Clinicians' perspectives on the treatment of psychopathic and borderline personality disorders: Identifying current strategies to better inform future treatment directions

Psychopathic personality disorder (PPD) is associated with increased risk for adverse outcomes, including perpetration of violent crime. Yet no empirically supported treatments exist which specifically target symptoms of PPD and the literature on the treatment of PPD is fraught with methodological inadequacies. Pessimism reigns supreme regarding the treatment of PPD. Given the absence of a sound research base, the present study was designed to survey mental health professionals (MHPs) to determine their attitudes and experiences with respect to the treatment of PPD. Survey data from 150 MHPs who answered questions about the treatment of PPD were compared to data from 132 MHPs who answered similar questions about the treatment of BPD. MHPs were asked about their training and attitudes toward PPD or BPD, and their experiences treating a specific patient with PPD or BPD. Results indicated that MHPs had significantly more negative attitudes toward treating PPD than BPD, and these negative attitudes were associated with perceptions of poorer treatment outcomes for both PPD and BPD patients. Despite these nuances, 77% of MHPs reported some improvement in their patient with PPD’s symptomatology, compared to 90% of MHPs in the BPD group. Reported symptom improvement of specific PPD and BPD patients was not associated with MHP’s characteristics or the characteristics of patients, with one exception (e.g., comorbid acute mental illness was associated with reports of more negative treatment outcome for BPD patients). Reported improvement in the symptomatology of specific PPD and BPD patients was associated significantly with characteristics of the treatment (e.g., more time spent in treatment), and with reports of therapy interfering behaviours by patients (although the pattern of associations was different for PPD and BPD patients; e.g., manipulative behaviour was significantly associated with reports of poor treatment outcome for PPD patients, but not for BPD patients). Overall, the findings suggest that extreme clinical pessimism regarding the treatment of PPD may be unwarranted and that, with appropriate treatment, symptoms of PPD may improve. The implications of the findings for the development, implementation, and evaluation of treatments for PPD are discussed.