Program Profile: PSYCHOPATHY.COMP (Portugal)

This is an individual compassion-focused, therapy-based intervention adapted from traditional compassionate-focused therapy to reduce psychopathic traits in youth in a correctional setting in Portugal. The program is rated Promising. The program was shown to statistically significantly decrease measures of psychopathic traits, grandiose manipulative, callous–unemotional, impulsive irresponsible, daring irresponsible, and conduct disorder traits.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes either 1) one study conducted in multiple sites; or 2) two or three studies, each conducted at a different site. Learn about how we make the multisite determination.

Program Goals

The PSYCHOPATHY.COMP program is an individual-based, compassion-focused therapy and is adapted from traditional compassionate-focused therapy. The program, implemented in Portugal, is designed specifically to reduce psychopathic traits and antisocial behavior in youths (ages 14 to 18) who are diagnosed with a conduct disorder and being held in a detention setting, while restoring the balance of the motivational and emotional regulation systems of youths through the promotion of compassionate motivation.

Program Theory

According to compassionate-focused therapy, humans have an innate set of basic motivations to survive, thrive, and form affiliative/attachment bonds, which are regulated by the threat system (protecting individuals from threats through archaic and automatic responses: freeze, flight, fight), the drive system (allowing individuals to experience positive feelings that encourage, guide, and motivate them to seek out resources to survive and thrive), and the soothing system (allowing individuals to experience tranquility and safeness [Gilbert 2019; Kumsta 2019]). In the compassionate-focused therapy framework, mental health problems emerge when there is an imbalance between basic motives and emotion regulation systems, particularly when the threat system commands individuals’ functioning, easily triggering fight/flight responses (Gilbert 2020). Central to the activation of the threat system are emotion regulation problems and shame (that is, unbearable, overwhelming, and persistent feelings of being inferior, inadequate, and worthless), both of which feature in internalizing and externalizing psychopathological symptoms and disorders (Elison et al. 2006; Gilbert 2019; Paulo et al. 2019).

Compassionate-focused therapy conceptualizes antisocial behavior patterns and psychopathic traits as evolutionary-rooted responses to deal with harsh rearing scenarios (for example, rearing environments marked by traumatic experiences such as unpredictability, threat, or child abuse; and/or by the absence of affiliative signals such as lack of warmth and safeness experiences), which interplay with other factors, such as genetic, epigenetic, and neural influences (Cowan et al. 2016; Del Giudice and Ellis 2015; Murray et al. 2018; Ribeiro da Silva et al. 2015; Waller et al. 2016). Youths in correctional settings tend to have 1) an overdeveloped and oversensitive threat system, 2) a drive system that is self-focused on short-term goals and wants, 3) an underdeveloped soothing system, and 4) central emotional dysfunctions (Ribeiro da Silva et al. 2015). Using principles of compassionate-focused therapy, the PSYCHOPATHY.COMP program attempts to reduce psychopathic traits by restoring the balance of the motivational and emotional regulation systems of youth by promoting compassionate motivation.

Program Components

The program is delivered over 20 individual sessions held weekly for 60 minutes each. Therapists trained in compassionate-focused therapy and in PSYCHOPATHY.COMP deliver the sessions. The therapists concentrate on developing a secure therapeutic relationship, evaluating the motivational stage of the youth, and encouraging compassionate mind training (CMT). CMT consists of training on specific practices designed to cope with the triggering of the threat system; that develop the soothing system; that balance the emotion regulation systems; to overcome fears, blocks, and resistances to compassion; and that promote the development of the different flows of compassion—giving compassion to others, receiving compassion from others, and practicing self-compassion (Gilbert 2019).

Each session is divided into three parts.

• Part 1 is a grounding and focusing exercise (for example, soothing rhythm breathing and engaged compassionate intention [Gilbert 2010]) to help youths relax and focus before the sessions begins. Next, the therapist provides an overview of the last session and explores any new insights or events from the previous week.
• Part 2 of the session is an experiential exercise (for example, role-playing hypothetical, past, and/or future events) based on the session theme wherein youths are guided to a better understanding of the session’s concepts.
• Part 3 begins with a summary of the session, and then youths are invited to do a CMT practice. At the end, youths are given a “Magic Card” displaying a keyword, a quote, or an image that summarizes the session’s theme (Ribeiro da Silva et al. 2017; Ribeiro da Silva et al. 2019).

The program consists of four modules:

• Module 1. The Basics of Our Mind. This module provides an understanding of humans’ basic emotions and needs, including the instinctive response to threats (social or physical [Gilbert 2019]). Youths are encouraged to understand that, even if they cannot change events, emotions, and thoughts, they can change the way they relate with them and act on them. CMT is introduced to begin the process of building youths’ compassionate minds and awareness (Ribeiro da Silva et al. 2019; Ribeiro da Silva et al. 2021b).
• Module 2. Our Mind According to Compassionate Focused Therapy. This module brings awareness to youth about the functioning of the human mind and body according to a compassionate-focused therapy framework and continues with CMT (Gilbert 2019; Ribeiro da Silva et al. 2017). Therapists compassionately allow youths to discover that, although they are “just one version of themselves” (for example, they probably would be different if genetic factors or rearing experiences had been different), their evolutionary, genetic, and contextual inheritance does not lead to determinism, as they all can take conscious actions as they increase their awareness about their own functioning (Ribeiro da Silva et al. 2019). Youths are guided through understanding the concepts of emotion regulation systems (that is, threat, drive, and soothing systems and their body, emotional, cognitive, and behavioral outputs), shame, and safety strategies (Gilbert 2019; Ribeiro da Silva et al. 2015).
• Module 3. Compassionate Mind Training (CMT). This module focuses explicitly on CMT (Ribeiro da Silva et al. 2017). Through experiential exercises (for example, role-playing hypothetical, past, and/or future events), youths gradually are exposed to the triggering of the threat system (mostly anger and shame exposure), allowing them to understand its outputs (both in the mind and in the body), to differentiate and integrate their multiple selves (for example, anxious, angry, sad), and to search for compassionate strategies to bear and manage their own distress in healthy ways (Ribeiro da Silva et al. 2017; Ribeiro da Silva et al. 2019).
• Module 4. Recovery, Relapse Prevention, and Finalization. This module is aimed at revisiting motivations for recovery and preventing relapse under the lens of compassion (Ribeiro da Silva et al. 2017). Youths are encouraged to genuinely understand that, although suffering will always be part of our lives, this therapeutic journey offers them several compassionate emotion regulation strategies that are now available when one must cope with suffering (Ribeiro da Silva et al. 2017; Ribeiro da Silva et al. 2019). Therapists should continually emphasize youths’ control and personal choices, as well as their responsibility toward change (Ribeiro da Silva et al. 2017; Ribeiro da Silva et al. 2021b; Steindl et al. 2018).

Study

Ribeiro da Silva and colleagues (2021a) conducted a quasi-experimental design study to assess the effectiveness of the PSYCHOPATHY.COMP program in reducing psychopathic traits (that is, grandiose–manipulative, callous–unemotional, and impulsive–irresponsible/daring–impulsive) among detained 14- to 18-year-old male youths in Portugal diagnosed with a conduct disorder and high levels of psychopathic traits. The presence of conduct disorder was diagnosed with the Mini-International Neuropsychiatric Interview for Children and Adolescents (Sheehan et al. 2010). Study participants were selected from six Portuguese juvenile detention facilities. Participants were excluded from the program if they were female, non-Portuguese speaking, detained for less than 12 months, or if they exhibited social impairments such as cognitive impairments, psychotic symptoms, or autism spectrum disorders. Treatment group participants (n = 58) received the PSYCHOPATHY.COMP program; control group participants (n = 61) received treatment as usual. Treatment as usual included around 20 individual weekly counseling sessions delivered by psychologists from the juvenile justice system. The treatment group did not attend the treatment-as-usual sessions, and the control group did not attend the PSYCHOPATHY.COMP program during the research period.

The average age of treatment group participants was 15.9 years old, and they were detained for an average of 19.5 months. A majority of the treatment group had previous contact with the juvenile justice system in either community-based programs (50 percent), detention (5.2 percent), or some other type of justice contact (20.7 percent). The majority of treatment participants (70.7 percent) were diagnosed with multiple comorbidities using the Mini-International Neuropsychiatric Interview for Children and Adolescents. Treatment group participants were diagnosed with an average of 3.6 comorbidities, which included oppositional defiant disorder (13.8 percent), alcohol use disorder (1.7 percent), substance use disorder (10.3 percent), and anxiety-related disorders (3.4 percent). The average age of control group participants was 15.7 years old, and they were detained for an average of 17.5 months. A majority of the control group had previous contact with the juvenile justice system in either community-based programs (49.2 percent), detention (3.3 percent), or some other type of justice contact (23 percent). The majority of control participants (73.8 percent) were diagnosed with multiple comorbidities, using the Mini-International Neuropsychiatric Interview for Children and Adolescents. Control group participants were diagnosed with an average of 3.7 comorbidities, which included oppositional defiant disorder (14.8 percent), alcohol use disorder (1.6 percent), and substance use disorder (9.8 percent). There were no statistically significant differences between the treatment and control groups on baseline characteristics.

All study participants were assessed using the Youth Psychopathic Traits Inventory Short and the Proposed Specifiers for Conduct Disorder. Participants in the treatment group were assessed before the first session of the program (baseline assessment), immediately after program completion (posttreatment assessment—about 6 months after the baseline assessment), and 6 months after program completion (6-month follow-up assessment). Participants in the control group were assessed with the same time interval using the same measures. The Youth Psychopathic Traits Inventory Short is an 18-item self-report version of the original Youth Psychopathic Traits Inventory (Andershed et al. 2002), which assesses psychopathic traits in youth, using ratings within three different factors: 1) grandiose–manipulative (grandiosity, arrogance, dishonest charm, and manipulation [Edwards 2020]); 2) callous–unemotional (low empathy, low guilt, and no remorse [Edwards 2020]); and 3) impulsive–irresponsible (risk-taking and thrill-seeking behavior [Edwards 2020]). Each factor is estimated by a set of six items, and each item is rated on a four-point scale (1 = “Does not apply at all” to 4 = “Applies very well”); higher scores are indicators of increased levels of psychopathic traits. The Proposed Specifiers for Conduct Disorder is a 24-item questionnaire designed to assess psychopathic traits in youth, using self-report ratings within four expected factors (Salekin 2017; Salekin and Hare 2016): grandiose–manipulative, callous–unemotional, and conduct disorder. Each factor is estimated by a set of six items; each item is rated on a three-point scale (0 = “not true,” 1 = “somewhat true,” 2 = “true”); higher scores are indicators of increased levels of psychopathic traits.

Treatment effects were tested following an intent-to-treat analysis using latent growth curve models. A negative slope indicated a decrease in psychopathic traits in treatment participants. Effect sizes for the rate of change observed in the dependent variables were then calculated using growth modeling analysis. No subgroup analysis was conducted.

Study

Ribeiro da Silva and colleagues (2021b) conducted a quasi-experimental design study to assess the effectiveness of the PSYCHOPATHY.COMP program in reducing psychopathic traits (that is, grandiose–manipulative, callous–unemotional, and impulsive–irresponsible/daring–impulsive) among detained Portuguese male youths diagnosed with a conduct disorder and high levels of psychopathic traits. This study used the same overall sample and design procedures as Study 1 (Ribeiro da Silva et al. 2021a). Treatment group participants (n = 24) received the PSYCHOPATHY.COMP program for about 6 months in addition to treatment as usual; control group participants (n = 22) received only treatment as usual. Treatment as usual aimed to increase educational and professional qualifications, as well as to promote behavioral regulation, and encompassed school frequency, a token economy system for behavior control, and the frequency of a cognitive–behavioral group program during individual weekly counseling sessions delivered by psychologists from the juvenile justice system.

The average age of treatment group participants was 15.7 years old, and they were detained for an average of 22.1 months. A majority of the treatment group had previous contact with the juvenile justice system in either community-based programs (41.7 percent), detention (4.2 percent), or some other type of justice contact (25 percent). The majority of treatment participants (62.5 percent) were diagnosed with multiple comorbidities, using the Mini-International Neuropsychiatric Interview for Children and Adolescents. Treatment group participants were diagnosed with an average of 3.5 comorbidities, which included oppositional defiant disorder (14.7 percent), alcohol use disorder (4.2 percent), substance use disorder (12.5 percent), and anxiety related disorders (4.2 percent). The average age of control group participants was 15.5 years old, and they were detained for an average of 20.3 months. A majority of the control group had previous contact with the juvenile justice system in either community-based programs (40.9 percent) or some other type of justice contact (13.6 percent). The majority of control participants (72.7 percent) were diagnosed with multiple comorbidities using the Mini-International Neuropsychiatric Interview for Children and Adolescents. Control group participants were diagnosed with an average of 3.9 comorbidities, which included oppositional defiant disorder (3.6 percent) and substance use disorder (3.6 percent). There were no statistically significant differences between the treatment and control groups on baseline characteristics.

All study participants were assessed using the Youth Psychopathic Traits Inventory Short. Participants in the treatment group were assessed before the first session of the program (baseline assessment) and immediately after program completion (posttreatment assessment—about 6 months after the baseline assessment). Participants in the control group were assessed with the same time interval, using the same measures. The Youth Psychopathic Traits Inventory Short is an 18-item self-report version of the original Youth Psychopathic Traits Inventory (Andershed et al. 2002), which assesses psychopathic traits in youth using ratings within three different factors: grandiose–manipulative (grandiosity, arrogance, dishonest charm, and manipulation [Edwards, 2020]); callous–unemotional (low empathy, low guilt, and no remorse [Edwards 2020]); and impulsive–irresponsible [risk-taking and thrill-seeking behavior [Edwards, 2020]). Each factor is estimated by a set of six items and each item is rated on a four-point scale (1 = “Does not apply at all” to 4 = “Applies very well”); higher scores indicate increased levels of psychopathic traits.

Effect sizes were computed using partial eta squares. A Reliable Change Index (RCI) was computed (Jacobson and Truax 1991) to assess significant clinical change after the delivery of the treatment program. The RCI was designed to test the efficacy of a particular therapy or program by evaluating intrasubject clinical individual change. Instead of focusing on the differences of mean scores, it provides information about treatment effects for each individual, allowing testing whether an individual improves or deteriorates in comparison with baseline. No subgroup analysis was conducted.

Therapists were psychologists who had a minimum of 6 years’ clinical experience as well as intensive training on compassion-focused therapy with a compassion-focused therapy expert in an initial face-to-face 35-hour workshop, followed by online sessions totaling 30 hours. Therapists also were experienced in delivering the PSYCHOPATHY.COMP program to youths who have been charged with an offense (each therapist had previously delivered the program to two justice-involved youths). Therapists had weekly supervision sessions with compassion-focused therapy experts totaling 40 hours (Ribeiro da Silva et al. 2021a).

An independent rater observed about 5 percent of the treatment sessions to assess treatment integrity. The independent raters were three compassion-focused therapy experts who used a therapy assessment guide developed by the research team to evaluate the global quality of the session (considering the compassion-focused therapy approach and the protocol of the sessions), the therapeutic relationship, and the therapeutic skills (Ribeiro da Silva et al. 2021a).

These sources were used in the development of the program profile:

These sources were used in the development of the program profile: