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Stout explores the largely unknown origins of ASPD, providing insight into the complex causes of this personality disorder. She cites twin studies that use the “Psychopathic Deviate” personality scale to assess a person’s likelihood of having ASPD, as well as a similar study done on twin men who served in the Vietnam War. These studies seemed to determine that ASPD is about 50% heritable, while the other 50% is environmental. Neuroscientific studies have found that people with ASPD demonstrate no more reaction to emotional words than to neutral words, and their cerebral cortex seems to process emotion-oriented tasks from a more mathematical perspective.
From the environmental side, typical theories surrounding psychological disorders always point toward childhood abuse and trauma, but people with ASPD do not consistently have these experiences. Other theories point to issues of attachment in early life as the cause, but children with attachment disorders do not share the same charisma or desire to manipulate that children with ASPD have. Stout also explores the issue of Romanian children who were adopted in the West in the 1990s. These children grew up in orphanages, without much emotional or psychological support. While these children did have attachment problems, they did not have typical ASPD traits.
All of this points to the possibility of culture as the underlying environmental influence. Collectivist cultures that emphasize interconnectedness and social dependence have a strikingly lower rate of ASPD, although Stout adds that the possible cause of this may relate to how people with ASPD in these cultures have learned to intellectually adapt. People with ASPD still need to fit in and may adopt more community-focused behaviors in response to communitarian environments. Individualist cultures, on the other hand, emphasize self-centeredness, and Western culture also tends to celebrate “the warrior,” or the person willing to be violent for the sake of saving others.
One of Stout’s patients, a woman named Hannah, came seeking therapy when her father shot an intruder who was running away from their home. Hannah wrestled with the nature of the shooting and her father’s personality, which Hannah’s powerful denial had led her to ignore for years. A first, Hannah insisted that her father had shot the man by accident and was deserving of sympathy, but the more she told Stout and the more she brought her memories to the forefront of her consciousness, the more Hannah realized that something was going on with her father.
Hannah recalled her father being sexually inappropriate with her friends growing up, as well as with students at the high school where he was a principal. She also recalled that her father seemed to see her and her mother more as trophies than as people and that he would intentionally neglect them when he felt like they weren’t living up to his standards. Hannah’s father shot the intruder as he was running away and was sentenced to a decade in prison. Hannah and her mother started receiving calls about drugs, and Hannah started to suspect that her father was a dealer. She confronted him in prison, asking whether he sold heroin and whether he had killed anyone else. Hannah’s father only laughed. In the end, she decided that she could not maintain a relationship with him.
Stout lists 13 rules for protecting oneself from people with ASPD: Question authority, accept that people without a conscience exist, watch out for people who lie repeatedly, trust your instincts, be suspicious of flattery, don’t confuse fear and respect, don’t encourage antisocial behavior, avoid those who appear to have ASPD, question your pity for others, do not try to “save” people with ASPD, remember the goodness in humanity, and take “revenge” for abuse by living a good life, not by trying to harm those who have harmed you. Hannah enacted this last piece of advice by becoming a human rights lawyer.
The origins of the conscience are unclear and complex, but many theories exist as to how humans developed this almost universal trait. Evolutionary theories point toward gene selection of altruistic traits for group and species survival, as well as kin selection to include people’s tendency to also help those closest to them. Because evolution occurs at all levels, some individuals evolved the individually advantageous trait of ASPD even as most others evolved the collective advantage of a conscience.
Through developmental psychology, more of the picture becomes clear. Children were originally theorized to develop through a series of set moral stages (both Jean Piaget and Lawrence Kohlberg theorized this in their own way), and it was later believed that women and men tend to prioritize different types of moral reasoning (justice versus compassion). Cultural individualism and collectivism also have an impact on how morality and conscience develop in people. Stout reflects on her feelings after the September 11th terrorist attacks and her sudden inclination to reach out to people she hadn’t spoken to for years. She feels that whatever the true origin of the conscience is, it can still be defined by humanity’s need to remain together.
In these chapters, Stout continues her exploration of The Importance of Conscience in Human Interaction. She argues that the near-universal inclination to connect with others is what ultimately defines the essence of the conscience, which people with ASPD, lacking this attachment, struggle to comprehend. In making this point, Stout uses vivid imagery to emphasize the emotional state of a patient, “Hannah,” in a moment of harsh realization that her father did not feel empathy: “The tears came, soundless ones, no weeping noises, as if the rest of her were unaware she was crying. Streams fell from her eyes and rolled down onto her white silk shirt, making translucent stains. Apart from this, her demeanor remained unchanged, stoic. Her face did not fall” (141). This description emphasizes the stoicism that Hannah had to learn while dealing with a father who had ASPD. The example demonstrates how antisocial behavior can be normalized within a family. Despite recognizing certain troubling behaviors—such as sexual inappropriateness with students and dealing drugs—Hannah never fully understood the true nature of her father’s actions. This emphasizes the challenges of Protecting Against the Consequences of ASPD, as people with the disorder can often hide their behavior, making it difficult for others to recognize the signs until it is too late.
Stout explores the “nature versus nurture” debate, challenging ideas of personal responsibility and moral autonomy. Since people with ASPD lack the moral sensibilities common among other people, the degree to which they are responsible for their actions is a matter of debate. Ultimately, Stout does not try to resolve the ambiguity of these questions. She notes that nature plays a role, as evidenced by the Psychopathic Deviate scale and twin studies, which suggest that ASPD may be 50% heritable. Stout introduces several scientific theories to frame the discussion of ASPD within the context of evolutionary biology. George C. Williams’s theory of gene selection posits that evolution is driven by the survival of genes, not individuals or groups. This ties into kin selection, as described by W. D. Hamilton, which suggests that individuals are more likely to protect the genes of close relatives. On the other hand, nurture factors are also involved. For example, studies on Romanian orphans who were raised in loveless environments and later adopted suggest that lack of attachment can lead to aggressive and manipulative behaviors. The text also notes that culture may play a role: Individualistic cultures appear to encourage selfishness, whereas collectivist cultures foster a greater sense of interconnectedness, though emotional understanding of this interconnectedness cannot be forced.
References to well-known figures such as Napoleon and Mother Teresa serve to highlight the extremes of human nature, with the text noting that the human species has produced individuals capable of both great atrocities and profound compassion. In a shift from scientific analysis to emotional reflection, Stout concludes with a statement on oneness, ending the chapter with a meditation on how “we are all one,” tying this concept back to the essence of the conscience, which is rooted in our shared humanity.



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