October 10, 2011

California deals big blow to bogus paraphilia diagnoses

Government evaluators in California have been instructed to be more cautious in invoking ad hoc psychiatric diagnoses such as "paraphilia not otherwise specified-nonconsent" to justify the civil commitment of sex offenders.

In a report in today's Psychiatric Times, Allen Frances calls the move by California's Department of Mental Health a "giant step forward in ending the Paraphilia NOS fad."

The new marching orders are likely to have national repercussions. California has a large cadre of sexually violent predator evaluators, many of whom moonlight in other states and in federal court as well.

As Frances reports, evaluators were summoned to a training workshop at which "they were explicitly instructed to adhere closely to the intent of DSM-IV and to desist from making idiosyncratic paraphilia diagnoses. The training made clear that a diagnosis of 'Paraphilia NOS nonconsent' would require affirmative supportive evidence that the rapist is sexually aroused specifically by raping rather than all the many very much more common situations in which rape is simply criminal."

Increasingly, government evaluators had been using so-called "NOS" diagnoses to justify civil commitment of men whose sex offenses were not driven by any recognized mental disorder. Because rape is a crime rather than a mental illness, it is not included as a diagnosis in any psychiatric manual. Similarly, evaluators have taken to labeling men who sexually assaulted post-pubertal minors but did not meet the diagnostic criteria for pedophilia with the ad hoc label of "paraphilia not otherwise specified-hebephilia."

Frances expressed optimism that California's policy change signals the beginning of the end for “paraphilia NOS” in court:
The misdiagnosis of rape as a mental disorder has been a forensic disaster,  allowing the widespread misuse of involuntary psychiatric hospitalization.... [T]he California DMH has only limited control over its errant state SVP evaluators, who by contract are entitled to exercise their individual 'clinical judgment' however mistaken and baseless it may be. 'Paraphilia NOS' will likely linger longer than it should. But the tide has clearly turned in California and California is likely to be a bellweather state; its return to proper diagnostic practice undoubtedly will spread across the country.
Blog readers may also be interested in Frances's commentary on a proposed change in the diagnostic criteria for Posttraumatic Stress Disorder (PTSD) in the upcoming DSM-5. The change could open the door for increased forensic misuse of this controversial diagnosis. Frances's report is HERE.


RS said...

Do you know if the men that have been committed with this diagnoses have any recourse?

Karen Franklin, Ph.D. said...

RS: That is a great question, and I don't know the answer. Once civilly committed, these men are pretty much at the mercy of hospital clinicians, who are unlikely to pursue a change in diagnosis just because of a non-binding recommendation given to the DMH's forensic evaluators (who are independent contractors; a separate status from the hospital staff). To my knowledge, most of these men no longer have legal representation once their commitments are final, so they have little means to protest. If anyone else has a different thought, please chime in.

Anonymous said...

A re-evaluative overhaul in the NOS would seem to be the only means of assistance for these souls. Considering recent developments in California, that's a possibility; however, who know how long such developments will take. Many progress over years, others never. That leaves countless individuals incarcerated for life.

Then again, what would it take to eliminate the NOS from both publication in the DSM and implementation in court proceedings?