Mentalization therapy for antisocial personality disorder

A UK randomized trial offers cautious hope for a condition widely assumed to be untreatable.

Antisocial personality disorder (ASPD) is one of the conditions clinicians feel most helpless about, strongly linked to offending and widely assumed to be untreatable. This UK randomized controlled trial offers cautious hope, and unusually, it looked at the money too. Men with ASPD who had been convicted of an offence and were on community probation in England and Wales were randomized to receive either mentalization-based treatment adapted for ASPD (a therapy that builds the capacity to understand one’s own and others’ mental states) added to usual probation, or probation as usual alone. Researchers tracked outcomes over 24 months from a whole-society perspective, health care, criminal justice, and the broader costs of offending. Missing data made firm conclusions difficult, but the available picture favored the therapy: participants who got it tended to spend less time in custody, showed lower aggression, and the approach came out cost-effective, with each unit reduction in aggression associated with roughly £93 in savings. Quality-of-life differences were minimal. As a first full economic evaluation in this population it’s preliminary, but it suggests a wall clinicians rarely get through may not be as solid as assumed, and that treating ASPD could pay for itself through less aggression and less custody.