September 25, 2013

California prisons careening closer to cliff

For a minute there, it looked like California's prisons were on the verge of positive reforms. But the current situation in the state's massive prison system -- one of the largest in the world -- is far from encouraging. It's been a kaleidoscope of bad news lately.

Chemical weapons

Private prison company annual report (credit Huff Post)
Guards have been videotaped tossing chemical grenades and pumping pepper spray into the cells of psychotic prisoners, some of them screaming and delirious. In one case, the prisoner's offense was not taking his psych meds; an asthmatic prisoner was sprayed for refusing to leave a holding cage, according to AP news coverage. A federal judge will rule next week on whether the public has a right to see the disturbing videos as part of a legal case challenging abusive discipline of mentally ill prisoners and inadequate mental health care for prisoners on death row. An expert observer described the chemical arsenals possessed by California guards as "shocking."

Realignment woes

Another snippet from the Correctional Corp of America
Meanwhile, things are getting worse in many of the state's 58 county jails. The state's "realignment plan," in which nonviolent offenders stay in county jails rather than going to prison, is causing lots of headaches for jails and prisoners alike. The idea was to reduce prison overcrowding while keeping prisoners closer to home and within range of reintegration services. But the plan shifts the burden onto cash-strapped counties that are ill-equipped to handle a large influx of convicts. In state prisons, convicts get yard time and some educational or vocational programming. In many jails, in contrast, they can sit in a room the size of your bathroom for five years or more. Sheriffs are complaining of a rise in violence, and forecasting a rash of lawsuits like those dogging the state prisons. According to an ACLU report, rather than reforming incarceration policies, counties are scrambling to add new jail beds. One exception is in progressive San Francisco, where jailers, prosecutors and defense attorneys alike have embraced realignment as an opportunity to create community-based alternatives to incarceration.

Hunger strike

Private prisons benefit from immigration crackdowns
After two months, prisoners ended their hunger strike over long-term isolation without any tangible victories. In a remarkable show of solidarity, the strike initially included more than 30,000 prisoners from around the state. By the end, the numbers had dwindled to about 100. The strike was called off after two legislators – Loni Hancock and Tom Ammiano -- announced they would hold public hearings into the prisoners’ complaints over the security housing units, or SHUs. Hancock said that concerns over the use and conditions of solitary confinement in California's prisons "can no longer be ignored."

Private prisons

Finally, and perhaps most disturbingly, on Monday a massive private prison corporation announced that state Governor Jerry Brown had signed a deal to ship 1,400 prisoners to its private facilities. The GEO Group, formerly the infamous Wackenhut Corrections Corporation, is a Florida-based corporation that manages 96 facilities with about 73,000 beds worldwide, including in the USA, Australia, South Africa and the United Kingdom.  

Click on image to visit Huffington Post infographic and related resources
The states of fiscal emergency in the public sector encourage governments to contract with private prisons that promise cost savings. But private prison corporations like Geo Group and the Corrections Corporation of America are short-sighted quick fixes. They encourage prison growth by mandating that governments guarantee them a certain minimum occupancy. It's kind of like when the American Psychological Association contracts with hotels in a convention city; if not enough psychologists rent rooms, the APA must pay the difference. In a report released this month, In the Public Interest found that nearly two-thirds of contracts between private prison companies and state and local governments included such quotas. Arizona recently paid $3 million to a prison company for failing to meet a 97 percent occupancy quota, the Huffington Post reported.  

The Post, one of the few media outlets to regularly cover this disturbing trend, has published an infographic illustrating the widespread nature of these contracts, which discourage criminal justice reform by "leaving taxpayers footing the bill for lower crime rates." As part of its coverage, the Post took a peak at annual shareholder reports of the Corrections Corp. of America that reveal its "aggressive business strategy based on building prison beds, or buying them off the government, and contracting them to government authorities." (The drop quotes in the post are just a few of the nuggets they unearthed.)

"Profits, after lining the pockets of shareholders, are used to create more beds and to lobby state and federal agencies to deliver inmates to fill them," the Post reports. "The resulting facilities can be violent and disgusting."

As one example, the Post reported on the horrendous conditions that quickly developed after the Corrections Corp. of America bought a formerly public prison in Ohio. Educational programming for prisoners and salaries of staff were slashed, violence and drug use skyrocketed, and correctional officers jumped ship en masse, leaving newcomers to run the facility. Prisoners in isolation were left to wallow in their own filth, with no access to running water or toilets.

September 22, 2013

Efficacy of sex offender treatment still up in the air

Sex offender group treatment, Larned State Hospital, Kansas
"Did he complete treatment?"

That is a front-burner question for judges and jurors in sexually violent predator trials. Understandably, before they decide to release someone who has been convicted of sexually molesting a child, they want reassurance that he is sincerely remorseful and has acquired the tools to turn his life around. In short, they want a certificate of rehabilitation attesting to his low risk.

But does formal sex offender treatment really lower risk?

A systematic review found no scientifically rigorous studies that establish a link between treatment completion and a reduced risk of reoffending among men who have sexually abused children.

This isn't altogether fresh news. We knew from earlier research reviews that:
  • Any effect of treatment was modest, at best
  • Treatment works best for the tiny minority of very high-risk offenders, while possibly aggravating risk for the broad majority of men at lower risk of recidivism 
  • Older offenders, due mainly to their very low risk, derive no tangible benefits from treatment
But considering both the prevalence and the harm of child sexual abuse, there is surprisingly little high-quality research on effective interventions. Partly, this is because of the lock-'em-up-and-throw-away-the-key mentality of policy makers. And partly it is because of the ethical difficulties in implementing random-design procedures, a hallmark of the scientific method, because men assigned to a control group would be denied treatment that could reduce their risk and in some cases shorten their prison terms.

Patient at "treatment program" in Minnesota
Scouring research databases, a six-member, international research team was able to locate only three well-designed experimental studies. These included one with adults, one with adolescents and one with children. In only the study with adolescents was treatment shown to reduce recidivism. That project used multisystemic therapy, a very promising approach that integrates the family and larger community in the treatment. 

Even broadening the search to include observational studies that lacked experimental designs, the research team found only five studies with a low enough risk of research bias to be deemed reliable. None of the five observational studies demonstrated that formal treatment -- primarily cognitive behavioral therapy with relapse prevention -- impacts sexual reoffending.

High-bias studies, in which the study design introduced a high probability of unreliable findings, were excluded. An example of such research bias would be a study in which treated and untreated offenders differed on a variable known to affect risk. When subjects are  not randomly assigned to treatment or control groups, any observed differences between groups may be due to factors outside of the treatment itself.

Treatment in most formal sex offender programs is cognitive behavioral, and relies primarily on manual-based group therapy. For example, group exercises challenge distorted thinking, denial and minimization.

The research team found no  minimally adequate studies whatsoever on the efficacy of pharmacological treatment with antiandrogen drugs, more popularly known as "chemical castration." They found this omission "particularly striking," in light of the prominence of this method in public debates. 

Can treatment cause harm?

Given "the overall unimpressive treatment effects" that were found, the researchers cautioned clinicians working with sex offenders to consider the potential negative effects of treatment:
"Journeymen" by Ricky Romain (reproduced with permission)
"Under certain circumstances, with some people and some interventions, treatment could increase the risk of sexual reoffending. For instance, prolonged or intense interventions for offenders at low risk of relapse, or grouping low risk offenders with those at high risk for reoffending, could result in adverse outcomes."

They especially cautioned against unnecessary treatment of children. With recidivism risk very low among untreated children, treatment may lead to "unjustified stigmatization and could negatively affect the child’s development…. If these children are subjected to excessively intense or inappropriate therapy, this could increase the risk for future antisocial behavior."

The team was headed up by prominent researcher and professor Niklas Långström and included Canadian researcher R. Karl Hanson, psychologist Pia Enebrink, forensic psychiatrist Eva-Marie Laurén and researchers Jonas Lindblom and Sophie Werkö. The research was commissioned and partially funded by the Swedish government.

The Convention on the Protection of Children against Sexual Exploitation and Sexual Abuse, ratified by 27 countries so far, mandates effective treatment to sexual abusers of children, individuals at higher risk of committing such offences, and children with sexual behavior problems.

This mandate is a bit of a problem, given the inconclusive evidence that the dominant treatment approach works.

Manualized, one-size-fits-all approach

My own belief is that the one-size-fits-all approach of manualized group therapy, driven in part by a shortage of highly qualified and talented clinicians in bureaucratic institutions, can never meet the needs of a heterogeneous population of offenders. Indeed, in the hands of poorly trained technicians, much of what passes for "treatment" is actually punishment in disguise. As anthropology professor Dany Lacombe noted in her insightful ethnographic study,  sex offender treatment can paradoxically cement deviance through its obsessional fixation on sex. As an 18-year-old patient told Lacombe:
"They want to hear that I always have fantasies and that I have more bad ones than good ones. But I don't have bad ones that often. I make up the bad ones. I make them really bad because they won’t leave me alone." 
"Contained" by Ricky Romain (with artist permission)
Genuine treatment, as we all should remember from our graduate school training, is all about the empathic relationship -- not the technique. Indeed, although more and more psychologists have internalized the insurance industry's mantra that cognitive-behavioral therapy (CBT) is the "evidence-based" treatment of choice for a variety of conditions, this is not actually true. For example, in a new randomized clinical trial published in the American Journal of Psychiatry, psychodynamic therapy performed just as well in the treatment of depression.

The research team cautioned that their failure to find significant effects of treatment should not be interpreted to mean that treatment as currently implemented is ineffective. The low base rates of recidivism among sex offenders make it difficult to find treatment effects without very large sample sizes and long follow-up periods, they point out.

Additionally, an early study out of California provided some evidence that it was not the formal completion of treatment per se that reduced risk but, rather, the internalization of treatment messages and a desire to change -- something that is harder to measure. 

The research team issued a call for large-scale, multinational randomized controlled trials. In the meantime, in the absence of solid proof that manualized cognitive-behavioral group therapy works as intended, they recommend a shift to more individualized assessment and treatment.

That's a solid, and very welcome, recommendation.

The study is: "Preventing sexual abusers of children from reoffending: Systematic review of medical and psychological interventions" by Niklas Långström, Pia Enebrink, Eva-Marie Laurén, Jonas Lindblom, Sophie Werkö and R Karl Hanson. It is freely available online from the British Medical Journal (HERE). 

Subscribers: View the conversation and add your comment by scrolling to the bottom of the original blog post (HERE). 

September 6, 2013

Free, one-stop shopping: Bulletin showcases new violence articles

The first monthly bulletin from the Alliance for International Risk Research just hit my email box, collating August's journal offerings on violence risk assessment and management. A quick sampling from the 17 articles listed:
  • Large MM, Ryan CJ, Callaghan S, Paton MB, and Singh SP (2013) Can violence risk assessment really assist in clinical decisionmaking? Australian & New Zealand Journal of Psychiatry (online first Aug 2013)
  • Rettenberger M, Haubner-Maclean T, and Eher R (2013) The contribution of age to the Static-99 Risk Assessment in a population-based Prison sample of sexual offenders. Criminal Justice & Behavior (online first June 2013)
  • Lund C, Hofvander B, Forsman A, Anckarsater H, and Nilsson T (2013) Violent criminal recidivism in mentally disordered offenders: a follow-up study of 13-20 years through different sanctions. International Journal of Law and Psychiatry, 36, 250-257
  • Caldwell MF (2013) Accuracy of Sexually Violent Person Assessments of Juveniles Adjudicated for Sexual Offenses Sexual Abuse (online first March 2013).
AIRR's goal is to make information about the latest research on violence risk assessment available to researchers, practitioners, and policymakers for free. I you don't have access to an academic database you still have to find a way to access the articles themselves, but that can generally be done through a request of the author.) If you haven't already signed up to receive your monthly email, you can do so by clicking HERE

September 4, 2013

'Authorship bias' plays role in research on risk assessment tools, study finds

Reported predictive validity higher in studies by an instrument's designers than by independent researchers

The use of actuarial risk assessment instruments to predict violence is becoming more and more central to forensic psychology practice. And clinicians and courts rely on published data to establish that the tools live up to their claims of accurately separating high-risk from low-risk offenders.

But as it turns out, the predictive validity of risk assessment instruments such as the Static-99 and the VRAG depends in part on the researcher's connection to the instrument in question.

Publication bias in pharmaceutical research
has been well documented

Published studies authored by tool designers reported predictive validity findings around two times higher than investigations by independent researchers, according to a systematic meta-analysis that included 30,165 participants in 104 samples from 83 independent studies.

Conflicts of interest shrouded

Compounding the problem, in not a single case did instrument designers openly report this potential conflict of interest, even when a journal's policies mandated such disclosure.

As the study authors point out, an instrument’s designers have a vested interest in their procedure working well. Financial profits from manuals, coding sheets and training sessions depend in part on the perceived accuracy of a risk assessment tool. Indirectly, developers of successful instruments can be hired as expert witnesses, attract research funding, and achieve professional recognition and career advancement.

These potential rewards may make tool designers more reluctant to publish studies in which their instrument performs poorly. This "file drawer problem," well established in other scientific fields, has led to a call for researchers to publicly register intended studies in advance, before their outcomes are known.

The researchers found no evidence that the authorship effect was due to higher methodological rigor in studies carried out by instrument designers, such as better inter-rater reliability or more standardized training of instrument raters.

"The credibility of future research findings may be questioned in the absence of measures to tackle these issues," the authors warn. "To promote transparency in future research, tool authors and translators should routinely report their potential conflict of interest when publishing research investigating the predictive validity of their tool."

The meta-analysis examined all published and unpublished research on the nine most commonly used risk assessment tools over a 45-year period:
  • Historical, Clinical, Risk Management-20 (HCR-20)
  • Level of Service Inventory-Revised (LSI-R)
  • Psychopathy Checklist-Revised (PCL-R)
  • Spousal Assault Risk Assessment (SARA)
  • Structured Assessment of Violence Risk in Youth (SAVRY)
  • Sex Offender Risk Appraisal Guide (SORAG)
  • Static-99
  • Sexual Violence Risk-20 (SVR-20)
  • Violence Risk Appraisal Guide (VRAG)

Although the researchers were not able to break down so-called "authorship bias" by instrument, the effect appeared more pronounced with actuarial instruments than with instruments that used structured professional judgment, such as the HCR-20. The majority of the samples in the study involved actuarial instruments. The three most common instruments studied were the Static-99 and VRAG, both actuarials, and the PCL-R, a structured professional judgment measure of psychopathy that has been criticized criticized for its vulnerability to partisan allegiance and other subjective examiner effects.

This is the latest important contribution by the hard-working team of Jay Singh of Molde University College in Norway and the Department of Justice in Switzerland, (the late) Martin Grann of the Centre for Violence Prevention at the Karolinska Institute, Stockholm, Sweden and Seena Fazel of Oxford University.

A goal was to settle once and for all a dispute over whether the authorship bias effect is real. The effect was first reported in 2008 by the team of Blair, Marcus and Boccaccini, in regard to the Static-99, VRAG and SORAG instruments. Two years later, the co-authors of two of those instruments, the VRAG and SORAG, fired back a rebuttal, disputing the allegiance effect finding. However, Singh and colleagues say the statistic they used, the receiver operating characteristic curve (AUC), may not have been up to the task, and they "provided no statistical tests to support their conclusions."

Prominent researcher Martin Grann dead at 44

Sadly, this will be the last contribution to the violence risk field by team member Martin Grann, who has just passed away at the young age of 44. His death is a tragedy for the field. Writing in the legal publication Das Juridik, editor Stefan Wahlberg noted Grann's "brilliant intellect" and "genuine humanism and curiosity":
Martin Grann came in the last decade to be one of the most influential voices in both academic circles and in the public debate on matters of forensic psychiatry, risk and hazard assessments of criminals and ... treatment within the prison system. His very broad knowledge in these areas ranged from the law on one hand to clinical therapies at the individual level on the other -- and everything in between. This week, he would also debut as a novelist with the book "The Nightingale."

The article, Authorship Bias in Violence Risk Assessment? A Systematic Review and Meta-Analysis, is freely available online via PloS ONE (HERE).

Related blog reports:

September 3, 2013

Violence prevention: DC to host major collaborative venture

From U.S. Attorney General Eric Holder to legal scholar Barbara Bennett Woodhouse, the speakers at next month's APA-ABA collaborative conference read like a who's who in the field of violence prevention.

To give a flavor:
  • Carl Hart, the neuroscientist whose memoir I recently featured, will speak on the contribution of U.S. drug policy to violence
  • James Garbarino, author of the terrific book Lost Boys: Why Our Sons Turn Violent and How We Can Save Them, will address the developmental effects of violence -- a topic that forensic psychologists confront daily in our practices
  • Mary Ann Dutton, a leading researcher on domestic violence, will discuss preventing intimate partner violence
  • Patrick Tolan and Dewey Cornell will address youth violence in the schools 
  • Judge Jay Blitzman and colleagues will talk about disrupting the 'cradle to prison pipeline' by implementing alternatives to school suspension and exclusion 
  • Charlotte Patterson, a pioneer in LGBT research, will focus on reducing violence against sexual minorities 
  • Mark Soler, an attorney who taught my media law class way back in journalism school, will speak on alternatives to incarceration in juvenile justice 
  • Edward Mulvey will address mental illness and substance abuse in violence 
And that's just for starters. With more than 40 plenary and invited sessions, the lineup goes on and on, with a wide array of programming that should appeal to psychologists, attorneys, judges, legal and social science scholars, and anyone else interested in the roles of law and psychology in addressing the effects of violence:
  • Intergenerational transmission of violence
  • Violence in Native American communities
  • Offender reentry
  • Risk assessment and threat assessment
  • Hate crimes
  • Poverty and race in violence
  • Sexually violent offenders
  • Violence among military veterans
  • Elder abuse
  • and much more
A major goal of the conference, entitled "Addressing the Unspeakable: Confronting Family and Community Violence, The Intersection of Law and Psychology," is to build on the momentum of Eric Holder's Defending Childhood initiative, which aims to address the effects of violence on children, youth and families.

The conference is co-sponsored by the American Psychological Association and the American Bar Association, and continuation education credits will be provided for both legal and mental health professionals. Early registration ends this week, so register now if you're planning to attend.

The preliminary program is HERE; an overview of the event and its logistics is HERE; the online registration form is HERE