December 28, 2010

Prison therapy: It's all in the name

Look at the above picture. What do you see? You should see a monkey in a cage. (More precisely, a capuchin monkey rescued from a laboratory.)

Now look at the second picture. If you again see a cage (or two), your eyes are playing tricks on you. These are not cages. They are "therapeutic modules." It's the California prison system's response to a judicial mandate to provide treatment to mentally ill prisoners.

Using the correct term is important, according to a psychiatric expert quoted by Jack Dolan in today's Los Angeles Times: "If you call them cages, people inside might feel like animals and respond accordingly."

Pictured here is music therapist Daniel Tennenbaum, wearing a flak vest as he strums a sing-along rendition of Otis Redding's "Sitting on the Dock of the Bay":

... I had nothin to live for
And look like nothing's gonna come my way ...
Look like nothing's gonna change
Everything still remains the same ...
I'm just sitting on the dock of the bay
Wasting time

One wonders whether the "therapeutic module" euphemism is truly for the benefit of the prisoners, or more for the psychologists providing window dressing, who want to think that therapeutic healing is possible under such cruel and inhumane conditions.

And if mere renaming can alter reality, then Mina over at Psydoctor8 has a better idea. We could refer to the prisons as "Hawaii." Then, the prisoners might feel like hula dancers instead of caged animals.

December 21, 2010

Best wishes for the holidays

As you may have noticed, I am taking a holiday break from blogging. Until my return, I want to wish all of you -- and especially my loyal subscribers -- a wonderful holiday season and a new year of peace and happiness.

December 20, 2010

Juvenile In Justice: An online gallery

Art professor Richard Ross is traveling the United States and photographing juvenile institutions. The project, Juvenile In Justice, is partially funded by the Guggenheim Foundation and the Annie E. Casey Foundation and will be published next year. The 196 photos in the online gallery are well worth checking out. While you are there, visit his related collection, Architecture of Authority. Stunning stuff.

From the top: Los Angeles, California; Cook County, Illinois; Biloxi, Mississippi

December 13, 2010

Blogger challenges my post on sex offender risk assessment

My report on a promising new method for assessing sex offender recidivism risk prompted a reaction from Robin Wilson over at a new blog by the publishers of Sexual Abuse, the journal of the Association for the Treatment of Sexual Abusers (ATSA).

My interest dissolved into disappointment when I realized that the response sidestepped substantive discussion of the new research, a collaborative project by scholars in the United States, New Zealand, and Australia finding that accuracy of risk prediction can be enhanced by using age-stratified tables.

Instead of engaging with the scientific merits of this study, Dr. Wilson focused on the Static-99 actuarial tool, chastising me for being overly critical of that approach:
Dr. Franklin has something of a penchant for the flamboyant. Actually, I often appreciate a bit of bluster, but I think we also need to avoid bias and unnecessary sideswipes at our colleagues. In the spirit of honesty, let me say that I work in a civil commitment center and that I am a certified trainer for the Static-99 group of measures. So, my potential bias is on the table.
Is having an opinion a form of bias?

The term bias refers to a partiality that interferes with the ability to be fair or objective. Expressing a point of view does not make one biased. Rather, the articulation of informed opinion advances professional practice. Indeed, such "expert opinion" is precisely what courts seek from forensic psychologists when they solicit our testimony. An expert witness is expected to have a firm grounding in the applicable science, and to be able to critically analyze its strengths and weaknesses as it applies to a specific issue or case.

It is that process of reflection -- invoking complementary theoretical perspectives from criminology, sociology, anthropology and international studies relevant to forensic psychology -- that germinates many an idea for this blog. I welcome critical engagement with these ideas, but hope that interlocutors can themselves refrain from diversionary ad hominem arguments.

Why pick on the Static-99?

Dr. Wilson's main theme is that I am unduly critical of the Static-99 and its developers.

The Static-99 website promotes the tool as "the most widely used sex offender risk assessment instrument in the world." As Dr. Wilson himself notes in another publication, its "prolific use in sexual offender civil commitment proceedings" is one reason it generates so much debate.

But Dr. Wilson is correct in pointing out that many of the Static-99's flaws apply equally to its cousins. In referencing the Static-99, I in no way intend to exempt other actuarials from critique. Indeed, in previous posts I have discussed problems with the MnSOST-R and have reported the results of studies on the relative accuracy of the Static-2002, Risk Matrix 2000, RRASOR and other actuarial tools.

Dr. Wilson makes an essential point in defense of the Static-99. By encouraging us to anchor our risk estimates in empirical data, he reminds us, actuarials serve as a counterbalance against clinicians' inherent tendency to vastly overestimate sex offender risk:
Maybe, what Dr. Franklin should be highlighting more is the fact that some evaluators are falling prey to partisan concerns. A well done sex offender risk assessment [using an actuarial instrument] should say the same thing, regardless of who you are working for.
In principle, Dr. Wilson is entirely correct. Sadly, from my vantage point as a forensic psychologist working in the courtroom trenches, I see endemic partisan allegiance in this arena. The Static-99 is being systematically deployed to provide a scientific veneer for highly questionable practices in the service of civil commitment.

The problem is not just a handful of rogue evaluators. The latest permutation of the Static-99 fosters such misuse. I am referring to the developers' advice to assign sex offenders to one of four categories with different levels of actuarial risk. As I pointed out in a previous post, this procedure introduces a large element of clinical judgment into a procedure whose very existence is predicated on doing away with such subjectivity. In the polarized Sexually Violent Predator arena, evaluators now have an easy way to elevate their estimate of an offender's risk by comparing the individual to the highest-risk group rather than to the lower recidivism figures for sex offenders overall. This practice reflects a tautology, or logical fallacy. In a civil commitment proceeding the evaluator essentially says: "This offender is high risk. Just look at the recidivism rates for offenders in the high-risk group to which I have assigned him."

The Static-99 developers may be quite well intentioned, as Dr. Wilson says. But subjective intent is far less important than real-life effects. The road to Hell, as they say, is paved with good intentions. I will not be alone in cheering when I hear that the Static-99 developers have stepped up and publicly condemned the systematic misuse of their instruments in courthouses all across the United States.

If Dr. Wilson's point was to chastise me for the use of the term reliability where I meant to say accuracy, I stand corrected. (I have made the correction to the original post.) However, I make no apologies for expressing an informed viewpoint and, indeed, I unflinchingly embrace such a role as part of my professional obligation. The goal of my blog is not to convince people that I have all the answers. Rather, I am happy if I encourage critical reflection and stimulate people to read the original source material. In so doing, I hope I am doing my part to advance science and combat bias.

The award-winning Texas blog Grits for Breakfast has a more favorable reaction, with links to additional topics of interest.

Another severe attack at Napa Hospital

Less than two months after a psychiatric technician was strangled to death, another staff member has been beaten unconscious at Napa State Hospital, California's largest psychiatric hospital. Already abysmal staff morale is sinking lower as tensions rise among the captive patients, whose privileges have been curtailed since October's slaying.

Four years ago, the U.S. Attorney General's Office negotiated a consent decree mandating sweeping changes aimed at improving patient care and reducing suicides and assaults at the troubled hospital. A federal probe had revealed widespread civil rights violations, including generic "treatment" and overuse of seclusion and restraints. Napa, the only state psychiatric hospital in Northern California, houses defendants undergoing competency restoration treatment and those found not guilty by reason of insanity.

Earlier this year, another scandal hit the hospital, when its executive director was arrested on 35 felony charges stemming from the alleged molestation of a foster son. He was suspected of molesting at least four other boys going back to the 1970s.

Lee Romney of the Los Angeles Times, who has provided the best coverage of California's troubled state hospital system over the past few years, reported that patients at Napa are increasingly agitated in the wake of greater restrictions on their movement, exacerbating an already bleak picture:
Since 2006, the state's mental hospitals have been under a federal court order to improve conditions for patients. Yet safety for both patients and staff has deteriorated markedly at Napa State Hospital over the last year, data show. The other state hospitals subject to the federal consent judgment have also experienced a rise in violence since the state began implementing changes in care.
In case you need a job, by the way, the hospital is hiring.

Hat tip: Kathleen

December 10, 2010

News flash: Epic trial ends with sanity verdict

It took a jury only five hours to decide that Brian David Mitchell does not meet Utah's legal definition of insanity, and to find him guilty of all charges in the 2002 kidnapping of Elizabeth Smart.

The high-profile case teems with issues of import to forensic psychology and psychiatry, including malingering and the boundary between delusions and extreme religious beliefs.

The trial, as in the many past hearings, featured dueling experts. On one side was prominent New York City psychiatrist Michael Welner, who said Mitchell was sane and malingering a mental disorder to escape criminal liability. Defense attorneys criticized both Welner's fees, a whopping $750,000 (no, that's not a typo), and his methods. For example, he had FBI agents conduct about 30 interviews on his behalf, according to an Associated Press report by Jennifer Dobner.

On the other side was psychologist Richart DeMier, who evaluated Mitchell for 45 days at a federal prison in Missouri in 2008 and diagnosed him with paranoid schizophrenia. During his full day of testimony, DeMier was vigorously questioned about the sometimes-muddy distinctions between delusions and extreme religious views, a central issue throughout this case. He testified that the distinction is not an exact science, and that mental illness is not always black and white, according to a report in the Deseret News.

Experts also dueled ferociously at Mitchell's competency hearing last year. At one point during testimony by Jennifer Skeem, a forensic psychologist from California who grew up in Utah, the proceedings "seemed less about issues relating to Mitchell's competency and more about what she believed was 'character assassination' " by Welner, according to a Deseret News report. "I'm not a hired gun who intentionally collaborated with an unethical defense team," Skeem told the court.

Crazy or not, the self-styled prophet maintained his typically bizarre behavior during the reading of the verdict, loudly singing the hymn, "He Died, the Great Redeemer Died."

Judge Kimball’s 149-page competency ruling, which I highly recommended to any of you who do competency work, is HERE.

My previous coverage of this fascinating case, with links to other reports, includes:
Graphics credit: Scott Snow, KSL

December 5, 2010

Crazy Like Us: The Globalization of the American Psyche

A successful virus is adaptive. It evolves as needed to survive and colonize new hosts. By this definition, contemporary American psychiatry is a very successful virus. Exploiting cracks that emerge in times of cultural transition, it exports DSM depression to Japan and posttraumatic stress disorder to Sri Lanka.

Journalist Ethan Watters masterfully evokes the heady admixture of moral certainty and profit motive that drives U.S. clinicians and pharmaceutical companies as they evangelically promote Western psychiatry around the globe. On the ground in Sri Lanka following the tsunami, for example, hordes of Western counselors hit the ground running, aggressively competing for access to a native population "clearly in denial" about the extent of their trauma. Backing up the foot soldiers are corporations like Pfizer, eager to market the antidepressant Zoloft to a virgin population.

Watters has done his homework. Each of his four examples of DSM-style disorders being introduced around the world is rich in compelling historical and cultural detail. Despite their divergences, each successful expansion hinges on the mutual faith of both the colonizers and the colonized that Western approaches represent the pillar of scientific progress.

My review of Crazy Like Us, an engaging and enlightening book that I highly recommend, continues HERE.

Watters' Jan. 8, 2010 essay in the New York Times, "The Americanization of Mental Illness," is HERE.

December 1, 2010

Age tables improve sex offender risk estimates

First, how old is the bus driver?

If 30 people are riding on a bus, and 30 more people board the bus, how old is the bus driver?

The answer, many second-graders will assure you, is 60. (They know your question involves numbers, but they don't quite get the concept.)

Clinical psychologists are a bit like that. Most of us were not drawn to the field by a deep and abiding passion for numbers. This puts some in a quagmire when they jump into forensic work, and courts order them to predict future events with a high degree of mathematical precision.

Illusion of certainty, certitude in illusions

Since passage of the Psychologist Full Employment Act,* I have observed a growing group-think among government sex offender evaluators in particular. At the annual meetings of the Association for the Treatment of Sexual Abusers (ATSA), crowds flock to hear self-appointed gurus give the latest in a series of ever-changing instructions about how to use their pet formulas, freely available online, that promise to take the guesswork out of risk assessment.

Psychologists who lack statistical sophistication are especially likely to swoon over fancy-sounding terms such as receiver operating characteristics (ROC) and to overlook the gaping flaws in current actuarial methodology. Instead of deriving from sound scientific principles such as random sampling, the tools are strung together from a motley collection of random data, much of it never published or subjected to peer review. As I have reported in the past, the Static-99 family of instruments are not very accurate, and tend to err in the direction of overestimating risk.

So, what about that bus driver?

Getting back to the bus driver: Let's say the second-graders happened to be right, and he really is 60 years old. What are the odds that he will be arrested for a sex crime, given that he recently served time for sexual assault? (I know, I know. What bus company would have hired him? But, play along with me here.)

If you asked a randomly selected passenger aboard the bus, the answer would be close to 100%.

But as you know, the public drastically overestimates sex offender recidivism rates. Let’s say that in reality, the average sex offender who scores in the low range on actuarial risk instruments has a 5% chance of sexual recidivism, while the average high-scoring offender has a 29% risk. Obviously, without knowing more about the bus driver, all you can say is that his risk of reoffense is somewhere between 5% and 29%.

But that too would be wrong. Because of his age, the bus driver's recidivism risk over the next eight years is more in the range of 2.7%.

Which is probably lower than the risk of a passenger getting trampled if you hollered out, “Eek! Sex offender!”

Good news: Age-stratified tables improve accuracy

The single most robust finding of two centuries of criminological research is that desistance from crime is near universal. As they age, criminals stop offending. This holds true across all eras, cultures, and offender groups. Sex offenders are not exempt from this pattern. As their libidos decline, they too settle down or burn out. Unfortunately, this “age invariance effect,” as it has been called, has trouble filtering down into the muddy waters of the sex-offender industry. (See my online review of the book Desistance in the Open Access Journal of Forensic Psychology for more discussion of this.)

When age is not properly taken into accounting in estimating risk, the risk for older offenders -- such as our bus driver -- is overestimated, while the risk of younger offenders is underestimated.

Now, a collaboration by scholars from the United States, New Zealand, and Australia reveals that the accuracy of sex offender risk prediction can be significantly improved by using age-stratified tables to calculate risk.

The researchers tapped into an electronic database of all sex offenders in New Zealand who were released from prison over a 15-year period. They combined the data on those 5,880 offenders with recidivism data on 3,425 offenders published by Static-99 developer Karl Hanson in 2006, to develop what they call a "Multisample Age-Stratified Table of Sexual Recidivism Rates" (MATS-1).

Using Bayes's Theorem, the researchers were able to calculate likelihood ratios for different levels of risk. (Bayes's Theorem speaks to the probability of an event, taking into account both the phenomenon's base rate and the accuracy of a test. Cognitive scientists regard the Bayesian method as the gold standard, often using it synonymously with rational reasoning.)

Overall, the recidivism base rate of their combined international sample was 9% over a 10-year period, which is consistent with other reported research. Dividing offenders into three levels of risk based on their scores on actuarial risk instruments, the researchers found that those with low risk scores had an average 5% risk of reoffense within eight years, as compared with 12% for medium-risk offenders and 29% for offenders with high scores. By dividing sex offenders into various age groups, they were able to come up with more precise estimates of risk (see below table).

Evaluators should use this type of age-stratified procedure when giving estimates of recidivism risk, particularly for older offenders, the researchers advise. Estimating an offender's probability of recidivism based on the observed proportion of recidivists in a population is more accurate than relying on a set of untested assumptions. It is also much simpler and easier to explain to a trier of fact.

I highly recommend the article, published in the current issue of Sexual Abuse, which goes into a great deal of detail about the method and its superior stability and accuracy. The authors are Richard Wollert of Washington State University and the Mental Health Law and Policy Insitute at Simon Fraser University in Canada, Elliot Cramer, a statistician and professor emeritus from the University of North Carolina-Chapel Hill, Jacqueline Waggoner of the University of Portland, Alex Skelton of the New Zealand Department of Corrections, and James Vess of Deakin University in Australia. Request reprints from the first author (HERE).

Related blog posts:
For a good introduction to Bayesian reasoning, see Eliezer Yudkowsky's tutorial, "An Intuitive Explanation of Bayes' Theorem."

*The Psychologist Full Employment Act is the label conferred on the Sexually Violent Predator (SVP) laws by a leading psychology-law scholar in a recent plenary address.