Psychologist whistleblower awarded $1 million; fired after testifying about state hospital's competency restoration program

In an unprecedented case, a civil jury has awarded $1 million in damages to a psychologist who was retaliated against after she challenged the validity of a state hospital's competency restoration methods.

Experts at the trial included Thomas Grisso and Randy Otto, prominent leaders in the field of forensic psychology who have written and taught extensively on best practices in the assessment of competency to stand trial.

After a five-week trial with dozens of witnesses, the jury found that Napa State Hospital failed to apply generally accepted professional standards for competency assessment and coerced its psychologists to find patients competent to stand trial "without regard to the psychologist's independent professional judgment, and without application of objective, standardized, normed, and reliable instruments."

Photo credit: J. L. Sousa, Napa Valley Register

Melody Samuelson, the psychologist plaintiff, ran afoul of her supervising psychologists at the Northern California hospital in 2008, when she testified for the defense at a competency hearing in a capital murder case in Contra Costa County. She had treated "Patient A" the prior year and had doubts about whether he was capable of being restored to competency, as his current treatment team claimed. Both the prosecutor and a hospital psychiatrist who testified for the state complained about Samuelson's testimony to then-Chief Psychologist James Jones, who launched an investigation that ultimately led to Samuelson's firing.

Samuelson was reinstated after a three-day hearing in 2011. An administrative law judge ruled that hospital administrators had failed to prove that Samuelson overstated her credentials during her 2008 testimony. Samuelson was not yet licensed at the time.

Samuelson subsequently filed a civil suit against the hospital, the chief psychologist, and two other supervising psychologists, claiming they engaged in a string of retaliatory actions against her even after her reinstatement. These actions included initiating a police investigation for perjury and taking action against her state license. She said she incurred the wrath of hospital administrators by repeatedly objecting to sham competency restoration practices designed to get defendants out of the hospital as quickly as possible, whether or not they were actually fit for trial.

Napa is the primary state psychiatric hospital serving Northern California, and houses defendants undergoing competency restoration treatment and those found not guilty by reason of insanity.

It has long been general knowledge that the overcrowded hospital routinely certifies criminal defendants as mentally competent with little seeming regard for whether they are truly fit to stand trial. I have evaluated many a criminal defendant shipped back to court with a formal certificate of competency restoration, whose mental condition is virtually identical to when he was sent to Napa for competency training in the first place. (Typically, such defendants now proudly recite random legal factoids that have been drilled into them -- such as "the four pleas" -- that are often irrelevant and unnecessary to their cases.)

But until Samuelson blew the whistle, there was little direct evidence from within the institutions of intentionality rather than mere bureaucratic incompetence. Samuelson alleged in her civil complaint that Chief Psychologist Jones "made clear to Samuelson that he was committed to … returning patients to court as competent to stand trial, and to minimizing the time for attaining such positive outcomes, regardless of the actual competency of individuals to stand trial."

According to Samuelson’s lawsuit, one reason that psychologists were pressured to find patients competent was to improve outcome statistics as mandated by a federal consent decree. In 2007, around the time of Samuelson’s hiring, the U.S. Attorney General's Office negotiated the consent decree mandating sweeping changes aimed at improving patient care and reducing suicides and assaults at Napa. The federal investigation had revealed widespread civil rights violations, including generic "treatment" and massive overuse of seclusion and restraints. 

Rote memorization

A longstanding criticism of the hospital's competency restoration program is that it focuses on rote memorization of simple legal terminology, ignoring the second prong of the Dusky legal standard, which requires that a defendant have the capacity to rationally assist his attorney in the conduct of his defense.

In her lawsuit, Samuelson accused the hospital of violating the standard of care for forensic evaluations and treatment by relying upon subjective assessment methods that are easily skewed. Defendant progress was measured using an unstandardized and unpublished instrument, the Revised Competency to Stand Trial Assessment Instrument, or RCAI, and a subjectively scored "mock trial" that was scripted on a case-by-case basis by poorly trained non-psychologists, the lawsuit alleged.

According to testimony at the Napa County civil trial, the hospital drilled patients on simple factual information about the legal system rather than teaching them how to reason rationally about their cases. Staff distributed a handbook outlining the factual questions and answers, posted the RCAI items at the nurse's station, and administered the RCAI repeatedly, coaching patients with the correct answers until they could pass the test.

Although forensic psychology experts Grisso and Otto were retained by opposite sides -- Grisso by the hospital and Otto by the plaintiff -- they agreed that this process falls short of the standard of practice in the field. It ignores the Constitutional requirement that, in order to be fit for trial, a criminal defendant must have a rational understanding of his own case as well as the capacity for rational decision-making. 

It has long  been my observation that the hospital's program was generic and failed to address defendants' specific legal circumstances. Both Grisso, who authored one of the earliest and most widely referenced manuals for assessing competency to stand trial, now in its second edition, and Otto, co-author of The Handbook of Forensic Psychology and other seminal reference works, testified that competency evaluations must address the defendant's understanding of his or her own specific legal circumstances, sources close to the case told me.

Disclosure of test data unethical?

Another pivotal issue at trial, according to my sources, was whether Samuelson's disclosure of test data from two competency instruments she administered -- the Evaluation of Competency to Stand Trial-Revised (ECST-R) and the MacArthur Competence Assessment Tool (MacCAT-CA) -- was improper. Samuelson disclosed the data at Patient A's 2008 competency hearing, after obtaining an authorization from the patient and a court order from the judge.

The hospital peer review committee that first recommended Samuelson's firing reportedly claimed that this disclosure was unethical and a violation of the American Psychological Association's Ethics Code.

Nothing could be further from the truth. The current version of the Ethics Code contain no prohibition on this type of disclosure in legal settings. Furthermore, fairness dictates that the legal parties be allowed to view data that are being invoked to decide a defendant's fate, so as to be able to independently analyze their accuracy and legitimacy. 

The jury levied $890,000 in damages against the hospital, $50,000 personally against Jones, described in the lawsuit as "the ringleader" of the campaign against Samuelson, and $30,000 each against two other supervising psychologists -- Deborah White and Nami Kim -- who allegedly conspired with Jones. Although punitive damages were not awarded, the jury found that the three psychologists acted intentionally and with "malice, oppression or fraud" toward Samuelson.

The state has until the end of next month to appeal the verdict, according to reporter Jon Ortiz of the Sacramento Bee, the only media outlet to cover the verdict so far.

Hat tip: Gretchen White

* * * * *

The Sacramento Bee report on the verdict is HERE. Dr. Samuelson’s civil complaint is HERE; the jury’s verdicts are are HERE. 

. . . And, speaking of psychiatric care -- I highly recommend this incredible story of the one-of-a-kind town of Geel, Belgium. (Hat tip: Ken Pope) 

UPDATE: On Oct. 28, 2016, California's First District Court of Appeals denied an appeal by the state hospital, upholding the jury's verdict except for one portion of the monetary damages. In its detailed opinion, the appellate court fleshes out the rights of psychologist whistleblowers who come to believe that assessments are being conducted in a potentially unlawful manner within an institutional setting. One of the more fascinating issues addressed in both the trial and the appeal was the principle that institutional failure to properly tailor competency restoration training and assessment to the Dusky legal standard -- which mandates that an accused have the capacity to rationally assist his or her attorney -- constitutes a violation of the U.S. Constitution. "If, as plaintiff's counsel argued, [Napa State Hospital] personnel were certifying to the trial court that patients were competent to stand trial without properly assessing their competency, a patient's constitutional due process rights could potentially be implicated," the appellate court noted in approving Samuelson's right to have argued this point in the closing arguments of the trial. 

(c) Copyright Karen Franklin - All rights reserved

Efficacy of sex offender treatment still up in the air

Sex offender group treatment, Larned State Hospital, Kansas

"Did he complete treatment?"

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

But does formal sex offender treatment really lower risk?

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

This isn't altogether fresh news. We knew from earlier research reviews that:

• Any effect of treatment was modest, at best
• Treatment works best for the tiny minority of very high-risk offenders, while possibly aggravating risk for the broad majority of men at lower risk of recidivism 
• Older offenders, due mainly to their very low risk, derive no tangible benefits from treatment

But considering both the prevalence and the harm of child sexual abuse, there is surprisingly little high-quality research on effective interventions. Partly, this is because of the lock-'em-up-and-throw-away-the-key mentality of policy makers. And partly it is because of the ethical difficulties in implementing random-design procedures, a hallmark of the scientific method, because men assigned to a control group would be denied treatment that could reduce their risk and in some cases shorten their prison terms.

Patient at "treatment program" in Minnesota

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

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

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

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

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

Can treatment cause harm?

Given "the overall unimpressive treatment effects" that were found, the researchers cautioned clinicians working with sex offenders to consider the potential negative effects of treatment:

"Journeymen" by Ricky Romain (reproduced with permission)

"Under certain circumstances, with some people and some interventions, treatment could increase the risk of sexual reoffending. For instance, prolonged or intense interventions for offenders at low risk of relapse, or grouping low risk offenders with those at high risk for reoffending, could result in adverse outcomes."

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

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

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

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

Manualized, one-size-fits-all approach

My own belief is that the one-size-fits-all approach of manualized group therapy, driven in part by a shortage of highly qualified and talented clinicians in bureaucratic institutions, can never meet the needs of a heterogeneous population of offenders. Indeed, in the hands of poorly trained technicians, much of what passes for "treatment" is actually punishment in disguise. As anthropology professor Dany Lacombe noted in her insightful ethnographic study,  sex offender treatment can paradoxically cement deviance through its obsessional fixation on sex. As an 18-year-old patient told Lacombe:

"They want to hear that I always have fantasies and that I have more bad ones than good ones. But I don't have bad ones that often. I make up the bad ones. I make them really bad because they won’t leave me alone." 

"Contained" by Ricky Romain (with artist permission)

Genuine treatment, as we all should remember from our graduate school training, is all about the empathic relationship -- not the technique. Indeed, although more and more psychologists have internalized the insurance industry's mantra that cognitive-behavioral therapy (CBT) is the "evidence-based" treatment of choice for a variety of conditions, this is not actually true. For example, in a new randomized clinical trial published in the American Journal of Psychiatry, psychodynamic therapy performed just as well in the treatment of depression.

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

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

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

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

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

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

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.

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)

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).

New column: Ethics and captive populations

A recent photo in the Los Angeles Times pictured a psychologist administering therapy to a group of men locked in cages the size of phone booths. An expert advised that the cages should be called "therapeutic modules," lest the prisoners "feel like animals and respond accordingly." The arrangement is the prison's response to a judicial mandate to provide treatment to mentally ill prisoners. But as the photo illustrates, much prison therapy is far removed from traditional treatments that psychologists are trained to provide.

So begins my "Ethics Corner" column in the current issue of California Psychologist magazine, which evolved out of a blog post a few months ago, "Prison therapy: It's all in the name." The full column is HERE. I have also created a stand-alone web page of selected resources on correctional ethics (HERE).

Wearing body armor and sitting just out of urination range, psychologist Daniel Tennenbaum tries to engage Vacaville prisoners to sing along with "Sitting on the Dock of the Bay." Photo credit Los Angeles Times.

A plug for the CPA: For those of you in California, I hope you will think about joining the California Psychological Association if you are not already a member. The CPA gives psychologists a voice, has local associations that facilitate networking (and socializing), and provides a number of member benefits, including the Ethics Committee's free hotline.

Positive approach key to sex offender change

Trailblazing authors have walked the walk for 40 years

John distorts his offense history and refuses to accept his sexual deviance. Although the other members of his treatment group vigorously challenge him, they are not fully transparent in their own disclosures. The therapist feels stymied. What should she do?

First, she should abandon confrontation and negative labeling. Next, she should race lickety-split for her computer and order a radical new book that will help her succeed as a therapist and also feel better about herself.

The visionary book is Rehabilitating Sexual Offenders: A Strength-Based Approach, written by the team at Rockwood Psychological Services in Canada. Under the leadership of Bill Marshall, a pioneer in the field, the program has successfully treated sex offenders for 40 years. Unlike most sex offender treatment programs, Rockwood has a negligible refusal rate and a negligible dropout rate. Offenders enter therapy, they complete therapy, and when they get out they are very unlikely to reoffend.

Therapist is the key

As psychologists know from the general treatment research, the therapeutic alliance is a primary factor in successful therapy, with more impact than any specific theory or technique. With sex offenders, who are often mistrustful and reluctant to enter therapy or disclose information that may be used against them, the therapist is even more critical, accounting for between 30% to 60% of change.

Like anyone else (only more so), John isn’t going to benefit from confrontation or shaming. Instead of being critical or judgmental, an effective sex offender therapist is empathetic, warm, respectful, and even humorous at times.

Toss out those iatrogenic labels

Language is powerful. When we call people names -- pedophile, rapist, offender, sex offender, deviant – we encourage their negative and harmful beliefs about themselves. That certainly doesn’t reduce shame or foster change.

Instead, the Rockwood authors (Bill Marshall, his son Liam Marshall, Geris Serran, and Matt O’Brien) focus on strengths, invoking a vocabulary heavily influenced by the positive psychology movement and motivational interviewing.

Their guiding principle:

Inside every offender is a good person waiting to throw off the burden of his dysfunctional past. It is the therapist’s job to facilitate the emergence of that good person.

(Ironically, they do use the term “psychopath,” if only to say that scores on the Psychopathy Checklist  are NOT predictive of treatment failure or recidivism. Of the 70 offenders in their outcome research who scored high on psychopathy, only one reoffended during the 8-year follow-up period.)

The authors do not mince words in critiquing the dominant treatment approach that emphasizes deficits and avoidance. When treatment fails, they say, it is most likely because it was too confrontational. When confronted, patients learn to say what the therapist wants to hear, rather than to genuinely engage.

Denial: Not necessarily a bad thing

One of the most unusual features of the Rockwood program is its emphasis on helping men who continue to deny their offenses despite having been convicted. The therapists do not challenge these offenders to admit their crimes. In fact, they don’t think admissions are that big a deal. They offer several reasons for this:

• Given what we know from the false-confession literature, some deniers truly are innocent. And it is impossible to know which ones.

• Forcing an offender to match his account to his victim’s is silly, because we know from research that victim accounts are highly unreliable. 

• Men who deny offending or offer excuses actually have lower rates of recidivism. As Shadd Maruna found in his research with criminal offenders in the UK, excuse-making is related to good mental health as well as to guilt, which (unlike shame) suggests prosocial values.

For those engaged in treatment, the manual gives loads of practical advice on how to structure and run a program. For forensic evaluators on the outside looking in, who have watched in mounting horror as iatrogenic practices are systematically mislabeled as “treatment,” this book lays out the research that can help you explain real treatment to judges, jurors, and attorneys.

Rehabilitating Sexual Offenders is an auspicious debut for the American Psychological Association series, Psychology, Crime, and Justice, edited by Shadd Maruna. I can’t wait to see what’s next.

If you found this review helpful, please visit my Amazon review (HERE) and click on "yes" (this review was helpful). 

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).

 

Paint brushes and soap: The slippery slope of unfettered power

Courts rebuke detention centers for arbitrary and pretextual practices 

The case of the killer paint brush

When the government filed a petition seeking to civilly commit M.F. for sex crimes he might commit in the future, the elderly artist decided to go quietly. He gave up his right to a trial, in exchange for a legal order that he be allowed to do his art in his remaining years.

But officials at Missouri’s detention center resisted being told how to operate. M.F.’s security level was changed from green (low risk) to red (high risk), and his art supplies were taken away. When he challenged this in court, a government psychologist testified that the art supplies posed a threat to the institution’s security: Another patient could use them to hurt someone, or they might even block an evacuation route in the event of an emergency.

Calling the invocation of security “pretextual,”* a judge ordered the institution to return the paint brushes.

No soap unless we say so

In detention sites across the United States, objects far more innocuous than paint brushes are being wielded as weapons against captive sex offenders who -- like M.F. -- decline to enroll in proffered treatment.

In New Jersey, “A.J.,” a sex offender who declined treatment (insisting he is innocent) was denied basic hygiene items such as toilet paper, soap, shampoo, toothpaste, shaving cream and laundry detergent unless he could pay for them. The items were given free as prizes to sex offenders who enrolled in treatment. After a 3-day hearing, a judge ruled that the jailers were being “arbitrary and capricious”:

“Like food and clothing, personal hygiene items are central and core requirements of civilized existence. The refusal of the department of corrections to provide personal hygiene items to inmates at regular intervals is unreasonable. I also find that in this particular case the department of corrections sometimes observes its own rule and sometimes it doesn’t. So it’s capriciously applied as well.”

Tip of the iceberg

Arbitrary, vindictive, petty and sometimes just plain silly practices like these are not rare. Rather, they are commonplace experiences in the state hospitals where thousands of U.S. sex offenders are detained indefinitely based on future risk, after having finished their prison sentences.

The organizational culture is a setup for petty tyranny to run amok.

Unlike in a real hospital, there is an inherent tension between detainees and staff. Under the civil commitment laws, detention sites are supposed to provide treatment to reduce the sex offenders' future risk. But most of the residents decline to engage in treatment. They are resentful about being detained, and see the generic group therapy as a humiliating sham. For staff, in turn, the impossibility of their task lowers morale and can spawn resentment of offenders.

It is hard not to feel morally superior to the offenders. Many are not sympathetic characters. They have assaulted their way through life, leaving behind a swath of psychic destruction to children and women. Their mistreatment is easy to justify as deserved, or in service to the greater good of public safety.

Add to this incendiary mix the few bad apples in any organizational barrel. Literary trickster Carlos Castaneda called them little petty tyrants, who persecute and inflict misery without causing death. If you have ever worked in a prison or mental hospital, you know that such environments provide fertile soil for pinches tiranitos.

As we saw at Abu Ghraib, a frustrated work force with unfettered power over a maligned and powerless population is a recipe for abuse. Indigent prisoners don’t exactly have a voice to complain about abuses of authority. This is especially true for sex offenders. No one wants to hear a victimizer whining about being a victim. 

Alienation and despair

When Martin Seligman played mind games on dogs, giving punishments arbitrarily and not allowing escape, the dogs became apathetic and depressed. "Learned helplessness" resulted from their absolute lack of control or agency. The same thing happens with humans.

The arbitrary and capricious treatment that sex offenders are subjected to creates a vicious cycle. It ramps up alienation, despair, and bitterness. And this mindset is not exactly conducive to the types of prosocial change that we want to see in offenders.

Conditions are so unbearable in these facilities ostensibly designed for care and treatment that three offenders are using “necessity” as a defense for an attempted escape. The three tried to escape from Minnesota’s Moose Lake facility, which was the subject of an ACLU complaint over alleged violations of patients’ rights.

Last week, the would-be escapers unsuccessfully pleaded with a judge to let them stay in the county jail rather than returning them to the hospital, where they said conditions were intolerable:

“Please don’t subject me to any more mental and physical abuse without recourse. Please don’t send me back. I’d rather be euthanized.”

The judge nonetheless ordered the man sent back:

“I don’t have the jurisdiction to address the conditions [at the detention site] or the circumstances of your placement there.”

And therein lies the rub. Legislatures enact civil detention laws and set their parameters. But once the massive and costly facilities are up and running, it is easy for administrators and staff to forget that they are just functionaries, beholden to higher authorities for guidance. When this happens, the courts should step up. They hold ultimate responsibility for making sure that government operations are legal and fair.

A.J. and M.F. were lucky to have tenacious lawyers protecting their rights. Even then, their victories were tiny -- the right to soap and paint brushes. More typically, detainees are out of sight and out of mind. No one is watching, and no one cares.

Back in the day, Russian writer Fyodor Dostoyevsky mused that the degree of civilization in a society could be judged by entering its prisons. I wonder what his verdict would be if he could travel through time and visit a modern civil detention facility.

Related posts:

• "Treatment": Backwards and upside down? Don't focus on "denial" or "lack of empathy," warn sex offender treatment experts

• "Consumed With Sex": Sex offender treatment in risk society

*In the context of mental health law, legal scholar Michael Perlin defines pretexuality as “the ways in which courts accept—either implicitly or explicitly—testimonial dishonesty and engage similarly in dishonest and frequently meretricious decision-making, specifically where witnesses, especially expert witnesses, show a high propensity to purposely distort their testimony in order to achieve desired ends.” I used the term in the title of my just-published historical review of the term “hebephilia,” citing its use in court as a pretextual mental disorder.

Is Good Lives only for sex offenders?

A reader asked:

How applicable is the Good Lives Model (book review HERE) to working with people who have transgressed in ways other than sex offending?

Answer:

The theory was not developed for sex offenders in particular. It is being adopted for use with sex offenders under the premise that their patterns of desistance from crime are similar to those of other criminal offenders. Many types of rehabilitation programs are turning to the Good Lives Model and other positive psychology approaches. By way of illustration, here is a testimonial from a Canadian psychologist who uses it with men who have engaged in family violence:

We have been using the Good Lives Model (GLM) in a family violence program for men who batter for the past year. The framework allows us to maintain all the traditional processes one might typically see in an offender program. It also supports the use of a variety of strategies pulled from narrative therapy, solution focused therapy, zen psychology, biofeedback, cognitive behavioural, learning theory, etc. while maintaining a cohesive theoretical perspective.

The GLM approach supports a stronger focus on offender engagement. We find that the men are more able to see what their role is in therapy. We have been conducting exit interview with clients as they complete the program. It is interesting to hear how the values embedded in the program are translated into their narratives. I rarely heard this kind of ownership of change from men when we were teaching a relapse prevention-style group.

I found that shifting to the GLM from a purely cognitive-behavioral, relapse prevention, risk-needs-responsivity approach allowed me to align my understanding of what constitutes good therapy from the effective counselling literature (i.e., the therapeutic engagement of the client). At times I have found the strict manualized approaches to treatment to be more "psycho-educational" than therapeutic.

Our population is largely non-convicted, self-referred men where drop out rates are typically very high. People are finishing this program. Our outcome measures suggest clients experience an increase in self-monitoring, emotional self-regulation, and cognitive flexibility, with reductions in perceived levels of anger and aggression.

I did relapse-prevention sex offender programming for many years and continue to integrate those materials and strategies into the current curriculum. We just get to add a lot more and have the theoretical underpinning to back up our efforts.

Thanks to Ann Marie Dewhurst, Ph.D. of Edmonton for giving me permission to post this example of the Good Lives Model in action.

"Consumed With Sex": Sex offender treatment in risk society

Tuesday's post on sex offender treatment has been reposted on several discussion boards and listservs and is getting some hits from Alltop, a kind of cool online psychology news service. In doing research for an article I am writing about sex offense prevention, I just came across another one that may interest many of you. It's based on ethnographic research by Dany Lacombe, a professor of sociology and anthropology at Simon Fraser University, at a sex offender treatment program up in Canada.

Dr. Lacombe ended up dubbing the program Sex Offender School because of the way that it indoctrinated sex offenders into internalizing a high-risk identity as "a species entirely consumed by sex." Her observational analysis, "Consumed With Sex: The Treatment of Sex Offenders In Risk Society," published in the British Journal of Criminology, is fascinating. Here is the abstract:

This ethnography of a prison treatment programme for sex offenders examines the meaning of rehabilitation in the context of the 'new penology.' As it explores how cognitive-behaviourism structures treatment, it uncovers a therapeutics grounded in risk that actively constructs the identity of the sex offender. It shows how the management of risk relies on techniques of introspection and self-discipline—a patient's internalization of his crime cycle and relapse prevention plan—that target primarily sexual fantasies. These self-policing techniques radically transform the sex offender into a species entirely consumed by sex.

I recommend the entire article, which can be requested directly by emailing Dr. Lacombe.

Napa Hospital chief arrested for sexual assault

Police marched into California's largest psychiatric hospital today and arrested its executive director on 35 felony charges stemming from the alleged molestation of a foster son for more than a decade. The alleged victim, who was 10 when the abuse allegedly began, came forward when he learned that Claude Edward Foulk Jr. was in charge of the hospital. Foulk is suspected of molesting at least four other boys going back to the 1970s.

Foulk was appointed to head the beleaguered hospital in 2007, shortly after the U.S. Attorney General's Office negotiated a consent decree mandating sweeping changes aimed at improving patient care and reducing suicides and assaults. The federal investigation had revealed widespread civil rights violations at Napa, including generic "treatment" and massive overuse of seclusion and restraints. Napa is the only state psychiatric hospital in Northern California, and houses defendants undergoing competency restoration treatment and those found not guilty by reason of insanity.

At the time of his appointment, Faulk was lauded for his lengthy career in mental health services in both the private and public sectors, according to news accounts.

The arrest, breaking news on television and in print media across the country and even internationally, will do nothing to boost staff morale, already abysmal at Napa and elsewhere in California's state hospital bureaucracy. It surely won't improve patient care, either.

Action Alert: Help save Minority Fellowship Program

Despite a glut of mental health practitioners in some communities, ethnic minority communities in the United States continue to face extreme shortages. People in poor and minority communities have a harder time finding help and, when they do get treatment, it is typically of poorer quality, according to studies.

This problem will drastically increase if President Bush gets his way: The proposed budget for 2009 will eliminate the long-running Minority Fellowship Program, thereby reducing training opportunities for minority professionals who are more willing to work in critically underserved communities.

Clicking either here or on the "Contact Congress Now" box below will take you to an American Psychological Association-sponsored website where you can email your Congress member and urge him or her to save this 33-year-old fellowship program. It takes less than three minutes.

Do sex offenders have right to confidential therapy?

Normally, conversations between an individual and his or her therapist are confidential. But do convicted sex offenders lose that legal right to confidentiality?

That was the issue decided by a California appellate court this week.

Reynaldo Corona was mandated into sex offender treatment after being convicted of molesting his teenage stepdaughters. He complied with required group treatment through the Parole Outpatient Clinic (POC). But in addition, he voluntarily sought his own private therapy, for which he paid out of his own pocket.

When his parole agent found out, Corona was threatened with a return to prison unless he signed a waiver of privilege allowing his private therapist to communicate with parole officials.

On Wednesday, a Second District appellate court upheld the trial court's opinion that the parole requirement is unreasonable. As the court pointed out, such oppressive restrictions would discourage parolees from obtaining treatment that might reduce their risk to society.

Corona's decision to seek private therapy "would seem to be something for which he should be credited, rather than penalized," the court commented. "The People have not identified a nefarious reason for Corona's decision to engage in additional therapy."

The opinion is here. Hat tip to Adam Alban, who has further commentary at his Clinical Lawyer blog.

Helping prisoners get disability funds

The U.S. Department of Justice's Office of Justice Programs has issued a report on correctional programs that help prisoners apply for federal disability payments so that their treatment services will not be interrupted upon their release from custody.

The report, "Helping Inmates Obtain Federal Disability Benefits," examines programs in Texas and New York state prisons and a county jail in Philadelphia. All three programs help severely ill offenders qualify and apply for federal benefits that, in turn, enable them to get necessary treatment in their local communities upon release.

The report provides practical information for mental health and medical staff in correctional settings as well as prison counselors, correctional administrators, and probation and parole officers.

It is available online.

Confession to prison psychiatrist not confidential

The 9th Circuit Court of Appeals has issued a ruling with implications for forensic psychology, treatment in correctional settings, group therapy, psychotherapist-patient confidentiality, and correctional ethics more broadly.

The case goes way back to 1984, when 13-year-old Christy Ann Fornoff was sexually assaulted and smothered to death in Arizona. Physical evidence and suspicious circumstances linked Donald Beaty to the crime, and he was quickly arrested.

While awaiting trial, Beaty became depressed and went on a hunger strike. He was transferred to a psychiatric unit, where he agreed to participate in an experimental, coed therapy group. At one group session, a teenage girl confronted Beaty about his offense, and he became upset. Immediately after the group session, Beaty approached the prison psychiatrist who ran the group, George O'Connor. As O'Connor later recalled the conversation, Beaty said he was not a terrible person and that he had not meant to kill Ms. Fornoff.

Time went by. Beaty went to trial. The prosecution presented physical evidence linking him to the crime, but the jury hung 10-2 (for guilty). Meanwhile, O'Connor happened to be in court on another case. During some idle chitchat, he told a guard that Beaty had confessed to him. Through the grapevine, the prosecutor quickly heard this good news, and O'Connor was compelled to testify at Beaty's second trial. Not surprisingly, the verdict this time was guilty. Beaty was sentenced to death.

At issue in the capital habeas appeal was whether Beaty's statement to the psychiatrist was properly admitted, or whether it was protected as confidential. Beaty argued that he had signed a confidentiality agreement to participate in the group therapy and that he thought his conversation with the psychiatrist was confidential.

An appellate court disagreed. The confidentiality contract only applied to statements made while the group was in session, not to a private conversation immediately thereafter. The court also disagreed with Beaty that he was coerced into treatment. (This is relevant because a coerced confession to police may be excluded from evidence if it is shown that the suspect's independent will was overborne.)

The court distinguished Beaty's case from two earlier cases in which statements made to psychiatric clinicians in custodial settings were deemed protected from disclosure.

Case of Daniel Pens

In the first of these two cases, Daniel Pens was convicted of rape in 1981 and committed to a locked treatment program at Western State Hospital in Washington. The treating therapists assured Pens that information he revealed during his mandatory treatment would remain confidential and would not be disclosed to the courts. As part of his treatment, Pens confessed to additional rapes. After three years, the clinicians wrote a report to the court detailing Pens’ self-incriminating statements and concluding that he was too dangerous to be released.

In 1989, the Ninth Circuit ruled that Pens' admissions fell squarely within the Fifth Amendment privilege against self-incrimination, and could not be used against him in court. (The case is Pens v. Bail, 902 F.2d 1465.)

Case of "D.F."

The appellate court also distinguished the Beaty case from a far more fascinating case out of Wisconsin that is worthy reading for all mental health practitioners. In 1993, 12-year-old "D.F." of Wisconsin was charged with killing her two infant cousins. She was placed in a locked institution for troubled youths. Like many such programs, the program utilized a level system in which privileges and punishments were accorded based on participation in treatment. Patients who talked to clinicians and wrote in their journals could wear their own clothes, talk to other children, and move around freely.

Four months into her treatment, during a group therapy session, D.F. admitted killing her cousins. A staff member immediately reported the confession to Child Protective Services, which in turn notified the FBI. During a subsequent investigation, treatment staff secretly funneled information to the FBI while continuing to encourage DF to discuss her crimes in therapy.

At DF's trial, the judge suppressed the statements not on the basis of the privilege against self-incrimination (as in Beaty's case), but on the grounds of psychotherapist-patient privilege. The prosecution appealed to the district court.

The district court conducted an inquiry into the treatment center's operations. The court noted that treatment staff had close working relations with police agencies and, indeed, many acted as "law enforcement surrogates" in eliciting confessions from troubled teens. Warnings about the consequences of self-incrimination were minimal to non-existent. The district court upheld the suppression of DF's confession; the 7th Circuit Court of Appeals upheld that ruling in 1995. DF's treating clinicians, in the appellate court's view, were acting in the dual roles of prosecutor and healer. (The case is U.S. v. DF, 63F.3d 671.)

Harking back to Estelle v. Smith

In its decision in DF's case, the 7th Circuit went back to the landmark U.S. Supreme Court case of Estelle v. Smith (451 U.S. 454). To refresh your memory, that Texas case involved Ernest Benjamin Smith, who was sentenced to death for the armed robbery of a grocery store in which his accomplice fatally shot the clerk. Smith had the misfortune to have his competency evaluated by state psychiatrist Dr. James P. Grigson, who later earned the infamous nickname of "Dr. Death." At Smith's sentencing hearing, Grigson testified that Smith was "going to go ahead and commit other similar or same criminal acts if given the opportunity to do so." After hearing that ominous prediction, the jury voted for death.

In Estelle, the U.S. Supreme Court held that a court-appointed psychiatrist must give Miranda warnings before questioning a prisoner. In other words, it doesn't matter that the information-gatherer is a psychiatrist rather than a police interrogator. What matters is the purpose for which the information is being collected. Dr. Grigson, although not a government officer, was acting on the state's behalf.

The court's narrow ruling in Beaty is troubling, in that it may encourage prosecutors to seek incriminating information from clinicians working in custodial settings. The ethics of such disclosures remains a cloudy issue, with correctional clinicians holding a variety of views on when they are required or permitted to divulge information to authorities. At minimum, this line of case law should remind forensic practitioners of the need to provide a careful, Miranda-like warning to people we are evaluating, describing the lack of confidentiality and how the information they provide may be used. And certainly, Dr. O'Connor's casual disclosure of Beaty's confession to a guard – which set this case in motion – seems a breach of proper conduct.

Perhaps the best treatise on this topic is John Monahan's Who is the Client? The Ethics of Psychological Intervention in the Criminal Justice System. But that was written more than a quarter of a century ago, in 1980, and drastically needs updating in light of new case law and practice and the radical expansion of both the criminal justice system and the correctional treatment industry.

The case of Beaty v. Schriro, No. 05-99013, is available at the 9th Circuit's website.