BOOK REVIEW: Rasmus Rosenberg Larsen PSYCHOPATHY UNMASKED: THE RISE AND FALL OF A DANGEROUS DIAGNOSIS

While Psychopathy Unmasked is not the first work in the recent philosophical literature to criticise the forensic psychological conception of psychopathy, it is probably the most radical. Other recent works have suggested that psychopathy is often inadequately or inaccurately characterised, but they nonetheless take for granted that psychopathy (or its overlapping diagnosis of antisocial personality disorder) is a useful category that captures a clinically significant cluster of behavioural dispositions. A notable mention is Jonathan Glover’s excellent book, Alien Landscapes? (2014), which features interviews with inpatients at a forensic psychiatric hospital. These interviews challenge the forensic psychological image of the psychopathic person as someone who lacks moral capacity and instead call for more nuanced characterisations of the moral systems of people diagnosed with psychopathy. Another recent work is my paper, “Psychopathic Personalities and Developmental Systems” (Maung 2021), which offers a philosophical critique of how the forensic psychological characterisation of psychopathy as an immutable biological phenotype assumes a discredited form of genetic essentialism. Instead, applying the framework of developmental systems theory, I argue that the behavioural dispositions that comprise psychopathy are better understood as enduring effects of various biographical and social causes, such as emotional neglect and abuse by caregivers, which interact with moral and psychological development in ways that are also influenced by the contingencies of biological variation and cultural context. There has also been some criticism of the conception of psychopathy from within forensic psychology, such as Willem Martens’s (2008) critical analysis of Robert Hare’s (1980) “Psychopathy Checklist” (PCL), which is the standard tool used in the diagnosis of psychopathy.

However, Rosenberg Larsen goes even further in his critique. As noted above, some previous works suggest that psychopathy has been inadequately or inaccurately characterised, thus implying that the category could potentially be refined by arriving at more accurate descriptions and explanations of the behavioural dispositions that the category is supposed to capture. By contrast, Rosenberg Larsen proposes that the category of psychopathy ought to be abolished altogether. The core thesis of Psychopathy Unmasked is that there are no clinically significant differences between people classified as psychopathic and people classified as non-psychopathic that justify the continued use of this category in forensic psychology.

According to Larsen, the forensic psychological conception of psychopathy is based on five assumptions. These are: (1) that psychopathic persons are extraordinarily dangerous; (2) that psychopathy is chronically untreatable; (3) that psychopathic persons are deprived of moral capacities; (4) that psychopathy is “biological”; and (5) that psychopathy is theoretically corroborated. Each of these assumptions is assessed and debunked by Rosenberg Larsen.

Contesting the claim that psychopathic persons are extraordinarily dangerous, Rosenberg Larsen comprehensively analyses the findings from several systematic reviews on psychopathy. He concludes that there are no significant differences between people classified as psychopathic and people classified as non-psychopathic with regards to the rates of general recidivism, violent recidivism, sexual recidivism, and institutional adjustment. At most, there may be a small difference between the averages of the groups, but the overlap between the groups is so vast that the classification cannot reliably inform an inference about any individual case. This suggests that the diagnosis of psychopathy is a poor predictor of dangerousness.

Similarly, in response to the claim that psychopathy is chronically untreatable, Rosenberg Larsen examines a comprehensive range of studies and reviews on the effects of psychotherapeutic interventions on behavioural outcomes in people diagnosed with psychopathy. Here, the vast majority of studies show that psychotherapeutic interventions lead to behavioural improvements, thus discrediting the assumption of untreatability. Perhaps this should be unsurprising. As I have argued, this amenability of psychopathic behaviour to therapeutic change makes good sense if we view the endurance of a behavioural disposition as a dynamic process that involves interactive feedback between the individual and the environment, rather than as a static and biologically predetermined outcome (Maung 2021). Indeed, the dynamic nature of behavioural development is supported by Randall Salekin’s (2002) observation that psychopathic behaviour responds well to psychoanalytic therapy, cognitive-behavioural therapy, and psychodrama.

Regarding the claim that psychopathic persons are deprived of moral capacities, Rosenberg Larsen considers the results of empathy assessment studies, emotional recognition studies, moral reasoning studies, and moral dilemma tests. He shows that the majority of the results suggest no significant differences between people classified as psychopathic and people classified as non-psychopathic with regards to affective empathy, cognitive empathy, and moral reasoning. This complements what some other writers have suggested. As noted above, the interviews in Glover’s Alien Landscapes? (2014) reveal that the moral systems of people diagnosed with psychopathy are much more varied and nuanced than suggested by the forensic psychological image of a psychopathic person as an amoral agent. Likewise, Martens (2008) argues that there is no reliable evidence to suggest that people diagnosed with psychopathy are affectively shallow or are generally lacking in empathy. While Larsen does discuss the methodological shortcomings of specific studies, the discussion could perhaps have gone further by including a deeper examination of whether the operational conceptions of “empathy” measured by these psychological tests actually capture the ordinary conception of empathy that we consider to be morally significant. As Riana Betzler (2019) notes, not only is “empathy” both an ordinary term and a scientific term, but the scientific term is defined and measured in different ways across disciplines. Hence, the operationalisations used by some of these scientific studies on psychopathy may not capture the features we value in our interactions with one another. If that is so, then it remains possible that the clinical psychopathy assessment could reflect some feature of empathy that we implicitly deem to be relevant to our ordinary social interactions, but which is not straightforwardly captured by scientific operationalisations of “empathy”.

The claim that psychopathy is “biological” could be interpreted and criticised in different ways. As noted above, in a recent philosophical paper, I applied the framework of developmental systems theory to argue that psychopathy is not a genetic condition (Maung 2019). This is not to say that the genome is not involved at all, as all development involves the interaction of the genome and the environment, but rather it is to say that psychological development is so heavily contingent on the interpersonal environment, and so psychopathy is better understood as a complex outcome of how social causes such as early abuse and neglect interact with the contingencies of variation and development. However, Rosenberg Larsen’s main contention is that psychopathy is not a neurological condition. Accordingly, his criticism focuses on neuroscientific research on psychopathy. The claim here is not that the brain is not involved in the causation of psychopathic behaviour, for it is trivially the case that all behaviour has associated neural activity, but rather the claim is that there are no measurable and generalisable neural patterns that are found in people classified as psychopathic but are not found in people classified as non-psychopathic. To support this claim, Larsen reviews the results of studies that use electroencephalography, structural magnetic resonance imaging, and functional magnetic resonance imaging. He argues that these results fail to support the hypothesis that there are significant differences between the brains of psychopathic persons and non-psychopathic persons. Accordingly, neuroimaging studies cannot support inductive inferences about behavioural dispositions in specific cases. Interestingly, the claim that psychopathy is “biological” has also recently been criticised in the forensic psychology literature by scholars who argue that biographical and environmental factors have been unduly neglected in psychopathy research (Frazier, Ferreira, and Gonzales 2019).

Against the claim that psychopathy is theoretically corroborated, Rosenberg Larsen argues that psychological theories of psychopathy are falsified explanations. He focuses specifically on the emotion theory and the cognitive theory, which respectively claim that psychopathic persons have impairments in affective processing and cognitive processing when compared to non-psychopathic persons. According to Rosenberg Larsen, the emotion theory and the cognitive theory are undermined by experimental results that show no significant differences between the two groups. Here, it might have also been valuable to consider other theories that may have more empirical support. For example, Rosenberg Larsen does not specifically discuss explanations based on attachment theory and psychoanalytic theory which emphasise the causal roles of early social and interpersonal factors in the development of psychopathy (Gullhaugen and Nøttestad 2011; Schuster 1976). Indeed, these theories are supported by evidence that emotional neglect, abuse by parental figures, and a hostile social environment are causally associated with subsequent psychopathic traits (Gao et al. 2010; McCord and McCord 1964; Schimmenti et al. 2014; Waller et al. 2012), as well as by evidence that interventions on interactions with caregivers can mitigate and forestall psychopathic traits in children and adolescents (Hyde et al. 2016; Moretti, Holland, and Peterson 1994). Also, not specifically discussed by Rosenberg Larsen are explanations that emphasise the causal influences of cultural factors, such as the research which suggests that rates of psychopathy and antisocial personality disorder are higher in cultures that promote individualism than in cultures that promote collectivism (Compton et al. 1991; Cooke and Michie 1999). Relatedly, David Owen and Jonathan Davidson (2009) suggest that unconstrained political power is a causal factor that can promote the development and maintenance of grandiosity and antisociality, which are typically considered to be features of psychopathy.

Overall, Rosenberg Larsen’s analysis of the scientific evidence is very impressive. It displays a thorough understanding of the empirical and statistical methodologies used to study psychopathy, as well as a good appreciation of what the research findings imply. Hence, a proponent of the forensic psychological conception of psychopathy cannot claim that Rosenberg Larsen has misunderstood this study or misrepresented that study, because he has not. Rather, any reasonable disagreement could only be about what philosophical conclusions and practical recommendations should be made in light of the empirical evidence that is presented.

As mentioned above, Rosenberg Larsen recommends that the practice of psychopathy assessment ought to be abolished. He defends this on epistemological and ethical grounds. With regard to epistemology, Rosenberg Larsen argues that the category of psychopathy fails to support reliable inferences and predictions about dangerousness, treatability, and moral capacity which are of interest for legal practice. Hence, the assessment for psychopathy has poor predictive value in the forensic setting. With regard to ethics, Rosenberg Larsen argues that the practice of psychopathy assessment violates the principles of medical ethics proposed by Tom Beauchamp and James Childress (1979), which are beneficence, nonmaleficence, autonomy, and justice. By framing certain people as dangerous, untreatable, and amoral, the diagnosis of psychopathy unjustly harms these people, for it is often used to authorise more punitive custodial sentences, withhold therapeutic interventions, and withhold opportunities for rehabilitation.

Concerning the uses of psychopathy assessments in the legal context, I am in agreement with Rosenberg Larsen. Forensic psychopathy assessments do not respect the interests of the people being assessed but do the opposite. Denying a person the opportunity for therapy or rehabilitation on the basis of a psychopathy diagnosis is harmful, unjust, and empirically unjustified. Furthermore, the assumption that the person with psychopathy is untreatable becomes self-fulfilling, insofar as this assumption motivates the decision to withhold therapeutic and rehabilitative resources, which in turn removes the opportunity for the person to work on behavioural change. A similar point is made by Rachel Cooper (2012), who notes that some people who are diagnosed with antisocial personality disorder exhibit increasingly severe antisocial behaviours after receiving the diagnosis, because the diagnosis makes them view themselves as being untreatably bad. Hence, when used in the above manner, the diagnostic category of psychopathy perpetuates a narrative of hopelessness. Moreover, it paints a demeaning stereotype of a sort of person who is biologically defective, morally deficient, and irredeemably dangerous. There seems to be an ironic projection here, since by viewing the psychopathic person as intrinsically deficient and unworthy of rehabilitative care, one is displaying the very sort of callousness toward the psychopathic person that one is attributing to the psychopathic person.

Although I think Rosenberg Larsen is correct to call for a moratorium on the practice of psychopathy assessment in the forensic setting, I am left wondering whether the category nonetheless has some value in the therapeutic setting. While PCL scores may fail to predict outcomes that are relevant to legal practice, such as recidivism, institutional adjustment, and amenability to rehabilitation, this does not that mean that PCL scores do not capture anything at all that might be relevant in other contexts. Here, there is potentially some internal tension in Rosenberg Larsen’s position. Specifically, the contention that psychopathy is treatable seems to contradict the contention that the category of psychopathy does not capture anything of clinical significance, insofar as treatability presupposes that there is something that can be treated. According to Rosenberg Larsen, psychopathy treatment could be seen as “a clinical intervention that aims to reduce a person’s PCL score” (2025, 66). However, if the treatability of psychopathy is operationally defined by the ability of an intervention to reduce a person’s PCL score, then the claim that psychopathy is treatable supposes that the PCL score measures something that can be modified with the appropriate intervention.

To expand on the above, even if PCL scores do not serve as predictors of recidivism and maladjustment in the forensic setting, some of these features that are measured by PCL scores may still occasion problems for people in other everyday contexts. For example, antisociality, impulsivity, grandiosity, and affective blunting may be disvalued because they result in significant problems with social interactions and interpersonal relationships. Accordingly, there could be value in maintaining a categorical or dimensional diagnosis that captures these features so that they can be specified as targets for therapeutic interventions. Indeed, Rosenberg Larsen writes that

treatment here refers to helping the individual cope with or change some of the core symptoms of associated with the psychopathic personality, such as mitigating their impulsiveness or grandiose sense of self, or maybe even working on developing more empathic attitudes towards other people (Rosenberg Larsen 2025, 66).

As well as psychotherapeutic interventions in adults, these interventions may include social interventions in youths (Hyde et al. 2016; Moretti et al. 1994). Therefore, contrary to how psychopathy assessments are used in the forensic setting to withhold rehabilitative resources, the specification and evaluation of psychopathic features in the therapeutic setting could guide interventions that help people alleviate these features and mitigate their problematic effects. However, for this to receive uptake in clinical setting, it would require widespread denouncement of the untreatability narrative in the clinical discourse about psychopathy.

Another point of contention concerns Rosenberg Larsen’s claim that the category of psychopathy is redundant because its features lie on a continuum with the features of ordinary psychology. To defend this claim, Rosenberg Larsen appeals to Scott Lilienfeld’s (2022) posthumously published proposal that psychopathy could be a “constellation or configuration of several well-established personality dimensions” that can be understood with the resources of ordinary psychology rather than a unique kind that requires its own theoretical framework. However, I contend that such continuity with ordinary psychology does not necessarily undermine the integrity of the category. Many categories in science and medicine involve clusters of properties that lie along continuous dimensions. For example, hypertension is diagnosed when systolic pressure exceeds 140mmHg and when diastolic pressure exceeds 90mmHg. These variables are dimensionally continuous with ordinary physiology and, in principle, could be understood with the resources of physiology without necessarily requiring a special explanation. Nonetheless, hypertension is a clinically useful diagnostic category, because it picks out people who have increased risks of cardiovascular complications and who would benefit from treatment. Here, the distinction between non-hypertension and hypertension does not reflect a sharp difference in kind, but rather there are continuous variations in blood pressures and a subset of these variations are judged to be clinically significant because they are more likely to be associated with harms. Likewise, Lisa Bortolotti (2009) argues that delusions are continuous with ordinary beliefs, and so the distinction between an ordinary belief and a delusion is not a sharp difference in kind but may instead reflect the value judgement that a delusion is harmful to the person’s wellbeing in a way that an ordinary belief is not. Perhaps similar reasoning could apply to psychopathy. What we call psychopathy may indeed be a contingent cluster of behavioural dispositions that are dimensionally continuous with ordinary psychology and can be understood with ordinary psychological theory. Yet, it may still be useful to have a categorical or dimensional diagnosis that describes this cluster, because these behavioural dispositions, when expressed in certain combinations at certain degrees, can be relevant contributors to the social and interpersonal problems that some people bring to therapy. Here, as with hypertension and delusion, the justification for the classification may be ethical and pragmatic rather than ontological.

Part of the book I found especially interesting is Rosenberg Larsen’s discussion of the historical and cultural reasons why the forensic psychological conception of psychopathy has persisted in scientific research and legal practice despite the empirical challenges. Toward the close of the book, Rosenberg Larsen discusses how the uptake of Cleckley’s (1941) conception of psychopathy within the scientific community changed throughout the twentieth century and how this interacted with the increasing fascination with psychopathy in popular culture. In the 1980s and 1990s, there were several popular books and films about stereotypically psychopathic characters such as Patrick Bateman from American Psycho, Hannibal Lecter from The Silence of the Lambs, and Gordon Gekko from Wall Street. There was also a lot of attention in the popular media on serial killers such as Ted Bundy, John Wayne Gacy, Rodney Alcala, and Jeffrey Dahmer. According to Rosenberg Larsen, this fascination with psychopathy in popular culture could have reinforced the persistence of the forensic psychological conception of psychopathy in scientific research and legal practice. Such popular cultural narratives could have implicitly shaped scientists’ and clinicians’ assumptions about psychopathy. Furthermore, they could have provided incentives to study and popularise a conception of psychopathy that interests the wider public.

This is a very engaging hypothesis, which I had hoped to be explored more extensively in the book. While Rosenberg Larsen’s discussion here is excellent, I was left wanting more, for the interaction between popular culture and scientific enquiry is a very rich topic for philosophical analysis. For example, drawing on Ian Hacking’s (1995) framework for studying multiple personality disorder, it could have been interesting to explore how cultural narratives, legal practices, and scientific attitudes concerning psychopathy reinforce and modify one another through looping effects. Complementing the role of popular culture, it could also have been interesting to explore how the promotion of the forensic psychological conception of psychopathy may reflect and serve a certain political agenda. Indeed, it is easy to see how a narrative that tries to attribute criminality to an immutable biological defect in a certain sort of individual, rather than recognise it as a complex social issue, could serve to uphold an ideology that promotes the defunding of rehabilitative services and the directing of attention away from the need to address the social conditions that give rise to criminality, while extending punitive control over the populations affected by these social conditions. With this in mind, it is perhaps unsurprising that the rapid rise in cultural fascination with psychopathy took place during the expansion of neoliberal capitalism by Ronald Reagan and Margaret Thatcher in the 1980s.

In this review, I have laid out Rosenberg Larsen’s argument and have raised some minor reservations about some of the details. Overall, I agree with Rosenberg Larsen that the modern forensic psychological characterisation of the psychopathy is untenable, but I wonder about the extent to which this can be addressed by modifying how the diagnosis is characterised and utilised rather than by abolishing it altogether. Likewise, I agree with Rosenberg Larsen that the current practice of psychopathy assessment in forensic psychology is ethically unacceptable and empirically unjustified, but I wonder whether the diagnosis of behaviour associated with psychopathy could still be valuable in the psychotherapeutic setting. Nonetheless, these reservations do not detract from the overall quality and significance of the book. Psychopathy Unmasked is an excellent work of applied philosophy of science and one of the most important books to be written on the topic of psychopathy, with potentially significant implications for forensic psychology, psychiatric practice criminal law, and popular discourse. Some readers are likely to be reluctant to go everywhere Rosenberg Larsen wants to take them, but his incisive analysis should be taken seriously by all philosophers, psychologists, psychiatrists, and legal scholars interested in psychopathy.

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