Antisocial personality disorder (ASPD) is one of the most prevalent co-occurring disorders among people with substance use disorders (SUDs) (1, 2), and both are central to the externalizing spectrum of mental health problems (3). ASPD is strongly linked to association with deviant peers and traumatization (4), and offending (5, 6). While the condition often improves with time, many people continue to experience associated problems well into late adulthood and old age (7, 8).
Traditionally, people with ASPD have been described as ‘treatment rejecting’ (9), although much attention has been given to the importance of recognition and management of conduct disorders and antisocial behavior in children, young people, and adults (10–12). The few conducted treatment studies have generally included very few patients, but have shown promising results, underlining the fact that patients with a diagnosis of ASPD can be engaged in treatment. For example, in one of the studies, Davidson and colleagues offered cognitive-behavioral therapy to 52 men in a randomized trial in a community setting, and while the results were not statically significant, the authors noted that many of the patients at least received part of the treatment (13).
ASPD is often a complex condition and is highly comorbid, not just with SUDs, but also with other disorders such as anxiety and mood disorders (14). Recently, a study successfully tested mentalization-based treatment as a treatment for patients with comorbid antisocial and borderline personality disorder (15) including a dynamic schedule of psychotherapy of 140 sessions of therapy, both group and individual. Findings from this study indicate that the treatment could reduce symptoms related to antisocial behavior including anger, hostility, and impulsivity. Furthermore, a study from Sweden 30 patients with borderline personality and antisocial behavior received Dialectical Behavior Therapy, another intensive long-term treatment (16) and found that the patients reduced a range of dysfunctional behaviors significantly during treatment, and the majority completed the treatment (16).
Despite the high prevalence of comorbid ASPD and SUD, few interventions have been designed to target this important comorbidity (2). Some evidence support that antisocial traits are linked to retention in treatment specifically among people with SUDs who are voluntarily in treatment (17, 18). In addition, ASPD is associated with offending after discharge from treatment for SUD (5, 19). The lack of research has been reflected in a recent Cochrane review that concluded that the few studies that exist do not support any psychological interventions for ASPD in general (20). One of the main criticisms raised in this review was the absence of data on convictions after treatment in existing literature. This is a valid criticism given that one of the criteria for ASPD is criminal behavior that could lead to convictions (21).
One of the few methods that have been tentatively tested is the Impulsive Lifestyle Counselling program (ILC). The ILC program aims to build self-understanding through psycho-education, thereby raising awareness of dysfunctional impulsive patterns of action related to ASPD (22). Impulsivity in the form of low self-control is especially important for understanding the link between ASPD and offending behavior(23). Thus, interventions targeting impulsive behaviors related to ASPD have the potential to motivate change in antisocial behavior, including aggression and offending behavior, as well as substance use (24).
In a pragmatic multicenter trial, ILC was added-on to treatment as usual (TAU) and tested in outpatient treatment for SUDs in Denmark. Random assignment to treatment (n = 176) was associated with lower risk of dropout from treatment (25), greater perceived help for ASPD (26), and more number of days abstinent at three months follow-up but not beyond (27). No effects were found on self-reported aggression.
The aim of the present study was to assess the impact of random assignment to ILC on offending behavior after treatment. Specifically, we aimed to test whether patients randomized to ILC offended less frequently than patients randomized to treatment as usual (TAU) up to one year after randomization.