Understanding Female Offenders: Psychopathy, Criminal Behavior, Assessment, and Treatment

By Jason M. Smith, Carl B. Gacono and Ted B. Cunliffe

According to the Sentencing Project, between 1980 and 2017, the number of incarcerated women increased by more than 750%, rising from a total of 26,378 in 1980 to 225,060 in 2017 and the number continues to rise. Dealing with incarcerated women and specifically psychopathic women can be challenging. Understanding Female Offenders: Psychopathy, Criminal Behavior, Assessment, and Treatment provides readers with a better conceptualization of the psychopathic/non-psychopathic female. This includes better ways of interviewing, assessing, and treating these women, and clinical caveats with case examples to assist with clinical applications. This is the only comprehensive resource that provides specific knowledge about female offenders, particularly on female psychopathy and assessment.

• Describes the differences between ASPD and psychopathic women and men
• Presents PCL-R, Rorschach, and PAI data on female offenders, female psychopaths, and female sex offenders
• Reviews the current literature on female psychopathy studies
• Provides in-depth female offender case studies
• Discusses common biases in diagnosing, treating, and assessing in forensic settings with female offenders

• Language: English
• Publisher: Academic Press
• Release date: Mar 16, 2021
• ISBN: 9780128225851

Jason M. Smith

Jason M. Smith, PsyD, ABPP has worked in county jails, forensic private practices, and forensic hospitals. He completed an internship in the Kentucky Department of Corrections focusing on assessing, treating, and researching incarcerated offenders (mainly women). Since 2014, he has worked as a licensed Clinical Psychologist for the Federal Bureau of Prisons , where he has continued treating, assessing, and managing incarcerated women. With his co-authors, he has published on female offenders/psychopathy as well as theoretical Rorschach articles. He is on the Board of Assessors for Rorschachiana. He is a member of the American Board of Professional Psychology (ABPP) in Clinical Psychology. Dr. Smith has presented his research and workshops on assessing and treating female offenders in the US and Internationally. Dr. Smith was also awarded the APA Division 18 Criminal Justice Section Outstanding Dissertation Award (2014) and the SPA John E. Exner Scholar Award (2019).

Book preview

Understanding Female Offenders

Psychopathy, Criminal Behavior, Assessment, and Treatment

Jason M. Smith, PsyD, ABPP

Chief Psychologist, FBOP, WV, USA

Carl B. Gacono, PhD, ABAP

Retired Clinical and Forensic Psychologist, NC, USA

Ted B. Cunliffe, PhD

Clinical and Forensic Psychologist, Private Practice, FL, USA

Table of Contents

Cover image

Title page

Copyright

Dedication

Biographies

Acknowledgments

Chapter 1. Introduction

The Hare Psychopathy Checklist-Revised (PCL-R): Our Independent Measure

The Rorschach: Our Dependent Measure

Caveats for Understanding the PCL-R & Rorschach

Two Examples

Understanding Female Offenders

Chapter 2. Understanding Bias in Diagnosing, Assessing, and Treating Female Offenders

Science and the Scientific Method

Logic & the Scientific Method

Logical Fallacy

Political Correctness

Clinical Judgment, Implicit Bias, & Cognitive Heuristics

Confirmation Bias

Illusory Correlation

Suggestibility

Misinformation Effect

Racial Bias

Gender Bias

A Case of Bias

Myths about Female Offenders and Psychopaths

Summary and Discussion

Chapter 3. Understanding Antisocial and Psychopathic Women

Sociopathy, Antisocial Personality Disorder, & Psychopathy

Summary

Hysteria

Summary

Psychopathy Checklist-Revised (PCL-R)

PCL-R Studies With Females

Personality Assessment Inventory (PAI)

Summary

Rorschach

Summary

Our Female offender Study (N=337)

Psychopathic Females

Conclusion

Chapter 4. The Psychological Assessment of Female Offenders

Understanding Psychological Assessment

Issues in Assessing Female Offenders

Assessment Methods

Record Review

Clinical Interview

Intelligence

The Hare Psychopathy-Checklist-Revised (PCL-R)

Implications for Assessing Women with the PCL-R

Using the PCL-R in the Assessment of Female Offenders

PAI and Rorschach

Case Example: Katrina

Katrina’s PAI and Rorschach Assessment Summary

Katrina’s PCL-R Assessment

Conclusion

Chapter 5. Female Sex Offenders: Where Angels Continue to Fear to Tread

Personality Measures with Sexual Offenders

Our Female Sexual Offender Study

Case Examples

Summer’s Rorschach

Case Study II: Karen, a psychopathic sexual murderer

Karen’s Rorschach

Conclusion

Chapter 6. The Treatment and Management of Female Offenders

Clinical Issues with Antisocial Women

Female Psychopath Conceptual Model

Management versus Treatment

Treatment of Female Offenders

When to Treat?

Phase 1 Assessment of Treatability

Phase 2 Treatment Planning

Phase 3 Treatment Provision

Phase 4 Treatment Outcomes

A Treatment Example: The Case of Anna

Epilogue

Appendix A. The Clinical and Forensic Interview Schedule for the PCL-R: Adapted for Women

Appendix B. Descriptions of Eight Select Psychopathic Traits Evident in Women

Index

Copyright

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Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

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Dedication

We dedicate this book to those who have inspired us, provided clarity to our thinking, guided our research, and informed our applied work. We mention a few of them here:

Rorschach: Hermann Rorschach, Samuel Beck, Ernest Schachtel, David Rapaport, Merton Gill, Roy Schafer, Martin Mayman, Wayne Holtzman, Robert Holt, John Exner, Paul and Howard Lerner, Jeffrey Urist, Sidney Blatt, and Irving Weiner

Psychopathy: Robert Lindner, Hervey Cleckley, William and Joan McCord, William Reid, August Aichhorn, Samuel Yochelson, Stanton Samenow, Robert Hare, and George Partridge

Hysteria: Paul Chodoff, Henry Lyons, Theodore Millon, Mardi Horowitz, Aaron Lazare, and Gerald Klerman

Psychoanalytic/psychodynamic theory: Sigmund Freud, Otto Kernberg, Heinz Kohut, Melanie Klein, Anna Freud, Donald Winnicott, Wilhelm Reich, Charles Peterson, and Marvin Acklin

Biographies

Ted B. Cunliffe, PhD, is a Clinical and Forensic Psychologist licensed to practice in the State of Florida, and over the past 6   years, he has been in full-time private practice and provided expert witness services in various jurisdictions and courts within Florida and beyond (http://tedbcunliffephdllc.com/). He has provided assessment services and worked with forensic populations in a wide variety of settings including juvenile detention centers, adult prisons, juvenile probation, and outreach programs in the community for over 30 years. Specifically, he has served as a Staff Psychologist and Mental Health Director at a wide number of correctional facilities in Florida, California, and Canada. Further, he has provided expert witness services to the Florida, California, and Virginia courts in the areas of Competency to Stand Trial, Not Guilty by Reason of Insanity, Dangerousness, Death Penalty, Wrongful Death, Dependency, Mitigation, and Civil Litigation. His clinical and research interests include the forensic use of the Psychopathy Checklist-Revised, the Rorschach inkblot test, trauma-related disorders in a forensic context, domestic violence, stalking, criminal decision-making, dangerousness/violence risk assessment, and criminal recidivism. He can be contacted at [e-mail].

Carl B. Gacono, PhD, ABAP, was the Assessment Center Director at Atascadero State Hospital (CA) and the Chief Psychologist at the Federal Correctional Institution (Bastrop, TX), having worked over 20 years in correctional and forensic psychiatric facilities. He is the coauthor of The Rorschach Assessment of Aggressive and Psychopathic Personalities, senior editor of the Handbook of Forensic Rorschach Assessment, author of The Clinical and Forensic Interview Schedule for The Hare Psychopathy Checklist: Revised and Screening Version, editor of the Clinical and Forensic Assessment of Psychopathy: A Practitioner's Guide (first and second editions), and author or coauthor of more than 100 scientific articles and book chapters (https://www.researchgate.net/profile/Carl_Gacono). He received the Samuel J. and Anne G. Beck Award (1984) for excellence in early career research and the Walter G. Klopfer Award (2000). He is a member of the American Board of Assessment Psychology (ABAP) and a Fellow of the Society for Personality Assessment. As a noted artist, Dr. Gacono exhibits his paintings (see carlgaconoart.com and @carlgaconoart [Instagram]) and he has had several displayed on book covers including this one. Currently, Dr. Gacono maintains a consulting practice in Asheville, NC, where he lives with his son, Jackson. He can be contacted at [e-mail]. Visit maverickpsychology.com for our webinar trainings starting Summer 2021.

Jason M. Smith, PsyD, ABPP, has worked in county jails, forensic private practices, and forensic hospitals. He completed an internship in the Kentucky Department of Corrections focusing on assessing, treating, and researching incarcerated offenders (mainly women). Since 2014, he has worked as a licensed Clinical Psychologist (currently Chief Psychologist) for the Federal Bureau of Prisons ¹ where he has continued treating, assessing, and managing incarcerated women. With his coauthors, he has published on female offenders/psychopathy as well as theoretical Rorschach articles (https://www.researchgate.net/profile/Jason_Smith52). He is on the Board of Assessors for Rorschachiana, and he has received board certification from the American Board of Professional Psychology (ABPP) in Clinical Psychology. Dr. Smith has presented his research and workshops on assessing and treating female offenders both nationally and internationally. Dr. Smith was awarded the APA Division 18 Criminal Justice Section Outstanding Dissertation Award (2014) and the SPA John E. Exner Scholar Award (2019). He can be contacted at [e-mail]. Visit maverickpsychology.com for our webinar trainings starting Summer 2021.

Left to Right: Dr. Jason M. Smith, Dr. Ted B. Cunliffe, and Dr. Carl B. Gacono

This picture was taken on May 1, 2010, in Austin, Texas, at the Seminary of the Southwest after Carl gave PCL-R training. Jason was still a graduate student under the tutelage of Ted. Carl had been Ted's mentor during his graduate studies.

This marks the official beginning of this book.

W+ Ma.FC.FT+ 2 H,Sc 4.0 COP

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¹  

Opinions expressed in this book are those of the author and do not necessarily represent the opinions of the Federal Bureau of Prisons or the Department of Justice.

Acknowledgments

This book could not have been possible without my two coauthors, Drs. Carl Gacono and Ted Cunliffe; their insight, knowledge, mentorship, and friendship over the past 10   years have been invaluable not only for this book but also my career. I cannot thank you both enough, I am eternally grateful. I have enjoyed being the Scotty on this voyage. Two quotes best sum up our collaboration: Talent wins games, but teamwork and intelligence win championships and Some people want it to happen, some wish it would happen, others make it happen (Michael Jordan). I also want to acknowledge important people who have helped in my career, research, and/or this book, Eric Cohen, Rod Gillis, Michael DiTomasso, Ana Pi, Enna Taylor, Jackie Colorado, Josh Kaufman, Deb Coleman, Tanya Young, Brian King, Susan Brittain, Christy Jolly, Betty Banta, Kristen Schramm, Callie Blanton, Chris Piotrowski, Eric Lugo, Shannon Repine, Samantha Gsell, Sonya Humy, Melissa Ring, Charles Reshenberg, Patrick Fontan, Aaron Kivisto, Danielle McWatters, and Anne Andronikof. I also want to thank Joslyn Chaiprasert-Paguio, Sam Young, and Niranjan Bhaskaran at Elsevier and the Kentucky Department of Corrections ¹ . Also, Black Bear Burritos Evansdale in Morgantown, WV, where most of my writing over the past 6   years occurred. Finally, I would like to acknowledge my brother, Aiden, as well as my parents, Toni and James, who have helped me become the person I am today.

–JMS

I would like to acknowledge and thank my two coauthors, Drs. Jason Smith and Ted Cunliffe for this shared journey. As researchers/practitioners, we have shared a common vision. We have been committed to providing a road map to those professionals who work with these difficult individuals, a map that allows them to navigate through the mishmash of unscientific nonsense that plagues the current Rorschach/psychopathy literature. Seeking the truth is seldom a popular position. In fact, it can be a lonely one, as discovered by scientists before us, Dana Scully and Fox Mulder, and as noted by the master of logic himself, Sherlock Holmes, unwanted truths are not popular. Truly, Jason and Ted are two individuals who you would want in your foxhole (words of Lawrence Erlbaum), who you would want in your corner when it was time to go to the mattresses (Peter Clemenza), or who you would want to share the journey. Jason's dedication to a single topic (female psychopathy/Rorschach) is rare and has allowed me to complete a task begun, but not completed by Gacono and Meloy 1994—the extensive study of female psychopathy. On an even more personal note, I acknowledge my muse, Lynne Gacono (who died in 2015), and my son, Jackson Gacono. The former continues to inspire my painting, and the latter continues to teach me that whoever said God Created Men and Sam Colt Made Them Equal was incorrect, it is parenting that makes us equal.

–CBG

I would like to thank both of my coauthors for their support, steadfast diligence, and friendship over the past 10 years in the case of Jason and nearly 30 years in the case of Carl. Working together as a team against the storm of misinformation, bias, and pseudoscience, which seems to pervade the science of psychology these days, has been of inestimable value to me personally and professionally. Their fierce adherence to the scientist-practitioner model in a time when true scientist-practitioners are increasingly hard to find is greatly appreciated. Thank you to you both. Thanks also to my late brother, Douglas, for exposing me to the world of psychopathy, for without him, this lifelong journey may never have started. I would also like to extend gratitude to all the scientist-practitioners who have impacted me as I learned and applied the skills I have acquired over my life. Although there are too many to mention, a few individuals stand out: Carl Gacono, Jay Livingston, Bruce Bongar, Susan Sabol, Susannah Feder, Bill Wilcox, Randy Thomas, Bob Hart, and James Wade. Last and by no means least, I wish to thank my wife, Ilany Valle, for her undying support, love, and patience over the past 10 years and my older brother, Ayrie. Kudos and gratitude also goes to the army of diligent psychopathy and Rorschach researchers and clinicians who came before us, both living and deceased, who have placed truth, logic, and adherence to the scientific method above all things. I salute you.

–TBC

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¹  

The views and opinions expressed in this book do not necessarily reflect those of the Kentucky Department of Corrections.

Chapter 1: Introduction

Carl B. Gacono

Abstract

Understanding Female Offenders: Psychopathy, Criminal Behavior, Assessment, and Treatment represents the culmination of nearly four decades of research with antisocial and psychopathic personalities (Gacono & Meloy, 1994). As demonstrated throughout this text, the scientist-practitioner model informs our work. In this chapter, the clinical, forensic, and research experiences of the authors are described along with our experience and training using the Hare Psychopathy Checklist-Revised (PCL-R) and Rorschach. An introduction to the PCL-R and Rorschach is presented with caveats for understanding the current research and using these instruments with antisocial and psychopathic women. An overview of this text is provided.

Keywords

Antisocial personality; Assessment; Female offenders; Forensic; PCL-R; Psychopathy; Rorschach

I have no data yet. It is a capital mistake to theorize before one has data. Insensibly one begins to twist facts to suit theories, instead of theories, to suit facts.

Sir Arthur Conan Doyle, The Complete Sherlock Homes

Understanding Female Offenders: Psychopathy, Criminal Behavior, Assessment, and Treatment represents the culmination of nearly four decades of research with antisocial and psychopathic personalities. Inspired by the writings of Robert Lindner (1943; Samuel Beck & others) and guided by the theories of Otto Kernberg (1975), this work began in the early 1980s with the doctoral dissertations of Gacono (1988) and Heaven (1989). The research was published in numerous articles, book chapters, and summarized in The Rorschach Assessment of Aggressive and Psychopathic Personalities (Gacono & Meloy, 1994).

While the 1994 book included a sample of 38 incarcerated antisocial personality disordered women, Reid Meloy and I did not include an analysis of psychopathic women (PCL-R   ≥   30). Despite its breadth (chapters on Conduct Disorder [CD] children, CD adolescents, Antisocial Personality Disorder [ASPD] women, ASPD & psychopathic men, ASPD schizophrenic men and other smaller forensic samples; e.g. sexual homicide perpetrators) and impact, without this important piece, the 1994 book felt incomplete.

Fortunately, since then, I was presented with the opportunity to chair two important dissertations, A Rorschach Investigation of Incarcerated Psychopaths (Cunliffe, 2002) and, Female Psychopathy: A Rorschach Investigation of Personality Structure (Smith, 2013) that would launch our subsequent study of antisocial and psychopathic women. More importantly, both dissertation authors, Jason and Ted, have become reliable, trusted, and valued colleagues who understand the importance of including research as an essential component of their clinical work (scientist-practitioners). Jason has worked extensively with female offenders and his research is well represented in the peer-reviewed literature (e.g., Smith, Gacono, & Cunliffe, 2018, 2019, 2020a, 2020b, 2020c). The current book has evolved from Jason’s continuing research and commitment to the Rorschach and PCL-R (Chapters 3–5).

Despite the limits of the 1994 ASPD female sample, Reid Meloy and I had extensive experience evaluating and treating female offenders in a wide variety of settings. We had observed and discussed significant gender differences among offenders, and more specifically, among psychopaths (Gacono & Meloy, 1994). Our Rorschach findings ferreted out several subgroups of psychopaths, with at least one prominent group of males characterized by detachment, lack of emotion, and a grandiose sense of self (grandiose self-structure; a severe and malignant form of narcissism). In contrast, the presentation, assessment data, and social behavior of one group of female psychopaths were better described in terms of malignant hysteria (Gacono & Meloy, 1994; see Chapters 3–5). While Ted’s work (Cunliffe et al., 2016; Cunliffe & Gacono, 2005, 2008; Cunliffe, Gacono, Meloy, & Taylor, 2013) began our intensive study of antisocial women, Jason’s series of studies (Smith, Gacono, Cunliffe, Kivisto, & Taylor, 2014; Smith, Gacono, & Cunliffe, 2018, 2019, 2020a, 2020b, 2020c) have supported and extended our original hypotheses (Gacono & Meloy, 1994), refined the conceptual understanding of the female psychopath and the female sexual offender, and elucidated the gender differences among these antisocial groups (Smith, Gacono, Kivisto, & Cunliffe, 2019; see Chapters 3–6). These identified gender differences became instrumental for understanding, assessing, and treating antisocial women.

Our thinking has been shaped by clinical experience and theoretical writings concerning the severe personality disorders (see Chodoff & Lyons, 1958; Horowitz, 1977, 1991; Kernberg, 1975; Kohut, 1971; Meloy, 1988). We consider ourselves part of a long—honorable--but fading, tradition of the research practitioner (scientist-practitioner model; Boulder Model). In this tradition, theory coupled with clinical observation suggest hypotheses that are then put to scientific scrutiny through experimental design and hypothesis testing. This approach offers enlivened findings and practical recommendations that add conceptually to evolving theory that connects with real world practice.

As scientist-practitioners we rely on three sources for shaping our theoretical contributions and informing our clinical work. First, we are conversant in theoretical and conceptual writings related to psychopathy and personality development. Second, our clinical experience (assessment, providing treatment, etc.) provides an experiential component to theory through interacting with offenders, antisocial women, and psychopathic ones (see Chapters 3–6). This second component can be contrasted with approaches that rely on a purely academic understanding of concepts (Chapter 2). The direct experience of theory in action enhances the understanding of theory and concepts. The importance of the experiential component within the scientific method is noted by Caleb Carr (1994) in his insightful fictional book, The Alienist:

Roosevelt continued to test carefully: Do you have any evidence to support such a theory? Kreizler, None, of the kind that you mean. I have only a lifetime of studying similar characters. And the intuition it has given me (p. 56).

Thirdly, we apply the scientific method, which begins with observation and includes the use of statistical procedures to measure observed relationships, a and determine their significance (Chapter 2). Our inferences, interpretation of findings, and recommendations are based on a broad, multi-method approach to understanding the subject group, in contrast with research lacking an experiential component.

For Jason, Ted, and I utilizing these three sources has created a unique mastery, which is accentuated and solidified by including immersion (studying, rescoring, & reviewing multiple times) in large samples of assessment data. For example, in analyzing the Gacono and Meloy (1994) adolescent sample (N   =   100), I rescored the Rorschach protocols five times (2 with Comprehensive System [CS] scoring, 1 with the Extended Aggression scores, 1 time for object relations, and a final time for defensive operations). This allowed distinct patterns to emerge from the data that would not otherwise be observable. Theory and concepts become internalized in a manner that makes them available for applied usage including clinical interventions (Gacono, 2016c; Gacono & Meloy, 1994). Through multiple rescoring (5 times) of the female protocols discussed in this text, Jason has experienced this form of mastery.

The scientist-practitioner model can be contrasted with a purely academic research model which lacks an experiential component (direct observation of the subject studied, Gacono, 2019; see Chapter 2). The lack of clinical work with patients influences one’s understanding of theory, which contributes to poor research design, and results in conclusions that are faulty and/or misinformed. Even when the methodology and findings are sound, the researcher who does not utilize these three sources of information may not fully understand the implications of their data. The current, modern scientific method is composed of three elements: reliable observation, hypothesis development, and experimentation (Gauch, 2003; Gower, 1997, Chapter 2). Without the observation of natural objects, phenomena, or processes this type of research fails to meet the requirements of the scientific method. Research of this type has contributed significantly to ‘apparent controversies’, ‘pseudo-debates’, (Gacono, 2019; see Chapters 3, 5, and 6), and the ‘armchair’ quality (Hare, 1998) found in the current published literature.

In this regard, Jason’s interest in forensic populations began early, as his father was in law enforcement. His interest in psychopathy began in graduate school through his mentor Ted Cunliffe. His influences have been grounded in psychodynamic theory and cognitive-behavioral training, mostly with forensic populations. His early career work was largely with patients in a variety of clinical forensic settings (forensic private practice, inpatient forensic hospitals, jails, and state/federal prisons. Though he has had some experience with male forensic patients/inmates, his focus for the past decade has been the assessment, treatment, management, and research of adult forensic, mostly inmate, female populations.

Ted’s interest in psychopathy began with an association to a close family member afflicted with the condition. This sparked a lifelong personal, clinical, and research-based quest to understand psychopathic and antisocial individuals. Although he has worked with a wide variety of forensic and non-forensic populations, his interest in females began some 25 years ago during a Federal Prison practicum. Ted observed that the descriptions of male psychopathy did not fit the women. These observations led to his dissertation (Cunliffe, 2002) and several articles and book chapters (Cunliffe & Gacono, 2005, 2008; Cunliffe et al., 2013, 2016), as well as the gender based modified descriptions for PCL-R items contained in Appendices A and B. b His clinical work began as a front-line clinician and, continued later as a mental health director at several female correctional facilities. Since the early 1990s, he has used his grounding in psychodynamic theory and cognitive-behavioral training in the treatment, assessment, and management of female offenders and female psychopaths.

My own influences and experiences have been well documented elsewhere (see Gacono, 2016b), including both psychodynamic and cognitive-behavioral training, and have involved extensive assessment, treatment, management, and research with a wide range of children, adolescents, and adults within institutions, forensic hospitals, prisons, jails, and in the community (Gacono, 2016c; Gacono & Meloy, 1994). Between the three of us, we have interviewed, evaluated, treated, and/or managed thousands of offenders, several hundred PCL-R identified psychopaths, and administered hundreds of Rorschach and PCL-R protocols in various outpatient, hospital, probation/parole, jail, and prison settings.

Simply stated, theories have provided descriptions for and incisive understanding of what we have observed with patients and inmates; and our observations, when put to the rigors of the scientific method, have prompted us to delineate and expand the boundaries of theory. In this fashion, the chapters of this book evolved from empirical data, and in the style of Cleckley’s work (1941), comprise a clinical and research textbook where observation and theory converge. This text is both useful and informative, lacking the armchair quality of much research originating solely from academic settings (Gacono, 2019; Hare, 1998; Smith, Gacono, Fontan, Cunliffe, & Andronikof, 2020). It constitutes an essential resource for those working with female offenders.

Our methodology for studying female offenders has required the use of several standardized assessment methods (see Chapters 3–6). In our best effort to psychometrically map the intrapsychic life of antisocial and psychopathic women, we have come to rely heavily on the PCL-R and Rorschach for creating our independent and dependent measures, respectively.

The Hare Psychopathy Checklist-Revised (PCL-R): Our Independent Measure

While this text is about the female offender in general and the antisocial and psychopathic female in particular, our subjects have included children, adolescents, and adults with most of the diagnostic categories found within forensic contexts (Gacono & Evans, 2008; Gacono & Gacono, 2008; Gacono, Gacono, & Evans, 2008). We utilized the appropriate Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5; American Psychiatric Association [APA], 2013) diagnostic categories whenever indicated. However, we have found the Conduct Disorder (CD) and Antisocial Personality Disorder (ASPD) diagnoses to be of limited use for defining groups in forensic research (Gacono & Meloy, 1994) as the identification of ASPD in forensic settings is something like finding ice in your refrigerator (Bodholdt, Richards, & Gacono, 2000, p. 59).

The potential number of criteria combinations that allow one to meet the threshold for a CD or ASPD (adult) diagnosis equals 3.2 million (Rogers, Salekin, Sewell, & Cruise, 2000). Jails, prisons, and forensic hospitals may exhibit base rates of these disorders exceeding 75% of their population. Consequently, these diagnoses are not useful in creating a category or distinct group. The diversity among those with ASPD is highlighted in the following two examples. David was shy and had difficulty making eye contact during the clinical interview. He met the criteria for both ASPD and Avoidant Personality Disorder, an unusual combination (PCL-R total score   =   24). His treatment team requested an understanding of his sexual attraction to automobiles. His instant offense involved vehicle theft; however, his attachment to the cars made it difficult to sell the cars he stole. After a brief introduction, the second offender stated, Carl, you can call me Brinkley whereby he offered a vigorous handshake and proceeded to prop his feet up on the table (see Gacono, 1997). Regarding his victim Brinkley stated, It was like a mercy killing. I thought that if she lived, she would be a veg. Brinkley’s obvious bravado was in sharp contrast to David’s avoidant style. Brinkley had committed a sexual homicide and, upon assessment obtained a PCL-R score of 34, placing him in the psychopathic range. Brinkley met the criteria for both ASPD and Narcissistic Personality Disorder (NPD; see Gacono, 1997 for full case presentation: see Table 1.2 for a comparison of the DSM-5 ASPD criteria with other complementary classifications).

We have found that determining psychopathy level is essential, for meaningfully delineating those diagnosed with CD or ASPD (Gacono, 2000, 2016c). The personality and behavioral differences psychopaths (PCL-R   ≥   30) manifest, when compared to non-psychopaths, are significant (Chapter 3) and occur along with their lower base rates within correctional (around 23% of male inmates) and forensic psychiatric settings (11% or males; meet PCL-R criteria for psychopathy--the Cleckley psychopath (Cleckley, 1941; Hare, 1991, 2003)). Prevalence rates for women are three to five times less (9%–15%). Those that meet the threshold for primary psychopathy represent a more homogeneous grouping than the more generic DSM CD and ASPD diagnoses (Gacono, 2016a; see Chapters 3–6).

When administered properly (Gacono, 2000, 2005, 2016c), assessment with the Psychopathy Checklist-Revised (Hare, 2003) is the only method that provides a reliable and valid method for classifying adults as psychopathic (Gacono, 2000, 2016c; Richards et al., 2016; see Chapters 3–6). It is not ethical or competent to use the Psychopathy Checklist: Screening Version (PCL:SV; Hart, Cox, & Hare, 1995) or existing self-report measures for attempting to classify someone as psychopathic (Gacono 2016a; Richards et al., 2016). The 20-item scale (PCL-R; see Table 1.1) functions well as an independent classification from which other dependent measures, such as the Rorschach, can be taken (see Chapters 3 and 4).

We have extensive training with, and have considerable experience administering, and interpreting the PCL-R. My own training began in the early 1980s, prior to publication of the PCL-R manual (Hare, 1991). For our work, Tom Heaven, Reid Meloy, and I utilized a PCL-R prepublication manual supplied by Robert Hare. During that time, we were in close contact with Hare’s lab, sharing our findings and making suggestions for fine-tuning the PCL-R criteria, as we found several inconsistencies that needed modification.

Tom and I conducted 33 independent ratings with our dissertation subjects, obtained interrater reliability, and worked together with Reid to fine tune our use of the PCL-R and resolve scoring disagreements. We obtained very good interrater agreement (0.89) in the process of administering and scoring the 33 PCL-R protocols. This combination of an introductory workshop, small group practice, and consultation with Hare’s lab was one of several recommended approaches for learning the PCL-R (Hare, 2003).

My skills were finely tuned in the process of administering several hundred PCL-R protocols, primarily at Atascadero State Hospital (ASH). The training program I developed at ASH led to the ethical introduction of the PCL-R into their procedures (Gacono, 2000, 2016c) and led to the development of a time efficient procedure for administering and scoring the PCL-R and PCL:SV (Gacono, 2000, 2005, 2016c; Gacono & Hutton, 1994).

Table 1.1

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a  Factor 1;

b  Factor 2;

c  Does not load on any factor.

Supervised patient assessments, during which examiners establish a history of interrater agreement, is the only means of ensuring reliable and valid PCL-R administration, scoring, and interpretation (see Gacono, 2016c). Group training and/or a certification process, while useful for providing basic PCL-R information, has been shown to be ineffective in ensuring competent PCL-R usage (poor inter-rater reliability is found in the field, especially on Factor 1 (Edens, Boccaccini, & Johnson, 2010)). My training, which includes group instruction and supervised ratings--where interrater reliabilities have been the best reported in the literature (Bob Hare, Personal Communication), demonstrates what can be easily accomplished with proper PCL-R training (Gacono, 2016c; Gacono & Hutton, 1994). I have further trained others (to include but not limited to attorneys, clinicians, researchers, and probation officers), both nationally and internationally.

Jason’s training began with work in the psychopathy research group led by Ted Cunliffe. He later attended group training with me (where we practiced rating several taped PCL-R interviews). Subsequently, Jason has sent me, at least a dozen cases to review. He has attended additional trainings with Reid Meloy. He has conducted over two hundred assessments in jails, forensic hospitals, and prisons (mainly female offenders). Jason continues to consult with his co-authors on select protocols and has established a documented history of adequate interrater reliability for the PCL-R. Our interrater reliabilities have been very good beginning with our respective dissertations (Spearman Rho statistics; Gacono, 1988   =   0.89; Cunliffe, 2002   =   0.98; Smith, 2013   =   0.98).

Although he was introduced to the PCL-R during his undergraduate work at the University of British Columbia, Ted’s work with the instrument began in earnest while completing his dissertation (1994; under the supervision of Carl Gacono). Over the next several years with Amy Muntz, he administered approximately 100 PCL-R and Rorschach protocols at a women’s medium to maximum federal prison. Since that time, Ted has continued to use both instruments in research and clinical work in several correctional facilities and private forensic practice. Ted has conducted several hundred interviews and assessments with both male and female offenders.

Our PCL-R field interrater reliability has been reported throughout out work (e.g., Cunliffe, 2002; Cunliffe & Gacono, 2005; Gacono & Meloy, 1994; Smith et al., 2014; Smith, Gacono, & Cunliffe, 2018). The PCL-R data in this book was obtained with a PCL-R Factor, facet, and total interrater reliability score ≥ 0.87. Throughout this text, whenever the term psychopathy is used as a category it refers to an individual with a PCL-R score ≥ 30.

The Rorschach: Our Dependent Measure

Our use of the CS Rorschach as a dependent measure and primary investigative tool began in the 1980s (Gacono, 1988; Heaven, 1989). The Rorschach measures personality traits, characteristics, and constructs such as self-esteem, affect regulation, perceptual accuracy, reality testing, stress tolerance, styles of managing stress, and so on. Once a PCL-R score ≥ 30 is used to form a psychopathic group, we statistically compare their personality traits (measured by the Rorschach and Personality Assessment Inventory [PAI, Morey, 1991]) with non-psychopathic individuals (i.e., PCL-R score   ≤   24).

Our reasons for using the CS Rorschach remain the same as they were for Reid and me in 1994 (Gacono & Meloy, 1994). First, all three of us have had extensive training in its administration and interpretation. My graduate studies included Rorschach training utilizing the Comprehensive System, Kwawer’s (1980) borderline object relations categories, and the Lerner and Lerner (1980) defense scales with James Madero, Ph.D. Subsequently, I trained and consulted with Phil Erdberg, Ph.D., John Exner, Ph.D., Irving Weiner, Ph.D., and Paul Lerner, Ed.D.

Jason had one Rorschach introductory graduate course. His real education began working in group and individual sessions with Ted during his graduate studies. He subsequently was trained in the Comprehensive System through Rorschach Workshops, his principle teacher being Barry Ritzler, Ph.D. I provided Jason with more instruction on the CS and in the use of the supplemental scales (Cooper, Perry, & Arnow, 1988; Kwawer, 1980; Lerner & Lerner, 1980), the Extended Aggression Scores (Gacono & Meloy, 1994) and the Rorschach Oral Dependency scale (ROD; Masling, Rabie, & Blondheim, 1967). Currently, Jason uses the Rorschach (CS with the supplemental scales), along with the PAI and PCL-R with incarcerated females. He continues to attend regular scoring meetings with members of the Comprehensive System International Rorschach Association (CSIRA; https://www.csira-arisi.org/).

Ted’s training in the Rorschach began in 1993 when he was taught by former Rorschach Workshops instructor, Jay Livingston while he was in graduate school. He also attended a range of Rorschach workshops led by Carl Gacono, Ph.D., Reid Meloy, Ph.D., Irv Weiner, Ph.D., and Phil Erdberg, Ph.D. Additionally, he received training and supervision in the use of the measure from myself and Jay Livingston throughout his graduate work from 1994 to 2002. Since then, he has used the Rorschach, PCL-R, and PAI in his forensic assessments and has used the Rorschach extensively in assessing and treating individuals with trauma-related disorders.

We continue to cross-check each other’s scoring (with both the PCL-R & Rorschach; Gacono, Gacono, Meloy, & Baity, 2008). As we have reported and presented the data in this book, our inter-rater reliability kappa coefficients have ranged from 0.75 (good) to 1.00 (excellent; Cunliffe & Gacono, 2005; Gacono & Meloy, 1994; Smith, Gacono, & Cunliffe, 2018).

Second, the CS Rorschach continues to be used by clinicians. In 1994, Gacono and Meloy reported that the Rorschach is ranked eighth among psychological tests used in a national survey of outpatient mental health facilities (Piotrowski & Keller, 1989). It is the second most widely used test with adolescent patients, and the most popular projective technique with this population (Archer, Maruish, Imhof, & Piotrowski, 1991). It is also the second most widely used psychological test by members of the Society for Personality Assessment, an international organization of psychological scientists and practitioners (Gacono & Meloy, 1994; Piotrowski, Sherry, & Keller, 1985). Watkins, Campbell, Nieberding, and Hallmark (1995), reviewed 30 years of survey studies of psychological assessments (1960–90) and found that the Rorschach was one of the most frequently used psychological tests in most clinical settings, was one of the most popular instruments, along with the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1943), to be studied, and had received continuing emphasis in most clinical psychology training programs. In forensic evaluations, psychiatrists were found to specifically request the use of the Rorschach approximately 25% of the time (Rogers & Cavanaugh, 1983).

More recently, and despite the mostly unfounded criticisms leveled at the Rorschach, studies and reviews of the literature have confirmed that the CS Rorschach is still highly regarded across academic settings, internship sites, and in professional practice (see review by Piotrowski, 2015), as well as garnering extensive research interest evident in the clinical literature (Piotrowski, 2018). With regard to training, Bates (2016), in an in-depth survey of clinical internship directors, reported that 26% of interns use the Rorschach. Moreover, 48% of the directors expressed desire for pre-internship training in the Rorschach from their incoming interns.

These findings were supported by more recent data reported in a study of 355 APA internship settings, across diverse placement sites, where the Rorschach was used between 26% and 35% of this sample, depending on type of setting (children, adult, eclectic; Stedman, McGeary, & Essery, 2018). In a national survey of mental health counselor programs (N   =   210), Neukrug, Peterson, Bonner, and Lomas (2013) found that the Rorschach was covered in assessment coursework by 95% of the graduate faculty. Finally, in the most recent national survey of 279 practicing psychologists, Wright et al. (2017) reported that the Rorschach was ranked among the top tests by the sample studied, as it was used by 54% of practitioners.

Third, the five most common scoring systems for the Rorschach have been integrated and standardized by John Exner (2003) within the Comprehensive System (CS). The CS has an extensive research base and has been widely used in clinical and forensic practice, meeting the standards of admissibility and acceptance (Gacono & Evans, 2008; Gacono, Evans, & Viglione, 2008; McCann & Evans, 2008; Meloy, 2008; Piotrowski, 1996a, 1996b, 1996c, 2007, 2017). Recently, a newer Rorschach scoring system, the Rorschach Performance Assessment System (R-PAS; Meyer, Viglione, Mihura, Erard, & Erdberg, 2011), has been introduced. The research behind it, however, is fraught with problems (Kivisto, Gacono, & Medoff, 2013; Gacono 2019; Gacono & Smith, 2021; Smith, Gacono, Fontan et al., 2018, 2020; see Chapters 2 and 3). Consequently, its use in any applied context, clinical or forensic, without further validation of its utility and validity (using R-PAS administered protocols) would be premature, easily challenged in court, and ultimately detrimental to the use of the Rorschach (Gacono & Smith, 2021).

Fourth, psychoanalytic theory in the mid and latter part of the 20th century provided a foundation for the development of several Rorschach supplemental scoring systems. These have included systems for object relations (Blatt & Lerner, 1983; Kwawer, 1980), defenses (Cooper et al., 1988; Lerner & Lerner, 1980), developmental psychopathology (Urist, 1977), dependency (Masling et al., 1967), trauma (Armstrong & Loewenstein, 1990), aggressive drive derivatives (Gacono, Gacono, Meloy, et al., 2008; Gacono & Meloy, 1994), and thought organization (Athey, 1974; Meloy & Singer, 1991). These additional reliable and valid scoring systems provides a useful complement to the CS scoring, allowing for the quantification of important Rorschach content. As noted by Gacono and Meloy (1994), much of the psychoanalytic Rorschach research during the 1970s and 1980s has been signified in four books (Kissen, 1986; Kwawer, Lerner, Lerner, & Sugarman, 1980; Lerner, 1991; Lerner & Lerner, 1988).

Fifth, in our study of antisocial and psychopathic women we have espoused an integrative approach that utilizes CS structural, CS sequence, and other content analyses. When studying the personality functioning of an individual (Gacono, 1997) or groups (Gacono, Gacono, Meloy, et al., 2008), the use of the entire Rorschach greatly increases one’s conceptual understanding and/or clinical yield (Gacono & Evans, 2008). While the Comprehensive System (Exner, 2003), alone, provides psychodynamic information concerning self-esteem regulation, affect management, defenses, object relations, and interpersonal functioning, the various psychoanalytic methods are useful in further deepening our understanding and quantifying specific psychodynamics. We recommend, however, using only the CS derived data in an applied context especially in those where the protocol will be subject to forensic scrutiny (Gacono, Evans, et al., 2008).

Sixth, the Rorschach is unique in that it is a perceptual-associative-judgmental task that partially bypasses volitional controls, yet yields important data, some of which are projected material (Exner, 2003). While one can refuse to engage in the task (not report what this might be?), the Rorschach itself is difficult to fake (Ganellen, Wasyliw, Haywood, & Grossman, 1996; Grossman, Wasyliw, Benn, & Gyoerkoe, 2002; Hartmann & Hartmann, 2014). As research has demonstrated (Ganellen, 1994, 1996), it is difficult to manipulate by conscious effort to underreport or overreport psychological difficulties. It is this unique element, which adds to the Rorschach’s value in forensic assessment (Ganellen, 1994, 1996; Ganellen et al., 1996; Grossman et al., 2002; Gacono, Evans, & Viglione, 2002).

Self-report measures with criminal populations, on the other hand, continue to be notoriously unreliable and subject to manipulation (Gacono, 2016c; Gacono & Meloy, 1994; Hare, 2003). In addition to the forensic offender’s ability to manipulate self-report data, once, administered to these ASPD offenders the MMPI or MMPI-2 is frequently invalid. In one case, a psychopath turned in his completed MMPI-2 in 15   min, informing me with a smile that he had taken a speed-reading course in prison. More than one-fourth of the MMPI-2s I have administered in forensic hospitals and prisons--in any other context (i.e. intake, treatment planning & progress, etc.) than a specific court ordered evaluation--indicate that the person had answered randomly on the second half of the test. Many, if not most, of these offenders exhibit poor attention, concentration, and are easily bored, all contributing to the fact that they, quite frankly, just do not care to and are not willing to complete the test. Several other patients have fallen asleep while attempting to complete the MMPI-2. We do, however, acknowledge finding interesting and significant convergence using the PAI, Rorschach, and PCL-R with women (Smith et al., 2020b; Smith, Gacono, Kivisto, et al., 2019; see Chapters 3 and 5).

Limited assessment time, coupled with a consideration of the ratio of that time to clinical yield, encourages thoughtful choices regarding which measures a practitioner uses. Incremental utility increases when instruments provide empirically sound data and, at the same time, involve face-to-face interaction with the offender. Both the Rorschach and PCL-R do this. Invaluable assessment information is obtained by observing the offender’s behaviors, reactions to the examiner, and testing procedures (Gacono, 2016c).

Criticisms related to administration time for these instruments are simply unfounded. Regarding the PCL-R, good, ethical, clinical, and forensic practice requires the examiner/researcher to review all the records, prior to interviewing the client regardless of whether one administers the PCL-R or not. It is a simple task to record relevant PCL-R historical information during the typical record review (see Gacono, 2000, 2005). Consequently, the average length of time for completing the PCL-R, after record review, is 45   min--when using the Clinical and Forensic Interview Schedule (CFIS) for scoring the PCL-R (Gacono, 2000, 2005; also see Appendix A). A similar amount of time (around an hour) is required to administer and score the average Rorschach--when the examiner is skilled enough to do most of the scoring during the administration (a skill that only develops over the course of administering many [at least 100] Rorschach protocols). Inefficient use of time is related to the competence level of the examiner and are not inherent qualities of the instruments. Using these two instruments, together, in over 300 evaluations, I have found them to be invaluable, each providing unique and essential information for a comprehensive evaluation (Gacono, 2000, 2016c, Chapters 3–6).

In contrast to the PCL-R and Rorschach, in both clinical and research settings with forensic subjects, the psychologist is wise to minimize the use of self-report tests (Gacono & Meloy, 1994). When necessary, however, only those tests, with robust measures of distortion, such as the MMPI-2 and PAI should be considered. Self-report tests with high face validity, such as the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) should be assiduously avoided, unless they are being purposefully used to measure distortion by comparing them with other less obvious measures.

Finally, the CS Rorschach is the most empirically defensible instrument to access data that is both psychological and preconscious, or unconscious (Gacono & Meloy, 1994). This level of access is consonant with the notion that psychopathy, and other personality disorders, will only be understood when an inclusive levels approach is undertaken (Gacono & Meloy, 1988, 1994; Stone & Dellis, 1960).

Caveats for Understanding the PCL-R & Rorschach

Determining which of today’s research findings are valid is no easy task. In our research, we have discovered that many PCL-R and Rorschach studies are poorly designed and fraught with internal validity issues (Cunliffe et al., 2012; Gacono, 2019; Gacono & Smith, 2021; Smith, Gacono, Fontan et al., 2018, 2020; see Chapters 2 and 3). Every study requires scrutiny prior to accepting its findings. As Exner (1995) stated, a huge number of published investigations … are clearly marked by errors in design, implementation, and/or analysis (p. 3).

These poorly designed studies were utilized in larger meta-analyses without assessing their internal validity problems (Cunliffe et al., 2012; Gacono, 2019; Smith, Gacono, Fontan et al., 2018, 2020). Consequently, the invalid meta-analytic findings add confusion to important conceptual issues (Cunliffe et al., 2012; Smith, Gacono, Fontan et al., 2018, 2020), where they contribute to ‘apparent controversies’ and ‘pseudo-debates’ (Gacono, 2019; Gacono & Evans, 2008; Hare, 1998; Piotrowski, 2017). Consequently, it requires some degree of sophistication to separate the wheat from the chaff (Chapters 2–4).

Psychopathy. Psychopathy is not synonymous with Antisocial Personality Disorder (see Chapters 2–6). Antisocial Personality Disorder (ASPD; DSM-5; American Psychiatric Association [APA], 2013) evolved from a social deviancy model (Robins, 1966) and the term sociopathy (DSM; APA, 1952). Appearing in the first DSM (APA, 1952), sociopathy included a variety of conditions such as sexual deviation, alcoholism, and dissocial and antisocial reactions. While only the antisocial reaction was similar to psychopathy, the replacement of Sociopathy with ASPD in DSM-II (APA, 1968) and the increased focus on behavioral criteria would widen the gap between ASPD and psychopathy (Gacono, 2016a; see Chapter 3).

Psychopathy, although its generic roots extend back several centuries (Millon, Simonsen, & Birket-Smith, 1998), emerged as a discreet character type from Cleckley’s (1941) traditional psychiatric conceptualization that included a combination of personality traits and behaviors. From a DSM-5 perspective, psychopathy can be understood as a disorder comprised of selected behavioral and affective features of all Cluster B syndromes, Antisocial, Narcissistic, Histrionic, and Borderline Personality Disorders (Gacono, Nieberding, Owen, Rubel, & Bodholdt, 2001; see Table 1.2).

Several caveats spring from psychopathy’s two-factor, four facet structure versus the single factor associated with ASPD (Gacono, 2016c; Gacono, Loving, & Bodholdt, 2001; Hare, 2003).

1. Whereas one can arrive at the ASPD diagnosis by a virtually unlimited number of criteria combinations (3.2 million; Rogers et al., 2000), so that vastly different individuals are included in this single diagnosis, psychopathy (PCL- R≥30) constitutes a more homogeneous syndrome.

Table 1.2

2. Base rates for ASPD and psychopathy are different. While ASPD community rates are estimated at 5.8% of males and 1.2% of females, medium to higher security forensic populations will typically have rates of 50%–80%. Psychopaths will comprise only 15%–25% of the same forensic population.

3. In terms of predictive validity, high PCL-R scores have been associated with a higher frequency and wider variety of offenses committed (Hare, 2003), higher frequency of violent offenses (Hare, 2003), higher re-offense rates (Hare, 2003), poor treatment response (Ogloff, Wong, & Greenwood, 1990; Rice, Harris, & Cormier, 1992), and more serious and persistent institutional misbehavior (Gacono, Meloy, Sheppard, Speth, & Roske, 1995; Gacono, Meloy, Speth, & Roske, 1997; Heilbrun et al., 1998). The ASPD diagnosis is not associated with these same outcomes (Lyon & Ogloff, 2000; Lyon, Ogloff, & Shepard, 2016).

Psychopathy can be conceptualized both in dimensional (i.e., along a continuum of severity) and categorical terms (i.e., as a taxon or discrete syndrome). When concerned with how psychopaths differ from non-psychopaths, the researcher is using psychopathy as a category or taxon and should use the appropriate PCL-R cut-off score of ≥ 30 (Gacono & Gacono, 2006). Our study of women mostly included DSM diagnoses (Personality Disorder or ASPD) and a determination of psychopathy (PCL-R   ≥   30).

Understanding that psychopathy can be conceptualized in both a dimensional and categorical (taxon; PCL-R   ≥   30) manner is essential to interpreting research findings (Gacono & Gacono, 2006; Gacono, Loving et al., 2001). Research findings are frequently obscured when authors make categorical inferences (discuss psychopathy; PCL-R   ≥   30) from studies utilizing dimensional research designs (e.g., correlations of behavior with total PCL-R scores and/or absence of a psychopathic group   ≥   30 scorers; Chapters 3–5).

When used dimensionally, psychopathy is conceptualized as existing along a continuum of severity. Clinically, one is more interested in determining what ranges of PCL-R scores are best at predicting behavior, than whether or not a given individual meets the threshold score for a designation of psychopath (PCL-R   ≥   30; Gacono, Loving et al., 2001). For example, the Violence Risk Appraisal Guide (VRAG) and Sex Offender Risk Appraisal Guide (SORAG; Quinsey, Harris, Rice, & Cormier, 1998) are forensic instruments that use differing PCL-R cut scores as part of a weighted formula for predicting violence and sexual violence risk. PCL-R scores, rather than a diagnosis (category), become one of several factors in decision-making. For research purposes, our understanding of psychopathy (category) is enhanced when groups of psychopaths (PCL-R   ≥   30) were compared to groups of non-psychopaths (PCL-R   ≤   24) or, at minimum, when there were sufficient numbers of PCL-R   ≥   30 scorers in a given study. What might seem obvious--for a study to make inferences about psychopathy it must have psychopaths in it.

Two common research procedures that can create samples without psychopaths involve using the PCL:SV or a self-report measure for creating a psychopathic group, and/or lowering PCL-R cutoff scores to form a psychopathic group (Gacono & Gacono, 2006). Not a substitute for the PCL-R, the PCL:SV is for screening purposes only (Gacono, Loving et al., 2001). Unlike the PCL:SV, the PCL-R allows for a categorical designation of psychopathy (PCL-R   ≥   30). Although the PCL: SV is appropriate for examining relative differences within a given sample, it cannot be used to make inferences about psychopaths when used incorrectly as the independent measure for forming psychopathy groups.

A similar issue exists when using self-report measures of psychopathy (Lilienfeld & Andrews, 1996; Lilienfeld & Widows, 2005). These instruments suggest that individual traits (dimensional--inherent in any one of several disorders and non-disorders) are individually psychopathic (category). In reality, a designation of psychopath is appropriate only when a sufficient number of individual traits are fully present. It is the aggregate of traits, rather than an individual trait, that determines the presence of a psychopath. With some exceptions, self-report measures assess traits or dimensions, as opposed to categories (presence of a psychopath) and correlate most strongly with Factor 2 of the PCL-R and not the core traits assessed by Factor 1. Additionally, mislabeling traits such as self-centeredness, impulsivity, impaired empathy, and irresponsibility, as inherently psychopathic returns psychology to the pre-1900s pejorative trend of including all Personality Disorders under the rubric of psychopathy. Even established self-report measures, such as the MMPI-2 or PAI, are never appropriate for establishing psychopathic groups (Hare, 1991, 2003; Smith et al., 2020b).

A related concern involves lowering PCL-R cut-off scores to form a ‘psychopathic’ group (a very common, mistaken practice in female offender studies). Researchers do this for one reason--their samples do not contain enough numbers of actual psychopaths (PCL-R   ≥   30). While this procedure can be part of an acceptable research design, the author(s) must refrain from making inferences about psychopaths (category) when they have few, if any, psychopaths in their sample. When lowered PCL-R cut-off scores were used to establish groups,