“Help! I am being held hostage in a reality show!”

The Suspicion System: How the social world shapes delusions

Not so long ago, any decent-sized psychiatric hospital had at least two or three Jesus Christs in residence, and plenty of other patients serving as conduits for the CIA or the KGB.

Nowadays, Jesus Christ is harder to find. You are far more likely to encounter reality TV stars: patients whose every move is choreographed by hidden directors, videotaped by hidden camera crews, and broadcast without consent to an audience of millions. “We see many, many young people who have had the sensation of being filmed,” a psychiatrist at a public clinic in London told the New Yorker. His estimate: One or two out of every 10 patients he sees. 

This so-called Truman Show Delusion is not so irrational in our modern surveillance state, where we (and our cars) are photographed and videotaped whenever we venture into the public space, microphones capable of recording our conversations and instantly beaming them to authorities are hidden in street lighting, and – as exposed by Edward Snowden – the NSA is intercepting vast swaths of our communications and storing them in a massive, top-secret vault in the Utah desert. Soon, our homes will afford no privacy; the CIA is cheering the advent of the “smart home” as a bonanza for clandestine eavesdropping. If you scoff at the notion that They are watching you, revisit the chilling scene in the Bourne Ultimatum (2007) in which Matt Damon tries to avoid the cameras in London’s Waterloo Station.   

The solipsist premise of Peter Weir’s 1998 Truman Show, starring Jim Carrey as an insurance adjuster who realizes that his entire life is actually a TV show, was not original. The psychiatric patient in Robert Heinlein’s 1941 short story, “They—,” was convinced that he was an actor on a stage; the troubled protagonist of Philip K. Dick’s 1959 novel, Time Out of Joint, also starred in his own self-constructed reality. But in an innocent era before the entrenchment of the panoptical gaze or reality TV – in which any random person, it seems, can wake up to find him- or herself an instant social media celebrity – these stories were fantastical, and thus incapable of producing mass contagion. 

But the cultural environment influences more than just the superficial content of persecutory or grandiose delusions. Far more profoundly, it impacts who will catch psychosis, and why. This blog’s readers may know that early use of cannabis significantly increases the risk of psychosis, as does experiencing childhood adversity such as severe abuse or parental loss. You may also be aware that merely growing up in a city puts one at heightened risk of mental breakdown; there is a near-linear correlation between population density and psychosis. But consider these further research findings:

• The greater a nation’s income inequality, the higher its per capita rate of psychosis. 

• Immigration is a major risk factor for psychosis – and not just for the immigrants themselves, but for their first-generation offspring. Nor is this risk equally distributed: It is highest for darker-skinned people relocating to whiter countries, especially if they settle outside of ethnic enclaves.

The burden of social defeat

In Suspicious Minds: How Culture Shapes Madness, psychiatrist Joel Gold and his philosopher brother Ian identify social fragmentation as the construct tying these seemingly disparate strands together. More precisely, the experience of social defeat, in which a person who is persistently demeaned, humiliated, or subordinated ultimately comes to see himself as a second-class citizen.

I have long found delusional beliefs fascinating. In particular, I enjoy talking with delusional people, and trying to understand the meaning of their beliefs. In this, I’ve gained a lot from the theories of luminaries in the field such as Brendan Maher, Richard Bentall and John Read. But Suspicious Minds is brilliant in pulling together all of the extant research to create a single unified theory, one that foregrounds and humanizes the delusional person’s experience.

The theory developed out of Joel Gold’s experiences as attending psychiatrist at New York City’s notorious Bellevue Hospital. After treating several patients with Truman Show delusions, he – in partnership with his brother Ian, a philosophy professor at McGill University in Canada – published a 2012 article on the phenomenon in Cognitive Neuropsychiatry. That, in turn, generated a deluge of emails from people all around the world who were relieved to realize they were not the only one who thought their lives were being secretly filmed and broadcast to the masses.

The Gold brothers’ theory of delusions as a social phenomenon goes against the grain in this era of pharmaceutical industry domination and biological reductionism, especially here in the United States, where the social context of mental illness has been systematically suppressed in favor of simplistic theories of genetic or chemical imbalances.

But things have a way of circling back around. Almost 50 years ago, against the backdrop of the assassination of Martin Luther King and the ensuing inner-city rebellions, African American psychiatrists William Grier and Price Cobbs dissected the psychic burden of prejudice. To survive, they wrote in their influential 1968 book Black Rage, oppressed people must maintain a delicate balancing act of being ever-vigilant and suspicious, yet without succumbing to frank paranoia:

“[S]urvival in America depends in large measure on the development of a ‘healthy’ cultural paranoia. [The black man] must maintain a high degree of suspicion toward the motives of every white man and at the same time never allow this suspicion to impair his grasp of reality. It is a demanding requirement and not everyone can manage it with grace…. Of all the varieties of functional psychosis, those that include paranoid symptoms are by far the most prevalent among black people.”

The panoptical gaze in The Bourne Ultimatum

Suspicion, then, is necessary and adaptive, especially for those most vulnerable to exploitation. But when chronic stressors overwhelm the brain’s capacity to cope, delusions are kindled. This is the essence of the Golds’ theory of delusions as the product of an overtaxed “Suspicion System.”

Drawing on recent research in neuroscience and evolutionary psychiatry, the Golds locate the Suspicion System in the amygdala – evolved to anticipate threat by interpreting ambiguous signs of potential social danger – and connected brain regions. Delusions take hold, they posit, with a breakdown in communication between this early-warning Suspicion System and the more rational, slower-thinking (“System 2” in Daniel Kahneman’s formulation) cognitive network that should be dampening the amygdala’s over-enthusiasm.

A solid theory should not only be logical, elegant, and empirically supportable, but should also explain diverse manifestations of a phenomenon. The Golds’ theory explains not just persecutory delusions, but each of the other 11 major delusional themes (e.g., grandiose, religious, erotomanic) as well. For example, grandiosity  – which we see in the Truman Delusion  – can be interpreted as a way of deflecting threat, much like a puffer fish blows itself up or a cat arches it back when faced with danger:

“Flexing your social muscles makes you less vulnerable to exploitation by others, and putting your high status front and center in a potential exploiter’s mind might make them think twice about victimizing you…. Grandiosity is thus a symptom of a Suspicion System on overdrive, a caricature of the normal adaptive strategies we employ every day…. Paranoia and grandiosity … are functionally connected: paranoia is a broken form of threat detection, and grandiosity is a broken threat response.”

With ever-growing income disparity and economic stress, social network disintegration, loss of privacy,  and social media's increasingly panoptical reach, we may expect more and more alienated people with trouble psyches to succumb to Truman Show delusions. Let us hope that, in treating them, we do not lose sight of their humanity, for they really are  not so different from us. As the Golds put it, “mental illness is just a frayed, weakened version of mental health.”

Indeed, if we listen, these frantic souls may even have something to teach.

Sex addiction: Science or pop fad?

Thirty-one years ago, when Patrick Carnes walked onto the Phil Donahue television show to promote his new book on sexual compulsivity as an addiction, his notion was – in his own words – “widely perceived as a joke.” 

But Carnes got the last laugh. With the mainstreaming of the addiction industry (eating, gambling, exercising and working are all potential addictions now), Carnes has risen to become guru of a lucrative empire with dozens of rehab centers staffed by thousands of paraprofessionals. Media outlets including Newsweek have uncritically jumped aboard, warning of a grim, pornography-fueled plague afflicting up to 5 percent of the U.S. population.  

With neuroscience all the rage, celebrities including Bill Clinton and Tiger Woods have been recast from mere cads to tragic victims of a progressive and often-fatal “brain disease.” The push for scientific legitimacy reached a zenith in 2013, with an unsuccessful bid to legitimize “hypersexuality” by adding it to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

So, what changed over the course of the last three decades that made the public more receptive to seeing sexual misconduct through the lens of addiction?

In their meticulously researched Sex Addiction: A Critical History, three cultural historians from the University of Auckland in New Zealand trace the rise of this social movement primarily to a politically conservative, sex-negative backlash against the sexual liberation movement of the 1960s and 1970s. 

One clue to its underlying cultural values, historians Barry Reay, Nina Attwood and Claire Gooder observe, is the movement's enduring strand of homophobia. Even before Carnes's 1983 book Out of the Shadows popularized sexual addiction, the term had been invoked by Lawrence Hatterer, a psychiatrist whose work in the 1950s-1960s focused on curing the “illness” of homosexuality. Heteronormativity remains prominent in the field, with gay men who violate heterosexual norms of sexuality labeled as sex addicts.

Unlike many purported disorders that are promoted by researchers or the pharmaceutical industry, sex addiction is a bottoms-up movement, with people self-diagnosing themselves via self-help books or quick-and-dirty Internet surveys. Its infiltration into popular culture owes in large part to the media’s abdication of its role as scientific gatekeeper, argue the authors of Sex Addiction. As the Columbia Journalism Review also pointed out in a critique of the Newsweek puff piece, “The problem with relying on therapists, as most of the articles over the years have done, rather than qualified experts in academia, is that they have a vested interest in promoting the idea that there’s a widespread problem. The more people believe it, the more money they make."


In contrast to the lay public, academic scholars have remained skeptical of a construct that is too broad and amorphous to have any scientific validity; everything from viewing pornography or having an illicit affair to feeling ashamed about one's sexuality can count toward a diagnosis. Indeed, research studies have found that people’s anxiety over their sexual behavior is tied more to their moral values and level of religiosity than to the actual intensity of their behavior.

It is findings such as these that open sexual addiction up to ridicule. One prominent critic, David Ley, author of The Myth of Sex Addiction, has mocked sexual addiction literature as "valley-girl science" -- a hodge-podge of anecdote and metaphor rather than any provable theory. As he told a Salon interviewer:

“All of these behaviors have been happening for millennium — people cheating, people having lots of sex…. There’s nothing new about this…. For every one of the behaviors they raise as addictive — whether it’s porn, strip clubs, masturbation, infidelity, going to prostitutes — I can present 10,000 people who engage in the exact same behavior and have no problems, and they can’t explain why that is.”

Historically, hysteria over sexual depravity is somewhat cyclical. Way back in the 1870s, a crusade against "smut" by a U.S. Postal Inspector and politician named Anthony Comstock resulted in thousands of arrests and the destruction of 15 tons of books. Interestingly, Comstock's passion for moral purity stemmed from his own personal demons; as a youth, he was said to have masturbated so compulsively that it almost drove him to suicide.

Treating a case of "Madness of the Womb" (1600s)

The pathologizing of female lust has a particularly long tradition, dating back hundreds if not thousands of years. In the late 1600s, women were diagnosed with nymphomania (a diagnosis that still exists in the World Health Organization's International Classification of Diseases, or ICD), or “madness of the womb," a disease said to be triggered by amorous courtings, lascivious books and dancing. As with today’s sexual addiction, the condition was considered progressive; if not promptly treated it would lead to “true and perfect madness.” Treatment included bleeding, cool baths with lettuce and flowers, marriage to "a lusty young man" or -- no kidding -- rubbing of the afflicted woman's genitals by "a cunning midwife."

Nowadays, as then, there is a common pattern in the way proponents of scientifically questionable new problems attempt to establish their legitimacy. First, they announce discovery of the problem; next, the problem’s lineage is traced back through time to show that it existed all along but was overlooked or neglected. Finally, and most critically, alarmist claims are made about a growing epidemic.

This pattern could be observed in the 2013 campaign to legitimize “hypersexuality” by making it a DSM disorder. For example, the claims-making process included articles by psychiatrist Martin Kafka  tracing hypersexuality’s lineage back to the pioneering sexologists of the 19th century. But in their first-rate scholarship, the Auckland historians scoured those primary sources – the writings of early sexology heavyweights such as Magnus Hirschfeld, Havelock Ellis, Richard von Krafft-Ebing and Iwan Bloch – and found that their descriptions of the sexually compulsive bore little resemblance to contemporary hypersexuality or sex addiction. Rather, the early sexologists described tortured souls who were both rare and bizarre, typically suffering from more global psychiatric or organic maladies rather than a primary sexual disorder. For example, writing in 1908 about the “sexually insane,” Iwan Bloch described him as resembling a “wild animal” who:

“rush[es] at the first creature he meets … to gratify his lust …. He seizes in sexual embrace any other living or lifeless object, and in this state may perform acts of paederasty, bestiality, violation of children, etc. In these most severe cases we can always demonstrate the existence of mental disorder, general paralysis, mania, or periodical insanity … as a cause.”

Judging from singular descriptions like this, the early hypersexual was an extraordinary creature, a far cry from the mundane individual proposed for the DSM-5. Indeed, the proposed operational definitions for contemporary hypersexuality are striking in their breadth. For example, one diagnostic criteria proposed for the DSM-5 was experiencing seven or more orgasms per week by any method. Based on one survey of the general population in Sweden, this arbitrary cutoff would have pathologized almost half of all men (44%) and more than one out of five women.

Despite official rejection of hypersexuality by the American Psychiatric Association in 2013, the ideology of sexual addiction is gradually seeping into forensic quarters. For example, in some civil detention sites for sex offenders, minimally trained "treatment providers" play the role of moral arbiters, determining what forms of sexual desire are "appropriate" based not on their illegality or potential harm but whether the providers find them "healthy."

To be deemed “healthy” in some such programs, captive patients are required to develop vanilla “masturbation fantasy scripts” that resemble a corny Hallmark card:

"My masturbation fantasy involves Amanda. She is 40* years old, with flowing auburn hair and large green eyes. We enjoy cuddling by the fireplace, taking long walks on the beach in the moonlight, and gazing into each other’s eyes by candlelight."

(*The fantasy object must be the same approximate age as the offender; if she is more than five years younger, he will be told to rewrite his script to make it more "appropriate.")

Despite the enduring popularity of teachers, nurses and -- especially -- librarians as objects of male fantasy, in the burgeoning sexual offender treatment industry, even these cultural tropes may be labeled as "deviant." In one case I was involved in, a man's fantasy of seducing a librarian was advanced as evidence of sexual danger, based on the notion that the library (even after hours) is a public setting.

Of course, this not-so-thinly veiled moralism masquerading as treatment has no empirical support as a method to reduce former sex offenders’ risk to the public. But it does comport with popular cultural notions of addiction and sexual compulsivity, however unproven -- even bizarre -- they may at times be.

* * * * *

Sex Addiction: A Critical History by Barry Reay, Nina Attwood and Claire Gooder is as well written as it is insightful; I highly recommend it. Also recommended is clinical psychologist David Ley’s thoughtful work, The Myth of Sex Addiction.  

Newtown, CT: Latest massacre brings more hand-wringing

Our nation's collective inertia surrounding mass killings is perhaps best illustrated in a YouTube clip splicing together speeches by Presidents Obama, Bush (II) and Clinton. Lots of hand-wringing and calls for prayer. Little in the way of concrete strategies.

Not that there is any simple fix. The causes are complex and additive: Easy access to super-lethal weapons, inadequate treatment resources for the mentally ill, and -- perhaps most of all -- a culture that glorifies violence.

Children in Karachi, Pakistan commiserate over shared pain

We are, after all, the world's leading imperial power. We aren't surprised at the spectacles of violence in Imperial Rome. Yet are we that different? We exert global control largely through military might, and celebrate violence in the service of a righteous cause. Where is the outrage over our country's slaughter of at least 176 children (almost 10 times the number killed in Newtown) by unmanned drone strikes in Pakistan over the past seven years? Those children are considered expendable, "collateral damage" in pursuit of a legitimate, larger goal. As rabble-rousing filmmaker and author Michael Moore Tweeted, "A county that officially sanctions horrific violence is surprised when a 20-year-old joins in?" Yet, amazingly, children on the other side of the world, in Karachi, Pakistan, held a candlelight vigil in solidarity with the children of Sandy Hook.

Untreated mental illness

As shown in a Mother Jones interactive map of 65 mass murders since 1962, a majority of the killers were mentally ill, and displayed signs of such before their rampages. High-quality, affordable, dependable and stable treatment, in which the clinician forges a real human connection with the patient, can save lives. And the great thing is, prevention does not necessitate prediction. We don't need to be able to do the impossible, and pinpoint which depressed, psychotic, manic, alienated or socially withdrawn man (yes, the shooters are overwhelmingly male) might have become the next Adam Lanza. Or the next suicide, an act twice as prevalent as homicide. Yet, high-quality treatment is scarce, and getting scarcer. Instead, jails and prisons are primary sites for the impersonal medication maintenance that passes for treatment these days.

Misplaced emphasis?

Back-to-back slaughters at the movie theater in Aurora, Colorado, the shopping mall in Portland, Oregon and now Sandy Hook Elementary School in Newtown, Connecticut -- among others -- give an impression of an alarming rise in mass shootings in the United States. Surprisingly, that perception may be inaccurate.

Tracking murders in which four or more people were killed in one incident, criminologist James Alan Fox found that the numbers rise and fall from year to year, but without trending in any direction. On average, there are about 20 mass murders per year in the United States, bringing the deaths of about 100 people, according to an interview in the San Francisco Chronicle. The deadliest in U.S. history, by the way, was way back in 1927, when a 55-year-old school board treasurer in Michigan set off dynamite that killed 38 elementary school children and six adults.That paled in comparison to Anders Breivik's 2011 bombing and shooting attacks in Norway, which killed 77 people, most of them teenagers.

Another prominent criminologist, Jack Levin, agrees with Fox that the focus on mass murder is misplaced, especially vis-à-vis the gun control debate. The broad majority of the 8,000+ people killed by guns in the U.S. each year die singly, often at the hands of family members or due to interpersonal disputes or drug-related conflicts. One-off incidents notwithstanding, schools remain far safer statistically than homes, streets or roadways.

Blaming "the media"

If the attention is being misfocused, that brings us to the role of "the media" in mass violence. It is certainly plausible that the media frenzy surrounding each new outbreak contributes to copycat crimes. If you are angry and alienated, why not go out in a blaze of glory rather than with a silent whimper. Teach society a lesson; be remembered.

Yet I cringe when I hear blame heaped at the feet of "the media." As a former daily newspaper journalist I can attest to the fact that "the media" as a monolithic, all-powerful entity is a fiction. Sure, over-the-top TV news crews (who hardly merit the title of journalist) mercilessly badger victims' families in the interest of titillating viewers. But despite increasingly narrow ownership of the major news outlets by a handful of enormous conglomerates, newspapers, magazines, and even blogs still feature plenty of thoughtful analyses and investigative reports. And although these narratives have some influence in shaping public perceptions, they ultimately reflect more than construct the larger realities in which they are embedded. "They," in other words, are us.

The half-life of vigorous public discourse seems to be roughly a month. Then, another event generates headlines, and we're spastically chasing that thread. Until another tragedy strikes, and the spiral starts over. All the while, there is so much noise (to use Nate Silver's terminology) that the signal can be hard to detect. As Ohio public defender Jeff Gamso muses,

People will speak of evil. They will talk about gun control and how this proves we need more -- or less -- of it. They will talk about security, as if wrapping ourselves in plastic will keep us all safe when all it will really do is suffocate us.... If you would hate, hate the fact that we are reactive, always trying desperately to prevent what happened yesterday. And doing it badly. 

Perhaps this time will be different. Perhaps this latest in a string of rampages represents a tipping point. But I kind of doubt it. It's far easier to propose arming school teachers than to directly challenge the culturally embedded fermentation of entitlement and alienation that kindles rageful violence that gives no quarter.

Further resources:

My NPR commentary after the Aurora massacre can be heard online or by downloading the MP3 podcast HERE.

For you Twitter folks, I've Tweeted a series of media analyses on Sandy Hook that I found particularly insightful. You can find them at my Twitter site or in the Twitter feed in the right-hand column of my blog's home page.

My blog posts after previous mass shootings include:

• Aurora massacre: To speak or not to speak? (July 22, 2012)
• Arizona rampage: Analyzing the analyzers (Jan. 23, 2011)
• Virginia Tech: Can school shootings be prevented? (April 19, 2007)

And here, finally, is an oldie but goodie on the futility of trying to predict rare events:

Systems failure or black swan? New frame needed to stop memorial crime control frenzy (Oct. 19, 2010)

Amnesty issues scathing report on prolonged solitary confinement

Critique follows lawsuit alleging psychological torture at infamous Pelican Bay  

Tucked away in a remote corner of Northern California is one of the most brutal behavioral experiments of the modern era: Upwards of 500 men housed for more than a decade straight in tiny, windowless, concrete tombs.

Pelican Bay, which opened in 1989, was specifically designed to foster maximum isolation. Prisoners are denied phone calls, contact visits, and recreational or vocational programming. But the designers did not plan for the sensory deprivation to be perpetual; stays in the "SHU" (Segregated Housing Unit) were originally intended to last 18 months or less.

Now, in a scathing report, Amnesty International has lambasted conditions in the SHU as "cruel, inhuman, or degrading" punishment that violates international law on the treatment of prisoners.

California holds more than 3,000 prisoners in SHU's, with more than 1,000 at Pelican Bay. No other U.S. state is believed to have held so many prisoners for such long periods in indefinite isolation, the Amnesty International investigators found.

A spokesman for the prison system responded with the rather outlandish nonsequitur that California has no solitary confinement, because SHU prisoners are able (if they have funds) to buy televisions and watch cable channels, including ESPN.

The Amnesty report follows on the heels of a class-action lawsuit filed by the Center for Constitutional Law on behalf of 10 SHU prisoners who claim that long-term isolation is slowly destroying their bodies and minds, in violation of international standards against torture and inhumane treatment.

The lawsuit, Ruiz v. Brown, alleges that prisoners have no means to escape solitary confinement, other than to become government informants against prison gangs, which would put them and their families at risk.

While the prison system claims these are the "worst of the worst," the men claim they are being held in solitary confinement as punishment for their lack of cooperation with prison administrators, based on very thin evidence of gang affiliation. For several, their housing status alone prevents them from being eligible for parole.

Evidence of their supposed continued gang affiliation, the lawsuit says, includes:

• Saying "hello" to a prisoner from a different gang
• Possessing a drawing of an Aztec tattoo
• Possessing a pamphlet in Swahili, a language spoken by 60 million Africans that is categorized by the Department of Corrections as a "banned language"
• Having a Black Power tattoo
• Having a book about George Jackson (Paul Liberatore's The Road to Hell: the True Story of George Jackson, Stephen Bingham, and the San Quentin Massacre)

Plaintiff Paul Redd, for example, has spent 33 of the past 35 years in solitary confinement, the last dozen at Pelican Bay. He would be eligible for parole if not for his purported status as a "captain" in the Black Guerrilla Family despite no evidence of any gang activity in the past six years. His SHU status is allegedly based on old confidential memoranda stating he had communicated with other BGF members, plus possession of drawings, collages and booklets related to George Jackson and the Black Panthers.

A hunger strike last year, supported by up to 6,600 prisoners at 13 other prisons around the state, led to raised hopes, but so far no meaningful reform.

Psychological effects of long-term isolation

What happens when you lock humans inside a concrete sensory deprivation chamber for a period of decades, denying them all physical connection, human warmth, and even glimpses of nature?

In their lawsuit, prisoners who have spent a mind-boggling one to two decades in solitary confinement describe an inexorable descent into hopelessness and despair, with crippling loneliness and a constant struggle to stave off psychosis. They report pervasive insomnia, anxiety, hallucinations, mood swings, violent nightmares, panic attacks and a profound rage that they attempt to stifle by numbing all feeling. One prisoner described feeling like "walking dead," while another said he hears disembodied voices and feels like he is "silently screaming 24 hours a day."

Plaintiff Danny Troxell, for example, reports that he does not initiate conversations, is not motivated to do anything, and feels as if he is in a stupor much of the time. He often becomes "blank" or out of touch with his feelings.

These symptoms echo the findings of mental health experts who examined Pelican Bay prisoners as far back as 1995, six years after the prison opened, in connection with an earlier lawsuit (Madrid v Gomez) over the mental health effects of solitary confinement. At that time, Stuart Grassian, MD, an expert on segregation psychosis, found many men were already deteriorating into psychosis, paranoia, suicidality, and other psychological reactions to their unnatural isolation. Craig Haney, meanwhile, found that nearly all of the prisoners he sampled during that period reported symptoms of psychological distress such as intrusive thoughts, oversensitivity to external stimuli, difficulties with attention or memory, profound depression and social withdrawal.

Over time, prisoners can barely recall what it feels like to experience physical contact with another human being. Luis Esquivel, for example, has not shaken another person’s hand in 13 years and fears that he has forgotten the feel of human contact; "he spends a lot of time wondering what it would feel like to shake the hand of another person," according to the class-action lawsuit.

And what about mental health treatment?

"Every two weeks, a psychologist walks past the prisoners' cells, calling out 'good morning,' or 'you okay?' The psychologist walks past eight cells in approximately 30 seconds during these 'rounds.' "

Last year, a Special Rapporteur with the United Nations declared that prolonged solitary confinement constitutes torture, and that even 15 days in solitary confinement violates an individual’s human rights.

In the wake of its investigation, Amnesty is calling for ratcheting down isolation so it is only used as a "last resort" for severely unruly prisoners who endanger others, immediate removal of prisoners who have already spent years in the isolation units, and improving conditions for those who remain by allowing them more exercise and opportunity for human contact and phone calls to their families.

The Amnesty report can be found HERE; the amended petition in Ruiz v. Brown is HERE. An online petition in support of the SHU prisoners' demands is HERE.  The featured artwork is by Gabriel Reyes, one of the plaintiffs in the class-action lawsuit. More information on Reyes and his art is HERE.

Related blog posts:

• Supermax: Hell on earth or . . . not as bad as we thought? (Jan. 6, 2011)

• Historic hunger strike by Supermax prisoners continues (July 15, 2011)

• Willie Bosket: Tale of a wasted life (Sept. 23, 2008)

• Why does the United States lock up so many people? (Jan. 29, 2012)

• Claim in 15-year-old girl's stabbing will highlight prison failures (Nov. 9, 2007)

On providing invited testimony in a legislative hearing

Reflections of a forensic psychologist

Floyd L. Jennings, JD, PhD, a clinical psychologist and attorney with a long-time clinical practice, currently works in county government to address the problems of the chronically mentally ill in the criminal justice system. In this capacity, he testified this week before a state legislative committee. Here, he reflects on that experience:

As special resource counsel to the Mental Health Division of the Harris County Public Defender (Houston, Texas), I was asked to provide testimony to the Texas House Subcommittee on Criminal Jurisprudence -- and did so on 29 February 2012.

For those having a history of legislative contact, serving as a witness in a hearing may be not at all discomforting. But to one for whom it was a new experience it was quite different.

First, the charge of the committee was to address whether alternative sentencing for mentally ill persons would be desirable. I argued simply that no changes in sentencing were needed -- because it would be difficult to craft, impossible to implement as it would trade on definitions of applicability, and moreover, courts already have the option of considering a defendant's state of mind as either mitigating or exculpating. 

On the other hand, diversion strategies for the lower-level misdemeanor offender could have enormous cost benefits and not compromise public safety. As well, pre-trial jail psychiatric services could be provided at modest direct cost through the use of physician extenders, and provide just that opportunity for stabilization necessary to enable rapid disposition of the matter, shortening any period of confinement. Finally, I argued that opportunities for post-disposition placement tiered to the acuity of the person would dramatically reduce recidivism.

Second, the affective dimensions of proffering testimony are profound -- the setting is elegant and the committee is seated above the witness much like justices in a supreme court. Witnesses are presented with questions for which there are often no easy answers, but to which some response must be made. My case was no exception.

Third, I learned that the lucidity of the argument may have little consequence. I was upbraided for failing to provide the legislature with specific means of cost savings through transfer of mental health services to the "private sector", although there is no private sector entity with the duty to provide mental health services to the chronically mentally ill on a statewide basis. And even if existing, no private sector entity has the resources to provide such. The tone of questions made it plain that legislators would prefer to have government provide all the goods and services that governments rightly provide, but at no cost, or with private sector funding.

Fourth, the venue of a public hearing is no occasion for stirring rhetoric or confrontation. I felt I should have reminded the committee that the present moment is not the occasion for abandonment of those functions which are uniquely governmental -- the care of the weakest members of society who are ill equipped to care for themselves. But in retrospect, and having viewed the videotape of the proceeding, it was far the better to have remained on task, and narrowly focused upon the committee's charge.

Finally, the message for psychologists, and mental health providers in general, is multifold: Involvement in the legislative process is to venture into unfamiliar and discomforting territory. However, social change is rarely achieved in a sterile environment, or one involving only warm and supportive exchanges. Moreover, to call upon governmental entities to fulfill their statutory duty as well as higher moral purpose, it to expose oneself to a certain amount of discord. In short, it goes with the territory. 

Would I do it again? 

I hope so, because in the course of the day I realized there were many I knew personally who were also participating in the process and there is also something rewarding about believing that perhaps you touched even one person having decision-making power to effectuate change.

The video of Dr. Jennings’ testimony is online HERE (beginning at 1:44:50).

First joint psychology-law program with disability focus

New York Law School and John Jay College of Criminal Justice have announced a new joint degree program in forensic psychology and law that will launch in Fall 2012 and focus on disability law.

New York Law School already offers 13 courses on mental disability law, while John Jay already offers an M.A. in forensic psychology. But this will be the first program of its kind, according to New York Law School professor Michael Perlin, who is also the director of he law school's Mental Disability Law Program.

"I'm very excited about the joint program because it highlights the interdisciplinary nature of what we are trying to do through our mental disability law program," Perlin told the National Law Journal. "We created courses specifically to appeal to both lawyers and mental health professionals. This program helps create a synergy that ensures, as best we can, that graduates will have a deep understanding of the other discipline."

"Our graduates will be well-trained lawyers for people with mental disabilities issues and have the potential to become legal advocates, work on public policy or become law professors in this unique niche," said James Wulach, the director of the M.A. Program in Forensic Mental Health Counseling at John Jay College.

Students must apply and be accepted to both schools separately and will finish with a Master of Arts in forensic psychology from John Jay and a Juris Doctor from New York Law School. Perlin expects an initial enrollment of about 25 students.

The National Law Journal story is HERE.

Violence risk in schizophrenics: Are forensic tools reliable predictors?

The high-profile cases of Jared Lee Loughner and Anders Behring Breivik have contributed to high public demand for accurate prediction of violence potential among the mentally ill. While the number of risk assessment tools designed for this purpose has exploded in the past two decades, no systematic review has been conducted to investigate how accurate these tools are for predicting risk in individuals with schizophrenia.

But never fear: Jay Singh of the University of Oxford and colleagues (whose recent meta-review questioned overbroad claims about the accuracy of actuarials in risk assessment) have stepped into the breach, this time examining whether existing tools have proven efficacy for this task.

Reporting in this month's special issue of Schizophrenia Bulletin on violence and schizophrenia, the authors state that despite the existence of at least 158 structured tools for predicting outpatient violence risk, only two studies have measured instruments' predictive validity in discharged patients diagnosed with schizophrenia.

Instead of reporting on instruments' accuracy for specific patient groups, most studies report predictive validity estimates for heterogeneous groups of psychiatric patients. This forces clinicians and the public to assume that these group-level data apply to any individual diagnostic group.This assumption turns out to be a problem, due in part to the large differences in base rates of violence in psychiatric patients. We know, for example, that individuals with substance abuse disorders are more prone to violence, in general, than those diagnosed with major depression.

Examining the psychometric and predictive features of 10 widely used tools for assessing risk in mentally disordered offenders and civil psychiatric patients, the authors found "little direct evidence to support the use of these risk assessment tools in schizophrenia, specifically."

Overall, schizophrenics have low base rates of violence, with an estimated prevalence of between 10 and 15 percent. As I've discussed here in the context of sex offenders, the rarer a behavior is, the harder it is to successfully predict, leading to erroneous predictions of high risk in people who are not truly dangerous. The authors quote another research finding that in order to prevent one stranger homicide by a schizophrenic, governments would need to detain a whopping 35,000 patients.

That sounds to me like a black swan problem.

As in their previous meta-meta-analysis, the authors critique the almost exclusive use of the area under the curve (AUC) statistic to validate risk assessment instruments. Proponents of the AUC like it because it measures predictive utility independent of the base rate of the behavior in question. But this is as much a weakness as a strength, leading to a false sense of confidence in our ability to accurately predict the risk of individuals in heterogeneous groups of patients:

"High" AUC values for heterogeneous groups of psychiatric patients may have led researchers, clinicians, and policymakers to believe that instruments perform well for all diagnostic groups. However, it is problematic to suggest that structured instruments would be able to identify high-risk individuals with the same accuracy in groups with higher and lower base rates of violence.

In another interesting finding, Singh and colleagues found that the item content of violence risk tools varies markedly, with many tools including unique factors not contained in other instruments. This is a problem, unless these items are truly correlated with risk.

The authors call for updated reviews of the risk and protective factors underlying violence in different psychiatric groups -- including, for example, executive dysfunction in schizophrenics -- before additional risk assessment tools are constructed.

The review is available by contacting Dr. Singh (click HERE), who shortly will be coming to America to accept a post with the Mental Health Law and Policy Department of the University of South Florida.

Related blog post: Violence risk meta-meta: Instrument choice does matter (June 19, 2011)

Steffan's Alerts #4: Supermax, school shooters and Asperger's

Click on a title to read the article abstract; click on a highlighted author's name to request the full article.

Ethics of solitary confinement and supermax prisons

The Journal of Forensic Psychology Practice has published online a new issue focusing on ethics in criminal justice settings. Sharon Shalev offers an analysis of ethics in solitary confinement and supermax prisons and calls for more active participation by health professionals in these settings.

Asperger’s Disorder and the criminal justice system

Criminology and Criminal Justice has published Laura Caulfield and Ann Browning’s review of the literature on the connection between Asperger’s Disorder and criminality as well as the criminal justice system’s understanding of the condition.

Serious assaults on prison staff

In the Journal of Criminal Justice, Mark Cunningham and colleagues examine assaults on prison staff occurring over a 14 month period in a state correctional system. They provide data on prevalence of serious assaults and characteristics of inmate perpetrators and staff victims.

Are school shooters and suicide bombers more alike than different?

Adam Lankford and Nayab Hakim posit that they are, based on their review of school shooters in the United States and suicide bombers in the Middle East. Their article appears in Aggression and Violent Behavior.

Assessing intervention targets in sex offender treatment

Melissa Grady and colleagues review the psychometric properties and validation of measures commonly used in sexual offending treatment programs. The authors offer recommendations on measures to assess core treatment areas in their new article in Aggression and Violent Behavior.

Treatment for child sexual abuse victims and their families

In the same issue of Aggression and Violent Behavior, Poonam Tavkar and David Hanson offer information on effective treatment options for victims of child sexual abuse and their non-offending family members.

Steffan's alerts are brought to you by Jarrod Steffan, Ph.D., a forensic and clinical psychologist based in Wichita, Kansas. For more information about Dr. Steffan, please visit his website.