Treatment Planning With the Psychopathy Checklist

International Journal of Offender Therapy and Comparative Criminology Treatment Planning With the PCL-R

Treatment Planning With the Psychopathy Checklist–Revised (PCL-R) James L. Loving Abstract: The Psychopathy Checklist–Revised (PCL-R) is an essential component of any assessment protocol within forensic and correctional settings. Both nomothetic and idiographic interpretations aid the clinician in screening and treatment planning. Whereas the PCL-R can be effective in identifying those who are at highest risk of disrupting treatment efforts and jeopardizing the safety of those around them, through item analysis, it also provides clues to the nonpsychopath’s unique treatment needs. Specific recommendations are offered regarding the implementation of the PCL-R for screening and treatment planning, and illustrative case examples are provided to enliven essential points.

At first glance, this topic conveys an oxymoron of sorts. The Psychopathy Checklist–Revised (PCL-R) (Hare, 1991) is the foremost assessment tool for measuring psychopathy, which is widely viewed as antithetical to treatment amenability. In fact, historically pessimistic conclusions about treating psychopaths (e.g., Cleckley, 1976) are supported by the extant research (Meloy, 2001). Any discussion of “successful methods currently in existence for treating psychopathy” would be quite brief (Gacono, Nieberding, Owen, Rubel, & Bodholdt, 2001). Similarly, if the only use of the PCL-R were to detect psychopaths, the instrument’s contributions to treatment planning would be extremely limited (Gacono, 1998, 2000b, 2000c; Gacono et al., 2001). The PCL-R, however, provides valuable data that can inform treatment planning in forensic or correctional treatment settings for offenders regardless of psychopathy level.1 As one component of an assessment protocol, the PCL-R can assist with screening, program implementation, and decision making throughout the course of treatment. In this article, I provide a brief overview of the PCL-R literature and then outline the empirical findings that inform treatment planning at a nomothetic level. That is, what does an individual’s PCL-R total score imply for treatment planning? Next, idiographic applications of the PCL-R, including a method for comparing discrepancies across factor scores and item scores, are discussed. Idiographic understanding is especially relevant to the PCL-R’s use with nonpsychopaths, as this heterogeneous group of individuals are often grouped together under the rubric of Antisocial Personality Disorder (APD) (American Psychiatric Association [APA], 1994) in a way that contributes little to individualized treatment planning. Throughout, I balance empirical findings with illustraNOTE: The author may be contacted at the address that appears at the end of this article or at [email protected]. International Journal of Offender Therapy and Comparative Criminology, 46(3), 2002  2002 Sage Publications

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tive case examples and clinical experiences to maintain a practical and applied focus.

THE PCL-R AND PSYCHOPATHY Psychopathy has been defined (Cleckley, 1976; Hare, 1991) as a characterological condition marked by a persistent pattern of antisocial or impulsive behaviors as well as a constellation of personality traits most closely akin to those of Narcissistic Personality Disorder (APA, 1994). With adult offenders, psychopathy has been associated with many important outcome variables, so that its assessment with the PCL-R has been deemed essential practice for clinicians in forensic and correctional settings (Gacono, 2000b, 2000c; Hart, 1998). This is especially true in the context of violence risk assessment, where the PCL-R has been incorporated as an integral component of prominent actuarial assessment methods (e.g., Quinsey, Rice, Harris, & Cormier, 1998). The PCL-R, which has been referred to as the “gold standard” among psychopathy assessment methods (Fulero, 1995), is a clinical rating scale that requires thorough review of collateral records and an in-depth semistructured interview.2 It is composed of 20 items corresponding to features believed to be present in the prototypical psychopath. Each item is scored on a 3-point scale (0, 1, or 2) based on how fully the individual meets the item’s operationalized criteria (Hare, 1991). Total scores range from 0 to 40, and in research settings, a score of at least 30 is traditionally used to designate the presence of psychopathy. A wealth of empirical literature demonstrates psychopathy’s association with numerous problematic outcome variables. In samples of adult male offenders,3 psychopaths identified by the PCL (Hare, 1980) or PCL-R have been shown to engage in more frequent and varied criminal offenses (Hare & Jutai, 1983; Hart, Kropp, & Hare, 1988), more violent offenses (Hare & McPherson, 1984), higher rates of reoffending upon release to the community (Hare, McPherson, & Forth, 1988), and more serious and persistent misbehavior while institutionalized or incarcerated (Gacono, Meloy, Sheppard, Speth, & Roske, 1995; Gacono, Meloy, Speth, & Roske, 1997; Heilbrun et al., 1998). Additionally, the few available treatment outcome studies suggest a poor prognosis using traditional methods (Ogloff, Wong, & Greenwood, 1990; Rice, Harris, & Cormier, 1992; Young, Justice, Erdberg, & Gacono, 2000). Specifically, high levels of psychopathy predict poor treatment response. Consistent with traditional conceptualizations of psychopathy (Cleckley, 1976), the PCL-R consists of two stable, oblique factors (Hare, 1991; Harpur, Hare, & Hakstian, 1989). Factor 1 items assess interpersonal and affective features such as superficial charm, lack of empathy, and shallow affect, which collectively are believed to fuel and sustain the typical psychopath’s long-standing history of antisocial behavior. This persistent pattern of impulsive and antisocial conduct is the essence of Factor 2, which includes items such as early behavior problems, poor

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behavioral controls, and irresponsibility. Factor 1 and Factor 2 scores have shown differential associations with various outside variables; most relevant to this discussion is that Factor 2 is closely related to ASPD diagnosis, whereas Factor 1 is not as highly correlated with ASPD.4 Because PCL-R assessment is a time-intensive endeavor, a screening version (PCL:SV) (Hart, Cox, & Hare, 1995) has been developed for use in forensic and clinical settings. The PCL:SV consists of 12 items drawn from the PCL-R, and the two instruments involve similar procedures for data collection and item scoring. However, use of the screening version, including record review, interview, and scoring, may be completed in less than 90 minutes (Hart et al., 1995), whereas the PCL-R may require much more time.5 The PCL:SV yields a two-factor structure similar to its predecessors, and extremely low scores (i.e., ≤12 of 24 possible points) have been shown to rule out the presence of psychopathy with a low false-negative rate (Hart et al., 1995). Higher scores alert the clinician that a more in-depth assessment of psychopathy is warranted. Keep in mind that the PCL:SV was not designed as a tool for thorough assessment of psychopathy, but it may be used in situations when comprehensive assessment is impractical and brief screening is clearly sufficient (Bodholdt, Richards, & Gacono, 2000; Hart et al., 1995).

NOMOTHETIC APPLICATIONS Regardless of psychopathy level, certain broad guidelines are applicable whenever clinicians are conducting treatment planning with forensic or correctional populations. Because of the high base rate of ASPD, the typically adversarial relationship between patient and institution, and other factors, treatment planning in these settings poses particular challenges. As Young, Justice, Erdberg, and Gacono (2000) pointed out, “Attempts at either management or treatment with all ASPD patients should: (a) occur only after careful assessment (Gacono, 1998), (b) utilize approaches with proven efficacy, and (c) be conducted in settings that ensure the safety of the clinician and other patients” (p. 315). These broadly applicable principles are especially salient when working with psychopathic offenders, so specific assessment of psychopathy with the PCL-R can be invaluable to treatment planning. In any offender treatment setting, it is critical to identify high psychopath levels in patients as soon as possible and to tailor programming accordingly. This is in the best interests of both the patient and the integrity of the treatment milieu. High PCL-R scores have been associated with higher rates of violence, both in the institution and following release to the community (Hare & McPherson, 1984; Heilbrun et al., 1998; Rice et al., 1992; Young et al., 2000). PCL-R psychopaths also have been shown to be more likely to engage in other forms of institutional misconduct, such as malingering, initiating sexual relations with female staff, and dealing drugs (Gacono et al., 1995, 1997). Collectively, these types of behaviors

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can have a negative impact on the overall effectiveness of institutional management and treatment, as staff or patients are lured into maladaptive behaviors or as they become less active and involved in treatment due to legitimate fears over physical safety (see Kosson, Gacono, & Bodholdt, 2000, for managing countertransference reactions to psychopathic patients). To reduce disruptions to institutional functioning, screening incoming offenders is essential. In some settings, large offender populations, inadequate availability of records, and other realistic constraints make it impractical or impossible to use the PCL-R for initial screenings. Insofar as it is feasible, the PCL:SV may be used to screen larger numbers of incoming offenders. At the same time, a smaller number of patients may be targeted for more in-depth assessment using the PCL-R (Gacono, 2000c). Certain factors, such as a patient’s documented prior history (e.g., numerous violent offenses, history of escape behavior) or persistent problematic behavior that emerges during detention, signal the need for PCL-R assessment (Gacono, 2000c). This selective use of the PCL-R still requires an investment of professional training and time, but it is expected to yield substantial benefits by identifying the small proportion of the population who are at risk of causing the greatest physical harm and social disruption in the long term. As emphasized elsewhere (e.g., Gacono et al., 2001), very few well-designed treatment outcome studies have controlled specifically for psychopathy. Rather than studying outcomes for psychopathic versus nonpsychopathic offenders, research has traditionally been hindered by the inclusion of broader offender groups, such as violent offenders or those with ASPD. However, available findings appear to be consistent with the “therapeutic nihilism” (Lion, 1978) that has traditionally pervaded the mental health community with regard to psychopaths’ prognosis for change, at least using currently available treatment modalities. For example, in studies investigating the effectiveness of therapeutic milieu interventions (found in many correctional or forensic facilities) to reduce violence or criminal activity, psychopaths showed less motivation for treatment, less effort, less improvement, more problematic conduct, and higher likelihood of premature termination than their nonpsychopathic counterparts (Ogloff et al., 1990; Rice et al., 1992; Young et al., 2000). In fact, in one of these studies (Rice et al., 1992), results suggested treatment might actually have a negative impact on psychopaths, in that psychopaths who received treatment subsequently reoffended upon release at a higher rate than did untreated psychopaths. These findings, though preliminary, bode poorly for the prognosis of psychopaths in response to currently available treatment approaches. Until innovative, empirically supported interventions are developed, treatment planning for these individuals must include a cautious and realistic assessment of prognosis and progress. Treatment planning for offenders with elevated PCL-R scores involves management considerations and includes ensuring that the facility provide sufficiently high levels of structure to reduce the threat of violence and to control other


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disruptive behaviors. A transfer to a higher security setting may be necessary, as attempting to work with highly psychopathic individuals under less-thanadequate levels of structure can jeopardize both the integrity of the treatment and the physical safety of the parties involved (Gacono et al., 2001; Meloy, 1988). Other lines of PCL-R research provide additional information about offenders who present elevations on the PCL-R, which may assist in more informed treatment planning for these individuals. Numerous studies have explored the cognitive, affective, and linguistic experiences of psychopaths, and although a detailed discussion is beyond the scope of this article, they can be found elsewhere (e.g., Hare, 1998c; Newman, 1998; Steuerwald & Kosson, 2000). At the risk of oversimplifying, it is clear that psychopaths (PCL-R ≥ 30) tend to process information, especially affective and linguistic information, in ways that are different from nonpsychopaths. For example, because they are less acutely attuned to their own emotional experiences or those of others, psychopaths’actions are less likely to be impacted by emotional cues related to guilt or anxiety. Interventions that intend to increase offenders’ empathy for victims or have them process emotional experiences may be contraindicated for psychopaths (Lösel, 1998), and it has been suggested that such interventions only help to improve psychopaths’skills at “faking” emotions in interpersonal situations. A behavior management model that emphasizes containing and reducing problematic behaviors is perhaps the most prudent way to conceptualize goals for these individuals. This includes the use of behavioral interventions emphasizing the immediate and consistent implementation of sanctions that are sufficiently strong and meaningful to the offender. Traditional conceptualizations of the psychopathic offender and the nascent treatment outcome literature suggest that his negative behavior is more likely to be altered through intensive behavioral containment strategies and by imparting interventions through the lens of “enlightened self interest” (i.e., helping the offender discover “what’s in it for me”; see Young et al., 2000) than by attempting to modify the affective and characterological features that predispose him to those types of behaviors. In some situations, it may be necessary to exclude psychopathic offenders from traditional interventions not only because they are not expected to benefit personally, but also because they are expected to have a detrimental impact on the treatment progress of their peers. At the other end of the continuum, low PCL-R total scores are not in and of themselves particularly enlightening in terms of treatment planning. Paraphrasing Hart (1998) to extend his conclusions about the PCL-R in violence risk assessment to the current discussion of treatment planning, the presence of severe psychopathic traits suggests a conclusion of poor treatment amenability, but the absence of psychopathy does not compel a conclusion of high treatment amenability. This is because patients with low (or moderate) psychopathy levels comprise a vastly heterogeneous group whose risk factors and treatment needs are quite diverse. As any clinician can attest, patients can be treatment resistant for

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reasons that are entirely independent of psychopathy, although it is possible to lose sight of this fact when overevaluating psychopathy at the expense of other conditions. For example, an ASPD patient with a PCL-R score of 20 may have a concurrent sexual deviation and severe drug and alcohol problems that complicate the clinical picture and significantly impact prognosis (Gacono, Nieberding, et al., 2001).

IDIOGRAPHIC APPLICATIONS Most discussions of the PCL-R emphasize nomothetic interpretation, especially the implications of elevated PCL-R scores, but idiographic PCL-R interpretation has been incorporated elsewhere (Gacono, 1998, 2000a). Offenders are a vastly diverse group who differ widely in terms of their risk factors for violence and recidivism, their treatment needs, and their obstacles to successful behavioral management or treatment (Gacono, Nieberding, et al., 2001). Nomothetic use of the PCL-R is most useful for treatment planning with psychopathic offenders, because when psychopathy levels are high (i.e., PCL-R total score ≥ 30), a predictable constellation of features converge to present expectable obstacles to treatment across individuals. Idiographic use of the PCL-R can add important individualized data to the treatment planning process, especially when psychopathy levels are low to moderate (Gacono, Nieberding, et al., 2001). When an individual’s PCL-R total score is less than 30, scores within the PCL-R (i.e., factor scores and item scores) are generally more variable, so that comparing these scores to each other adds to a richer understanding of the person and his unique areas of need. This approach is akin to ipsative interpretation of intellectual test data, where identifying subtest scores that are significantly high or low compared to the person’s overall performance can yield rich hypotheses about his particular intellectual strengths and weaknesses (see, e.g., Kaufman, 1994). Extending the analogy of intelligence testing, in some circumstances (e.g., screening), a single global score such as a Full Scale IQ, is sufficient to inform decision making. However, in other situations or in particular cases, this isolated score fails to capture the individual with sufficient depth and richness to inform treatment planning. The clinician may then compare data points at increasingly refined levels, comparing Verbal IQ versus Performance IQ, other global factor scores versus each other, and various subtest scores relative to each other. Similarly, a PCL-R total score is sometimes sufficient (e.g., for screening, or when the total score is extremely high or very low), but more often it is a starting point from which the clinician moves toward increasingly refined hypotheses about the individual. PCL-R data points can be compared on at least two levels beyond nomothetic interpretation of the total score: factor scores and item scores. The two-factor structure of the PCL-R and other psychopathy checklists6 allows a richer understanding of the individual. This is especially true when one factor score is much higher than the other, which is most likely to occur in cases


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where the total score is moderately elevated. Less research has been devoted to interpreting the PCL-R at the factor level, so specific cut scores and similar data are not available. Interpretation is qualitative and is only advisable when the discrepancy is noticeably large. Consider two offenders, both obtaining a PCL-R total score of 19. Mr. A earns a Factor 1 score of 14, which is extremely high (i.e., out of a possible 16) and accounts for most of his total score. Although he may demonstrate fewer behavioral problems and less criminal activity (e.g., PCL-R Item 20 < 2) than many inmates, problematic interpersonal and affective features are prominent (glibness, grandiosity, to impaired remorse, empathy; Items 1, 2, 6, and 8 each = 2). The egocentricity and interpersonal detachment that accompany this high Factor 1 alert the clinician that Mr. A may be less amenable to traditional interventions. In contrast, Mr. B’s Factor 1 score is only 5, so that most of his total score derives from Factor 2 items. His behavioral history is marked by long-standing conduct problems (PCL-R Items 12 and 18 both = 2) and multiple legal contacts (Item 20 = 2), but he displays a relative absence of antisocial attitudes or psychopathic object relations (Items 1, 2, 6, 7, 8, and 16 each < 2). The clinician looks to other individual and environmental risk factors to understand Mr. B’s “impulsivity” and subsequently devises treatment to target these specific factors.

Individuals with high Factor 1 but low Factor 2 scores may be deceptively high risk and treatment resistant (though not as much as those who are high on both factors). Although their overt behavior is relatively less problematic, they manifest ingrained personality features such as heightened narcissism (high scores on PCL-R items reflecting glibness and grandiosity), a dismissive or aggressive interpersonal stance, and/or emotional detachment (items related to lack of remorse, callous lack of empathy, and failure to take responsibility for one’s actions) that are generally incompatible with treatment success. In some cases, they curb their behavior sufficiently (e.g., impulsivity item score not elevated) to impress clinicians or to earn release to the community, only to persist in subthreshold antisocial interactions later. In treatment situations, clinicians must be acutely sensitive to efforts by these offenders to disingenuously put on the impression of treatment progress to “get over on” the clinician (Bursten, 1973) or to achieve an ulterior goal such as release. At the conceptual extreme are individuals Widom (1977) termed successful psychopaths, who possess notable antisocial personality features but often avoid the criminal system altogether because they manage their behavior effectively and channel their antisocial proclivities toward socially acceptable, entrepreneurial endeavors. Individuals with the opposite PCL-R factor configuration (i.e., low Factor 1/high Factor 2) are at risk for different reasons. They often present as the “common criminal” or habitual offender and easily meet the diagnostic criteria for ASPD, often with concurrent Axis I conditions including depression and substance abuse. Positively, many of these impulse-ridden offenders (e.g., PCL-R items for proneness to boredom, impulsivity, and poor behavioral controls = 2) have a capacity to connect with others and some awareness of their emotional

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experiences (shallow affect < 2), including fragmented guilt or remorse (lack of remorse or guilt < 2), and these factors facilitate treatment through traditional interventions when they are effectively implemented. In these cases even more than others, initial treatment planning must include a careful screening of co-occurring conditions that contribute to the repeated behavioral dysfunction (e.g., substance abuse as a critical risk factor for violence and recidivism; see for example, Monahan et al., 2001). They have displayed a long-standing pattern of maladaptive and/or antisocial behavior and continue to be at risk of violence and/or reoffending until they change their attitudes and behaviors through interventions such as medication management (for depression and poor anxiety tolerance) and other traditional treatment methods targeted toward their proneness to boredom, impulsivity, anger problems, and substance-abuse-related syndromes. Item analysis provides yet another layer of idiographic interpretation (Gacono, 1998, 2000a). Beyond serving as a guide to the presence or absence of psychopathy (taxon) or as one point in an actuarial risk assessment, PCL-R data, specifically clinical item and item cluster analysis, provides valuable information concerning treatment planning and characterological diagnosis in “nonpsychopathic offenders.” (Gacono, 2000a, p. 407)

Conclusions generated at this level must be viewed as even more tentative than those from analysis of factor scores or total scores, because reliability estimates for scores at the item level are expectably lower than reliability of scores at the factor or total-score levels (Hare, 1991). Keeping the need for caution in mind, the clinician can generate hypotheses about an individual’s specific treatment needs by noting the pattern of PCL-R items’ scores across the protocol. Item analysis is expected to yield varying degrees of insight for an offender’s individualized treatment planning, depending on the particular items involved. For example, whereas a score of 2 on Item 1 (glibness/superficial charm) does little to suggest a specific treatment modality, an offender who scores a 2 on Item 10 (poor behavioral controls) without exception will need some form of anger management instruction. In the same fashion, whereas a score of 2 on PCL-R Items 1 and 2 (glibness, grandiosity) suggests narcissistic traits or even a narcissistic personality disorder, a score of 0 on Items 12 and 17 (promiscuous sexual behavior and short-term marital relationships, respectively) in a nonpsychopathic offender with a very low Factor 1 composite score is likely to signal the need for interpersonal skills training, as this “profile” is consistent with a schizoid or avoidant offender (Gacono, 1998). Even for those who earn high PCL-R total scores, item analysis may identify areas of particular strength that can be capitalized on in treatment, working to combat the negative “halo effect” that might otherwise dampen treating professionals’ efforts.


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Mr. C, who was seen in a forensic psychiatric hospital, had a lengthy history of offenses, as well as instances of verbally and physically aggressive behavior. As part of an assessment to assist with developing a behavior management plan, the PCL-R was administered, and Mr. C obtained a moderately high total score of 28. Inspection of his item scores showed mostly 2-point scores, but most notable were lower scores he received on items related to poor behavioral controls (Item 10 = 1) and impulsivity (Item 14 = 1). In conjunction with other assessment findings, this data supported the conclusion that Mr. C’s aggressive actions were often purposeful and goal directed, even though on the unit his “outbursts” had initially been seen as uncontrolled and spontaneous. The treatment team used this information to tailor treatment plans—for example, reducing their previous emphasis on developing anger management skills and instead working with Mr. C to develop effective but less harmful ways of getting his needs met by other people. When Mr. C’s behavior became disruptive on the unit, staff were alert to the likelihood that he was acting out in a goal-directed manner, so they were less inclined to be derailed by his protests that he had “lost it.”

For individuals whose PCL-R total score falls within the low or moderate range, item analysis may suggest specific areas of concern. Again, without attention to specific item content, clinicians’ perceptions of the patient may be skewed by a halo effect, which in this situation could lead to an underestimate of his risk. After a period of incarceration following multiple assault charges, Mr. D was being considered for release to the community.7 In conjunction with earlier treatment planning efforts, he had been assessed using the PCL-R. He earned a relatively low total score of 13, and certain no-point items were seen as positive prognostic indicators (e.g., zeros on lack of remorse or guilt [Item 6] and lack of empathy [Item 8]). These findings were consistent with treating clinicians’ impressions of Mr. D as genuinely repentant for his past behaviors and motivated to pursue a prosocial lifestyle. However, 2-point scores on items involving need for stimulation (Item 3), lack of realistic goals (Item 13), and impulsivity (Item 14) raised specific concerns about Mr. D’s ability to follow through with positive plans when released to the community. In connection with other interventions, intensive efforts were made to develop highly specific and reasonable short- and long-term goals for his eventual release. Also, Mr. D was assisted in developing focused and reasonable plans for remaining substance free, structuring his daily activities effectively, and identifying available resources to meet those goals. Relapse prevention efforts, although critical for all offenders prior to release, were seen as a particularly vital focus of Mr. D’s treatment.

PCL-R item analysis, when integrated with data from other sources (Gacono, 1998, 2000a), can yield richly individualized yet credible information to understand the individual and his unique treatment needs. As noted by Gacono (1998), all PCL-R data represent a global quantification of historical and dispositional variables, which require further elucidation through the use of other personality instruments, such as the Rorschach, to gain a fuller understanding of an individual patient.

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PCL-R administration provides a standardized method for quantifying and organizing observable attitudes and behaviors. . . . The Rorschach adds to and refines hypothesis generated by the PCL-R . . . PCL-R items quantify observable attitudes and documented behaviors, whereas Rorschach data correlate with them. The PCL-R and Rorschach assess different but complementary personality dimensions. (pp. 51-52)

CONCLUSION Despite constraints on time and financial resources and related limitations that pressure professionals to reduce the frequency and depth of their assessment efforts, assessment is a critical component of any behavior management or treatment program. Psychological assessment can be a critical and cost-effective component of well-designed treatment, as its ability to provide a more comprehensive and sound understanding of the individual guides the selection of appropriate interventions and the monitoring of subsequent progress (Meyer et al., 1998). In forensic and correctional settings, the need to incorporate psychological assessment data is particularly critical, because clinical judgment is even more compromised by the deception and poor insight that characterize so many of the patients encountered there. The PCL-R and PCL:SV can be invaluable sources of information as part of an approach that seeks to understand the individual across multiple domains and through multiple methods (Monahan et al., 2001). Although these tools require an initial investment in terms of staff training and administration time, the long-term costs of insufficient screening and assessment are much greater, as they could contribute to inappropriate decision making that compromises effective treatment and risks the physical safety of patients and staff alike (Gacono, 2000b, 2000c).

NOTES 1. Although research studies generally treat psychopathy as a categorical, all-or-nothing variable, in applied settings the construct is often viewed dimensionally (i.e., as existing along a continuum of severity; Bodholdt, Richards, & Gacono, 2000; Gacono, Loving, & Bodholdt, 2001). When the term psychopath is used, I am referring to individuals at the extreme end (i.e., PCL-R ≥ 30) of a continuous spectrum. 2. The PCL-R may be scored reliably using extensive records alone (Grann, Långström, Tengström, & Stålenheim, 1998; Wong, 1988) but never from interview alone (see Gacono, 2000c, and Hare, 1998a, for guidelines regarding the clinical and research applications of the instrument). 3. Suggestions throughout this article are made for male offender samples. With additional research, many of these principles might be applied to other populations, such as female offenders, juvenile offenders, and nonoffenders in the community. 4. Most offenders carrying an Antisocial Personality Disorder (ASPD) diagnosis earn high Factor 2 scores but not necessarily high Factor 1 scores. ASPD is exceedingly common in offender populations (with estimates as high as 50% to 80%, depending on the setting), but psychopathy requires high


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scores on both Factors 1 and 2 and so is much less common (PCL-R ≥ 30 in approximately 15% to 25% of offenders). 5. Note that Gacono’s (2000b) Forensic and Clinical Interview Schedule for the PCL-R can be completed in approximately 45 minutes after a complete review of records. 6. Recently, Cooke and Michie (2001) provided evidence for a three-factor hierarchical model of PCL-R psychopathy. Still, the dominant model remains the previously replicated two-factor solution for the PCL and PCL-R (Hare, 1991; Harpur et al., 1989); a similar two-factor structure has been revealed for the PCL:SV (Hart et al., 1995). 7. Other articles in this series discuss the application of particular instruments not only to screening and treatment planning but also to monitoring treatment progress. Because the PCL-R assesses lifelong features, including several static factors, it is not useful as a method of gauging treatment progress. Scores are not expected to change significantly over time. This is one legitimate criticism of the PCL-R (see Hare, 1998b) and one of several reasons to reiterate the need for integrative assessment rather than overreliance on a single instrument for any purpose.

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