Novel Therapy May Reduce Violence in ASPD

Mentalization-based treatment for antisocial personality disorder (MBT-ASPD) — a therapy that helps individuals understand and interpret their own and others’ thoughts and feelings — significantly reduced aggression in male offenders on probation compared with probation as usual, findings from a new trial showed.

Participants who received MBT-ASPD committed 46% fewer offenses than those who received only probation services 3 years after randomization. There were also sustained reductions in general and intimate partner violence.

“Antisocial personality disorder has historically been difficult to treat, but our findings demonstrate that a psychological intervention requiring relatively limited therapist training can meaningfully improve outcomes for individuals with this condition while also reducing their impact on society,” lead investigator Peter Fonagy, PhD, of University College London, London, England, said in a press release.

The findings were published online on February 18 in Lancet Psychiatry.

Widespread, Devastating Consequences

US prevalence rates of ASPD range from 2.1% to 4.2%, and its consequences are widespread and devastating.

In addition to the emotional and physical damage sustained by victims of crime and their families, the economic burden tied to criminal justice costs, hospitalization, and lost productivity is estimated at more than $17 billion in the United Kingdom, the report stated.

To compound this problem, behaviors and personality traits linked to ASPD — aggression, dishonesty, and lack of remorse, among others — have been notoriously difficult to treat.

Fonagy originally developed MBT in the 1990s with colleague Anthony Bateman, MD, of the University of Copenhagen in Copenhagen, Denmark, to treat individuals with borderline personality disorder (BPD). The goal of the therapy was to address their difficulties with affect, impulse regulation, and interpersonal functioning by helping them to better understand what another individual might be thinking or feeling and putting themselves in their shoes to better understand their behavior.

Mentalization develops in infancy. An individual’s ability to mentalize depends on the quality of primary attachments with caregivers.

Close infant-caregiver relationships foster secure attachment, which in turn facilitates optimal mentalization abilities including the ability to interpret and respond appropriately to social cues and regulate emotions in interpersonal interactions.

However, when infants and children are neglected, abused, and otherwise traumatized, they are more likely to develop disorganized attachment, and lack the foundation to develop adequate mentalization skills.

This could result in emotional dysregulation and a disregard for how their actions affect those around them.

In addition to BPD, MBT has been adapted to treat individuals with posttraumatic stress disorder, eating disorders, substance use disorder, and depression.

Evidence showed that MBT for BPD was largely successful. A 2020 meta-analysis revealed that long-term MBT was associated with a significantly lower risk of engaging in self-harm or suicidal behavior than treatment as usual for individuals with BPD.

Adaptation of a Successful Treatment

ASPD shares some of the same traits as BPD, including a lack of impulse control, manipulation, and rage, so Fonagy adapted it for individuals with ASPD.

However, there was still a lack of solid evidence for MBT’s success in ASPD. In 2021, Fonagy established the Mentalization for Offending Adult Males trial to explore whether MBT-ASPD could reduce aggression and violent offenses.

The study included 313 adult men with ASPD from 13 probation centers across England and Wales. All were on probation for a criminal offense. Major offenses committed by participants ranged from violence, including assault, wounding, and death threats, to nonviolent infractions such as drunk and disorderly conduct or minor criminal offenses.

All participants had a diagnosis of ASPD, and an Overt Aggression Scale–Modified (OAS-M) score ≥ 15. The OAS-M assesses both verbal and physical aggression, with higher scores indicating higher levels of aggression. Participants had a mean age of 34.2 years and 79% were White individuals.

Participants were randomly assigned in a 1:1 ratio to receive either a 12-month course of MBT in addition to standard probation services or probation services alone.

Probation alone lasted for a year and involved regular meetings with an offender manager and optional participation in risk and anger management programs, domestic violence courses, and substance abuse interventions.

A total of 157 participants received MBT-ASPD and probation services, and 156 received probation services alone. Study personnel were blinded to group allocation.

Exclusion criteria included convictions for child sexual offenses, or diagnoses of neurodevelopmental disorders, schizophrenia, or bipolar disorder.

The mentalization-based treatment involved weekly 75-minute group therapy sessions and monthly 50-minute individual therapy sessions.

In the group sessions, participants explored the mental states driving various behaviors, with a particular focus on interpersonal conflict. They were encouraged to consider how others might think and feel about them and reflect on their own thoughts and emotions regarding others.

The individual sessions were designed to enhance essential skills such as self-awareness, empathy, and reflective thinking. The primary outcome was aggression as measured by the OAS-M, 12 months after randomization.

Secondary outcomes included violent incidents, alcohol and drug use, self-harm and suicidal behaviors, psychiatric symptoms, and mentalizing abilities, all of which were evaluated every 3 months post-randomization.

Drop in Aggression, Violence

A year after baseline, aggression levels of participants in the MBT-ASPD group were approximately 50% lower than those in the probation alone group as measured by the OAS-M (90 vs 186, respectively; adjusted mean difference, −73.5; effect size, 0.74; P P = .0037).

Participants in the MBT-ASPD group also showed significant decreases in violence after a year compared with those in probation as usual group (P = .0021), but these changes did not extend to beyond 18 months.

Three years post-randomization, participants in the mentalization group had committed 46% fewer offenses than those in the standard probation group, with an incident rate ratio (IRR) of 0.54 (P = .0024).

Notably, attending at least half of the MBT-ASPD sessions was associated with fewer offenses, consistent with a causal relationship between MBT-ASPD and reduced recidivism. Significant reductions in total offenses (P = .021) were noted in this group.

In the MBT-ASPD group, there was an initial increase in major offenses during the first year (IRR, 1.50; P = .33) which was followed by a significant reduction during the 25- to 36-month period compared with probation as usual (IRR, 0.42; P = .0016).

In addition, participants in the probation as usual group spent more time in prison after randomization (6.96 months) than those in the MBT-ASPD group (4.54 months).

Further, while both groups showed a decrease in ASPD symptoms, the MBT-ASPD group showed a significantly larger reduction of 63% in the number of ASPD symptoms at the 12-month follow-up (P = .035).

Mentalizing significantly improved in the MBT-ASPD group 12 months after randomization (P = .040).

Fonagy told Medscape Medical News he is optimistic about the potential of MBT-ASPD, even among the most violent criminals, including those with homicide convictions.

However, he is far less confident that the therapy could alter the behavior of individuals who commit violent sexual crimes, he added.

“Our study highlights the importance of creating environments for those convicted of violent crimes that foster, rather than undermine, a respectful attitude toward mental states — including feelings, beliefs, wishes, and desires,” he said.

“Unfortunately, our prison systems often create conditions that are deeply incompatible with mentalizing. It would be difficult to design a human environment more hostile to mentalization than our current systems of incarceration,” Fonagy added.

In yet-to-be published data, the investigators also found that MBT-ASPD is cost-effective compared with probation as usual.

Limitations included the study’s assessor-masked design with a probation as usual comparator, which complicated the distinction between MBT-ASPD’s specific effects, and the effects of the increased attention typically associated with psychological treatments. There was also missing data.

A Public Health Priority

In an invited commentary accompanying the article, Lois W. Choi-Kain, MD, of Harvard Medical School in Boston, noted that interventions designed to reduce antisocial behavior “are a fundamental public health priority not only in harm reduction but also in helping offenders with this diagnosis re-enter organized lawful society as a second chance to adapt, find a niche, and realistically develop a constructive role with regard to meeting their own needs while considering the wellbeing of others.” 

Commenting on the findings for Medscape Medical News, Ryan Wagoner, MD, agreed. He noted that a hallmark sign of ASPD is an absence of empathy, which raises the risk for not only affective but also predatory violence.

Wagoner is chair of the Department of Psychiatry and Behavioral Neurosciences and a forensic psychiatrist at the University of South Florida in Tampa, Florida.

While MBT-ASPD cannot create empathy in someone who doesn’t have it, he explained that with practice it’s possible for individuals to strengthen these skills and eventually develop a better understanding of others’ perspectives.

Wagoner speculated whether MBT-ASPD could also be beneficial in prison settings. “Prison psychiatrists and correctional staff often deal with violent assaults, so if this could reduce those, and it isn’t costly to administer, it’s the right thing to do,” he said.

This study was funded by the National Institute for Health and Care Research. Fonagy reported receiving honoraria for the MBT-ASPD training. Choi-Kain and Wagoner reported no financial disclosures.