That sentence is provocative, but it's also completely true, in a completely uninteresting way. The official definitions for medical terms in America are recorded in the Diagnostic Standard Manual, or DSM. There is no diagnosis in the DSM named psychopathy. There is no such thing as a psychopath because there is no official definition of such a concept.

And that might already be surprising to some people. You often hear people talk about psychopaths like they're a settled medical fact, a way some people just are. But that's simply not true. There is no agreed on definition, which means it is, at most, a proposal. It's an idea some doctors think might explain some people, but it has failed to reach widespread consensus.

Doctors who believe in psychopathy will often cite various kinds of evidence which sound more convincing than they really are. For instance, they will cite that MRI studies find differences between the brains of people who are psychopaths and those who aren't and make interpretations of those. That sounds powerful, except it tells you nothing about the causes of those differences. Brains are highly plastic and reflect people's experiences. MRIs can identify differences between London bus drivers who follow one route, and London taxi drivers; this does not mean anyone is born a London taxi driver. Similarly, many will cite psychopathy having around a 50% heritability. But heritability isn't quite what it sounds like. It's not a direct measure of how heritable through genes something is. In fact, heritability is more complicated and hard to interpret than that. Also, 50% is only moderate; some studies find that PTSD, which I think we can agree has a rather strong circumstantial factor, could have up to a 70% heritability.

Some of you might be thinking "Okay, so psychopath isn't a real thing. What about sociopaths? That's different, right?" Well, not really. There also isn't an official definition for sociopath. Also, sociopath and psychopath don't come from the work of one doctor who separated patients into those two groups, like bipolar 1 and bipolar 2. Rather, the words were coined separately by different doctors, both studying basically the same people. Since neither have official definitions, any distinction between the two is unofficial and after the fact.

But let's not kid ourselves. "This word has no official definition so there is no such thing" doesn't satisfy anyone. You want to know about the idea, not the word. You want to know whether we should call some people "psychopaths" not whether we happen to currently. And yes, I believe the answer to that is also no, but it's a more complicated question, and it's gonna take more time to examine.

So what is the idea of a psychopath? What would we need evidence of for us to decide that, basically, it's a well-founded concept and worth naming? Robert Hare, probably the most important of the scientists who believe in psychopathy says in his book (and yes, this is the real title) Without Conscience: "Their hallmark is a stunning lack of conscience; their game is self-gratification at the other person's expense. Many spend time in prison, but many do not. All take far more than they give." I think this is a pretty good description of the average person's idea of psychopathy, what I'll call the lay definition. Psychopaths are people who, due to some quirk of their nature, do not experience moral feelings the way other people do. Hurting people doesn't bother them; if anything, they like it. Hare even suggests that all of their emotions are fundamentally shallow and fleeting. Most importantly, they are, by nature, selfish, dangerous, and incurable.

Frankly, that definition should seem a little strange right off the bat. According to it, the most important, fundamental pieces of a psychopath's nature are not medical, or even scientific. How can you measure whether someone has a conscience, much less whether they experience emotions in a deep way or "take far more than they give"? How do you prove someone is incurable, as opposed to simply not cured yet? These aren't scientific concepts; no experiment could prove them. It reads like a moral judgment, not a psychiatric description, and it's weird that it comes from, by any measure, a leading expert, the sort of person you'd really expect to be most careful about that.

Another distinctly non-medical detail of the lay definition that's slightly subtler is implied by the "but many do not". You often hear the claim that there are fields, like lawyers or politicians, which are full of psychopaths. Obviously, no one's actually found any evidence of that, because there's no definition by which to gather such evidence. But also, if psychopathy were like other diagnoses, the very claim would be bizarre. Every diagnosis in the DSM-5 comes with the same disclaimer: this diagnosis only applies if the symptoms "are not better understood as normative for the individual‟s developmental stage or sociocultural environment." In other words, if being terrible helps you succeed in your job, being terrible is rational, not a symptom. Your job that's messed up; no one can diagnose you for doing it well.

A scientific diagnosis is not a moral judgment. But what if we tried to make a scientific diagnosis such that it would evoke a certain moral judgment? For instance, rather than saying a person has no conscience, we say that they have a pattern of taking advantage of other people, and express little remorse for it. That's empirical, but if you saw such a person, you'd likely judge them as lacking in conscience. Instead of saying they take more than they give, we can say they tend to be ego-centric and readily exploit others. Instead of shallow emotions, we'll say they have poor impulse control and struggle to form relationships.

You've probably guessed that, in my opinion, this category already exists. It's called Antisocial Personality Disorder, or ASPD, and it is in the DSM-V. ASPD is a real diagnosis, and there are people who have been diagnosed with it. And it is related to the lay idea of psychopathy in exactly the way we've imagined. The symptoms that define ASPD include patterns of ego-centrism, failing to form relationships, and taking advantage of other people. Personality traits include being manipulative and callous. Less obvious connected, they also include poor impulse control and engaging in risky or self-destructive behaviors. It's based particularly in the work of Hervey M. Cleckley, author of (once again, this is the real title) The Mask of Sanity, the earliest work that unambiguously describes the modern concept of psychopathy.

It is by no means the origin of the concept, but we'll get back to that.

Now, let's be very careful. Just because someone fits this new category we've made wouldn't mean they are a psychopath in the lay sense. Evoking a moral judgement is not the same as deserving it. Robert Hare, for one, is very firm that ASPD is not psychopathy. We've made a diagnosis for a person who sometimes behaves the way we expect the lay psychopath to behave. But if there are no lay psychopaths, we still might find other people who act that way for entirely different reasons. Finally, we have a question that we can examine with evidence. Does what we know about people who are diagnosed with ASPD fit the picture of an empty shell with no conscience, as suggested by psychopathy, or do its details suggest a different, more sympathetic story? Let's take a look.

The first thing you find when you start looking at people diagnosed with ASPD is this: ASPD is overwhelmingly associated with childhood trauma. In fact, the usual way to be diagnosed with ASPD is to be diagnosed with a conduct disorder and then turn 18. Conduct disorders are often criticized as pathologizing children's trauma responses. Repeated studies have found a strong link between childhood trauma and ASPD. It even gets more specific than that. Betrayal trauma, that is, trauma done to someone by a caregiver or beloved figure, and, at least in men, physical abuse, are especially associated with ASPD.

Lay psychopathy is definitely not a trauma disorder. It's a way a person is born, some fundamental character of their genetics or very early development. Doctors who believe in psychopathy often express a desire to reject trauma from discussions of psychopathy. Robert Hare, in an article arguing that Clifford Boggess, a serial killer who suffered horrific child abuse, is a psychopath, responds to his trauma with this: "There is little doubt that the neglect and abuse of a child can cause serious psychological and behavioral problems, including depression, low self-esteem, suicide, acting out, and violence. But for every product of an abusive, dysfunctional background who commits a terrible violent crime there are scores of others from similar backgrounds who lead normal, productive lives. Further, many notorious killers were raised in warm, nurturing family environments." Possibly true, but Clifford Boggess was not one of them. And yet, Hare simply ignores Boggess' history of trauma after this. An argument this nonsensical suggests a deep discomfort with discussing trauma. After all, connecting psychopathy to trauma completely disrupts its meaning as a moral judgment. Trauma is inherently sympathetic.

Looking back at the defining traits of ASPD, many of them take on new meaning when looked at in the light of trauma. Out of that context, ego-centrism sounds malicious. But when someone's parents or caregivers are hostile or negligent, it makes sense that a child would learn they have to look out for number one; They're the only ones who will. Similarly, taking advantage of other people sounds different when you know it's someone who's been taken advantage of by their closest caretakers. Experiences of early betrayal have taught them trust is a fool's game and you need to get people before they get you.

Already, we're building up a different picture of those with ASPD. Rather than mentally shallow monsters, we begin to see people who were deeply hurt as children and have learned to treat other people as enemies because of it. That leads us to the second question. Is ASPD treatable? If it isn't, if people with ASPD are doomed to be violent criminals forever, then maybe this sympathetic picture doesn't matter very much. They'll still always act in anti-social, exploitative ways. But if ASPD can improve, if there is even the possibility of treatment, then treating them as monsters rather than victims is deeply cruel.

Far from treatment being totally ineffective, symptoms of ASPD tend to get better with no treatment at all. That doesn't mean disappearing entirely, but the condition gets steadily less severe, often over a person's thirties and forties. Problems tend to go from being high risks of violent crime to struggling to make friends and not being motivated at work.

That's hard to explain if you think of a person with ASPD as a rational but evil mastermind, but it makes perfect sense if you understand them as trauma victims slowly learning more healthy ways to socialize. The thirties and forties are times when they will begin settling into stable social networks. This both confronts them with the bad consequences of using cruelty and dominance to avoid vulnerability and provides them with an opportunity to explore the kinds of healthy relationships they didn't have as children. This becomes especially clear when you look at some of the factors that predict better outcomes for people with ASPD: marriage, a close family or community, and degree of socialization.

As for treatment, there's much less information about that than you might assume. The whole subject is almost unstudied. This is the first thing any discussion of treatment for ASPD will tell you. It's not that people tried to cure ASPD and failed. Rather, very few people have tried it at all. Most of the data is from much smaller efforts and, while some approaches do show promise, there isn't enough data to recommend a gold standard.

Worse, much of what has been tried has been tried under the worst possible conditions: prison. Prison creates an inherent antagonism that undermines the treatment: the more someone tries to comply, the more they get read as just trying to manipulate the system and get out of prison. Nurses in prison treat ASPD patients as inherently suspicious and untrustworthy, undermining their chance to prove otherwise. And yet, even some prison programs have produced positive results, and ASPD patients are, despite stigma assuming the opposite, found by studies to be overwhelmingly compliant with treatment.

While there's little information about treatment for ASPD, there is actually a lot of research into conduct disorder, the disorder which has the same symptoms but for patients under 18 years old. While managing conduct disorder is not easy, multiple treatments are effective. The most effective are ones that involve the family and people around the child, such as multi-systemic therapy and parent management. These are the kinds of interventions that are most difficult once someone's an adult. However, it would be strange if they were effective up to the age of eighteen and then suddenly nothing was.

So if we look at the symptoms that people who talk about psychopathy describe, we come up with ASPD. But instead of a wicked villain who cares only about themselves, this collection of symptoms suggests a traumatized human, full of extreme emotions they don't know how to handle. Instead of being unchangeable, we find them getting better on their own, and there's reason to think treatment is possible, if not easy.

So if psychiatry doesn't support the lay picture of psychopathy, what does? Where did we get this idea, if not from scientific evidence? I've mentioned before that psychopathy is a moral idea, and I think this is the answer. Psychopathy comes not from science but from people's moral judgments, and the field which they use to enforce them, the law.

From this point of view, all of the things which seemed so distinctly non-medical about the lay psychopath suddenly make sense. Of course our definitions focused on internal states rather than external actions. Of course they come with sharp pronouncements about vague ideas like how much a person takes or gives. Most of all, of course they make conclusions about whether treatment is ever possible, because whether someone can be treated determines their legal treatment.

But the strongest evidence that "psychopath" is a legal and not a medical term comes from looking at its history. Hervey Cleckley is considered the father of psychopathology for his book The Mask of Sanity. It focuses on interviews with people, including successful businessmen, who Cleckley felt were psychopaths, in the sense of lacking moral feeling. The Mask of Sanity was published in 1941. The first law which, by name, targeted psychopaths was passed 6 years earlier, in 1935.

This law, the first of what are called first sexual psychopath laws, was passed in Michigan. It ordered a judge to examine a prisoner if he seemed "though not insane, feebleminded or epileptic … to be psychopathic, or a sex degenerate, or a sex pervert, with tendencies dangerous to public safety." At that time, "psychopathic" was a general term which could refer to any mental disturbance; these laws, however, which eventually spread to 26 states, defined the response to them, the moral judgment that was its most important substance. If someone was deemed a psychopath, they would be locked up indefinitely.

Today, these sexual psychopath laws have been repealed or are unused. Their vagueness was a large part of their ultimate collapse. Giving the law system the ability to imprison anyone who committed any sex crime if they fit an undefined standard was a bad idea, and in practice, it went about as badly as you could imagine it going. One of the most common targets of sexual psychopath laws were, get ready, gay men arrested for the crime of sodomy, who were then permanently imprisoned until they could be "cured" of their orientation. Another main target was, here's another doozy, black men who had relationships with white women. In 1967, the Supreme Court struck down Colorado's sexual psychopath law, beginning their eventual decline.

I can't say that Hervey Cleckley was inspired by sexual psychopath laws when writing his book. The person that people pictured as their enemy when they passed sexual psychopath laws isn't identical to Cleckley's picture. There are scientific ideas that could be seen as background to Cleckley, including, yes, quite a bit of phrenology and such wildly non-scientific terms as "emptied souls". What we can say is that a science of psychopathy did not give birth to a legal response to them. The law was locking up psychopaths first. The moral category was already there.

We might like to think that we're past that kind of thing, but in fact, despite the lack of firm medical backing, the law has found new ways to name people as psychopaths, and to lock them up or execute them for it. It's time to go back to Robert Hare, and the Psychopath Checklist Revisited.

The Psychopath Checklist Revisited is Robert Hare's masterwork. It consists of twenty items which a psychiatrist can rank from 0 (does not apply at all) to 2 (extremely applicable). A score over 30 is supposed to represent the range of psychopathy. The PCL-R can become involved at several points in the criminal justice system. It can be used in sentencing, as evidence against someone in parole hearings, and in trials where mental health is at issue. In echo of sexual psychopath laws, it is particular common in cases having to do with sexual violence.

The PCL-R is justified in a somewhat complex way. When the test is challenged on the grounds that there is no official definition for any such category as "psychopath", its defenders will say that it's a powerful tool for determining whether someone is likely to reoffend upon being released from prison. However, there are other tests that are specifically designed to do that, and they do a better job at it than the PCL-R. When it's challenged on that front, defenders say it isn't meant to be a risk-assessment tool, but that it tests for a specific construct, psychopathy. The reason it's appropriate to test for psychopathy, while it isn't fully defined, is because it's associated with risk. The troubling circularity of these arguments is never addressed.

The issues with the PCL-R run deeper than this though. Because the PCL-R assumes that the people taking it are fundamentally untrustworthy, it gives the doctor ranking the score an enormous amount of freedom to make their own judgements. Some items from the test include glib and superficial charm, shallow affect, lack of realistic long-term goals, irresponsibility, lack of responsibility (separately) and lack of remorse or guilt. All of these basically ask the clinician to decide what they think of the patient. They are inherently subjective. The rules for whether to rank someone a 1 or a 2 are even more vague and up to the individual clinician.

This likely accounts for how wide the gap can be between scores on the test as administered by different doctors. Even a test performed by Robert Hare himself with trained doctors under laboratory conditions watching filmed interviews found that the inter-rater reliability for any individual item "largely fell below any appropriate standards". Things get worse when brought into real trials, where it's found that on average doctors hired by the prosecution rank convicts seven points higher than those hired by the defense. In individual cases this swing can often be even higher; in the relatively famous (and tragic) case of Quintin Jones, there was a swing of 22 points, more than half the points possible.

The amount of the PCL-R which is subjective is troubling, but the amount of it that's simple fact is also a problem. The PCL-R includes items such as juvenile delinquency, early behavior problems, revocation of condition release and criminal versatility which refer explicitly to a criminal's past behavior rather than their present state. Once someone has items like these in their history, their PCL-R score is likely to remain high no matter what they do. The PCL-R, in other words, weighs the scale against people changing and growing. This can be particularly egregious if, as is shockingly common, the PCL-R is done without an interview, by a doctor who encounters the criminal only by reading their file.

It will probably not surprise people that the PCL-R is subject to racial bias. Certain items on the test seem to be particularly affected by the convicts' race, and worse, it's introduced more often against defendants of color than against white defendants.

Despite all of these massive problems with the PCL-R, prosecutors love it. The image of a psychopath is inherently terrifying, and its introduction has a startling effect on juries. The prosecution is overwhelmingly the one that brings up the PCL-R. For the defense, even mentioning the idea of psychopathy hurts their client. One experiment with a mock jury found that the jury is more likely to sentence someone to the death penalty once psychopathy is raised. Psychopathy is made to sound like a scientific category, but it can never escape its true nature as a moral one.

Take, for instance, Cameron Todd Willingham, arrested for setting a fire that killed his three children. While the prosecution had, seemingly, a strong scientific case that the fire had been set and an inmate who claimed to have heard Willingham admit to the deed in prison, there was a whole: Willingham had no motive. So, the prosecution brought in two experts who, based entirely on file evidence, testified that Willingham was a psychopath. This meant that there was no need to look for a motive; he was just the kind of person who did that sort of thing. Later, it would turn out that the supposedly scientific evidence of arson was completely unscientific guesswork and the witness of the confession admitted he made it up in exchange for a promise for leniency from the police (if that sounds extraordinary, it sadly isn't). Willingham, an innocent man, was executed, and psychopathy kept people from asking questions that should have saved him.

In all of these problems, we see again and again the danger of a moral concept that pretends to be a medical one. It's one thing to make a harsh moral judgment of someone, but by painting that moral judgment as a scientific diagnosis, they do something worse. They claim to make not just a moral judgment, but the moral judgment, a moral judgment with the certainty and uniqueness of scientific fact. Further, they get to make it without ever looking at the sort of context that we'd normally demand. Pesky issues like "trauma" and "motive" can be dismissed in favor of a science guy who read a file declaring the vibes are off. In a child-like way, we might be comforted by such moral certainty, but as adults, we should recognize it as a lie.

There is something called ASPD. It often involves aggression and violence. But is there such a thing as a psychopath, the moral idea? Are there people who simply lack basic humanity and emotions and must be left to rot in prison? Are there people whose basic emotions are fakes, pretenses to a human experience they can't ever access?

It's always difficult to prove that something doesn't exist. We can say the evidence for it is weak. We can say the people who we would expect to fit the concept if it were real don't actually seem to. We can say there's reason to believe that a non-medical idea has been imported into medicine. We can say the concept is dangerous and causes problems where it's used. But none of that technically proves there's no such thing.

But I shouldn't have to prove that. People who believe in such an extreme idea are the ones who should prove it, and we all know that. That's why they often pretend the evidence is so much better than it is; they know that psychopathy is an idea it would be plainly dangerous to adopt without much stronger evidence than they can honestly provide.

But I would like to end by laying my cards fully on the table: in my opinion, psychopathy is not just a bad scientific idea, but a bad moral idea. It teaches us to approach people suspiciously rather than empathetically. It teaches us to look at people who have done something awful (or are accused of doing something awful) and instead of asking "What could drive a human to this?", ask "Is this really a human?". Psychopathy is an idea that demonstrably makes us crueler, and that is the worst sin for any moral idea. Criminals are the people who, of all people, perhaps most need our compassion and empathy, and I refuse, on the evidence, and as a matter of principle, to deny it to them.

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