See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/271619550
請參閱本出版品的討論、統計資料和作者簡介：https://www.researchgate.net/publication/271619550

Article in International Journal of Forensic Mental Health • October 2012
文章刊載於《國際法醫心理健康期刊》• 2012 年 10 月
DOI: 10.1080/14999013.2012.746762

This article was downloaded by: [John Jay College of Criminal Justice]
本文由[約翰傑伊刑事司法學院]下載
On: 21 July 2015, At: 06:52
時間：2015 年 7 月 21 日，06:52
Publisher: Routledge  出版商：Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: 5 Howick Place, London, SW1P 1WG
Informa Ltd 於英格蘭及威爾斯註冊，註冊號碼：1072954 註冊辦事處：5 Howick Place, London, SW1P 1WG

Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ufmh20
出版詳情，包括作者須知和訂閱資訊：http://www.tandfonline.com/loi/ufmh20

To cite this article: Michele Galietta & Barry Rosenfeld (2012) Adapting Dialectical Behavior Therapy (DBT) for the Treatment of Psychopathy, International Journal of Forensic Mental Health, 11:4, 325-335, DOI: 10.1080/14999013.2012.746762
引用本文獻：Michele Galietta & Barry Rosenfeld (2012) Adapting Dialectical Behavior Therapy (DBT) for the Treatment of Psychopathy, International Journal of Forensic Mental Health, 11:4, 325-335, DOI: 10.1080/14999013.2012.746762

To link to this article: http://dx.doi.org/10.1080/14999013.2012.746762
本文獻連結：http://dx.doi.org/10.1080/14999013.2012.746762

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
Taylor & Francis 盡一切努力確保我們平台上出版品所含的所有資訊（以下簡稱「內容」）的準確性。然而，Taylor & Francis、我們的代理人及授權人對於內容的準確性、完整性或適用於任何目的性，均不作任何明示或暗示的陳述或保證。本出版品中表達的任何意見和觀點均為作者的意見和觀點，不代表或獲得 Taylor & Francis 的認可。內容的準確性不應被依賴，應向主要資訊來源獨立查證。對於因使用內容而直接或間接產生、相關或引起的任何損失、訴訟、索賠、訴訟程序、要求、成本、費用、損害賠償及其他任何形式的責任，Taylor & Francis 概不負責。

This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
本文章僅供研究、教學及私人學習使用。嚴禁任何實質性或系統性的複製、再分發、轉售、借貸、再授權、系統性供應或以任何形式分發給任何人。存取與使用的條款及條件請參閱 http://www.tandfonline.com/page/terms-and-conditions

Keywords: psychopathy, personality disorder, treatment, psychotherapy, Dialectical Behavior Therapy
關鍵字：精神病態、人格障礙、治療、心理治療、辯證行為治療

Few mental abnormalities create more havoc for society than the psychopathic personality. The effects of the disorder are profound, including criminal behavior, violence, and self-harm (DeMatteo, Heilbrun, & Marczyk, 2005; Douglas, Vincent, & Edens, 2006; Hare, 1999; Hemphill, Hare, & Wong, 1998; Verona, Patrick, & Joiner, 2001). Moreover, the behavioral consequences of psychopathy result in trementdous social and economic costs that are born by the mental health, criminal justice and public health systems (Coid et al., 2006; Harris, Rice, & Cormier, 1991; Salekin, 2008). Although the labels and specific criteria used to describe this personality disorder have varied across diagnostic systems and cultures (e.g., dissocial, antisocial, psychopathic, so-
很少有精神異常比精神病態人格對社會造成更大的破壞。這種障礙的影響是深遠的，包括犯罪行為、暴力和自殘（DeMatteo, Heilbrun, & Marczyk, 2005; Douglas, Vincent, & Edens, 2006; Hare, 1999; Hemphill, Hare, & Wong, 1998; Verona, Patrick, & Joiner, 2001）。此外，精神病態的行為後果導致精神健康、刑事司法和公共衛生系統承擔巨大的社會和經濟成本（Coid et al., 2006; Harris, Rice, & Cormier, 1991; Salekin, 2008）。儘管用於描述這種人格障礙的標籤和具體標準在不同的診斷系統和文化中有所不同（例如，反社會、精神病態、所謂的）

ciopathic; American Psychiatric Association [APA], 2000; Ogloff, 2006; World Health Organization, 2008), and may evolve further with the forthcoming publication of the DSM5 (APA, 2012; Krueger & South, 2009; Patrick, 2007), there is little doubt as to the existence of a personality disorder characterized by impulsivity, irresponsibility, and a callous disregard for others that is often masked by a superficial charm and rationality (Bishop & Hare, 2008; Cleckley, 1976; Cooke, 2008; Marcus, Fulton, & Edens, 2012; Snowden & Gray, 2011). ${}^1$${}^1$^(1){ }^{1} Prevalence estimates for psychopathic personality disorder (PPD) vary markedly dependent on settings and definitions (APA, 2000; Babiak, Neumann, & Hare, 2010; Cooke, 1995), but typically range from 16 to $25\mathrm{\%}$$25\mathrm{\%}$25%25 \% among offender populations in the United States (Rotter et al., 2002).
反社會人格；美國精神醫學會 [APA]，2000；Ogloff，2006；世界衛生組織，2008），並可能隨著即將出版的 DSM5（APA，2012；Krueger & South，2009；Patrick，2007）而進一步發展，但毫無疑問，確實存在一種以衝動、不負責任和冷酷無情地漠視他人為特徵的人格障礙，這種障礙通常被膚淺的魅力和理性所掩蓋（Bishop & Hare，2008；Cleckley，1976；Cooke，2008；Marcus, Fulton, & Edens，2012；Snowden & Gray，2011）。 ${}^1$${}^1$^(1){ }^{1} 反社會人格障礙（PPD）的盛行率估計值因環境和定義而異（APA，2000；Babiak, Neumann, & Hare，2010；Cooke，1995），但在美國的罪犯人口中，通常介於 16% 到 $25\mathrm{\%}$$25\mathrm{\%}$25%25 \% 之間（Rotter et al.，2002）。

Although the damage, both interpersonal and criminal, inflicted by psychopathic individuals is undisputed, surprisingly little attention has been paid to this disorder by the mental health community, and in particular, on developing effective treatment approaches (Harris & Rice, 2006; Salekin, Worley & Grimes, 2010; Skeem et al., 2011). There are
儘管反社會人格者所造成的傷害，無論是人際關係還是犯罪方面，都是無可爭議的，但令人驚訝的是，心理健康界對這種疾病的關注卻很少，特別是在開發有效的治療方法方面（Harris & Rice，2006；Salekin, Worley & Grimes，2010；Skeem et al.，2011）。有

numerous reasons why research on effective treatments for PPD has lagged behind research for other personality disorders. For example, the majority of easily identifiable psychopathic individuals are located within the criminal justice system, where treatment is not a funding priority. The National Justice Institute (NIJ) typically supports few mental health treatment initiatives, and then only for selected populations. Moreover, among the general public, acts of serious violence and criminal behavior typically fuel cries for punishment and may even create an anti-treatment sentiment.
有許多原因導致針對 PPD 有效治療方法的研究落後於其他人格疾患。例如，大多數易於辨識的精神病態個體都位於刑事司法系統中，而治療並非該系統的優先資助項目。美國國家司法研究院（NIJ）通常很少支持心理健康治療計畫，即使有也僅限於特定人群。此外，在一般大眾中，嚴重的暴力行為和犯罪行為通常會引發要求處罰的呼聲，甚至可能產生反治療的情緒。

The dearth of research focusing on the treatment of PPD may also reflect the “therapeutic pessimism” that has long characterized the mental health community’s perspective on these disorders (D’Silva, Duggan, & McCarthy, 2004; Salekin, 2002; Salekin et al., 2010; Skeem et al., 2011). Some researchers have actually argued that treatment may result in adverse outcomes, with treated psychopaths being more likely to reoffend violently than untreated offenders (Harris & Rice, 2006). Take, for example, Rice, Harris, and Cormier’s (1992) widely cited analysis of a Canadian Therapeutic Community. Their analysis suggested that violent re-offending was more common among psychopaths who completed treatment compared to those who were not treated, whereas treatment resulted in lower recidivism for non-psychopaths. However, because offenders were not randomly assigned to treatment, nor was treatment standardized (and included highly controversial, if not frankly inappropriate elements such as psychedelic drug use), these results say little about whether more appropriate interventions might yield clinical benefits.
針對 PPD 治療的研究匱乏，也可能反映了長期以來精神健康社群對這些疾患所抱持的「治療悲觀主義」（D’Silva, Duggan, & McCarthy, 2004; Salekin, 2002; Salekin et al., 2010; Skeem et al., 2011）。有些研究人員甚至主張，治療可能會導致不良後果，接受治療的精神病患比未經治療的罪犯更有可能再次暴力犯罪（Harris & Rice, 2006）。舉例來說，Rice、Harris 和 Cormier（1992）對加拿大一個治療社群進行了廣泛引用的分析。他們的分析指出，與未經治療的精神病患相比，完成治療的精神病患更容易再次暴力犯罪，而治療則降低了非精神病患的再犯率。然而，由於罪犯並非隨機分配接受治療，治療也未標準化（且包含高度爭議性，甚至可說是完全不適當的元素，例如迷幻藥物使用），因此這些結果對於更適當的介入是否能產生臨床效益，並無太多說明。

More recently, clinicians have become increasingly optimistic about the potential treatability of psychopaths. Skeem and colleagues (Skeem, Monahan, & Mulvey, 2002), in their study of psychiatric patients who participated in “treatment as usual,” found that psychopaths who received a sufficient “dose” of treatment (i.e., participated in seven or more sessions within ten weeks after discharge) were significantly less likely to engage in violence following their release from the hospital compared to psychopaths who completed fewer than seven sessions. While additional research is needed in order to replicate these findings, as well as to better understand the relationship between treatment and risk reduction, these findings have generated optimism among forensic mental health clinicians (Draycott, Askari, & Kirkpatrick, 2011; Pickersgill, 2011).
近期，臨床醫師對於精神病患的潛在可治療性越來越樂觀。Skeem 及其同事（Skeem, Monahan, & Mulvey, 2002）在他們針對參與「常規治療」的精神病患所做的研究中發現，接受足夠「劑量」治療（即出院後十週內參與七次或更多次療程）的精神病患，在出院後從事暴力行為的可能性顯著低於完成少於七次療程的精神病患。儘管需要更多研究來複製這些發現，並更好地理解治療與風險降低之間的關係，但這些發現已在法醫精神健康臨床醫師中引起樂觀情緒（Draycott, Askari, & Kirkpatrick, 2011; Pickersgill, 2011）。

The majority of information about treatment of psychopathic individuals comes from treatment studies of criminal offenders. Such studies have typically targeted specific aspects of criminal behavior (i.e., criminogenic needs; Polaschek, 2010) such as criminal cognitions (Davidson et al., 2009), anger management (Bus, Stefan, & Visu-Petra, 2009; Towl & Dexter, 2009), and substance abuse (Messina et al., 2010). The choice and implementation of interventions is usually guided by the Risk-Needs-Responsivity (RNR)
關於精神病態個體治療的大部分資訊，來自針對犯罪者的治療研究。這類研究通常鎖定犯罪行為的特定面向（即犯罪成因需求；Polaschek, 2010），例如犯罪認知（Davidson et al., 2009）、憤怒管理（Bus, Stefan, & Visu-Petra, 2009; Towl & Dexter, 2009），以及藥物濫用（Messina et al., 2010）。介入的選擇與執行通常依循風險-需求-反應（RNR）原則。

Model (Andrews et al., 1990), which focuses attention on those needs deemed to have the greatest association with reoffense (Skeem, Polaschek, & Manchak, 2009). However, criminogenic interventions typically generate small treatment effects and they have had only limited success in reducing recidivism rates or eliminating many of the core deficits that characterize PPD (Tyrer et al., 2009). One possible explanation for the limited success of traditional criminal justice system interventions is that they often focus narrowly on changing cognitions and behavior, with virtually no attention to emotion regulation and impulse control. When included as targets in treatment, emotions have typically been limited to anger and targeted using cognitive strategies. In other words, these interventions require that an individual have the ability to benefit from psychoeducation about emotion and to connect his or her own experience of anger to the material learned in treatment. This requires capacities that may be lacking in many individuals with PPD (e.g., abstract thinking or observing one’s own actions and urges).
模式（Andrews et al., 1990），該模式將注意力集中在那些被認為與再犯關聯最大的需求上（Skeem, Polaschek, & Manchak, 2009）。然而，犯罪成因介入通常只產生微小的治療效果，並且在降低再犯率或消除許多 PPD 的核心缺陷方面，其成功有限（Tyrer et al., 2009）。傳統刑事司法系統介入成功有限的一個可能解釋是，它們通常狹隘地專注於改變認知和行為，而幾乎不關注情緒調節和衝動控制。當情緒被納入治療目標時，通常僅限於憤怒，並使用認知策略進行干預。換句話說，這些介入要求個體能夠從關於情緒的心理教育中獲益，並將其自身的憤怒經驗與治療中學到的內容聯繫起來。這需要許多 PPD 個體可能缺乏的能力（例如，抽象思考或觀察自己的行為和衝動）。

Emotion dysregulation and impulsivity have increasingly been recognized as central elements of several highly problematic personality disorders (Fairholme et al., 2010; Kuo & Linehan, 2009). Linehan (1993) identified emotion dysregulation as the core psychopathology in Borderline Personality Disorder (BPD). Early conceptualizations of psychopathy also identified emotional deficits as a key characteristic for the syndrome (Cleckley, 1976). Similarly, an ever-growing literature on neurological deficits in psychopathy has demonstrated deficiencies in emotion perception and regulation among individuals with psychopathy (Blair, 2005; Muller, 2010; Raine & Yang, 2005). Thus, the failure to address deficits in emotion recognition and regulation may have resulted in many of the unimpressive treatment outcomes observed for PPD individuals.
情緒失調和衝動性已日益被視為幾種問題嚴重的性格疾患之核心要素（Fairholme et al., 2010; Kuo & Linehan, 2009）。Linehan（1993）將情緒失調認定為邊緣型人格（BPD）的核心精神病理學。精神病態的早期概念化也將情緒缺陷視為該症候群的關鍵特徵（Cleckley, 1976）。同樣地，關於精神病態神經缺陷的文獻不斷增加，已證明精神病態個體在情緒感知和調節方面存在缺陷（Blair, 2005; Muller, 2010; Raine & Yang, 2005）。因此，未能解決情緒辨識和調節方面的缺陷，可能導致了許多針對精神病態個體所觀察到的不佳治療結果。

Another possible source of poor treatment outcomes relates to the treatment of psychopathy as a homogeneous construct. Originally conceived of as a distinct syndrome, recent research indicates that psychopathy may not be best conceptualized as a unitary construct (Marcus et al., 2012). While the question of how to best conceptualize psychopathy is beyond the scope of this article, it is clear that individuals high in psychopathy represent a heterogeneous population. This heterogeneity is perhaps best evidenced by the long-standing distinction between “Primary” (or Type 1) and “Secondary” (or Type 2) psychopaths (Hare & Neumann, 2009; Marcus et al., 2011). The Primary or Type 1 psychopath has been characterized as cold, callous, and detached, yet with a superficial charm and grandiose self-perception. Secondary, or Type 2 psychopaths, on the other hand, have typically been described as impulsive and emotionally labile, with poor social controls (Lykken, 1995). Importantly, emotion plays a key role in both of these types, with Type 1 psychopaths experiencing too little affect (i.e., such as the failure to experience anxiety) and the Type 2 psychopaths displaying deficits in emotion regulation (Grieve & Mahar, 2010; Lander et al.,
另一種可能導致治療效果不佳的原因，與將精神病態視為同質性建構有關。精神病態最初被認為是一種獨特的症候群，但近期研究指出，將精神病態概念化為單一建構可能並非最佳方式（Marcus et al., 2012）。儘管如何最佳地概念化精神病態已超出本文範疇，但顯然精神病態程度高的人群代表著一個異質性群體。這種異質性或許最能從「原發性」（或第一型）和「次發性」（或第二型）精神病態者之間長期存在的區別中得到證明（Hare & Neumann, 2009; Marcus et al., 2011）。原發性或第一型精神病態者被描述為冷酷、無情、超然，卻帶有膚淺的魅力和誇大的自我認知。另一方面，次發性或第二型精神病態者通常被描述為衝動、情緒不穩定，且社會控制能力差（Lykken, 1995）。 重要的是，情緒在這兩種病患中都扮演著關鍵角色，第一型精神病態患者的情感反應過於遲鈍（例如，無法體驗焦慮），而第二型精神病態患者則在情緒調節方面表現出缺陷（Grieve & Mahar, 2010; Lander et al.,
2012). Indeed, Skeem and colleagues have described Type 2 psychopaths as high in anxiety and suggest that the inability to manage this anxiety results in impaired “emotional intelligence,” which accounts for many of the behavioral problems exhibited by this subgroup (Vidal, Skeem & Camp, 2010).
2012）。事實上，Skeem 及其同事曾將第二型精神病態患者描述為高度焦慮，並認為無法控制這種焦慮會導致「情緒智商」受損，這解釋了該亞群體所表現出的許多行為問題（Vidal, Skeem & Camp, 2010）。

The heterogeneity among psychopathic offenders is further evident in the recent conceptualization of psychopathy developed by Cooke and colleagues (Cooke et al., 2004; Cooke, Michie, & Hart, 2006). Their recently published instrument, the Comprehensive Assessment of Psychopathic Personality (CAPP), identifies six domains of psychopathy: attachment, behavior, cognitions, dominance, emotionality, and self. Of particular relevance for the treatment of PPD, the domain of emotionality “reflects problems with mood regulation, such as the tendency to experience shallow, labile emotions” (Cooke et al., 2004, p. 6). Although still preliminary, recent research using this instrument has supported the importance of this domain as an important aspect of psychopathy (Hoff et al., 2012; Kreis et al., 2012) and highlights the conceptual and behavioral overlap between aspects of BPD and psychopathy.
精神病態罪犯之間的異質性，在庫克及其同事（Cooke et al., 2004; Cooke, Michie, & Hart, 2006）近期發展出的精神病態概念中，得到了進一步的證明。他們最新發表的測量工具「精神病態人格綜合評估」（Comprehensive Assessment of Psychopathic Personality, CAPP），識別出精神病態的六個領域：依附、行為、認知、支配、情緒和自我。其中，與精神病態人格障礙（PPD）治療特別相關的是情緒領域，它「反映了情緒調節的問題，例如傾向於經歷膚淺、不穩定的情緒」（Cooke et al., 2004, p. 6）。儘管仍處於初步階段，但近期使用此工具的研究已支持此領域作為精神病態重要面向的重要性（Hoff et al., 2012; Kreis et al., 2012），並突顯了邊緣型人格障礙（BPD）和精神病態在概念和行為上的重疊之處。

Patrick and his colleagues (e.g., Patrick, 2007; Skeem et al., 2011) have offered another approach to conceptualizing psychopathy, in his “triarchic” model. This model posits that psychopathy can be conceptualized as a combination of three distinct constructs: boldness, meanness, and disinhibition. What is noteworthy about this model is that each of these three constructs can be related to emotion. For example, boldness and meanness are often associated with deficits in emotion perception (boldness) or emotional experience (meanness), while disinhibition may result from intense emotionality and/or poor emotional regulation abilities.
派翠克及其同事（例如，Patrick, 2007; Skeem et al., 2011）在他的「三元」模型中，提出了另一種概念化精神病態的方法。此模型假設精神病態可被概念化為三種不同建構的組合：大膽、刻薄和去抑制。此模型值得注意的是，這三種建構都與情緒相關。例如，大膽和刻薄通常與情緒知覺（大膽）或情緒體驗（刻薄）的缺陷相關，而去抑制可能源於強烈的情緒反應和／或不良的情緒調節能力。

Given the importance of emotion in multiple aspects of psychopathy, as well as the growing evidence for a conceptual and behavioral link to BPD, we looked to the personality disorder treatment literature in selecting an intervention best suited to treat individuals high in psychopathy. The intervention with the most empirical support for any personality disorder is Dialectical Behavior Therapy for Borderline Personality disorder (e.g., Linehan et al., 1999, 2002; van den Bosch et al., 2002). In addition, Linehan’s model posits that the behavioral difficulties associated with BPD are consequences of the core problem of emotion dysregulation (a pervasive inability to manage emotions). According to this theory, two elements (a biological vulnerability and an adverse environment) interact with one another over time to produce increasingly maladaptive behaviors.
考量到情緒在精神病理學多個面向的重要性，以及越來越多證據顯示其與邊緣型人格之間在概念和行為上的關聯，我們在選擇最適合治療精神病理學程度高之個體的介入時，參考了人格疾患治療文獻。在所有人格疾患中，獲得最多實證支持的介入是針對邊緣型人格的辯證行為治療（例如，Linehan 等人，1999、2002；van den Bosch 等人，2002）。此外，Linehan 的模型認為，與邊緣型人格相關的行為困難是情緒失調（一種普遍無法管理情緒的狀態）這個核心問題的結果。根據此理論，兩種要素（生物脆弱性與不利環境）會隨著時間相互作用，產生越來越適應不良的行為。

Linehan’s model, which was developed to explain the emergence of BPD symptoms, proposes that the child is born with a sensitive temperament characterized by high levels of emotionality. Such individuals, according to Linehan, react to even low levels of environmental stimuli; their reactions are extreme and their emotions, once engaged, take longer than average to return to baseline. This predisposition, how-
Linehan 的模型旨在解釋邊緣型人格疾患（BPD）症狀的出現，該模型提出兒童天生具有敏感的氣質，其特徵是高度情緒化。Linehan 認為，這類個體即使面對低程度的環境刺激也會產生反應；他們的反應極端，且一旦情緒被觸發，需要比一般人更長的時間才能恢復到基準線。這種傾向，然而，
ever, is not enough to produce BPD; it is the response of those in the child’s environment that is crucial to the development of BPD symptoms. Aversive environments, described by Linehan (1993) as “invalidating,” ignore the emotional needs of the child. In particular, such environments often ignore reasonable communication of emotional distress and punish emotional expression and emotionally driven behaviors, regardless of the reasonableness of the child’s emotional reaction. Perhaps most importantly, invalidating environments often provide intermittent reinforcement of extreme or impulsive behaviors. Consistent with Linehan’s theory, a growing literature has demonstrated an important role for both the biological underpinnings of psychopathy (e.g., Frick & Marsee, 2006; Patrick & Bernat, 2010;) as well as the impact of aversive environmental factors (e.g., Graham et al., 2012), In short, current theory and research on the etiology of psychopathy supports the hypothesis of a reciprocal relationship between biology and environment to produce the constellations of behaviors observed in individuals identified as being high in psychopathy (Waldman & Rhee, 2006).
然而，這不足以導致邊緣型人格疾患；兒童所處環境的回應，對於邊緣型人格疾患症狀的發展至關重要。Linehan（1993）將厭惡環境描述為「無效化」，這種環境會忽視兒童的情感需求。特別是，這類環境通常會忽視情感困擾的合理溝通，並懲罰情感表達和情感驅動的行為，無論兒童的情緒反應是否合理。或許最重要的是，無效化環境經常對極端或衝動行為提供間歇性增強。與 Linehan 的理論一致，越來越多的文獻證明了精神病態的生物學基礎（例如，Frick & Marsee, 2006; Patrick & Bernat, 2010;）以及厭惡環境因素的影響（例如，Graham et al., 2012）都扮演著重要角色。簡而言之，當前關於精神病態病因學的理論和研究支持生物學與環境之間存在互惠關係的假設，這種關係產生了在被認定為高度精神病態的個體中觀察到的一系列行為（Waldman & Rhee, 2006）。

Whereas emotional sensitivity appears to be the primary biological underpinning to BPD, it is likely that there are two distinct constitutional contributions to psychopathy. The first of these proposed biological vulnerabilities is an emotional sensitivity, similar to that described by Linehan, which interacts with environmental factors to create what is typically conceptualized as “Type 2” psychopathy-a construct in which disinhibition, impulsivity, and emotional dysregulation play prominent roles. Type 1 psychopathy, on the other hand, appears to reflect a biologically-based deficiency in emotion perception and emotional experiencing. This deficiency also interacts, over time, with aversive environmental influences to produce Type 1 traits such as lack of empathy or callousness, and a lack of anxiety (e.g., boldness). The apparent fit between Linehan’s Biosocial model of BPD, coupled with the extent to which symptoms of BPD overlap with facets of psychopathy, appeared to provide a theoretically rich justification for further adapting Dialectical Behavior Therapy (DBT) to the treatment of psychopathy.
情緒敏感性似乎是邊緣型人格障礙（BPD）的主要生物學基礎，而精神病態則可能存在兩種截然不同的先天性因素。第一種被提出的生物學脆弱性是情緒敏感性，類似於 Linehan 所描述的，它與環境因素相互作用，形成通常被概念化為「第二型」精神病態的結構，其中去抑制、衝動和情緒失調扮演著重要角色。另一方面，第一型精神病態似乎反映了情緒感知和情緒體驗上基於生物學的缺陷。這種缺陷也隨著時間與厭惡的環境影響相互作用，產生第一型特徵，例如缺乏同理心或冷酷無情，以及缺乏焦慮（例如：大膽）。Linehan 的 BPD 生物社會模型與精神病態的某些面向症狀重疊的程度，兩者之間的明顯契合，似乎為進一步將辯證行為治療（DBT）應用於精神病態的治療提供了理論上豐富的理由。

Ours is not the first attempt to apply DBT to an offender population. In their review of the literature, Berzins and Trestman (2004) surveyed several DBT programs in forensic and correctional settings. However, much of this nascent literature has focused on subgroups of offenders with other disorders, such as Borderline Personality disorder (BPD), substance abuse, or juveniles (Evershed et al., 2004; Fruzetti & Levensky, 2000; McCann, Ball, & Ivanoff, 2000; Nee & Farman, 2006; Trupin et al., 2002). To our knowledge, the only published randomized clinical trial of DBT in an offender sample is our pilot study of DBT for stalking offenders (Rosenfeld et al., 2007). However, samples of stalking offenders typically display an unusually low rate of psychopathy compared to general offender samples (Reavis, Allen, & Meloy, 2008; Storey et al., 2009). Moreover, when
我們並非首度嘗試將辯證行為療法（DBT）應用於犯罪者族群。Berzins 和 Trestman（2004）在他們的回顧文獻中，調查了數個在法醫和矯正機構中實施的 DBT 計畫。然而，這項新興文獻大多聚焦於患有其他疾患的犯罪者亞群，例如邊緣型人格（BPD）、物質濫用或青少年（Evershed et al., 2004; Fruzetti & Levensky, 2000; McCann, Ball, & Ivanoff, 2000; Nee & Farman, 2006; Trupin et al., 2002）。據我們所知，唯一已發表的針對犯罪者樣本進行 DBT 的隨機臨床試驗，是我們針對跟蹤騷擾犯罪者進行 DBT 的初步研究（Rosenfeld et al., 2007）。然而，與一般犯罪者樣本相比，跟蹤騷擾犯罪者樣本通常表現出異常低的心理病態發生率（Reavis, Allen, & Meloy, 2008; Storey et al., 2009）。此外，當

DBT has been implemented in forensic or correctional settings, the primary focus has frequently been on decreasing self-injury, violence, or other overtly problematic behaviors in emotionally labile individuals rather than addressing the broad spectrum of affective deficits characteristic of psychopathy. Anecdotal accounts describing the application of DBT for “Dangerous and Severe Personality Disorder” have occasionally been published (e.g., Hogue et al., 2007), but we are unaware of any systematic data (e.g., randomized controlled trials, or RCTs) regarding the effectiveness of these efforts. Although our research applying DBT to stalking offenders (e.g., Rosenfeld et al., 2007) provided only limited opportunities to assess the appropriateness of this treatment approach for psychopathic offenders (given the low rate of psychopathy in stalking offenders), the gradual expansion of our treatment focus has enabled us to pilot test DBT with a much wider range of offenders, including some with high levels of psychopathy. This paper describes our observations based on this pilot intervention and will outline future directions for this intervention approach.
DBT 已應用於法醫或矯正機構，其主要重點通常是減少情緒不穩定個體的自傷、暴力或其他明顯有問題的行為，而非處理精神病態特有的廣泛情感缺陷。偶爾有描述將 DBT 應用於「危險和嚴重人格障礙」的軼事報導（例如，Hogue 等人，2007），但我們並未發現任何關於這些努力的效能的系統性數據（例如，隨機對照試驗，或 RCTs）。儘管我們將 DBT 應用於跟蹤罪犯的研究（例如，Rosenfeld 等人，2007）僅提供了有限的機會來評估這種治療方法對精神病態罪犯的適用性（考慮到跟蹤罪犯中精神病態的發生率較低），但我們治療重點的逐步擴展使我們能夠對更廣泛的罪犯進行 DBT 試點測試，其中包括一些精神病態程度較高的罪犯。本文描述了我們基於這次試點介入的觀察結果，並將概述這種介入方法的未來方向。

Our experience with psychopathic individuals who have participated in our DBT treatment program has highlighted several needs and challenges. First, it appears that any treatment targeted to this population requires a unique set of components that are often missing from existing interventions, including traditional applications of DBT. Second, while psychopaths are a heterogeneous group (e.g., including emotionally over-regulated, under-regulated and mixed individuals), many have deficits in abstract thinking and problem solving that are not addressed adequately by the standard elements of DBT. Third, and contrary to our initial expectations (and the extant literature), our pilot work has suggested that it is important to understand and treat the entire range of emotions rather than just anger or hostility (which is often the centerpiece of offender treatments). In fact, we have frequently observed severe, impulsive anger to be a secondary emotion, in response to a brief flash of fear or vulnerability, particularly in individuals who have a history of childhood trauma. Of particular importance, given the fact that individuals referred to our program are typically court-mandated, are strategies to enhance commitment to treatment. Indeed, clinicians who work primarily with “voluntary” clients may assume that the threat of punishments (e.g., incarceration for failure to comply with treatment requirements) would provide adequate motivation for engagement in treatment. Our observation is quite the opposite: not only is treatment engagement just as relevant in a court-mandated population as a voluntary one, it is perhaps more crucial and has been the focus of extensive efforts on our part. The next section will describe various aspects of our adaptation of DBT for psychopathic (PPD) individuals.
我們在 DBT 治療計畫中與精神病態個體的經驗，突顯了數項需求與挑戰。首先，針對此族群的任何治療，似乎都需要一套獨特的組成要素，而這些要素在現有介入措施中往往闕如，包括 DBT 的傳統應用。其次，儘管精神病態者是一個異質性群體（例如，包括情緒過度調節、調節不足和混合型個體），但許多人在抽象思考和問題解決方面存在缺陷，而 DBT 的標準要素並未能充分解決這些問題。第三，與我們最初的預期（以及現有文獻）相反，我們的試驗性工作表明，理解和治療所有情緒範圍而非僅僅是憤怒或敵意（這通常是罪犯治療的核心）至關重要。事實上，我們經常觀察到嚴重的衝動性憤怒是一種次級情緒，是對短暫的恐懼或脆弱性閃現的反應，尤其是在有童年創傷史的個體中。 特別重要的是，考量到轉介至我們計畫的個案通常是法院強制要求的，因此強化其對治療的承諾是關鍵策略。事實上，主要與「自願」個案合作的臨床醫師可能會認為，懲罰的威脅（例如，因未能遵守治療要求而入獄）足以提供參與治療的動機。然而，我們的觀察卻恰恰相反：治療參與度不僅在法院強制要求的族群中與自願族群一樣重要，甚至可能更為關鍵，這也一直是我們努力的重點。下一節將描述我們為精神病態（PPD）個案調整 DBT 的各個面向。

As in standard DBT, our application of DBT for PPD is a staged treatment. The first stage is pre-treatment. Moving from pre-treatment to treatment requires that the client commits to change and that the therapist and client agree on goals of the treatment. In addition to providing ample validation, clinicians use the technique of “pros and cons” to assist clients in deciding whether to participate in DBT or be referred back to Probation for another treatment option. Very few clients decline to participate in our treatment program when the full range of commitment techniques is employed, but the presence of a real choice, albeit limited, is essential. Although the demands of our DBT treatment program are considerable (e.g., regular attendance, homework, and between-session phone calls), it was also offered free of charge, which provided a strong incentive for many low-income participants.
如同標準的 DBT，我們將 DBT 應用於 PPD 的治療是分階段進行的。第一個階段是前置治療。從前置治療進入正式治療，需要個案承諾改變，並且治療師和個案就治療目標達成一致。除了提供充分的認可，臨床醫師還會使用「優缺點分析」的技巧，協助個案決定是否參與 DBT，或是被轉介回緩刑監督單位尋求其他治療方案。當所有承諾技巧都運用上時，很少有個案會拒絕參與我們的治療計畫，但提供一個真實的選擇（儘管有限）是至關重要的。儘管我們的 DBT 治療計畫要求很高（例如：定期出席、家庭作業和會期之間的電話聯繫），但它也是免費提供的，這為許多低收入的參與者提供了強大的誘因。

Because many clients mandated to receive mental health treatment are adamant that they were forced into treatment, and thus have no independent motivation to change, we use a number of other strategies to enhance treatment engagement. For example, we use validation techniques to explicitly acknowledge the frequent injustices in the legal system and the fact that being mandated to treatment may actually decrease motivation for many individuals. Although our adaptation uses all of Linehan’s standard commitment strategies, we have found that highlighting the “freedom to choose with absence of alternatives” is among the most useful in fostering commitment in this setting.
由於許多被強制接受心理健康治療的個案，堅稱他們是被迫接受治療，因此沒有獨立的動機去改變，我們採用了許多其他策略來增強治療參與度。例如，我們使用認可技巧來明確承認法律體系中常見的不公，以及被強制治療實際上可能會降低許多人的動機。儘管我們的改編使用了 Linehan 所有標準的承諾策略，但我們發現，強調「在沒有其他選擇的情況下自由選擇」是在這種情境下培養承諾最有效的方法之一。

Once an adequate level of commitment has been achieved (which may still be modest), agreeing on goals for the treatment becomes the next task. Clients with BPD may be angry, hopeless, and unwilling to relinquish self-destructive behaviors, but they are suffering, and this suffering often creates some motivation for a better life. However, individuals with PPD typically externalize responsibility for any suffering they experience, often believing that “the system” is the source of their problems. Thus, one of the crucial tasks of treatment with PPD individuals is finding and amplifying any distress they may be experiencing, even if the distress is attributed to external circumstances. Linehan (1993) recommended strategies to help clients make a commitment to working for a “life worth living,” but these strategies require considerable adaptation for individuals with PPD. In our experience, identifying a life free from criminal justice intervention is often a powerful motivator, so long as the individual can visualize what such a life would be like.
一旦達到足夠的承諾程度（即使可能仍屬適中），接下來的任務就是就治療目標達成共識。邊緣性人格疾患（BPD）的個案可能感到憤怒、絕望，且不願放棄自我毀滅的行為，但他們正在受苦，而這種痛苦往往會激發他們追求更好生活的動機。然而，精神病性人格疾患（PPD）的個案通常會將他們所經歷的任何痛苦歸咎於外部，常認為「體制」是他們問題的根源。因此，治療 PPD 個案的關鍵任務之一是找出並放大他們可能正在經歷的任何痛苦，即使這些痛苦被歸因於外部環境。Linehan（1993）建議了幫助個案承諾追求「值得活的人生」的策略，但這些策略對於 PPD 個案需要進行相當大的調整。根據我們的經驗，只要個案能夠想像沒有刑事司法介入的生活會是什麼樣子，那麼識別出這樣的生活往往是一個強大的動機。

Very little has been written about case conceptualization in DBT (Koerner, 2007), but it is an essential part of the individualized therapy intervention. In conducting case conceptualization for individuals with PPD, the reason an individual was referred for treatment is a natural starting point.
關於辯證行為療法（DBT）中的個案概念化，相關文獻甚少（Koerner, 2007），但它卻是個別化治療介入中不可或缺的一部分。在對患有精神病態人格違常（PPD）的個案進行概念化時，個案被轉介治療的原因是一個自然的切入點。

In standard DBT the therapist obtains a thorough history of suicide attempts and self-harm behaviors, but the focus with PPD clients includes extensive information gathering around the individual’s history of violence towards others and other serious criminal behaviors. At the start of treatment, the instant offense is examined using a behavioral chain analysis (BCA) of the moment-by-moment experience of the individual during the event. For any other past instances of serious violence, the therapist conducts a thorough chain analysis as well. This involves gathering sequential information about cognitions, emotions, bodily sensations, and actions. Ideally, the therapist also has an independent account of the incident (e.g., official records, probation reports, etc.), although such corroborating (or contradictory) data may be unavailable or of limited utility, particularly for historical incidents that are acknowledged during the initial phase of treatment.
在標準的 DBT 中，治療師會詳細了解個案過去的自殺企圖和自傷行為，但對於 PPD 個案，重點則包括廣泛收集其對他人施暴及其他嚴重犯罪行為的歷史資訊。治療開始時，會針對當下的犯罪行為，運用行為鏈鎖分析（BCA）來檢視個案在事件發生時的即時經驗。對於任何其他過去的嚴重暴力事件，治療師也會進行徹底的鏈鎖分析。這包括收集關於認知、情緒、身體感覺和行動的連續資訊。理想情況下，治療師也會有事件的獨立描述（例如：官方記錄、緩刑報告等），儘管這類佐證（或矛盾）資料可能無法取得或效用有限，特別是對於在治療初期承認的歷史事件。

The therapist and client use the information from these BCAs to better understand the factors influencing the individual’s behavior and to create a hierarchy of treatment targets. Treatment targets are prioritized based upon the standard DBT individual therapy targets, with Level I corresponding to Life-Threatening Behaviors, Level II to Treatment-Interfering Behaviors, and Level III to Quality-of-Life Interfering Behaviors. Each category of treatment targets might include multiple, hierarchically ordered behaviors (e.g., threatening to kill someone with some degree of intent, assaulting someone, threats to harm without intent to carry out the act, carrying weapons). Treatment-interfering behaviors have the potential to damage the therapy relationship by burning out the therapist or causing the individual to terminate treatment. With PPD offenders, these behaviors are frequent and often quite severe. For instance, threatening the therapist, dishonesty, and re-arrests are common behaviors among individuals with PPD that can negatively impact treatment. Therapists, on the other hand, are also prone to experiencing strong feelings about their clients with PPD (e.g., anger, disgust) and may withdraw, become judgmental, or become authoritarian and controlling in sessions. Quality-of-life interfering behaviors include having few friends, an unsatisfactory job, and inadequate or unstable housing. Therapists also note skills deficits (e.g., too little experienced emotion or poor emotion regulation abilities-or both) and any other factors related to risk reduction not already captured from the BCAs completed in the initial individual sessions. Treatment targets are modified throughout the course of treatment as necessary, whether due to treatment-related improvement or an evolving clinical picture (e.g., symptoms that were denied or not evident initially).
治療師和個案利用這些行為鏈分析的資訊，來更了解影響個體行為的因素，並建立治療目標的優先順序。治療目標的優先順序是根據標準的 DBT 個體治療目標來排列，其中第一級對應危及生命的行為，第二級對應干擾治療的行為，第三級對應干擾生活品質的行為。每個類別的治療目標可能包含多個按層級排序的行為（例如，帶有某種程度意圖地威脅要殺死某人、攻擊某人、沒有實施意圖的傷害威脅、攜帶武器）。干擾治療的行為有可能會耗盡治療師的精力或導致個體終止治療，進而損害治療關係。對於 PPD 罪犯而言，這些行為頻繁且通常相當嚴重。例如，威脅治療師、不誠實和再次被捕是 PPD 個體中常見的行為，這些行為可能會對治療產生負面影響。 另一方面，治療師也容易對患有 PPD 的個案產生強烈感受（例如：憤怒、厭惡），並可能在會談中退縮、變得評斷式的，或變得專制和控制。干擾生活品質的行為包括朋友很少、工作不滿意，以及住房不足或不穩定。治療師還注意到技巧缺失（例如：情緒體驗過少或情緒調節能力差——或兩者皆有），以及任何其他與風險降低相關、但尚未從初次個別會談中完成的行為鏈分析中獲得的因素。治療目標會根據需要，在整個治療過程中進行修改，無論是出於治療相關的改善，還是不斷演變的臨床狀況（例如：最初否認或不明顯的症狀）。

The weekly session structure is grounded in the standard DBT treatment manual, and begins with the therapist reviewing a diary card on which the client tracks behaviors such as violence (or urges to engage in violence), substance abuse, deceitfulness, emotions and experiences such as boredom, and skill use for the week. Using the hierarchy from the client’s individualized treatment targets (described above),
每週會談的結構以標準的 DBT 治療手冊為基礎，首先治療師會檢閱日誌卡，個案在日誌卡上追蹤行為，例如暴力（或從事暴力的衝動）、物質濫用、欺騙、情緒和經驗（例如無聊），以及該週的技巧使用情況。治療師根據個案個別化治療目標（如上所述）的優先順序，
the therapist sets an agenda for each session. The therapist and client collaboratively add to or modify the agenda, but items that relate to potentially life-threatening behaviors or other Level I treatment targets are given the highest priority. In each session, the therapist conducts a BCA to understand behaviors related to the highest treatment targets. Importantly, the stance of the therapist throughout each session is intended to be nonjudgmental-more curious than confrontational. The therapist employs the standard DBT techniques of alternating validation and change strategies throughout treatment.
為每次會談設定議程。治療師和個案會共同增補或修改議程，但與潛在危及生命的行為或其他第一級治療目標相關的項目會被賦予最高優先權。在每次會談中，治療師會進行行為鏈分析（BCA），以了解與最高治療目標相關的行為。重要的是，治療師在每次會談中的立場應是非批判性的——更多的是好奇而非對抗。治療師在整個治療過程中採用 DBT 標準技巧，交替使用認可和改變策略。

Although a description of all DBT strategies is not possible, it is important to highlight one important element of the treatment: validation. Validation refers to communicating (to the client) that one sees the reasonableness or validity of their thoughts, feelings, and behavior. In standard DBT, validation is an important mechanism for keeping the client’s emotions regulated, enabling the process of therapy to take place. This is equally true for individuals with PPD, but can be particularly challenging in the context of aggressive behaviors; the therapist must be careful never to validate (or treat as reasonable) behaviors that are inherently invalid, such as violent or hurtful actions. To accomplish this goal, the therapist often needs to validate only part of the client’s experience. For example, a thought such as “I can’t be taken advantage of” has some validity, but assaulting someone to avoid looking weak would not be considered a valid response. One can also validate an emotion that gives rise to a behavior without validating the behavior itself. However, with PPD offenders who may experience relatively few emotions, it can be difficult to maintain therapeutic engagement since there are often few emotions to validate. Nonetheless, it is essential to find aspects of the individual’s behavior or presentation that can be validated, as this is crucial to developing and maintaining the treatment relationship.
雖然無法描述所有辯證行為療法（DBT）的策略，但仍須強調其中一個重要元素：認可。認可指的是（向個案）傳達治療師理解其想法、感受和行為的合理性或有效性。在標準辯證行為療法中，認可是維持個案情緒穩定的重要機制，有助於治療過程的進行。這對於邊緣型人格障礙（PPD）患者同樣適用，但在面對攻擊性行為時可能特別具挑戰性；治療師必須謹慎，絕不能認可（或視為合理）本質上不合理的行為，例如暴力或傷害他人的行為。為達成此目標，治療師通常只需認可個案經驗的一部分。例如，「我不能被佔便宜」這種想法具有一定的合理性，但為了避免顯得軟弱而攻擊他人則不被視為合理的反應。治療師也可以認可引發行為的情緒，而不認可行為本身。 然而，對於可能經歷相對較少情緒的 PPD 罪犯來說，由於通常很少有情緒可以認可，因此很難維持治療投入。儘管如此，找到個體行為或表現中可以被認可的面向至關重要，因為這對於建立和維持治療關係至關重要。

Self-disclosure is another important and useful strategy in DBT, but is challenging in the context of PPD. In fact, a dialectical tension exists with regard to self-disclosure, since such disclosures can compromise the safety of treatment staff. Our treatment team frequently limits disclosure of any specific details about the therapist’s life (e.g., where they live) and we exercise caution when using social media such as Facebook without appropriate security filters. At the same time, we have found that appropriate, albeit limited, self-disclosure, particularly about the therapist’s feelings and reactions to the client’s behaviors, is essential for the treatment of individuals with PPD.
自我揭露是 DBT 中另一個重要且有用的策略，但在 PPD 的背景下卻具有挑戰性。事實上，在自我揭露方面存在一種辯證的張力，因為此類揭露可能會危及治療人員的安全。我們的治療團隊經常限制揭露治療師生活中的任何具體細節（例如，他們住在哪裡），並且我們在使用社群媒體（例如 Facebook）時會謹慎行事，除非有適當的安全過濾器。同時，我們發現適當但有限的自我揭露，特別是關於治療師對個案行為的感受和反應，對於 PPD 個體的治療至關重要。

Skills groups occurred in weekly 90 -minute sessions that clients attended either immediately before or after their individual therapy session. Because of the unique needs of our offender population (compared to women with BPD, on whom DBT was initially developed), we have modified many of the
技巧團體每週進行一次，每次 90 分鐘，個案會在個人治療時段之前或之後立即參加。由於我們的罪犯族群有其獨特需求（與最初發展 DBT 時所針對的 BPD 女性不同），我們已修改了許多
skills taught in the weekly Skills Group. First, the language used to describe and discuss skills has been simplified, so that the reading level required is much lower than was characteristic of Linehan’s original skills (given the educational limitations typical of offenders referred for treatment). Although groups are both diagnostically and demographically varied, examples have been tailored to an urban, low SES, and predominantly male population. We have also added skills developed for other DBT settings, such as “Walking the Middle Path,” which was developed for adolescents, but appears useful for fostering validation in individuals with PPD. This skill set is particularly useful for PPD offenders who, while perhaps superficially charming and social, often have little ability to genuinely validate others. We have also added skills that target problem recognition and problem solving, as these seem to be global deficits for many offenders, including those with PPD. We use a technique called “Urge-surfing,” originally developed for DBT treatment of substance abuse, as this skill is helpful for managing the impulse to use or sell illegal drugs as well as helping the individual to avoid engaging in other impulsive behaviors. On the other hand, some DBT skills have been avoided in our adaptation such as the “Alternate Rebellion” skill, which may reinforce the satisfaction PPD individuals derive from deceiving others.
每週技巧團體中教授的技巧。首先，用於描述和討論技巧的語言已經簡化，因此所需的閱讀程度遠低於 Linehan 原始技巧的特點（考慮到轉介治療的罪犯通常存在教育限制）。儘管團體在診斷和人口統計學上存在差異，但範例已針對城市、低社會經濟地位和以男性為主的群體進行調整。我們還增加了為其他 DBT 情境開發的技巧，例如「行中庸之道」，這是為青少年開發的，但似乎有助於促進 PPD 個體的認可。這套技巧對於 PPD 罪犯特別有用，他們雖然表面上可能迷人且善於交際，但往往缺乏真正認可他人的能力。我們還增加了針對問題識別和問題解決的技巧，因為這些似乎是許多罪犯（包括 PPD 患者）的普遍缺陷。 我們使用一種稱為「衝動衝浪」（Urge-surfing）的技巧，此技巧最初是為藥物濫用者的 DBT 治療所開發，因為這項技巧有助於管理使用或販售非法藥物的衝動，並幫助個體避免從事其他衝動行為。另一方面，我們在改編時避免使用某些 DBT 技巧，例如「替代性叛逆」（Alternate Rebellion）技巧，因為這可能會強化 PPD 個體從欺騙他人中獲得的滿足感。

Finally, we have emphasized techniques for using mindfulness to recognize and grow emotions, as well as to generate compassion for others. Individuals with PPD, because of their limited range of emotions, often have difficulty with empathy. However, compassion does not necessarily require understanding the emotional experience of another and many individuals can learn to behave in a more empathic manner. Our DBT approach incorporates skills that teach clients to utilize body postures (e.g., half-smile) to soften judgments, reduce willfulness and oppositional behaviors, and develop some compassion for others. Although empathy for another person’s experience makes it easier to reduce anger and resist urges to harm that person, it is not necessary for meaningful behavioral change. One can, in essence, strive to develop more concern for others and achieve such feelings through mindfulness practice.
最後，我們強調了運用了了分明來辨識和培養情緒，以及對他人產生慈悲的技巧。由於情緒範圍有限，PPD 個案通常難以產生同理心。然而，慈悲不一定需要理解他人的情緒體驗，許多人可以學習以更具同理心的方式行事。我們的 DBT 方法結合了教導個案運用身體姿勢（例如：微笑）來軟化判斷、減少執意和對抗行為，並對他人產生一些慈悲的技巧。儘管對他人經驗的同理心能更容易地減少憤怒並抵抗傷害他人的衝動，但這對於有意義的行為改變並非必要。本質上，一個人可以努力培養對他人的更多關懷，並透過了了分明練習來實現這些感受。

Individuals who feel little need for therapist contact, such as those with PPD, often find telephone coaching to be a perplexing aspect of the treatment. In standard DBT, clients are instructed to call when they are in a stressful situation and don’t know what do. However, our experience using DBT with offenders has demonstrated that many will rarely, if ever, call a therapist for assistance. Hence, telephone calls may need to be initiated by the therapist or set up on a schedule in order to provide an opportunity to review and practice skills that have been taught. The importance of this step is bolstered through our pre-treatment orientation, in which we emphasize the importance of practicing new skills in the
對於治療師接觸需求較低的個體，例如患有 PPD 的人，通常會覺得電話諮詢是治療中令人困惑的一環。在標準的 DBT 中，個案被教導在遇到壓力情境且不知所措時打電話。然而，我們將 DBT 應用於犯罪者身上的經驗顯示，許多人很少（如果有的話）會打電話向治療師尋求協助。因此，電話可能需要由治療師主動發起，或安排在固定時間，以便提供機會複習和練習已教導的技巧。透過我們的治療前導向，我們強調在新情境中練習新技巧的重要性，這一步驟的重要性因此得到加強。
real world in order to effectively change problem behaviors. Indeed, when clients begin to utilize coaching in earnest, this is often a turning point in treatment. However, unlike standard DBT, in which BPD clients are not permitted to call their therapists for coaching within 24 hours following an incident of self-harm, we do not preclude therapist contact following violent or aggressive behavior because there appears to be little risk of reinforcing aggression. Dysregulated clients may still call therapists as needed, as they do in standard DBT. Of note, in order to maintain the privacy (and safety) of staff therapists, we utilize a telephone service that allows individuals to call a toll-free number that rings through to the therapist’s personal cellular telephone but does not reveal the location or telephone number of the therapist. It is important to note that we have had no instances of problems associated with between-session contacts.
現實世界中，以便有效地改變問題行為。事實上，當個案開始認真利用指導時，這往往是治療的轉捩點。然而，與標準 DBT 不同的是，標準 DBT 不允許 BPD 個案在自傷事件發生後 24 小時內致電治療師尋求指導，但我們不排除在暴力或攻擊行為後與治療師聯繫，因為似乎很少有強化攻擊性的風險。失調的個案仍然可以根據需要致電治療師，就像他們在標準 DBT 中一樣。值得注意的是，為了維護工作人員治療師的隱私（和安全），我們使用一種電話服務，允許個人撥打免費電話，該電話會轉接到治療師的個人手機，但不會透露治療師的位置或電話號碼。重要的是，我們從未發生過與會期之間聯繫相關的問題。

The Consultation Team is considered to be the backbone of DBT treatment. It is the structural mechanism by which therapists receive feedback about their actions in terms of consistency with the DBT model. It is also a primary mechanism for providing support to therapists who deal with extremely challenging individuals that can often leave the therapist feeling hopeless, disrespected and angry, or unsure how to proceed in treatment. In working with individuals with PPD, we have found Consultation Team to be essential in identifying and deterring therapist burn-out. There are also frequent dialectical tensions that arise in determining what is “valid” behavior. Quite simply, working with criminal offenders in general, and those with PPD in particular, is extremely challenging and Consultation Team is important to keep therapists functioning effectively. Consultation Team meets for one to two hours weekly, with an agenda set by study therapists, based on self-assessments of their own needs, as well as assessment of ongoing client issues (e.g., individuals who are in danger of termination due to non-attendance or at heightened risk for violence or other behavioral problems). Ongoing education about the literature on DBT, psychopathy, and offender treatment in general are elements of our Consultation Team as well. Finally, a central part of our treatment program, particularly as it has evolved for the treatment of PPD, centers on generating compassion. We routinely ask therapists to apply mindfulness exercises during Consultation Team to help them generate compassion for the challenging individuals they work with, in hopes of more effectively teaching their own clients to generate compassion themselves.
諮詢團隊被視為 DBT 治療的骨幹。它是治療師就其行為與 DBT 模式一致性方面獲得回饋的結構性機制。它也是為處理極具挑戰性個案的治療師提供支持的主要機制，這些個案常讓治療師感到絕望、不受尊重、憤怒，或不確定如何在治療中繼續進行。在與 PPD 個案合作時，我們發現諮詢團隊對於識別和預防治療師職業倦怠至關重要。在判斷何謂「有效」行為時，也常出現辯證性的張力。簡而言之，與一般犯罪者，特別是 PPD 個案合作，極具挑戰性，而諮詢團隊對於維持治療師有效地運作至關重要。諮詢團隊每週開會一到兩小時，議程由研究治療師根據他們自身需求以及對持續個案問題的評估（例如，因未出席而面臨終止治療危險或暴力或其他行為問題風險增高的個案）自行設定。 持續學習有關 DBT、精神病態和一般罪犯治療的文獻，也是我們諮詢團隊的要素。最後，我們治療計畫的核心部分，特別是針對 PPD 治療所發展出來的，著重於培養慈悲。我們經常要求治療師在諮詢團隊中運用了了分明練習，以幫助他們對所服務的具挑戰性個體產生慈悲，希望能更有效地教導他們自己的個案學會產生慈悲。

Finally, ancillary treatments are often necessary in our treatment of PPD individuals, including referrals for substance abuse treatment or psychopharmacological interventions. Because our participants are court-mandated, ancillary
最後，在我們治療 PPD 個案的過程中，輔助治療往往是必要的，包括轉介至物質濫用治療或精神藥理學介入。由於我們的參與者是法院強制要求的，輔助
treatment needs are often handled by the individual’s Probation Officer, but specific referrals are frequently provided by treatment staff to insure optimal treatment. The treatment team also uses a structured protocol for the assessment of danger to self and others, and any individual deemed to pose an imminent risk that cannot be managed by the study therapist (in our community-based treatment setting) requires appropriate action. Such actions may range from contact with the Probation Officer to involvement of campus security personnel or, if necessary, the New York City Police Department. Fortunately, such actions have rarely been necessary.
治療需求通常由個案的緩刑監督官處理，但治療人員會經常提供具體的轉介，以確保最佳的治療效果。治療團隊也使用一套結構化的方案來評估對自己和他人的危險性，任何被認為構成迫切危險且無法由研究治療師（在我們以社區為基礎的治療環境中）處理的個案，都需要採取適當的行動。這些行動可能包括聯繫緩刑監督官、涉及校園安全人員，或在必要時聯繫紐約市警察局。幸運的是，這些行動很少是必要的。

Mr. A, a 31-year-old African American male, was referred for treatment after a domestic violence arrest that involved shoving his girlfriend and reportedly attempting to take her mobile phone. He had an extensive criminal history beginning at age 15, including multiple arrests for domestic violence, gun possession and distribution, involvement in organized prostitution, and narcotic sales. Although raised by his mother, he had repeatedly been placed in residential treatment as a child. There was a documented history of extensive physical abuse, both in his biological home and in some of the group homes in which he lived. His diagnosis following the intake assessment was Cannabis Abuse and Antisocial Personality Disorder (APD). Although he readily acknowledged having sold narcotics, he claimed it was “not good for business to use” illegal drugs. He revealed numerous psychopathic traits, scoring a 19 on the PCL-SV, with particular elevations on factor 2 (based on the original 2-factor structure); his factor 1 score was 7 and his factor 2 score was 12.
A 先生，31 歲，非裔美國男性，因涉及推擠女友並企圖搶奪其手機的家暴事件被捕後，轉介接受治療。他從 15 歲起就有廣泛的犯罪紀錄，包括多次因家暴、非法持有及販賣槍枝、參與組織賣淫及販毒而被捕。儘管由母親撫養長大，他從小就多次被安置在住宿型治療機構。有文件記載他曾遭受廣泛的身體虐待，無論是在原生家庭或是一些他曾居住的團體家屋中。入院評估後的診斷為大麻濫用及反社會人格障礙症（APD）。儘管他坦承曾販賣毒品，但他聲稱「吸食」非法藥物「對生意不好」。他展現出許多精神病態特徵，在 PCL-SV 量表上得分為 19 分，尤其在因素 2（基於原始的雙因素結構）上有顯著升高；他的因素 1 得分為 7 分，因素 2 得分為 12 分。

At the time he was referred for treatment, Mr. A was living with a relative because he had lost his housing due to pending criminal charges and an order of protection preventing him from contacting his ex-girlfriend. His first session involved commitment strategies around goals. He initially expressed little motivation for treatment, and validation involved the therapist’s acknowledgment that it was reasonable for him to be annoyed about being required to attend treatment. The therapist also focused on problem solving to facilitate his attendance (e.g., planning transportation routes and estimating the time needed to travel). This step was well-received by Mr. A, allowing the therapist to work more directly on commitment to the treatment process. The therapist stressed that, since Mr. A was court-ordered to attend some form of treatment, he might choose to complete DBT and attempt to find some personal benefit. She asked him how his life was going in a nonjudgmental and respectful manner. Within three weeks of beginning treatment, Mr. A had articulated an overarching goal: to obtain independent housing and to “get a straight life” (i.e., to support himself through legal means rather than criminal activity). He explained that he wanted to avoid another prison sentence, as he hated being told what to do and not having freedom, and felt unsafe in a “busi-
A 先生在被轉介治療時，正與一位親戚同住，因為他因刑事訴訟待審以及保護令禁止他與前女友接觸而失去了住所。他的第一次會談涉及圍繞目標的承諾策略。他最初對治療表現出很少的動機，而認可則涉及治療師承認他對被要求接受治療感到惱火是合理的。治療師也專注於解決問題，以促進他的出席（例如，規劃交通路線和估計所需的通勤時間）。A 先生對這一步驟反應良好，這讓治療師能夠更直接地致力於治療過程的承諾。治療師強調，由於 A 先生被法院命令接受某種形式的治療，他可以選擇完成 DBT 並嘗試找到一些個人益處。她以不帶批判且尊重的方式詢問他生活過得如何。在開始治療的三週內，A 先生 A 曾明確表達一個總體目標：獲得獨立的住所並「過上正直的生活」（即透過合法途徑而非犯罪活動來養活自己）。他解釋說，他想避免再次入獄，因為他討厭被告知該做什麼以及沒有自由，而且在一個充斥著年輕、更具攻擊性的毒販的「生意」中感到不安全。
ness” populated by younger, more aggressive drug dealers. He stated “the younger kids running drugs can’t be trusted.” The next three sessions involved numerous behavioral chain analyses (BCAs) focusing on past violent acts. Because of his violent past, these BCAs were essential in understanding the different pathways to violent behaviors for Mr. A.
他表示「那些年輕的毒販不可信」。接下來的三次會談涉及大量的行為鏈分析（BCA），重點放在過去的暴力行為上。由於他過去的暴力史，這些 BCA 對於理解 A 先生暴力行為的不同途徑至關重要。

In developing a case formulation for Mr. A, we noted a mixed picture of impaired affect recognition and emotion dysregulation. Mr. A presented with little affect and he had superficial connections to others, but he also had little understanding of the impact of his actions on those people closest to him. He was often involved in relationships of convenience and became enraged if he felt disrespected or the person annoyed him. The instant offense also appeared to be cue driven, with intense anger following a thought that his girlfriend was cheating on him. Mr. A also acknowledged numerous instances of instrumental violence. Application of BCAs revealed that these incidents appeared to have been behaviorally reinforced and were primarily related to drug sales and other criminal behaviors. Motivating factors for the violence were to maintain his reputation, ensure his safety, and obtain compliance from others in order to make money.
在為 A 先生進行個案概念化時，我們注意到他同時存在情感辨識受損和情緒失調的複雜情況。A 先生的情感表達很少，與他人的連結也很膚淺，但他對自己的行為對身邊親近之人的影響卻知之甚少。他經常涉入權宜之計的關係，如果他覺得自己不受尊重或對方讓他感到惱怒，他就會勃然大怒。這次的犯罪行為似乎也是由線索驅動的，在認為女友背叛他之後，他產生了強烈的憤怒。A 先生也承認了許多工具性暴力的案例。行為鏈分析（BCAs）顯示，這些事件似乎在行為上得到了強化，主要與毒品銷售和其他犯罪行為有關。暴力的動機是為了維護他的聲譽、確保自身安全，並讓他人順從以賺取金錢。

Mr. A’s treatment targets included eliminating all interpersonal violence (Level I). This included reactive violence related to cognitive perceptions of being disrespected, cheated on, or being left. It also included instrumental violence inherent in illegal activities for profit, and threats (actual or perceived, such as angry looks or intimidation) to harm others. Treatment interfering behavior targets (Level II) included a “take-it or leave-it” attitude towards treatment and reticence to try new skills, as well as decreasing other behaviors that interfered with his treatment (e.g., missing sessions, not completing homework. His quality-of-life enhancing targets included finding independent housing and meaningful work, and developing leisure activities (Level III).
A 先生的治療目標包括消除所有的人際暴力（第一級）。這包括與認知上感到不被尊重、被欺騙或被拋棄有關的反應性暴力。它也包括為獲取利益而進行非法活動中固有的工具性暴力，以及傷害他人的威脅（實際或感知，例如憤怒的眼神或恐嚇）。干擾治療的行為目標（第二級）包括對治療抱持「要嘛接受，要嘛放棄」的態度，以及不願嘗試新的技巧，同時也減少其他干擾他治療的行為（例如：缺席療程、未完成家庭作業）。他提升生活品質的目標包括找到獨立的住所和有意義的工作，以及發展休閒活動（第三級）。

Treatment involved weekly monitoring of all relevant emotions, targeted behaviors (especially violence towards others or urges to engage in violence), and urges to sell illegal substances. Early in treatment (sessions 6 through 8), ruminations about his ex-girlfriend and teaching distress tolerance for loneliness and dissatisfaction with his life were emphasized. Behavioral activation strategies were used to get the client to leave his residence and increase his engagement with others, so that real-life opportunities to practice skills would arise. Sessions 8 through 10 focused extensively on decreasing treatment-interfering behaviors such as encouraging the client to attend sessions on time and to complete the weekly diary card.
治療內容包括每週監測所有相關情緒、目標行為（特別是針對他人的暴力行為或從事暴力行為的衝動），以及販賣非法物質的衝動。在治療初期（第 6 到第 8 次會談），重點放在他對前女友的反芻思維，以及教導他對孤獨和對生活不滿的痛苦耐受。行為活化策略被用來讓個案離開住處，並增加他與他人的互動，以便產生練習技巧的真實生活機會。第 8 到第 10 次會談則廣泛聚焦於減少干擾治療的行為，例如鼓勵個案準時參加會談並完成每週的日誌卡。

Each week, the therapist conducted a BCA on the highest priority target behaviors, such as an incident in which he threatened a co-worker who had asked him to change seats. The therapist identified a particular point in the chain where using a skillful behavior (i.e., the “Dear Man” technique, which emphasizes effective ways to ask for something or refuse a request) would have resulted in a different outcome.
每週，治療師會針對最高優先順序的目標行為進行行為鏈分析（BCA），例如他威脅一位要求他換座位的同事的事件。治療師找出行為鏈中一個特定點，如果當時使用一個有技巧的行為（即「Dear Man」技巧，該技巧強調有效提出要求或拒絕請求的方式），結果將會不同。

She then taught Mr. A the relevant interpersonal effectiveness skill and had him practice it in session. The therapist also highlighted possible applications of other skills taught in the Skills group (e.g., identifying anger and decreasing it through opposite action). He went back to work and tried the skills and was surprised by their effectiveness. This appeared to be a turning point in treatment, whereby he began to try to use new skills. As treatment progressed, Mr. A’s practice of mindful awareness of his bodily sensations increasingly enabled him to identify his emotions before he lost control of them. The therapist provided feedback about his insensitivity to the experience of others, explaining reciprocity in relationships and teaching an interpersonal effectiveness skill (i.e., the “Give” skill, which focuses on developing a more gentle style with others and validating others’ perspectives).
她接著教導 A 先生相關的人際效能技巧，並讓他在會談中練習。治療師也強調了在技巧團體中學到的其他技巧可能應用之處（例如，辨識憤怒並透過相反行動來減少憤怒）。他回去工作並嘗試了這些技巧，對其效能感到驚訝。這似乎是治療的一個轉捩點，他開始嘗試使用新的技巧。隨著治療的進展，A 先生練習正念覺察身體感受，這使他越來越能在情緒失控之前辨識出情緒。治療師針對他對他人經驗的麻木不仁給予回饋，解釋了人際關係中的互惠原則，並教導了一項人際效能技巧（即「給予」技巧，其重點在於與他人發展更溫和的風格並認可他人的觀點）。

Mr. A’s relationships with his relatives and co-workers continued to present opportunities to observe his urges to engage in physical violence, threats, or intimidation. By the mid-point of treatment, Mr. A had begun calling the therapist between sessions for coaching on what to do in challenging situations. As he developed more skillful behaviors, his emotional control and interpersonal skills began to improve. He began receiving positive feedback from those in his immediate environment and his living situation became less stressful. He began to accept the fact that he did not need to like his job in order to be able to maintain it.
A 先生與親友和同事的關係，持續提供機會觀察他從事肢體暴力、威脅或恐嚇的衝動。到了治療中期，A 先生已開始在會談之間致電治療師，尋求如何在具挑戰性情境中應對的指導。隨著他發展出更具技巧的行為，他的情緒控制和人際技巧開始改善。他開始從身邊的人那裡獲得正向回饋，生活壓力也減輕了。他開始接受一個事實：他不需要喜歡自己的工作也能夠維持它。

Throughout treatment, Mr. A’s desire to “go straight” (i.e., lead a law-abiding life) remained intact, but his willingness to work toward this goal waxed and waned. Each time, the therapist would connect small actions (e.g., treating people at work respectfully so he could keep his job) to the overarching goal of independence and a life free of legal problems. He struggled with frequent and intense urges to sell drugs, as the potential financial rewards of drug sales were powerful. Each time, the therapist and Mr. A would conduct a “pros and cons” analysis, focusing on the fact that he was tired of feeling unsafe, and wanted to become independent and lead a non-criminal life.
在整個治療過程中，A 先生「改邪歸正」（即過守法生活）的願望始終未變，但他為實現此目標的意願卻時有起伏。每次，治療師都會將小行動（例如：在工作中尊重他人以保住工作）與獨立和擺脫法律問題的總體目標聯繫起來。他努力對抗頻繁且強烈的販毒衝動，因為販毒潛在的經濟報酬非常誘人。每次，治療師和 A 先生都會進行「優缺點分析」，重點放在他厭倦了不安全的感覺，並希望變得獨立、過非犯罪生活的事實上。

Additional treatment-interfering behaviors occurred in group. Although he appeared to be learning skills and using them, he was often sullen and did not participate actively in group. He repeatedly stated that he did not like group and often forgot to complete homework assignments. These behaviors were targeted as they occurred. On one occasion (Session 13), the therapist spoke to Mr. A about his having used his cell phone during group (which is not permitted) and he stormed out of the individual session. Perhaps atypical for an offender treatment, the therapist called the client, attempted to repair the relationship and requested that he return. He did and although strained, he tolerated receiving feedback and continued to improve.
團體治療中出現了其他干擾治療的行為。儘管他似乎正在學習並運用這些技巧，但他經常悶悶不樂，沒有積極參與團體。他一再表示不喜歡團體，並且經常忘記完成家庭作業。這些行為在發生時就被列為目標。有一次（第 13 次會談），治療師與 A 先生談論他在團體中使用了手機（這是被禁止的），結果他憤怒地衝出個別會談。對於罪犯治療來說，這或許不尋常，但治療師打電話給這位個案，試圖修復關係並要求他回來。他回來了，儘管關係緊張，但他忍受了接受回饋，並持續進步。

By the end of treatment ( 24 sessions of concurrent individual and group treatment), Mr. A had saved enough money to rent his own apartment and was able to experience considerable satisfaction at the accomplishment. At 2-year follow-up,
治療結束時（24 次同時進行的個別和團體治療），A 先生已存夠錢租了自己的公寓，並對此成就感到相當滿意。在兩年後的追蹤中，
he had no new arrests (confirmed by review of his computerized criminal history report) and, when interviewed, reported that he was involved in a new relationship that was free of violence. Based on his discussion of this relationship, he appeared to have developed some appreciation for the reciprocity that was previously lacking in his relationships. His interpersonal communication skills were dramatically improved. He had also initiated contact with his estranged son and had maintained the same job for 2 years. He explained that while he still did not like his job, he was doing well and planned to keep it until he found something better. He reported refraining from drug sales, despite occasional financial struggles.
他沒有新的逮捕紀錄（經查閱其電腦化犯罪歷史報告證實），且在訪談時表示，他正在一段沒有暴力的新關係中。根據他對這段關係的描述，他似乎對過去人際關係中缺乏的互惠性產生了一些理解。他的人際溝通技巧顯著改善。他也主動聯繫了疏遠的兒子，並在同一份工作上維持了兩年。他解釋說，雖然他仍然不喜歡這份工作，但他做得很好，並打算繼續做下去，直到找到更好的。他表示，儘管偶爾面臨財務困境，但他仍克制自己不販毒。

Of note is the therapist’s experience while treating Mr. A. Throughout treatment, Mr. A’s interpersonal deficiencies (e.g., factor 1 traits), while not as marked as his impulsive and antisocial behaviors (i.e., factor 2 traits), created difficulties in treatment. His lack of affective expression, ability to engage in instrumental violence without distress, and absence of concern for others, created strong feelings in the therapist. She utilized consultation team to develop nonjudgmental, behaviorally descriptive conceptualizations of his behaviors. At times, she expressed fear of the client, which was reasonable given the intimidating behaviors he could exhibit. Safety protocols, emphasizing ongoing risk assessment and management, and support from consultation team enabled her to continue to treat Mr. A effectively and address his behaviors directly. As treatment progressed, the therapist still felt little connection to the client. However, as he improved, the shared endeavor of moving towards the client’s goals of independent housing and a law-abiding life created enough of a bond to sustain and foster the treatment. Thus, an important aspect of treating individuals with psychopathy is supporting the therapist both emotionally and practically (e.g., assisting in the process of conceptualizing and managing risk), and in the delivery of the model, as there is often very little reinforcement for the therapist during the course of such challenging treatments.
值得注意的是治療師在治療 A 先生時的經驗。在整個治療過程中，A 先生的人際關係缺陷（例如：因素 1 特徵）雖然不像他的衝動和反社會行為（即：因素 2 特徵）那樣明顯，但卻為治療帶來了困難。他缺乏情感表達、能夠在沒有痛苦的情況下進行工具性暴力，以及對他人漠不關心，這些都讓治療師產生了強烈的情緒。她利用諮詢團隊來發展對他行為的非批判性、行為描述性概念化。有時，她對個案表達了恐懼，考量到他可能表現出的恐嚇行為，這是合理的。安全協議，強調持續的風險評估和管理，以及來自諮詢團隊的支援，使她能夠有效地繼續治療 A 先生並直接處理他的行為。隨著治療的進展，治療師仍然覺得與個案之間沒有什麼連結。然而，隨著他的改善，共同努力實現個案獨立居住和守法生活的目標，建立了足夠的連結來維持和促進治療。 因此，治療精神病態個案的一個重要面向是，在情感和實務上（例如，協助概念化和管理風險的過程）以及在模式的執行上，支持治療師，因為在這種具挑戰性的治療過程中，治療師通常很少獲得增強。

This case example, while admittedly selective, is meant to illustrate the potential utility of our adaptation of DBT in developing a therapeutic rapport with, and addressing some of the manifestations of psychopathy. Although our intervention has not been successful in all cases, many of the “treatment failures” have been individuals who were re-arrested prior to the development of a sufficient therapeutic alliance. Moreover, we have observed greater success with individuals who evidence emotion dysregulation problems and impulsive behaviors; those with constricted affect have posed greater, though not necessarily insurmountable challenges. However, despite our preliminary evidence of treatment successes, we recognize the need to continue refining this intervention, particular with individuals who lack the typical
本案例雖然有選擇性，但旨在說明我們對辯證行為療法（DBT）的改編在建立治療關係和處理精神病態某些表現方面的潛在效用。儘管我們的介入並非在所有案例中都成功，但許多「治療失敗」的個案是在建立足夠的治療聯盟之前就再次被捕。此外，我們觀察到在有情緒失調問題和衝動行為的個案中，成功率更高；而那些情感受限的個案則帶來了更大的挑戰，儘管不一定是無法克服的。然而，儘管我們有初步的治療成功證據，我們認識到需要繼續完善這種介入，特別是對於那些缺乏典型特徵的個案。
range of emotional experiences and interpersonal connectedness. We also recognize the need to improve our assessment of treatment outcomes, as reliance on self-reported improvement and changes, or crude indicators such as re-arrest, are clearly of limited utility. Future research and evaluation studies would benefit from inclusion of additional behavioral indicators of core treatment targets such as impulsivity and emotion regulation.
情緒體驗和人際連結的範圍。我們也意識到需要改進對治療結果的評估，因為依賴自我報告的改善和變化，或諸如再次被捕等粗略指標，其效用顯然有限。未來的研究和評估將受益於納入核心治療目標的額外行為指標，例如衝動和情緒調節。

Many questions remain about what, if anything, works to change the underlying pathology associated with psychopathy. Our approach, which focuses heavily on the role of affect regulation in relation to psychopathic traits and the associated problematic behaviors, offers a promising direction for future research. Our experience to date has impressed upon us the heterogeneity in the population identified as psychopathic. Deficits in affective experience and affect regulation may be one way to differentiate among individuals with PPD, as well as to tailor intervention strategies to the different patterns of affective dysregulation present in this population. We should, however, also acknowledge that our work to date has occurred in an outpatient setting, typically with individuals charged with relatively minor offenses. This approach may require further adaptation for inpatient or correctional settings, where the severity of PPD and its associated behavioral problems is often far greater. Clearly much work remains to be done in order to optimally treat this challenging population.
關於如何改變與精神病態相關的潛在病理，以及是否有任何方法能奏效，仍有許多疑問。我們的方法，主要著重於情感調節在精神病態特徵及相關問題行為中的作用，為未來的研究提供了一個有前景的方向。迄今為止的經驗讓我們深刻體會到，被診斷為精神病態的人群具有異質性。情感體驗和情感調節的缺陷，可能是區分 PPD 個體的一種方式，也能針對此人群中存在的情感失調模式，量身訂做介入策略。然而，我們也應該承認，我們迄今為止的工作是在門診環境中進行的，通常是針對犯下相對輕微罪行的個體。這種方法可能需要進一步調整，以適用於住院或矯正機構，因為在這些環境中，PPD 的嚴重程度及其相關的行為問題通常更為嚴重。顯然，為了最佳地治療這個具挑戰性的人群，仍有許多工作需要完成。

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
American Psychiatric Association. (2012). Proposed revisions to Antisocial Personality Disorder (Dyssocial Personality Disorder). Retrieved from http://www.dsm5.org/ProposedRevision/Pages/ proposedrevision.aspx?rid=16 on 02/15/12.
Andrews, D., Zinger, I., Hoge, R., Bonta, J., Gendreau, P., & Cullen, F. (1990). Does correctional treatment work? A clinically relevant and psychologically informed meta-analysis. Criminology, 28, 369-404, doi: 10.1111/j.1745-9125.1990.tb01330.x.

Babiak, P., Neumann, C. S., & Hare, R. D. (2010). Corporate psychopathy: Talking the walk. Behavioral Sciences & the Law, 28, 174-193, doi: 10.1002/bs1.925.

Berzins, L. G., & Trestman, R. L. (2004). The development and implementation of Dialectical Behavior Therapy in forensic settings. International Journal of Forensic Mental Health, 3, 93-103, doi: 10.1080/14999013.2004.10471199
Berzins, L. G., & Trestman, R. L. (2004). The development and implementation of 辯證行為治療 in forensic settings. International Journal of Forensic Mental Health, 3, 93-103, doi: 10.1080/14999013.2004.10471199

Bishop, D., & Hare, R. D. (2008). A multidimensional scaling analysis of the Hare PCL-R: Unfolding the structure of Psychopathy. Psychology, Crime, & Law, 14, 117-132, doi: 10.1080/10683160701483484.
Blair, R. J. R. (2005). Subcortical brain systems in psychopathy: the amygdala and associated structures. In C. Patrick (Ed.), Handbook of psychopathy (pp. 296-312). New York: Wiley.
Bus, I., Ştefan, E., & Visu-Petra, G. (2009). Anger management in the penitentiary. Cognition, Brain, Behavior: An Interdisciplinary Journal, 13, 329-334.
Cleckley, H. (1976). The mask of sanity. (5th ed.) St. Louis: Mosby.

Coid, J., Yang, M., Tyrer, P., Roberts, A., & Ullrich, S. (2006). Prevalence and correlates of personality disorder in Great Britain. British Journal of Psychiatry, 188, 423-431, doi: 10.1192/bjp.188.5.423.
Cooke, D. J. (1995). Psychopathic disturbance in the Scottish prison population: The cross-cultural generalisability of the Hare Psychopathy Checklist. Crime and Law, 2, 101-118.
Cooke, D. J. (2008). Psychopathy as an important forensic construct: Past, present and future. In Canter D., & Žukaustiené R. (Eds.), Psychology and law: Bridging the gap (pp. 167-189). Hampshire, UK: Ashgate Publishing.
Cooke, D. J., Hart, S. D., Logan, C., & Michie, C. (2004). Comprehensive Assessment of Psychopathic Personality - Institutional Rating Scale (CAPP-IRS). Unpublished manuscript.
Cooke, D. J., Michie, C., & Hart, S. D. (2006). Facts of Clinical Psychopathy: Toward Clearer Measurement. In C. Patrick (Ed.), The handbook of psychopathy (pp. 91-106). New York: Guilford Press.
Davidson, K. M., Tyrer, P., Tata, P., Cooke, D., Gumley, A., Ford, I., Walker, A., Bezlyak, V., Seivewright, H., Robertson, H., & Crawford, M. J. (2009). Cognitive behaviour therapy for violent men with antisocial personality disorder in the community: An exploratory randomized controlled trial. Psychological Medicine, 39, 569-577, doi: 10.1017/S0033291708004066.

DeMatteo, D., Heilbrun, K., & Marczyk, G. (2005). Psychopathy, risk of violence, and protective factors in a noninstitutionalized and noncriminal sample. International Journal of Forensic Mental Health, 4, 147-157, doi: 10.1080/14999013.2005.10471220.
Douglas, K. S., Vincent, G. M., & Edens, J. F. (2006). Risk for criminal recidivism: The role of psychopathy. In C. J. Patrick (Ed.), Handbook of Psychopathy (pp. 533-554). New York, NY: Guilford Press.
Draycott, S., Askari, R., & Kirkpatrick, T. (2011). Patterns and changes in psychopathic interpersonal behaviour in forensic inpatient treatment. Personality and Mental Health, 5, 200-208, doi: 10.1002/pmh. 171.

D’Silva, K., Duggan, C. & McCarthy, L. (2004). Does treatment really make psychopaths worse? A review of the evidence. Journal of Personality Disorders, 18, 163-177, doi: 10.1521/pedi.18.2.163.32775.
Evershed, S., Tennant, A., Boomer, D., Rees, A., Barkham, M., & Watson, A. (2004). Practice-based outcomes of dialectical behavior therapy (DBT) targeting anger and violence, with male forensic patients: a pragmatic and non-contemporaneous comparison. Criminal Behavior and Mental Health, 13, 198-214, doi: 10.1002/cbm.542.
Evershed, S., Tennant, A., Boomer, D., Rees, A., Barkham, M., & Watson, A. (2004). Practice-based outcomes of 辯證行為治療(DBT) targeting anger and violence, with male forensic patients: a pragmatic and non-contemporaneous comparison. Criminal Behavior and Mental Health, 13, 198-214, doi: 10.1002/cbm.542.
Fairholme, C. P., Boisseau, C. L., Ellard, K. K., Ehrenreich, J. T., & Barlow, D. H. (2010). Emotions, emotion regulation, and psychological treatment: A unified perspective. In A. Kring & D. M. Sloan (Eds.), Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment (pp. 283-309). New York: Guilford.
Frick, P. J., & Marsee, M. A. (2006). Psychopathy and developmental pathways to antisocial behavior in youth. In C. J. Patrick (Ed.), Handbook of psychopathy (pp. 353-374). New York: Guilford.
Fruzzetti, A. E. & Levensky, E. R. (2000). Dialectical behavior therapy for domestic violence: Rationale and Procedures. Cognitive and Behavioral Practice, 7, 435-447, doi: 10.1016/S1077-7229(00)80055-3.
Fruzzetti, A. E. & Levensky, E. R. (2000). 辯證行為治療 for domestic violence: Rationale and Procedures. Cognitive and Behavioral Practice, 7, 435-447, doi: 10.1016/S1077-7229(00)80055-3.
Graham, N., Kimonis, E. R., Wasserman, A. L., & Klein, S. M. (2012). Associations among childhood abuse and psychopathy facets in male sexual offenders. Personality Disorders: Theory, Research, and Treatment, 3, 66-75, doi: 10.1037/a0025605.
Grieve, R., & Mahar, D. (2010). The emotional manipulation-psychopathy nexus: Relationships with emotional intelligence, alexithymia and ethical position. Personality and Individual Differences, 48, 945-950, doi: 10.1016/j.paid.2010.02.028.

Hare, R. D. (1999). Psychopathy as a risk factor for violence. Psychiatric Quarterly, 70, 181-197.
Hare, R. D., & Neumann, C. S. (2009). Psychopathy. In P. H. Blaney & T. Millon (Eds.), The Oxford Textbook of Psychopathology (2nd ed.) (pp. 622-650). New York: Oxford University Press.

Harris, G., & Rice, M. (2006). Treatment of psychopathy: A review of empirical findings. In C. J. Patrick (Ed.), Handbook of Psychopathy (pp. 555-572). New York: Guilford.
Harris, G. T., Rice, M. E., & Cormier, C. A. (1991). Psychopathy and Violent Recidivism. Law and Human Behavior, 15, 625-637, doi: 10.1007/BF01065856.

Hemphill, J. F., Hare, R. D., & Wong, S. (1998). Psychopathy and recidivism: A review. Legal and Criminological Psychology, 3, 139-170, doi: 10.1111/j.2044-8333.1998.tb00355.x.

Hoff, H. A., Rypdal, K., Mykletun, A., & Cooke, D. J. (2012). A prototypicality validation of the Comprehensive Assessment of Psychopathic Personality Model (CAPP). Journal of Personality Disorders, 26, 414-427, doi: 10.1521/pedi.2012.26.3.414.
Hogue, T. E., Jones, L., Talkes, K., & Tennant, A. (2007). The Peaks: A clinical service for those with dangerous and severe personality disorder. Psychology, Crime & Law, 13, 57-68, doi: 10.1080/10683160600869791.
Koerner, K. (2007). Case formulation in dialectical behavior therapy for borderline personality disorder. In T. D. Eells (Ed.), Handbook of psychotherapy case formulation (2nd ed., pp. 317-348). New York: Guilford Press.
Koerner, K. (2007). <span class="term" data-term="case formulation">個案概念化</span> in <span class="term" data-term="dialectical behavior therapy">辯證行為治療</span> for <span class="term" data-term="borderline personality disorder">邊緣型人格</span>. In T. D. Eells (Ed.), Handbook of psychotherapy case formulation (2nd ed., pp. 317-348). New York: Guilford Press.
Kreis, M. K., Cooke, D. J., Michie, C. Hoff, H. A., & Logan, C. (2012). The Comprehensive Assessment of Psychopathic Personality (CAPP): Content validation using prototypical analysis. Journal of Personality Disorders, 26, 402-413, doi: 10.1521/pedi.2012.26.3.402.
Kreis, M. K., Cooke, D. J., Michie, C. Hoff, H. A., & Logan, C. (2012). The Comprehensive Assessment of Psychopathic Personality (CAPP): Content <span class="term" data-term="validation">認可</span> using prototypical analysis. Journal of Personality Disorders, 26, 402-413, doi: 10.1521/pedi.2012.26.3.402.
Krueger, R. F., & South, S. C. (2009). Externalizing disorders: Cluster 5 of the proposed meta-structure for DSM-V and ICD-11. Psychological Medicine, 39, 2061-2070, doi: 10.1017/S0033291709990328.
Kuo, J. R., & Linehan, M. M. (2009). Disentangling emotion processes in borderline personality disorder: Physiological and self-reported assessment of biological vulnerability, baseline intensive, and reactivity to emotionally evocative stimuli. Journal of Abnormal Psychology, 118, 531-544, doi: 10.1037/a0016392.
Kuo, J. R., & Linehan, M. M. (2009). Disentangling emotion processes in borderline personality disorder: Physiological and self-reported assessment of biological 脆弱性, baseline intensive, and reactivity to emotionally evocative stimuli. Journal of Abnormal Psychology, 118, 531-544, doi: 10.1037/a0016392.
Lander, G. C., Lutz-Zois, C. J., Rye, M. S., & Goodnight, J. A. (2012). The differential association between alexithymia and primary versus secondary psychopathy. Personality and Individual Differences, 52, 45-50, doi: 10.1016/j.paid.2011.08.027.
Linehan, M. M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press.
Linehan, M. M. (1993). Cognitive behavioral treatment of 邊緣型人格. New York: Guilford Press.
Linehan, M., Dimeff, L., Reynolds, S., Comtois, K., Welch, S., Heagerty, P., & Kivlahan, D. R. (2002). Dialectical behavior therapy versus comprehensive validation therapy plus 12 -step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence, 67, 13-26.
Linehan, M., Dimeff, L., Reynolds, S., Comtois, K., Welch, S., Heagerty, P., & Kivlahan, D. R. (2002). 辯證行為治療 versus comprehensive 認可 therapy plus 12 -step for the treatment of opioid dependent women meeting criteria for 邊緣型人格. Drug and Alcohol Dependence, 67, 13-26.
Linehan, M. M., Schmidt, H., Dimeff, L. A., Craft, J. C., Kanter, J., & Comtois, K. A. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. The American Journal on Addictions, 8, 279-292, doi: 10.1080/105504999305686.
Linehan, M. M., Schmidt, H., Dimeff, L. A., Craft, J. C., Kanter, J., & Comtois, K. A. (1999). 針對邊緣型人格和藥物依賴患者的辯證行為治療。The American Journal on Addictions, 8, 279-292, doi: 10.1080/105504999305686.
Lykken, D. (1995). The antisocial personalities. Hillsdale, NJ: Lawrence Erlbaum.
Marcus, D. K., Fulton, J. J., & Edens, J. F. (2012). The two-factor model of psychopathic personality: Evidence from the Psychopathic Personality Inventory. Personality Disorders: Theory, Research, and Treatment, 3, 140-154, doi: 10.1037/a0025282.
Marcus, D. K., Fulton, J. J., & Edens, J. F. (2012). 精神病態人格的雙因子模型：來自精神病態人格量表的證據。Personality Disorders: Theory, Research, and Treatment, 3, 140-154, doi: 10.1037/a0025282.
McCann, R. A., Ball, E. M., & Ivanoff, A. (2000). DBT with an inpatient forensic population: The CMHIP forensic model. Cognitive and Behavioral Practice, 7, 447-456, doi: 10.1016/S1077-7229(00)80056-5.
McCann, R. A., Ball, E. M., & Ivanoff, A. (2000). 針對住院法醫病患的辯證行為治療：CMHIP 法醫模型。Cognitive and Behavioral Practice, 7, 447-456, doi: 10.1016/S1077-7229(00)80056-5.
Messina, N., Grella, C. E., Cartier, J., & Torres, S. (2010). A randomized experimental study of gender-responsive substance abuse treatment for women in prison. Journal of Substance Abuse Treatment, 38, 97107.
Messina, N., Grella, C. E., Cartier, J., & Torres, S. (2010). 針對監獄中女性的性別回應式藥物濫用治療之隨機實驗研究。Journal of Substance Abuse Treatment, 38, 97107.

Muller, J. L. (2010). Psychopathy - an approach to neuroscientific research in forensic psychiatry. Behavioral Sciences and the Law, 28, 129-147, doi: 10.1002/bsl.926.
Muller, J. L. (2010). 精神病態——法醫精神病學神經科學研究的一種方法。Behavioral Sciences and the Law, 28, 129-147, doi: 10.1002/bsl.926.
Nee, C., & Farman, S. (2006). Female prisoners with borderline personality disorder: some promising treatment developments. Criminal Behaviour and Mental Health, 15, 2-16, doi: 10.1002/cbm.33.

Ogloff, J. (2006). Psychopathy / antisocial personality disorder conundrum. Australian and New Zealand Journal of Psychiatry, 40, 519-528, doi: 10.1111/j.1440-1614.2006.01834.x.

Patrick, C. J. (2007). Antisocial personality disorder and psychopathy. In W. O’Donohue, K. Fowler & S. O. Lilienfeld (Eds.) Personality disorders: Toward the DSM-V (pp. 109-166). Thousand Oaks, CA: Sage.
Patrick, C. J., & Bernat, E. M. (2010). Neuroscientific foundations of psychopathology. In T. Millon, R. F. Krueger, & E. Simonsen (Eds.), Contemporary directions in psychopathology: Scientific foundations of the DSM-V and ICD-11 (pp. 419-452). New York: Guilford.
Pickersgill, M. (2011). “Promising” therapies: Neuroscience, clinical practice, and the treatment of psychopathy. Sociology of Health & Illness, 33, 448-464, doi: 10.1111/j.1467-9566.2010.01286.x.
Polaschek, D. L. L. (2010). Treatment non-completion in high-risk violent offenders: Looking beyond criminal risk and criminogenic needs. Psychology, Crime & Law, 16, 525-540, doi: 10.1080/10683160902971048.
Raine, A., & Yang, Y. (2005). The neuroanatomical bases of psychopathy: A review of brain imaging findings. In C. Patrick (Ed.) Handbook of psychopathy (pp. 278-295). New York: Wiley.
Raine, A., & Yang, Y. (2005). The neuroanatomical bases of psychopathy: A review of brain imaging findings. In C. Patrick (Ed.) Handbook of psychopathy (pp.278-295). New York: Wiley.
Reavis, J. A., Allen, E. K., & Meloy, J. R. (2008). Psychopathy in a mixed gender sample of adult stalkers. Journal of Forensic Science, 53, 1214-1217, doi: 10.1111/j.1556-4029.2008.00839.x.
Rice, M., Harris, G., & Cormier, C. (1992). An evaluation of a maximum security therapeutic community for psychopaths and other mentally disordered offenders. Law and Human Behavior, 16, 399-412, doi: 10.1007/BF02352266.

Rosenfeld, B., Galietta, M., Ivanoff, A., Garcia-Mansilla, A., Martinez, R., Fava, J., Fineran, V., & Green, D. (2007). Dialectical Behavior Therapy for the treatment of stalking offenders. International Journal of Forensic Mental Health, 6, 95-103, doi: 10.1080/14999013.2007.10471254.
Rosenfeld, B., Galietta, M., Ivanoff, A., Garcia-Mansilla, A., Martinez, R., Fava, J., Fineran, V., & Green, D. (2007). 辯證行為治療 for the treatment of stalking offenders. International Journal of Forensic Mental Health, 6, 95-103, doi: 10.1080/14999013.2007.10471254.
Rotter, M., Way, B., Steinbacher, M., Sawyer, D., & Smith, H. (2002). Personality disorders in prison: Aren’t they all antisocial? Psychiatric Quarterly, 73, 337-349.
Rotter, M.、Way, B.、Steinbacher, M.、Sawyer, D. 及 Smith, H. (2002)。監獄中的人格障礙：難道他們不都是反社會的嗎？《精神醫學季刊》(Psychiatric Quarterly)，73，337-349。
Salekin, R. T. (2002). Psychopathy and therapeutic pessimism: Clinical lore or clinical reality. Clinical Psychology Review, 22, 79-112, doi: 10.1016/S0272-7358(01)00083-6.
Salekin, R. T. (2002)。精神病態與治療悲觀主義：臨床傳說或臨床現實。《臨床心理學評論》(Clinical Psychology Review)，22，79-112，doi: 10.1016/S0272-7358(01)00083-6。

Salekin, R. T. (2008). Psychopathy and recidivism from mid-adolescence to young adulthood: Cumulating legal problems and limiting life opportunities. Journal of Abnormal Psychology, 117, 386-395, doi: 10.1037/0021843X.117.2.386.
Salekin, R. T. (2008)。從青春期中期到成年早期的精神病態與再犯：累積的法律問題與受限的人生機會。《變態心理學期刊》(Journal of Abnormal Psychology)，117，386-395，doi: 10.1037/0021843X.117.2.386。
Salekin, R. T., Worley, C., & Grimes, R. D., (2010). Treatment of psychopathy: A review and brief introduction to the mental model approach for psychopathy. Behavioral Sciences and the Law, 28, 235-266, doi: 10.1002/bsl.928.
Salekin, R. T.、Worley, C. 及 Grimes, R. D. (2010)。精神病態的治療：一篇回顧與精神病態心智模型方法的簡要介紹。《行為科學與法律》(Behavioral Sciences and the Law)，28，235-266，doi: 10.1002/bsl.928。

Skeem, J. L., Monahan, J., & Mulvey, E. (2002). Psychopathy, treatment involvement, and subsequent violence among civil psychiatric patients. Law and Human Behavior, 26, 577-603, doi: 10.1023/A:1020993916404.
Skeem, J. L.、Monahan, J. 及 Mulvey, E. (2002)。精神病態、治療參與與民事精神病患的後續暴力行為。《法律與人類行為》(Law and Human Behavior)，26，577-603，doi: 10.1023/A:1020993916404。
Skeem, J. L., Polaschek, D. L. L., & Manchak, S. (2009). Appropriate treatment works, but how? Rehabilitating general, psychopathic, and high risk offenders. In J. L. Skeem, K. Douglas, & S. Lilienfeld (Eds.), Psychological science in the courtroom: Controversies and consensus (pp. 358-385). New York: Guilford.
Skeem, J. L., Polaschek, D. L. L., Patrick, C. J., & Lilienfeld, S. O., (2011). Psychopathic Personality: Bridging the gap between scientific evidence and public policy. Psychological Science in the Public Interest, 12, 95-162, doi: 10.1177/1529100611426706.
Snowden, R. J., & Gray, N. S. (2011). Impulsivity and psychopathy: Associations between the Barratt Impulsivity Scale and the Psychopathy Checklist revised. Psychiatry Research, 187, 414-417, doi:10.1016/j.psychres.2011.02.003.
Storey, J. E., Hart, S. D., Meloy, J. R., & Reavis, J. A., (2009). Psychopathy and stalking. Law and Human Behavior, 33, 237-246, doi: 10.1007/s10979-008-9149-5.

Towl, G. J., & Dexter, P. (2009). Anger management groupwork with prisoners: An empirical evaluation. In O. Manor (Ed.), Groupwork research (pp. 157-171). New York: Whiting & Birch.

Trupin, E. W., Stewart, D. G., Beach, B., & Boesky, L. (2002). Effectiveness of dialectical behaviour therapy program for incarcerated female juvenile offenders. Child and Adolescent Mental Health, 7, 121-127, doi: 10.1111/1475-3588.00022.

Tyrer, P., Cooper, S., Rutter, D., Seivewright, H., Duggan, C., Maden, T., Barrett, B., Joyce, E., Rao, B., Nur, U., Cicchetti, D., Crawford, M., & Byford, S. (2009). The assessment of dangerous and severe personality disorder: Lessons learned from a randomized controlled trial linked to qualitative analysis. Journal of Forensic Psychiatry & Psychology, 20, 132-146, doi: 10.1080/14789940802236872.
Van den Bosch, L., Verheul, R., Schippers, G., & van den Brink, W. (2002). Dialectical behavior therapy of borderline patients with and without substance abuse problems: Implementation and long-term effects. Addictive Behaviors, 27, 911-923, doi: 10.1016/S0306-4603(02)00293-9.

Verona, E., Patrick, C. J., & Joiner, T. E. (2001). Psychopathy, antisocial personality, and suicide risk. Journal of Abnormal Psychology, 110, 462-470, doi: 10.1037/0021-843X.110.3.462.
Vidal, S., Skeem, J., & Camp, J. (2010). Emotional intelligence: Painting different paths for low-anxious and high-anxious psychopathic variants. Law and Human Behavior, 34, 150-163, doi: 10.1007/s10979-009-9175-y.
Vidal, S., Skeem, J., & Camp, J. (2010). 情緒智力：為低焦慮和高焦慮精神病態變異體描繪不同路徑。法律與人類行為，34，150-163，doi: 10.1007/s10979-009-9175-y。
Waldman, I. D., & Rhee, S. H. (2006). Genetic and environmental influences on psychopathy and antisocial behavior. In C. J. Patrick (Ed.), Handbook of psychopathy (205-228). New York: Guilford Press.
Waldman, I. D., & Rhee, S. H. (2006). 精神病態與反社會行為的遺傳和環境影響。載於 C. J. Patrick (主編)，精神病態手冊 (205-228)。紐約：Guilford Press。
World Health Organization. (2008). ICD-10: International statistical classification of diseases and related health problems (10th Rev. ed.). New York: Author.
世界衛生組織。(2008)。ICD-10：疾病和相關健康問題的國際統計分類 (第 10 修訂版)。紐約：作者。