of projective identification, “You know what Travis, I would like to be there, but I would actually be quite sad that you chose to waste your life in such an irresponsible manner. I would be sad about that, just as I would be for any waste of a life.” Travis scratches his head and is puzzled because rather than becoming angry or frustrated (accepting the patient's sadism and acting accordingly) I am breaking up the projective identification cycle (confronting the defense).
In the audio, David wondered if it would be better to respond to the prisoner with, “I would think it would be distressing, to think I would take joy in your suffering. I am wondering if you believe I would be thinking about that 100% or if you question it at all.” Interestingly, with further reflection, this is actually not empathy because the one-sided smile the patient had when he said that Carl would like to watch him suffer suggests the patient’s sadistic core might not feel distress regarding having Carl watch him suffer with pleasure, but rather has pride that he “knows” Carl would have a sick enjoyment in his suffering. This “knowing” is, of course, the projection of himself onto Carl. If the client had a one-sided smile like this, a more accurate empathic statement might be, “I can see you are taking pride in thinking you know me well enough to think that I would want to watch you suffer.” This is a good example of how using microexpressions can guide a deeper empathy. (check your abilities to read microexpressions: here)
A general tenet purported by Dr. Otto Kernberg suggests confronting defenses within borderline personality organization and offering interpretations for narcissistic personality structure. This serves not as a hard and fast rule but only as a guide.
Confrontation does not come with anger or raising one’s voice, but in pointing out the inconsistencies with the hope that it helps their mind become more organized and not have so many faulty narratives. Show that you can outthink them and know the game they are trying to play. In part criminal thinking serves to aid the individual in maintaining an ideal self image. All issues must be considered when intervening with these difficult individuals.
Male
The primary personality style of the male psychopaths can be understood as malignant narcissism. They use devaluation, manipulation, and use of others to bolster their grandiose sense of self worth. They are detached and have a heightened self-focus that leads them to have a lack of attachment. They are loners by choice. On the Rorschach they tend to be higher on measures of self-focus, lack of attachment, lack of anxiety, poor interpersonal relationships that are infused with aggression, and primitive defenses.
Female
Female psychopaths have much greater affect (what we call pseudo-affect -- Smith Gacono, Cunliffe, 2021) than male psychopaths. They don’t have the grandiose sense of self that males do; their style is consistent with malignant hysteria (pollyannaish denial, rapid response of thought into emotion).
Some examples of rapid responses of thought into emotion include impressionistic responses, including “it looks like rain”, “it looks like snow”, “it looks like depression”. They also have a lot of abstractions, like “it could be a sign of this or a sign of that” which highlights their impressionistic style of speech (lacking in details).
They lack the insight to detail and have a positive outlook on things while denying the bad. When you challenge their personality and point out the bad, they react with anger or negativity. This occurs because they are using you to regulate their own emotions. Within the Rorschach test they use a lot of abstraction.
They also exhibit a pseudo-dependency wherein they need others to aid in managing emotions and mirroring to them that they are good.
The male psychopath looks in the mirror and sees a king, the female gazes in the mirror and sees a picasso like image of a damaged self.
Caveats
Don’t attempt to understand antisocial and psychopathic patients within the context of non-patient personality structure. Don’t fall victim to the logical fallacies involved in attempting to understand pathological functioning with the context of normal functioning. You may ask, “Isn’t it true that everyone wants, is, etc.?” We are not talking about everyone. This demonstrates a lack of empathy and one's own wishful projections.
We don’t have personality disorders.
We don’t rearrange our life around maintaining an image that does not exist.
Two people put into the same circumstance are not going to do the same thing.
Understand that the way they view the world is very different from the way people without personality disorders view it. The things that are being equated here are for clinical patients, not the normal population. You have to take the context of the situation and make your assessment on that. Otherwise, it is just speculation.
Our perceptions cannot be projected onto people without the context of their personality disorders and prior history. Consider when one says well don’t we all want… relating it to psychopathic rapists. This suggests that we are all equally prone to breaking into houses, stealing womens underware as trophies, viewing s/m pornography religiously, forcing others into violent sexual behavior. You can not separate the question form the individual's history and context. It makes absolutely no sense to ask this type of question.
Summary
Dr. Gacono recommends these three things:
Don’t let people talk you out of your clinical observations and intuitions.
Consider learning about ways of testing your observations and intuitions.
Consider that a lot of research has bias and needs evaluation of its methodology prior to accepting its conclusions (see Smith, Gacono, & Cunliffe, 2021).
Dr. Puder’s conclusions:
Psychopathy is not a diagnosis. As measured by the PCL-R, psychopathy is one issue used as part of an assessment battery to answer questions like is this criminal at high risk of committing violent offenses.
Pointing out discrepancies can be a way to help this population organize their personality and help them feel better organized. As therapists, we need to know that not everyone thinks or functions like us. Projection of our own world view onto others creates a number of problems that interfere with effective treatment/interventions.
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