Antisocial personality disorder was once deemed untreatable. Not anymore.
STUDY: Fonagy P et al, Lancet Psychiatry 2025;12:208–219, PMID: 40176122
STUDY TYPE: Randomized, assessor-blinded, controlled trial
FUNDING: National Institute for Health Research
Background
In 2020, the Cochrane group concluded there is “very limited evidence” for psychotherapy in antisocial personality disorder. Some even argue that group therapy can make them worse as they reinforce each other’s criminal traits through “deviancy training.” This study suggests the opposite.
The trial tested mentalization-based treatment (MBT), a psychodynamically-informed therapy that works by strengthening the ability to understand one’s own and others’ mental states. It sits alongside dialectical behavioral therapy (DBT), as one of the most empirically grounded therapies for borderline personality disorder.
The Study
313 men on community probation in England and Wales who met DSM-5 criteria for antisocial personality disorder were randomized to MBT plus probation as usual or probation as usual alone. The MBT group received weekly group therapy and monthly individual sessions for 12 months. Primary outcome was aggression measured by the Overt Aggression Scale-Modified (OAS-M) at 12 months.
At 12 months, aggression scores were nearly half those of the control group (90 vs 186 on the OAS-M), with a medium-to-large effect size of 0.74. Gains held at 18 months but faded by 24. By year three, total reoffending was 46% lower in the MBT group (incidence rate ratio 0.54), with major violent offenses down 58%. Fewer participants in the MBT group still met full criteria for antisocial personality disorder at 12 and 24 months. There was no change in alcohol use and drug use, self-harm, or suicidal behavior
The ability to mentalize (to understand others) improved significantly and mediate the reduction in aggression.
Limitations: High drop out rate of 41-45% (a common problem in this population), comparison to a less active control (although “probabtion as usual” does contain active treatment elements). Sample was men only in UK.
Practice Implications
- To learn MBT for antisocial, start with this chapter from Peter Fonagy and this manual from the Anna Freud center.
- For teens with conduct problems, Multisystem Therapy has evidence to work by teaching the families how to respond to the problems
- Learn more about antisocial in our four-part Carlat Podcast series on Jeffery Epstein.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
What’s Your Take? Share in Comments
- Have you tried mentalization based therapy? Which parts of it did you find most helpful?
