The Trauma Myth, Revisited

The Trauma Myth may be one of the most misunderstood books of the past decade. Based on its regrettable title, pedophiles erroneously believe it minimizes the harm of child sexual abuse; in the opposite corner, some misguided anti-abuse crusaders have demonized the Harvard-trained author as a pedophile apologist. As guest blogger Jon Brandt explains in this review -- first published in the Summer 2016 issue of The Forum, the newsletter of the Association for the Treatment of Sexual Abusers (ATSA) -- both fans and detractors of Susan Clancy have gotten the courageous researcher all wrong.

The Trauma Myth

by Susan Clancy

Book review by Jon Brandt, MSW, LICSW*

As a former child protection social worker, and now working with both victims and offenders, I was drawn to The Trauma Myth because of both the title, and subtitle: “The Truth About the Sexual Abuse of Children – and its aftermath.” When I first read Susan Clancy’s book, in 2010, nearly every page confirmed my professional experience with victims. I’m offering this review some six years after the book's publication because I believe most experienced professionals will agree that Clancy’s thesis is not just well-researched, but articulate and luminously persuasive.

Dr. Clancy is a Harvard-trained experimental psychologist. Her expertise is not in the field of sexual abuse; it is in the field of memory. This information is important in understanding how Clancy endeavored to interview adults who had been victims of childhood sexual abuse (CSA) – in part, to further understand the role of memory in how adults recalled traumatic experiences. Clancy acknowledges that her career had a rocky start – not only investigating adult memories of childhood sexual abuse, but to understand why some people seemed to believe in alien abductions. Clancy writes about the challenge of having to reconcile her research with two deep concerns: first, she had to abandon some of what she had been taught about the ‘trauma’ of sexual abuse, and second, she had to try to save her reputation and career.

After Clancy interviewed more than 200 Boston-area adult victims of CSA, she came to recognize that most victims’ memories were consistent with previous research – the vast majority of victims knew, liked, and/or trusted their abusers. And she confirmed another finding – that most CSA was tricked and manipulated, not the product of threats, force, pain, or injury. Even young children intuitively understand that when an older person inflicts pain, injury, or fear (elements of trauma), something is very wrong. But when sexual violations occur in the absence of violence and in the presence of trust, most victims reported being confused by the encounter, rather than traumatized. Less than one in ten adults that Clancy interviewed described being sexually abused as “traumatic.” Clancy considered that perhaps CSA is so traumatic that adults had repressed their memories, but that hypothesis ran counter to research that: (1) discredits repressed memories and (2) indicates that the more powerful life experiences are to an individual, the more the events are both strongly embedded and vividly recalled. Clancy goes on to articulately detail how children are indeed harmed by sexual abuse – in the aftermath.

Dr. Clancy has expressed some regret about the title of her book, but does not back-peddle from her findings – that CSA is not universally traumatic. She asserts that many professionals don’t really understand how, why, and when CSA is harmful, and imputing trauma when it’s not present might actually introduce secondary harm. Clancy expresses that children clearly do not have the developmental capabilities to understand interpersonal sex, that acceding to sexual touching is not the same as sexual consent, and that naïve cooperation is not complicity. In the absence of veritable trauma, the harm of CSA comes not from sexual touching, per se, but from relationship violations – a sense of betrayal, shame, and misplaced blame. Clancy explains that as a CSA victim begins to sexually and socially mature, and comes to understand what motivated their abuser, they feel duped and exploited. As victims try to reconcile how and why someone of trust would use them for sexual purposes, the ‘harm’ evolves. Clancy’s message is clear: if we don’t talk to kids about sex, we leave them vulnerable; if we don’t listen to kids who have been sexually abused, we re-victimize them; when we truly listen to child victims, we empower them to guide their own recovery – that helps to turn victims into survivors.

Dr. Clancy uses the controversies around her book to illustrate how difficult it is for professionals to navigate the nuances of CSA, and that it is incumbent on adults to protect children until they are mature enough to navigate the world of interpersonal sex. Clancy acknowledges that she was perhaps naïve in believing that rigorous science would protect the integrity of her research. What she was not prepared for was that CSA is virtually unspeakable – so abhorrent that, even among the educated, it was difficult to separate legitimate research from prevailing public opinion, or simply the politics of sex.

In 1998, psychologist, Bruce Rind and colleagues published an article on CSA in the American Psychological Association journal Psychological Bulletin. It was peer-reviewed, sound research, but so contrary to conventional beliefs of CSA that it resulted in an Act of Congress condemning his work. In 1981, Professor Alfred Kadushin (one of my graduate school advisors at the University of Wisconsin) published a book titled Child Abuse, an Interactional Event. He spent the rest of his career explaining that he was not blaming children for being abused.

The truth is, there has never been any time in history that sex could be separated from politics, or that science hasn’t waged an uphill battle against public opinion. The Socratic Method, or the applications of logic and scrutiny to understanding complex problems, is a predecessor of the Scientific Method, and one of the most important legacies of Socrates. It is ironic that Socrates could not survive the politics of his own time – he was condemned to death as a heretic. Nearly two millennia later, perhaps Galileo had taken note of the fate of Socrates. When Galileo found himself charged with heresy, to avoid being executed, he recanted his theory of the heliocentric solar system, and lived out his life under house arrest. It took another 350 years for the Catholic Church to acknowledge that Galileo had been right all along.

Susan Clancy wasn’t charged with heresy, at least not formally, but by her own admission, after a firestorm of controversy over The Trauma Myth, she fled the US to work in Nicaragua for several years. If Clancy was flattered by a favorable book review in the NY Times, she must have been horrified by a book review by NAMBLA [the North American Man/Boy Love Association]. Clancy’s book, and her story, are a testimony to professional courage in the face of deeply held, widespread, long-standing beliefs about the sexual abuse of children. Apparently, Clancy no longer writes or teaches about sexual abuse, based on a Google search, but she is still professionally active in research and education about the functions of memory.

There is so much right about The Trauma Myth that I am hesitant to be critical, but I think Clancy missed the mark on a few points. In my experience, some victims of CSA have the internal constitution to avoid both the trauma and the harm of sexual abuse. Other victims seem to have the resiliency and tenacity, with or without professional help, to truly earn the moniker of ‘survivor.’ Clancy views CSA as dichotomous – if there is a victim, there is an offender, who must be punished. If Clancy understood offending with the same verve, complexity, and nuances with which she understands victims, I think she would forgo the black and white, victim-offender paradigm in favor of the complex dynamics of offending, and the range of uniquely tailored interventions that serve victims, offenders, and their families. With a focus on the etiology and aftermath of CSA, it might not be obvious that Clancy was also advocating for both more prevention and better public policies.

The Trauma Myth is well researched, with endnotes in APA format. With just over 200 pages, and still professionally sound, it is easy reading. Most individuals are likely to approach the book with the same skepticism with which Clancy pursued her research. In the end, I think most professionals are likely to agree with many conclusions that Dr. Clancy found unassailable: that the popular, one-dimensional understanding of ‘trauma’ caused by child sexual abuse is largely a myth – a vestige of the 20th century.

*Jon Brandt is a clinical social worker who specializes in the evaluation, treatment and supervision to sexual offenders. His previous guest posts have reported on the link between pornography and contact sex offending and on an ongoing legal challenge to Minnesota's civil commitment of sex offenders. Many thanks to the editors of The Forum for granting me permission to post Mr. Brandt's review. The original review can be found HERE.

The psychic perils of forensic practice

John Bradford burst into tears. Hitting the road for the four-hour trek back to his home in Ontario, Canada, he could not stop crying and shaking.

An internationally renowned forensic psychiatrist, Bradford had been working around-the-clock on the high-profile case of Canadian Air Force Colonel Russell Williams, a decorated military pilot and commander of the country's largest military airbase who had spent his spare time torturing and murdering women.

Bradford's breakdown took him by surprise. Like other forensic practitioners, he had spent decades sitting across the table from rapists, murderers and sexual sadists. He was adept at emotionally distancing himself from their twisted psyches and wretched deeds. But the gruesome video of two young women screaming and begging for their lives (unsuccessfully, as he knew) proved a tipping point.

Descending into a very dark place, he was eventually diagnosed with posttraumatic stress disorder. He underwent lengthy therapy and drug treatment. Although he has now returned to his forensic practice, he is more cautious about the types of cases he will take on.

The profile by reporter Chris Cobb in the Ottawa Citizen, documenting Bradford's three-year struggle with vicarious traumatization, came as a complete shock to me. It was just three years ago that I served with Bradford on a team debating three controversial paraphilias being proposed for the DSM-5. Bradford, an advisor to the DSM-IV, was past president of the American Academy of Psychiatry and Law (AAPL), which hosted the debate. He holds numerous other accolades. He is a professor at the University of Ottawa, founder and clinical director of the Sexual Behaviors Clinic in Ottawa, and a Distinguished Fellow of the American Psychiatric Association, earning its prestigious Isaac Ray Award.

 Williams' victims, Jessica Lloyd and Marie-France Comeau

If he could fall apart, I wondered, who couldn’t?

Bradford described for the reporter how his mental state gradually morphed from calm and collected to irritable and angry, as he worked long hours on the Williams case. At one point, being cross-examined by a defense attorney in another case, he got so irritated by the attorney’s repetitiousness that he almost blurted out, "Why don’t you shut the f-- up, you a—hole?' "

It was then that he realized he was losing control.

"I knew there was something wrong but there was a lot of denial on my part," the 66-year-old Bradford told Cobb. "And that’s why it didn’t work when I first went into treatment. I was pessimistic and depressed, but if you’re a psychiatrist and a tough forensic guy you think you can blow anything off, right? And that’s what I did."

I was struck by the courage it must have taken Bradford to reveal his vulnerabilities to the world. I hope that his personal story can help stimulate conversation on the emotional dangers of this work. If Bradford can crumble, so can anyone, no matter how experienced, competent, or externally cool. Being part of a culture in which weakness is taboo, and can even be professional suicide, makes honest disclosure and help-seeking all the more difficult.

Confronting vicarious traumatization

Vicarious traumatization (also known as compassion fatigue, secondary trauma, or just plain burnout) has received some attention in professional circles in the past few years. There are books, journal articles, professional trainings, even websites.

The DSM-5 criteria for Posttraumatic Stress Disorder (PTSD) reflect this growing awareness. Criterion A, which lists the stressors that make one eligible for the diagnosis, now includes "experiencing repeated or extreme exposure to aversive details of the traumatic event(s)." To keep those who view disasters on TV from being diagnosed with PTSD, as happened after the 9/11 terrorist attack, the text clarifies that this applies to such people as "first responders collecting human remains or police officers repeatedly exposed to details of child abuse," and NOT to those exposed through the media, "unless this exposure is work related."

As this criterion implies, vicarious traumatization can strike not just forensic evaluators, but anyone who spends too much time rubbing up against trauma -- nurses, ambulance operators, child welfare workers, police, lawyers, judges, even jurors.

Studies on its incidence among forensic professionals are mixed. An unpublished survey by graduate student Julie Brovko and forensic psychologist William Foote of the University of New Mexico found low levels of vicarious traumatization among a convenience sample of 65 forensic psychologists. However, consistent with Bradford's case, more time in the field was correlated with more problems.

In contrast, a 2010 survey of 52 Australian clinicians providing treatment to convicted sex offenders found no evidence of compassion fatigue or burnout. The majority reported low stress and high levels of job satisfaction working with this challenging population. Ruth Hatcher and Sarah Noakes found that supervision and external social support helped clinicians avoid burnout.

One limitation of both of these studies is that they surveyed only those who remained active in the field. Anecdotal accounts suggest that some individuals leave forensic practice due to the emotional toll, which can produce feelings of estrangement, numbness, and hypervigilance.

An opposite danger?

Reflecting on Bradford's breakdown, I thought about the opposite tendency. Is it resilience that keeps other professionals from crumbling under the weight of witnessing constant perversion and misery? Or, might some be repressing their feelings in a manner that is not so healthy?

After all, to not be disturbed by graphic cruelty or stark oppression is in itself disturbing. Such psychic numbing whittles away at one's humanity.

In the memoir 12 Years a Slave (which I highly recommend), Solomon Northrup reflected on how the cruelty of slavery fostered casual violence not only toward slaves but also among white slaveholders. These men thought nothing of stabbing or shooting each other at the slightest provocation, the Southern "culture of honor" that remains with us today:

"Daily witnesses of human suffering -- listening to the agonizing screeches of the slave -- beholding him writhing beneath the merciless lash … it cannot otherwise be expected, than that they should become brutified and reckless of human life."

I've seen that phenomenon first-hand in institutions. Brutality breeds brutality, along with an indifference to brutality among institutionalized professionals that is equally troubling.

Mitigation?

Perhaps the first step in addressing the problem is for professionals to openly discuss the risk of professional burnout, vicarious traumatization, and psychic numbing. It’s very useful to have support and consultation groups where one can let one's guard down and be more vulnerable, debriefing after horrific case work with trusted colleagues.

Mindful meditation is so en vogue these days that I hesitate to join the bandwagon, but I do think it too can help reduce stress and emotional meltdowns.

Balance is also essential. Rest, relaxation, hobbies, exercise. It's not coincidental that Bradford broke down while working around-the-clock on a high-profile case. 

I'd be interested in others' thoughts on the emotional hazards of our work, and strategies or techniques for staying healthy.

Hat tip: Jeff Singer

Related resources:

• Brovko and Foote (2011), Vicarious Traumatization: Are forensic psychologists vulnerable to trauma exposure? (Presentation) 
• Culver, McKinney and Paradise (2011), Mental health professionals’ experiences of vicarious traumatization in Post-hurricane Katrina New Orleans, Journal of Loss and Trauma 16, 33-42 
• Harrison and Westwood (2009), Preventing vicarious traumatization of mental health therapists: Identifying protective practices, Psychotherapy Theory, Research, Practice, Training 46 (2), 203-219 
• Hatcher (2010), Working with sex offenders: The impact on Australian treatment providers, Psychology Crime and Law 16 (1-2) 
• Robertson, Davies and Nettleingham (2009), Vicarious traumatisation as a consequence of jury service, The Howard Journal 48 (1) 
• Tabor (2011), Vicarious traumatization: Concept analysis, Journal of Forensic Nursing 7, 203-208 
• Taylor and Furlonger, A Review of Vicarious Traumatisation and Supervision Among Australian Telephone and Online Counsellors, Australian Journal of Guidance and Counselling 21 (2), 225-235

Study links childhood trauma and adult aggression

Call for trauma-focused treatment of offenders

Children who experience abuse, neglect and family dysfunction have a heightened risk of developing health problems such as obesity, drug addiction, depression and heart disease in adulthood. That common-sense notion is widely accepted, and has been proven in a series of studies funded by the US Centers for Disease Control and Prevention (CDC) and Kaiser Permanente. The Kaiser-CDC project has amassed a large database of the life histories and health trajectories of middle-class residents of San Diego, California.

Now, a San Diego psychologist has deployed that project's Adverse Childhood Experiences (ACE) survey to link these negative childhood experiences with adult aggression and criminality, including domestic violence, sexual assault, stalking and child abuse.

In fact, the correlation is additive, the new study found: The more types of adversities a man underwent in childhood, the higher his likelihood of engaging in criminal aggression as an adult.

Men in the study who were referred to outpatient treatment following convictions for domestic violence, sexual offending, nonsexual child abuse or stalking reported about four times as many adverse childhood events as men in the general population. Men convicted of sex offenses and child abuse were especially likely to report being sexually abused as children.

The link between early damage and later aggression explains why treatment programs that focus primarily on criminal acts are not very effective, say psychologist James Reavis of San Diego, California and his colleagues.

"To reduce criminal behavior one must go back to the past in treatment, as Freud admonished us nearly 100 years ago," wrote Reavis and co-authors Jan Looman, Kristina Franco and Briana Rojas in an article slated for the Spring 2013 issue of The Permanente Journal. "Fortunately, evidence exists in support of both attachment-based interventions designed to normalize brain functioning and in the efficacy of psychoanalytic treatment."

Why the link between abuse and aggression?

Cumulative experiences of abuse and neglect disrupt both a child's ability to form secure attachments to others and his ability to regulate his emotions, the researchers posit. Thus, men abused as youngsters tend to either avoid intimacy altogether or are at risk to become violent in intimate relationships, due to a "bleeding out" of their suppressed inner rage.


Not only must treatment of offenders focus on healing their "neurobiological" wounds, the researchers say, but the findings also point to the need for more early childhood interventions to stop child abuse before its victims grow up to victimize others.

Stay tuned: A second article being prepared for publication will explore the link between early adversity and dysregulation in the hypothalamic-pituitary-adrenal axis that modulates stress responses.

The article, "Adverse Childhood Experiences and Adult Criminality: How Long Must We Live before We Possess Our Own Lives?" can be requested from the first author, psychologist James Reavis of San Diego (HERE). The article includes a copy of the ACE questionnaire, which is potentially useful in forensic cases as a means of quantifying experiences of child abuse and neglect.

APA rejects "hebephilia," last standing of three novel sexual disorders

To hear government experts on the witness stand in civil detention trials in recent months, the novel diagnosis of "hebephilia" was a fait accompli, just awaiting its formal acceptance into the upcoming fifth edition of the influential Diagnostic and Statistical Manual of Mental Disorders (DSM).

They were flat-out wrong.

In a stunning blow to psychology's burgeoning sex offender processing industry, the Board of Trustees of the American Psychiatric Association rejected the proposed diagnosis outright, not even relegating it to an appendix as meriting further study, its proponents' fall-back position.

The rejection follows the failure of two other sexual disorders proposed by the DSM-5's paraphilias subworkgroup. These were paraphilic coercive disorder (or a proclivity toward rape) and hypersexuality, an inherently hard-to-define construct that introduced the committee members' value judgments as to how much sex is within acceptable limits.

After abandoning those two disorders, the subworkgroup clung tenaciously to a whittled-down version of its proposed expansion of pedophilia to cover sexual attraction to early pubescent youngsters (generally in the age range of 11-14), ignoring widespread opposition from both within and outside of the APA.

The buzz is that senior psychiatrists in the APA were unhappy with the intransigence of psychologists in the subworkgroup who communicated the belief that if they just stuck to their guns, they could force the ill-considered proposal into the new manual, despite a lack of scientific support.

All three proposed sexual disorder expansions were widely critiqued by mental health professionals, especially those working in the forensic contexts in which they would be deployed. They led to a spate of critical peer-reviewed publications (including a historical overview of hebephilia by yours truly, published in Behavioral Sciences and the Law), and an open letter to APA leadership from more than 100 professionals, including prominent forensic psychologists and psychiatrists in the U.S. and internationally.

The unequivocal rejection sends a strong signal of the American Psychiatric Association's continuing reluctance to be drawn into the civil commitment quagmire, where pretextual diagnoses are being invoked as excuses to indefinitely confine sex offenders who have no genuine mental disorders. In marked contrast with the field of psychology, psychiatry leaders have expressed consistent concerns about the use of psychiatric labels to justify civil detention schemes.

Next time around, the APA might want to do a better job selecting committee members in the first place. The "paraphilias subworkgroup" was heavily biased in favor of hebephilia because of its domination by psychologists from the Canadian sex clinic that proposed the new disorder in the first place, and is the only entity doing research on it. But what a waste of time and energy to create a committee that comes up with wild and wacky proposals that are only going to end up getting shot down when the rubber meets the road.

Backpedaling on paradigm shift

As regular readers of this blog know, the DSM-5 developers' grand ambitions to bring forth a revolutionary "paradigm shift" produced alarm among mental health professionals and consumer advocacy groups both in the United States and internationally. The British Psychological Society, the UK's 50,000-member professional body, issued a strongly worded critique, and a coalition of psychological associations garnered more than 14,000 signatures on a petition opposing the wholesale lowering of diagnostic thresholds for disorder.

Yesterday's news release marked an about-face, with the APA now stressing that diagnostic changes in the DSM-5 were intended to be "very conservative."

"Our work has been aimed at more accurately defining mental disorders that have a real impact on people’s lives, not expanding the scope of psychiatry," said David J. Kupfer, MD, chair of the DSM-5 Task Force.

Consistent with this, several of the proposed changes that generated the most widespread alarm were rejected. The Board of Trustees rejected the highly controversial "attenuated psychosis syndrome" that could have created an epidemic of false positives, stigmatizing eccentric young people and lowering the threshold for prescribing potentially harmful antipsychotic drugs. It also backed away from an equally controversial, and complex, revamping of the personality disorders. These conditions, as well as a contentious Internet gaming disorder, will all be placed in "section 3" of the new manual as conditions meriting further study.

Allen Frances, the DSM-IV Task Force chair and a high-profile critic of the DSM-5 project, called the spin that the DSM-5 will have minimal impact on psychiatric diagnosis and treatment "misleading":

"This is an untenable claim that DSM 5 cannot possibly support because, for completely unfathomable reasons, it never took the simple and inexpensive step of actually studying the impact of DSM on rates in real world settings…. Except for autism, all the DSM 5 changes loosen diagnosis and threaten to turn our current diagnostic inflation into diagnostic hyperinflation. Painful experience with previous DSM's teaches that if anything in the diagnostic system can be misused and turned into a fad, it will be. Many millions of people with normal grief, gluttony, distractibility, worries, reactions to stress, the temper tantrums of childhood, the forgetting of old age, and 'behavioral addictions' will soon be mislabeled as psychiatrically sick and given inappropriate treatment."

Among the controversial diagnostic changes that will go forward in the DSM-5, due to be published in mid-2013:

• Asperger’s syndrome is being eliminated as a separate disorder (it will be folded into an autism spectrum disorder)
• Depression is being expanded to include some grief reactions
• A brand-new "disruptive mood dysregulation disorder" has critics fearing psychiatric labeling of children who have temper tantrums

Two other sets of changes have particular relevance to forensic practitioners. Substance abuse disorders have been reframed as "behavioral addictions," which Frances warns could be a "slippery slope" leading to "careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets."

Posttraumatic stress disorder (PTSD) will be included in a new chapter on trauma and stress-related disorders, with four distinct diagnostic clusters instead of the current three, and "more attention to the behavioral symptoms that accompany PTSD." Some worry that the reconfigured PTSD may lend itself to misuse of the hot-button diagnosis in forensic cases.

Yesterday’s APA news release outlining the changes can be found HERE. My hebephilia resource page is HERE.

Multiple personality excluded in Texas insanity case

A serial rapist’s attempt to claim insanity based on multiple personality disorder fell flat, as a judge ordered the expert's trial testimony stricken from the record as junk science.

Billy Joe Harris

Psychiatrist Colin Ross testified that Billy Joe Harris, the so-called "Twilight Rapist" who targeted elderly women, suffered from multiple personality disorder -- now known as dissociative identity disorder (DID) -- brought on by childhood abuse.

Ross, who runs the Colin A. Ross Institute that provides trainings on psychological trauma and dissociative identity disorder, testified that the condition’s presence in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association establishes it as a "real and valid disorder."

Ross testified that he gave the defendant three tests for DID. However, in a most unusual procedure, rather than personally administering the tests, he gave them to the defense attorney to administer. Thus, he has no way of knowing for sure who filled in the tests, or under what circumstances. 

Ross testified that the defendant's scores on a screening test, the Dissociative Experiences Scale, were so high that he questioned the test's validity. He also conceded that the defendant was "clearly telling stories that are not true" about other aspects of his life, for example falsely claiming to have served in Iraq when he was actually in Saudi Arabia. However, Ross testified that after getting a chance to talk personally with one of Harris's alters, "Bobby," he was convinced of Harris's claim of multiple personalities.

"I don't think he's faking the dissociative identity disorder," he testified. "I could be wrong."

The real culprit, David the Dog

The defendant, a former prison employee, also took the witness stand, "weaving tales of bestiality, aliens, transvestites and combat heroism," in the words of news reporter Sonny Long. Harris testified that he had three other personalities inside him, including a black Great Dane named David who committed the rapes.

A dramatic moment came during cross-examination, when prosecutor Bobby Bell asked to speak to the defendant's alter, also named Bobby. As Long described the scene:

Harris lowered his head momentarily, raised it back up, rolled his neck and declared in a deep voice to be "Bobby."

Several jurors stifled laughter during the subsequent give-and-take between Harris and Bell, according to Long's account in the Victoria Advocate.

But perhaps even more damaging to Harris's credibility was an audiotape played for the jury in which he talks to his girlfriend about having put on "a good show" in court one day. Earlier that day, he had fallen to the floor and twitched and shook until he was restrained. The girlfriend warned Harris that the telephone call was being recorded, to which Harris replied, "I know it."

Forensic psychologist Walter Quijano also testified for the defense. (If the name sounds familiar, he has been in the spotlight for using race as a risk factor in death penalty cases, as I recently blogged about.) He testified that when multiple personality popped up as an issue, he stepped back because that is not an area of expertise for him. However, he did testify that it is unusual for someone to begin a rape career so late in life. Harris is 54.

Mere presence in DSM doesn’t establish validity

After the defense rested, the prosecution called as a rebuttal witness a Minnesota psychologist and attorney who has made a crusade out of pushing so-called "junk science" out of the courts.

Robert Christopher Barden testified that dissociative identity disorder (aka multiple personality disorder) is a controversial condition looked upon with skepticism by the scientific mainstream. He cited several articles rejecting the condition as a viable diagnosis, despite its presence in the DSM.

"Because something is in the DSM doesn't mean it's reliable or should be allowed in a court of law," he testified, according to an article in the Victoria Advocate. "One of the ways to get junk science out of the legal system is you rely on the relevant scientific community. If something is controversial it means it's not generally acceptable."

Barden said the number of mental health professionals who tout dissociative identity disorder as viable are few and far between.

"There are a few pockets of people left who are doing this," he said. "The scientists I know condemn it to be the worst kind of junk science and dangerous to the public. Controversial and experimental theories should not be allowed to contaminate the legal system."

Concerning the tests given to Harris, Barden said, "There's no magic to these tests. It looks scientific. It looks professional, but when you get down into it, it's junk. It's unusual for a psychiatrist to interpret a psychological test and it's highly unethical for Mr. Cohen [the defense attorney] to give the tests."

After Barden’s testimony that the condition is not generally accepted by the scientific community, despite the fact that it is listed in the DSM, District Judge Skipper Koetter ordered Dr. Ross’s testimony on dissociative identity disorder stricken from the record.

Justice, Texas-style

In the end, the defendant’s overdramatization and courtroom theatrics likely did him in. During the trial, he trembled and twitched and sat in the courtroom with paper stuffed in his ears, which his attorney said was “to keep the voices from speaking to him."

The jury took only 10 minutes to convict Harris, and another 10 minutes later in the month to sentence him to life in prison.

After the verdict, Barden said in a press release that the outcome demonstrates “the power of science-law teams in protecting the legal system from junk science testimony."

Barden has been involved in hundreds of lawsuits, criminal prosecutions and licensure actions across the United States over the past two decades, targeting not only multiple personality disorder but also quack therapists in the repressed memory and rebirthing therapy movements.

Judge Koetter's ruling is not the last word, of course, as it is just one trial judge's opinion. Appellate courts in other states have ruled differently. For example, in the 1999 case of State v. Greene (139 Wn. 2d 64), the Washington Supreme Court held that dissociative identity disorder was a generally accepted diagnosis because it was listed in the DSM-IV, and therefore met the Frye test for admissibility. But the Court went on to say that the applicability of this diagnosis to the issue of criminal responsibility was problematic and that testimony about DID was not "helpful" to the jury. (The Trowbridge Foundation has more information on this case HERE.)

The battle lines over dissociative identity disorder have heated up in the dozen years since that ruling, so who knows how an appellate court might rule today.

For those interested in learning more about the controversy, I recommend the chapter "Dissociative Identity Disorder: Multiple Personalities, Multiple Controversies" by Scott Lilienfeld and Steven Jay Lynn, in their book, Science and Pseudoscience in Clinical Psychology.

Judge upholds indefinite detention of California sex offenders

In a long-awaited ruling, a San Diego judge has ruled that indefinite detention of Sexually Violent Predators (SVP’s) is constitutional, even though other forensic patients are entitled to periodic reviews.

The ruling in the legal challenge by sex offender Richard McKee came after a 6-week hearing featuring experts from around the United States. The California Supreme Court had ordered the hearing, saying prosecutors must justify the differential treatment of SVP’s by proving that they are categorically different from two other types of forensic patients. The other two classes of   people who are civilly committed based on criminal behavior are Mentally Disordered Offenders (MDO’s), who are hospitalized when they come up for parole due to the immediacy of their threat of violence to the public, and persons found not guilty by reason of insanity (NGI). Jessica’s Law, enacted by voters in 2006, eliminated the right of committed sex offenders to a recommitment trial every two years.

In his 35-page ruling, Judge Michael Wellington said prosecutors had met their burden of proving that SVP’s are a distinct class that is harder to treat and more likely to commit additional sexual offenses.

After hearing from all of the experts, the judge acknowledged the significant controversies regarding the reliability of the paraphilia diagnoses, the accuracy of actuarial risk prediction instruments such as the Static-99, and the base rates of recidivism.

If anything is clear from the evidence presented in this case, it is that key factual matters are controversial. It is also apparent that the evidence of the relative danger the classes represent is analytically nuanced and deeply rooted in developing medical and psychological science.

Psychiatric diagnoses unreliable

Interestingly, the testimony of state hospital representatives lent some support to McKee’s legal challenge.

For example, Dr. Alan Abrams, Chief Psychiatrist at the California Medical Facility at Vacaville, testified that sex offender diagnoses (pedophilia and other paraphilias) are imprecise, and he has little confidence in their accuracy.

Two professionals from Coalinga, the state hospital built to house SVP’s, also testified that they favor having an external review every two years. Dr. Robert Withrow, the hospital’s acting medical director, said indeterminate terms reduce hope in both patients and staff, and discourage patients from signing up for treatment. Dr. Kasdorf, also from Coalinga, agreed. He said patients work harder in treatment and have more trust in the system when they know they will get a hearing.

This contradicted testimony by David Thornton of Wisconsin's Sand Ridge civil detention center, who argued that periodic recommitment hearings are disruptive to treatment.

Actuarials controversial

Among the most controversial issues emerging from the trial was the value of actuarial instruments -- and the much ballyhooed Static-99 in particular -- to assess sex offenders' risk of recidivism.

Mark Boccaccini, who teaches psychometrics and psychology and law at Sam Houston State University in Texas, testified about his research showing that "the Static-99 has only marginal to moderate predictive reliability, little greater than chance." Boccaccini also testified that use of a single good actuarial tool is a better predictor than the use of multiple tools. Many government evaluators in California report data from other actuarial tools in addition to the Static-99, such as the MnSOST-R and the RRASOR.

California need not be enlightened

McKee's attorneys, from the San Diego Public Defender's Office, were allowed to present evidence of two alternate models: Texas's outpatient halfway house model, and Canada's Circles of Support and Accountability, which provides support to ex-convicts returning to the community. But ultimately the judge ruled that testimony irrelevant:

The [Canadian] representative who testified presented an impressive picture of a successful community-based program. While this evidence was offered to show that less restrictive alternatives exist to SVP treatment, it fails to gain traction in an equal protection context…. California is not obligated to follow Texas or Canada's examples however much more enlightened they may seem.

Bottom line, ruled the judge, is that we must make do despite the controversies and uncertainties:

It is this court's conclusion that the evidence presented satisfies the People's burden of establishing, by a preponderance of the evidence, that the different treatment given to SVP's under Proposition 83 [Jessica's Law] is "based on a reasonable perception of the unique dangers that SVP's pose rather than a special stigma that SVP's bear in the eyes of California's electorate." (McKee, supra, at 1210.) The fact that the evidence supporting this may be subject to controversy does not detract from its reasonableness or from the validity of the legislative distinctions based on it.

As someone who evaluates all three categories of offenders here in California --SVP’s, MDO’s and NGI’s -- I was astonished by the argument that the harm caused by SVP’s is categorically greater than that inflicted by members of the other two categories. Violence need not be sexual to inflict severe trauma. Some of the most disturbing cases I have been involved in were MDO and NGI cases in which psychotic individuals inflicted horrific brutality, torture and even death upon women and children. In contrast, I know of one young man who is currently committed to Coalinga as an SVP whose only offenses since age 18 were two consensual affairs with late teenage girls, one of whom even testified on his behalf at trial (saying she initiated the relationship and was a willing participant). Triggering his civil detention was not any sexual recidivism, but rather a parole violation for smoking marijuana.

That's the problem with separating criminals into artificial groups and then pretending they are all the same.

The art on this page is by Ricky Romain, an internationally acclaimed human rights artist in the UK whose work focuses on themes of justice, alienation and sanctuary. Mr. Romain has kindly given permission to showcase his art here. I encourage you to check out his extensive online gallery (HERE).

 

PTSD: Pandemic like swine flu?

Just about every week, an attorney calls me wanting a client evaluated for PTSD. Virtually everyone in forensic practice has probably seen highly dubious diagnoses of PTSD, deployed for obvious secondary gain. But even outside the courtroom, our cultural obsession with trauma and victimization may be creating an epidemic of wrongful PTSD diagnoses, at a public cost of billions of dollars.

Such is the controversial position that is "splitting the practice of trauma psychology and roiling military culture," writes science writer David Dobbs in a lucid analysis in Scientific American Magazine.

Critics contend that both the larger American culture and the medical culture within the Veterans Administration (VA) reflexively regard all bad memories, nightmares, and other signs of distress as evidence of Posttraumatic Stress Disorder (PTSD). Returning soldiers are encouraged to create a "trauma narrative" to explain their problems. This, unfortunately, gives them monetary benefits in the short term, but sucks them down a dead-end path that will mire them in chronic disability and "a psyche permanently haunted."

"This has nothing to do with gaming or working the system or consciously looking for sympathy," says Harvard University psychologist Richard J. McNally, an authority on memory and trauma and a leading critic. "We all do this: we cast our lives in terms of narratives that help us understand them. A vet who's having a difficult life may remember a trauma, which may or may not have actually traumatized him, and everything makes sense."

Unlike most psychiatric diagnoses, PTSD as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) must be caused by a traumatic event. However, the tie is really to the memory of an event. And, as research shows, memory is highly unreliable and malleable: "We routinely add or subtract people, details, settings and actions to and from our memories. We conflate, invent and edit."

Unfortunately, the fuzziness of the PTSD construct makes it very hard to distinguish from other disorders with overlapping symptoms, including depression and traumatic brain injury, increasingly common among soldiers returning from Iraq.

And giving treatment for PTSD (typically, controlled exposure to trauma triggers) may make other problems worse:

"If a depressed person takes on a PTSD interpretation of their troubles and gets exposure-based CBT [cognitive behavioral therapy], you're going to miss the boat," McNally says. "You're going to spend your time chasing this memory down instead of dealing with the way the patient misinterprets present events."

Critics such as McNally are calling for revisions in the upcoming edition of the DSM, due out in 2012, to better distinguish depression, anxiety and phobia from true PTSD.

They are also calling for an overhaul in the VA's disability system, to "remove disincentives to recovery and even go the extra mile and give all combat veterans, injured or not, lifetime health care."

Such changes, of course, are unlikely, given our entrenched "cultural obsession with trauma."

Interestingly, military historian Ben Shephard posits that the PTSD diagnosis benefits American society by absolving it of moral responsibility for the Vietnam war. As Dobbs summarizes it, American society gained:

"a vision of war's costs that, by transforming warriors into victims, lets us declare our recognition of war's horror and absolves us for sending them for we were victimized, too, fooled into supporting a war we later regretted. We should recognize war's horror. We should feel the soldier's pain. But to impose on a distressed soldier the notion that his memories are inescapable, that he lacks the strength to incorporate his past into his future, is to highlight our moral sensitivity at the soldier's expense."

Shephard, in his book A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century, is not arguing that PTSD does not exist. Indeed, "shell shock" or "battle fatigue" was recognized long before PTSD became a formal diagnosis in the wake of the Vietnam War. Rather, he argues that the construct overemphasizes permanent psychic damage when resilience is actually more common among humans exposed to traumatic stress.

It is this capacity to recover that is lost when combat veterans (and others) are encouraged to take on the identity of chronically broken men and women.

Photo credit: "Helplessness" by Dr. S. Ali Wasif (Creative Commons license)

Hat tip: Tim Derning

Forensic psychology angles in the Josef Fritzl case

The whole world seems glued this week to the bizarre case of Josef Fritzl. As you know, Fritzl is the Austrian man who kept his daughter and three of their children together locked in an elaborate basement dungeon for 24 years. As the dust settles, I'm trying to set aside my moral and emotional reactions to parse out the intriguing forensic psychology angles. Among them:

Insanity defense

At the top of the list is the defense's announcement that it will pursue an insanity defense.

"I believe that the trigger was a mental disorder, because I can't imagine that someone has sex with his own daughter without having a mental disorder," said his lawyer, prominent Viennese attorney Rudolf Mayer.

If the attorney is thinking about the archaic concept of moral insanity, he has a point. From a lay perspective, Fritzl has got to be deranged. How else could he engage in such an elaborate, long-running scheme against his own flesh and blood? Indeed, "mentally deranged" was how he was described by a barman at a brothel he frequented, based on his sadistic and deviant sexual behavior with the prostitutes there. (Prostitution is legal in Austria.)

Pundits don't seem to know much about Austria's legal standard of insanity, and I couldn't find it online. But in most countries, including in Western Europe, the insanity defense is rarely invoked and is even more rarely successful.

As one criminal defense lawyer recently put it, "You can be extremely crazy without being legally insane. You can hear voices, you can operate under intermittent delusions, you can see rabbits in the road that aren't there and still be legally sane."

I could be wrong, but it's hard for me to see how a retired engineer and real estate developer who could maintain such an elaborate subterfuge for a quarter of a century would meet the legal standard of insanity in terms of not knowing the difference between right and wrong.

However, even were Fritzl to pursue the defense, it would not mean that he would "get off," a common misperception regarding the insanity plea. Rather, he would likely be locked in a psychiatric hospital for the remainder of his natural life.

You can listen to a half-hour conversation among experts on NPR's Talk of the Nation. Featured are law professors Christopher Slobogin and Alan Dershowitz and Slate magazine legal correspondent Dahlia Lithwick. (Click on the NPR logo to the right.)

It will be interesting as case facts emerge to learn what complex algorithm may have produced Fritzl's twisted psyche. According to a sister-in-law, he grew up without a father, and his mother beat him on a near-daily basis. Certainly, that is one type of home environment that can produce a sexual sadist.

Competency to stand trial

Much public confusion exists about the distinction between legal insanity and incompetence to stand trial, and this confusion may be occurring in the Fritzl case as well.

Fritzl's attorney is quoted as saying that his client is "mentally incompetent" and that he will challenge any other decision reached by the psychiatrist who has been appointed by the court. Austrian law allows him to obtain an expert opinion from a psychiatrist of his choice.

While the legal construct of insanity pertains to an accused person's past state of mind, including whether he knew the difference between right and wrong at the time of his crime, competency pertains to the accused's present ability to understand the legal proceedings and assist one's attorney at trial.

As such, incompetency is not a permanent barrier to prosecution. If a person is found incompetent to stand trial, he is treated until he becomes competent, at which time he stands trial. (In the NPR program I link to, above, Dershowitz claims competency is often a permanent barrier to prosecution, but I believe he is wrong about that except in unusual cases in which a defendant cannot be restored to competency due to such things as severe retardation or dementia.)

Sex offending

Austria, like the rest of Western Europe, has not jumped on the imprisonment bandwagon in recent years. Its incarceration rate is 108 per 100,000, more than seven times lower than the United States'. Criminal code reforms in 1974 emphasized the importance of diversion as an alternative to incarceration. And Austrians are so opposed to capital punishment that they stripped California Gov. Arnold Schwarzenegger's name from a soccer stadium in his hometown because he refused to pardon a condemned man.

But as we here in the United States certainly know, extreme cases fuel extreme laws, and the heinousness of Fritzl's deeds may fuel a drive for harsher punishment in Austria, especially of sex offenders.

Indeed, Austria's justice minister is already vowing to spearhead a sweeping review of all sentencing laws and to propose legislation doubling prison sentences for "especially dangerous" predators.

Fueling outrage around the world is the fact that Fritzl had a prior sex offense conviction. Way back in 1967, when he was in his early 30s, he served time for rape. He also had a second conviction for attempted rape and an arrest for indecent exposure, according to reports.

Prosecutors are still deciding how to charge Fritzl so that he faces the maximum possible punishment. The maximum sentence for rape is 15 years, and unlike in the United States time is not added consecutively for multiple charges. He could get a few additional years if convicted of "murder through failure to act" for the death of an infant whom he admits incinerating. But since he is 73 years old, the difference in his sentence is probably moot except on a symbolic level.

Trauma psychology

Perhaps most interesting, and most unsettling, is the psychological effects of their ordeal on Fritzl's victims. These include Elizabeth, the daughter imprisoned for a quarter of a century, the children, and even Fritzl's wife Rosemarie, who claims to have had no inkling of her husband's deeds.

Elisabeth was initially kept tethered on a cable that allowed only limited movement. For about nine years, she and her older two children, 19-year-old Kerstin and 18-year-old Stefan, were kept in a tiny room together, meaning the children would have witnessed their grandfather’s sexual abuse of their mother.

Nineteen-year-old Kerstin remains quite physically ill, so we do not know much about her mental state. Stefan, however, shows signs of severely impoverished physical and psychological development, including trouble talking and moving around in the open after spending his entire life in a small, windowless basement. Younger son Felix, 5, probably has the best chance of recovery. The children reportedly communicate through a combination of speech and animal sounds, including growling and cooing, and become exhausted with the effort of trying to make themselves intelligible to outsiders.

As child psychologist Bruce Perry explains in his new book, The Boy Who Was Raised as a Dog, trauma and neglect at any age can cause gaps in neurological development that are difficult to reverse. Dr. Perry’s treatment is "neurosequential," meaning he sequentially targets brain regions left undeveloped by trauma. When children's brains are affected in infancy, for example, therapy may start with healing touch or rhythm before moving on to higher brain functions.

Elizabeth's psychological state is difficult to even fathom. Her father reportedly began raping her when she was 11 and continued to do so for a number of years. She bore seven of his children, one of whom died and three of whom were taken away from her to live upstairs. Imprisoned in the tiny cellar from the age of 18, she reportedly looks far older than 42.

"Why didn’t she try to escape?" some people have asked. We, of course, don't know that she did not try. But if she didn't, based on the limited available facts it seems reasonable to guess that it was due to a combination of fear, learned helplessness, and Fritzl’s diabolical control and terrorization. The initial door to the prison cell was a half-ton of reinforced concrete on steel rails. Fritzl apparently convinced Elisabeth and the children that the concrete door was wired to explode, and that poisonous gas canisters would explode if they tried to escape.

One can only hope that with high-quality treatment and support the family will have some chance of recovery. And that can only begin to happen after the legal case is resolved.

The Scotsman of May 9 has details of Fritzl's in-depth interview on his motives. Wikipedia has additional information and links to background sources.

New study on background factors in false confessions

A growing body of research suggests that many of the factors that lead people to confess to crimes that they did not commit are environmental: The suspect is isolated, exhausted, intoxicated, pressured, misled, etcetera.

Some factors pertaining to the individual have also been clearly established. Juveniles and mentally retarded people are far more easily steered into confessing.

Now, Gisli H. Gudjonsson of Iceland, the foremost researcher on this topic, has published a new study examining what other individual factors may contribute to false confessions. The study indicates that a person who has been exposed to multiple traumas in his or her life is more likely to report having given a false confession during a police interrogation.

These traumas include victimization (being the victim of violence or bullying) and experiencing the death of a significant other. A history of substance abuse was also associated with reporting a false confession.

The abstract of the article, published in the Journal of Forensic Psychiatry and Psychology, is available online. The full article is available for a hefty fee.

Battered Women's Syndrome gaining acceptance

The Battered Women’s Syndrome is gaining acceptance from judges and jurors, according to an article in the May 21 issue of Massachusetts Lawyers Weekly.

The controversial defense combines elements of self-defense and Posttraumatic Stress Disorder to explain why some women ultimately kill an abusive partner.

In jurisdictions where the defense is allowed, defendants can present jurors with specific instances of prior victimization to show self-defense or the lack of criminal intent necessary for certain convictions. The defense also enables attorneys to answer the question that is often paramount in jurors’ minds: Why didn't the woman simply leave?

The 2000 Massachusetts Supreme Court decision of Commonwealth v. Pike described the syndrome as a mental state common to women who are abused over an extended period. "Numbed by a dread of imminent aggression, these women are unable to think clearly about the means of escape from this abusive family existence," the decision states.

The defense can pose a major obstacle to prosecution by engendering sympathy for the defendant, according to the Massachusetts Lawyers Weekly article.

The full article, authored by David E. Frank, is available at the journal’s website, http://www.masslaw.com/feature.cfm.

Subtle brain changes after trauma exposure

A new study highlights how easily a traumatic incident can alter brain functioning, and how long that change can last.

The researchers studied people who had been close to the World Trade Center on 9/11. Four years after the attack, people who were within 1.5 miles of the disaster still showed greater activation of their amygdalas – the region of the brain that controls our fight-or-flight instincts – than a control group who had been further away.

Participants were shown pictures of either calm or fearful faces while their amygdala activation was measured through a functional magnetic resonance imaging (fMRI) procedure. Those who were close to the WTC on 9/11 showed greater amygdala activation to fearful faces.

The results suggest that exposure to a single traumatic event may produce long-term brain changes that cause even healthy-appearing people to react more fearfully to everyday events.

The article, by Barbara Ganzel of Cornell University and colleagues, is available from the American Psychological Association at http://www.apa.org/journals/releases/emo72227.pdf.

Iraq war: Epidemic of invisible brain damage?

The Washington Post published an article on April 8 by on the invisible head trauma created by the high-powered explosives being used by the U.S. military in Iraq. Forensic psychologists who evaluate combat veterans should be on the alert for neurological sequelae, as described in the following article by pediatric nephrologist Ronald Glasser:

This is the new physics of war. Three 155mm shells, linked together and combined with 100 pounds of Semtex plastic explosive, covered by canisters of butane or barrels of gasoline, can upend a 70-ton tank, destroy a Humvee or blow an engine block through the hood of a truck. Those deadly ingredients form the signature weapon of the war in Iraq: improvised explosive devices, known by anybody who watches the news as IEDs.

Some of the impact of these roadside bombs is brutally clear: Troops are maimed by projectiles, poisoned by clouds of bacteria-laced debris and burned by post-blast flames. But the IEDs have added a new dimension to battlefield injuries: wounds and even deaths among troops who have no external signs of trauma but whose brains have been severely damaged. Iraq has brought back one of the worst afflictions of World War I trench warfare: shell shock. The brain of a soldier exposed to a roadside bomb is shocked, truly.

About 1,800 U.S. troops, according to the Department of Veterans Affairs, are now suffering from traumatic brain injuries (TBIs) caused by penetrating wounds. But neurologists worry that hundreds of thousands more -- at least 30 percent of the troops who've engaged in active combat for four months or longer in Iraq and Afghanistan -- are at risk of potentially disabling neurological disorders from the blast waves of IEDs and mortars, all without suffering a scratch….

Here's why IEDS carry such hidden danger. The detonation of any powerful explosive generates a blast wave of high pressure that spreads out at 1,600 feet per second from the point of explosion and travels hundreds of yards. The lethal blast wave is a two-part assault that rattles the brain against the skull. The initial shock wave of very high pressure is followed closely by the "secondary wind": a huge volume of displaced air flooding back into the area, again under high pressure. No helmet or armor can defend against such a massive wave front.

It is these sudden and extreme differences in pressures -- routinely 1,000 times greater than atmospheric pressure -- that lead to significant neurological injury. Blast waves cause severe concussions, resulting in loss of consciousness and obvious neurological deficits such as blindness, deafness and mental retardation. Blast waves causing TBIs can leave a 19-year-old private who could easily run a six-minute mile unable to stand or even to think….

Almost as daunting as treating TBI is the volume of such injuries coming out of Iraq. Macedo cited the estimates, gleaned at seminars with VA doctors, that as many as one-third of all combat forces are at risk of TBI. Military physicians have learned that significant neurological injuries should be suspected in any troops exposed to a blast, even if they were far from the explosion. Indeed, soldiers walking away from IED blasts have discovered that they often suffer from memory loss, short attention spans, muddled reasoning, headaches, confusion, anxiety, depression and irritability….

The unseen damage can be long-lasting. Most of the families of our wounded that I have interviewed months, if not years, after the injury say the same thing: "Someone should have told us that with these closed-head injuries, things would not really get all that much better."