L.A. Times investigates "Titanic State Hospital"

"BREAKDOWN"

California's sex offender treatment and detention center in shambles

Two days ago, I posted about the continuing problems at Coalinga State Hospital, California's expensive new detention facility for civilly committed sex offenders. Today's L.A. Times features an in-depth look at the institution's problems. The article, "Breakdown: Turmoil replaces treatment at Coalinga hospital," is written by Scott Gold and Lee Romney, who have been covering California's troubled state hospital system over the past couple of years. Astonishingly, the reporters found a former psychiatric technician from the hospital who was willing to assert on record that many of the men being detained at Coalinga pose little risk to the community if released.

Excerpts of the hard-hitting article follow; the full article (plus a photo gallery) is available online.

Two years after California opened the nation's largest facility designed to house and treat men who have been declared sexually violent predators, Coalinga State Hospital is described by both patients and staff as an institution in turmoil.

Convinced that they stand little chance of being released and angry about perceived deficiencies at the hospital, patients are engaged in a tense standoff with administrators, according to interviews with more than 40 patients and staff members.

… "We're calling it the Titanic State Hospital," said a psychiatric technician who, like most other current employees, spoke on condition of anonymity, fearing reprisal from administrators. "We've lost control. I've been saying for a couple of months now that the monkeys are running the circus."

Patients, meanwhile, are despairing.

"It's hopeless," said Robert Bates, 41, who was sent to Coalinga after serving a 10-year prison term for committing a lewd and lascivious act. "This is a therapeutic setting, supposedly. But it's nothing more than a mock-up prison. They can call it what they want. But it's prison."

… Michael Feer, a psychiatric social worker with more than three decades of experience, worked at Coalinga for a year before leaving this spring. He now works in San Diego County with recently paroled sex offenders, men who in some cases committed the same crimes as those at Coalinga but who are being released into the community, he said.

Feer said that although all Coalinga patients qualify as violent predators on paper, he believes that more than a third of them would pose no threat if released.

"They did their time, and suddenly they are picked up again and shipped off to a state hospital for essentially an indeterminate period of time," Feer said. To get out, he added, "they have to demonstrate that they are no longer a risk, which can be a very high standard. So, yeah, they do have grounds to be very upset."

The hospital, Feer said, "is a setup" - ostensibly a treatment hospital but one built with a wink to a public that has little compunction about locking up sex offenders forever....

Article continues here.

9th Circuit upholds lifetime supervision of child pornographer

The Ninth Circuit Court of Appeals yesterday upheld lifetime supervision of a child pornographer after he finishes serving his prison term.

Gordon Cope, 58, was caught with computer images and videos depicting child pornography during an undercover FBI investigation of Internet chat rooms. He pleaded guilty to a single federal charge of possession of child pornography and was sentenced to 10 years in prison.

The appellate court held that lifetime supervision was "reasonable" and Constitutionally permissible in light of the California man's previous conviction in 1981 for attempted sexual assault on a minor.

Cope also appealed special sentencing provisions requiring that he comply with forced medications, penile plethysmography, Abel testing, and polygraph testing as part of mandatory sex offender treatment. The appellate court held that such requirements are permissible, but that Cope should have been provided with adequate notice and more explanation of why these special conditions were needed. The case was remanded back to the trial court for such proceedings.

Yesterday's ruling is available online.

Sex offender program boasts remarkable success rate

Amidst the continuing controversy about whether treatment works for sex offenders, one prison rehabilitation program is boasting an almost 100% success rate.

That is a 24-year-old program in Missouri, at the Farmington Correctional Facility. Only 4% of sex offenders who complete the "MoSOP" (Missouri Sex Offender Program) are rearrested for a new sex offense within three years; after 10 years, the nonrecidivism rate is a whopping 94%.

Those are pretty mind-boggling statistics, considering that the rearrest rate for non-sex offenders within three years is about two-thirds. (In a 15-state study conducted by the U.S. Bureau of Justice Statistics, car thieves had the highest rates of rearrest, at 79% within three years, followed by burglars, 3 out of 4 of whom were rearrested for another serious crime within three years of release.)

In Missouri, sex offenders who are sentenced to prison have the option of participating in MoSOP. The incentive is early release; those who decline are ineligible for parole and must serve their full prison term.

The program's approach - like most in the burgeoning sex offender industry - is cognitive-behavioral with a heavy focus on relapse prevention. Completion requires about 12 to 15 months, during which time prisoners engage in group and individual therapy, educational coursework, and intensive study that takes up most of their time.

Perhaps artificially elevating the success rate is that prisoners who fail to complete the program are not counted in the recidivism data. Only about 41% (or 521) of 1,273 prisoners finished the program between 2000 and 2004, for example; 2005 saw an additional 244 graduates. In 2006, only about half of all enrolled prisoners finished the entire two-phase program. I could not locate recidivism data for those who did not finish the treatment, although detected recidivism rates even for untreated sex offenders are fairly low, generally in the range of 14% to 17%.

A television news report on the Missouri program is available online.

New articles on sex offenders

The latest issue of Sexual Offender Treatment is now available online, with some interesting articles - all of them free. The journal is an international peer-reviewed journal published by the International Association for the Treatment of Sexual Offenders. Current articles include:

Myths and Facts about Sexual Offenders: Implications for Treatment and Public Policy
by Timothy Fortney, Jill Levenson, Yolanda Brannon & Juanita N. Baker

Abstract: The purpose of this study was to determine to what extent perceptions about sexual offenders are based on empirical evidence or misconceptions…. Results revealed that both sex offenders and the public overestimated the rate by which strangers victimize children, and overestimated the number of sex offenders who were victims of sexual abuse in childhood. Both offenders and the public overestimated the number of sex crimes that come to the attention of authorities. The public more extensively than offenders overestimated the frequency of sexual recidivism rates and underestimated the efficacy of sexual offender treatment in comparison to the literature.

The Logic of Sexually Violent Predator Status in the United States of America
by Daniel F. Montaldi

Abstract: Sexually Violent Predator (SVP) laws have placed great legal weight on psychosexual evaluations of sex offenders by mental health experts. The conclusions of these evaluations are used to civilly commit hundreds of offenders throughout the United States after the completion of their criminal sentences, possibly for life. This paper examines the reasoning used by evaluators and attorneys for the state to justify the claim that someone is SVP. [The article discusses] flaws in this reasoning and show how arguments for SVP status must proceed if the case for civil commitment is to be logically coherent and consistent with constitutional values.

The Therapeutic Challenge of the Learning Impaired Sex Offender
by Ron Langevin & Suzanne Curnoe

Abstract: Learning impairment in childhood and adolescence was examined in a sample of 1915 sex offenders and 279 non-sex offender and community controls. They were compared on school dropouts, grade failures, and placement in special education classes. The sex offenders showed significantly lower education and higher incidences of dropouts than community controls. The offender groups more often had failed grades and had been in special education classes than the population at large. Neurodevelopmental factors such as birth complications and defects, motor and language developmental abnormalities, ADHD, neurological disease and injuries, mental retardation, and learning disorders, all contributed to the educational deficits, but learning disorders diagnosed in childhood contributed most. The importance of assessing learning impairment for treatment compliance and effectiveness is discussed.

Back issues of the Journal are also available online for free, including interesting articles on juvenile offenders, diagnostic accuracy, actuarial assessment, treatment efficacy, incest offenders, phallometric assessment, diagnosing sexual sadism, and public policy issues.

Book Recommendation: The Center Cannot Hold

"The Little Engine that Could"

If you're deciding what to read next, I strongly recommend Elyn R. Saks' The Center Cannot Hold: My Journey Through Madness. I guarantee you won't forget it soon.

Saks is an acclaimed professor of law and psychiatry. She also struggles with severe symptoms of schizophrenia. She risked her reputation in academia in order to give hope to others like herself, and to counter the negative stereotypes about mental illness held by both the general public and mental health professionals:

"I wanted to dispel the myths ... that people with a significant thought disorder cannot live independently, cannot work at challenging jobs, cannot have true friendships, cannot be in meaningful, sexually satisfying love relationships, cannot lead lives of intellectual, spiritual, or emotional richness."

The topic is inherently compelling, and Saks masterfully describes what it is like to be tormented by inner demons, to be forcibly restrained on a hospital bed, to require medications that alter one's mental state and can cause horrific, irreversible side effects. She articulately describes her years of talk therapy, in which she came to understand the functional underpinnings of her psychotic thoughts, for example in warding off feelings that would have been consciously threatening.

I enjoyed her dry humor in highlighting the condescension and absurdities of the mental health system. In one case she reviewed during a legal internship, the patient was restrained because he refused to get out of bed. In another case, a young man was deemed delusional because he continually spoke with "imaginary lawyers" - who turned out to be none other than Saks and her colleague.

For years, in order to excel, Saks had to lead a double life. Swirling around her, constantly threatening, was the stigma of mental illness. While writing an academic paper on restraints, she asked a professor, "Wouldn't you agree that being restrained is incredibly degrading, not to mention painful and frightening?" With a kind and knowing look, the professor responded: "These people are different from you and me. It doesn't affect them the way it would affect us."

This book is especially important reading for mental health professionals in the United States, where medication reigns supreme (it has become practically taboo to recommend psychotherapy for severe psychosis, despite ongoing research establishing its efficacy) and coercion often trumps choice. Saks contrasts her experience of being hospitalized in the United States with her experience in England, where restraints have not been in widespread use for more than 200 years. In doing so, she gives us a deeper appreciation of the trauma induced by coercive and sometimes brutal treatment.

"The Little Engine that Could" is what her close friend Steve Behnke calls her, referring to her indomitable spirit even in the face of hospital clinicians' dire predictions about her future.

I highly recommend this courageous and brilliant memoir.

A 45-minute video of Saks' talk at this year's American Psychological Association convention is available online at her personal website. Other books by Saks include Refusing Care: Forced Treatment and the Rights of the Mentally Ill (2002) and Jekyll on Trial: Multiple Personality Disorder and the Criminal Law (1997).

More bad news from California: Jails designated as "treatment facilities"; mental health courts vetoed

Wouldn't it be great if, instead of supporting more prisons, California's governor signed legislation authorizing mental health treatment that might reduce the need for prisons in the future?

Sadly, that's just a fantasy.

After my post yesterday about Gov. Schwarzenegger vetoing three criminal justice reform measures, an alert subscriber notified me about two other forensic treatment-related decisions in which the governor came down on the wrong side:

SB 568: Jails designated as "treatment facilities"

With state mental hospitals crammed full of civilly committed sex offenders and the like, there's no longer room to treat mentally ill defendants who are too crazy to have their day in court. So, with the backing of the state's sheriff's departments, Gov. Schwarzenegger signed emergency legislation allowing the jails to forcibly medicate defendants who are incompetent to stand trial.

As I explained in my original post on this bill back in June, some forensic psychologists are concerned about this law. Jail psychiatric services are minimal; prisoners with severe mental disorders will be denied the type of around-the-clock services in a therapeutic setting that they may need to be restored to trial competency.

California's move toward minimizing treatment services may encourage other states to do the same. foisting additional fiscal burdens onto cash-strapped county governments. It's all part of the trickle-down effect of the criminalization of the mentally ill that began in the 1970s with the defunding of community mental health programs and escalated with the prison boom of the 1980s and 1990s.

SB 851: Mental health courts nixed

Gov. Schwarzenegger also placed himself on the wrong side of the national mental health court movement by vetoing a bill that would have expanded such courts in California. In vetoing SB 851, he cited the fiscal costs, estimated by the Department of Corrections at $14 million per year. He also claimed that mental health courts would "allow people who have committed crimes to avoid punishment completely because of a mental health issue." (Never mind that defendants often find the stringent treatment requirements of such courts more onerous than just doing their time.)

Let's look at some numbers. California's prison budget this year was a whopping $10 billion. That does not include another $7.4 billion just authorized for 40,000 new prison beds, or the estimated $330 million per year in interest on those construction bonds. Indeed, California is spending so much on keeping people locked up that in five years, annual prison spending will shoot past higher education expenditures.

If my math is correct, the annual budget for the mental health courts would be only about one-tenth of one percent of this year's prison operating budget.

If Gov. Schwarzenegger was interested in reducing recidivism, as he claims, he would be willing to expend that measly sum to provide mentally ill prisoners with the treatment that might rehabilitate them and allow them to lead productive lives. Keeping the mentally ill out of prison is not only humanitarian, but would reduce the need for new prison beds, providing big cost savings to us tax-paying citizens in the future.

But that's assuming that the governor was willing to stand up to the correctional industry, the state's most powerful lobby. No California governor has done that and survived.

Hat tip to Robert Canning for alerting me to these developments.

The ongoing debate: Does sex offender treatment work?

In the wake of the attempted rape arrest of a man who had spent eight years in sex offender treatment, Vanessa Ho of the Seattle Post-Intelligencer has a thoughtful article about the controversies surrounding the efficacy of sex offender treatment:

… While the overall climate for sex offenders has radically changed - with longer sentences and more restrictions - treatment has largely remained static, relying on the same cognitive-behavioral methods introduced in the 1980s.

"It's an ongoing question, there's no two ways about it," said Roxanne Lieb, director of the Washington State Institute of Public Policy, on the effectiveness of treatment. "Certainly, it's not a cure-all," she said.

Last year, Lieb's office released a study that found that Washington's prison treatment program for male sex offenders - one of the largest in the nation - had virtually no effect on reducing recidivism rates.

The study echoed a landmark 2005 study, in which researchers found that a California hospital program for confined sex offenders had no significant impact on curbing repeat crimes.

Both studies, however, have detractors who point to other studies showing that treatment works....

The full story, along with some nice graphs, is available online.

Medical doctors' unconscious racism affecting patient care

Does lurking racism affect the workings of our major institutions - government, the judiciary, medicine, and education? And how, if it is underground, can we even answer this question with anything more than speculation and opinion?

Where there's a will, there’s a way.

Psychological scientists have developed a tool called the Implicit Association Test that scientifically measures unconscious racism. That is, it can tell whether you have racial biases that you are not aware of. The test is being used to empirically assess for the presence of individual-level racism in societal institutions.

In the field of medicine, for example, we know that African Americans have higher infant mortality rates and death rates from cervical cancer, heart disease, and stroke than white patients. But are these differences due to outright racism on the part of doctors, or to other factors such as socioeconomic status or lack of health insurance?

While such macro-level factors are undoubtedly significant, a group of Harvard University psychology researchers have used the Implicit Association Test to prove that unconscious racial bias affects how doctors treat heart attack victims.

The study, reported in the current (September) issue of the Journal of General Internal Medicine, involved giving a hypothetical vignette to doctors about a patient suspected of having had a heart attack. In some cases, the patient was described a white; in others, he was described as black. In all other ways, the patient was the same. Doctors who scored high in unconscious racism on the Implicit Association Test tended to withhold aggressive treatment from the black patients.

The current issue of the journal also reports on another study – this one involving real patients - suggesting that similar racial factors play into doctors' decisions about whether to refer women for osteoporosis screening after a hip fracture.

These and other, recent studies suggest that the empirical study of individual-level racism is hitting its stride. Indeed, I posted recently about similar studies of automatic racial processes in the forensic realm, and how subtle racial bias on the part of police, probation officers, and others affects rates of arrest, prosecution, and incarceration.

Since unconscious bias is by definition outside of conscious awareness, and since racism is not as popular as it used to be, no one wants to admit to harboring it. Thus, it is difficult to confront without the empirical evidence of its existence.

Unfortunately, such study has barely touched the mental health field. Although we know that psychiatric diagnosis and treatment vary tremendously by race, for everything from schizophrenia to childhood Attention Deficit/Hyperactivity Disorder, the empirical study remains to be done on why this is so. Until we can identify the precise mechanisms, disparities will remain, affecting the quality of care and in some cases life or death itself.


You can take the Implicit Association Test online.

Reference: Green AR, Carney DR, Pallin DJ, Ngo LH, Raymond KL, Iezzoni LI, & Banaji MR. (2007). Implicit Bias among Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients. Journal of General Internal Medicine, 22, 1231-1238.

Photo credit: Vanity Press (Creative Commons license)

New study on desistance from crime

Every day, about 1,600 people are released from prisons in the United States. Until now, the primary focus has been on the "R word" - recidivism.

In a promising trend that I’ve posted about previously, some academicians and policy makers are turning to the "D" word - desistance.

As part of this welcome trend comes a new study by the National Research Council. The study, Parole, Desistance from Crime, and Community Integration, points to evidence-based interventions that significantly reduce recidivism. As a psychologist, I was happy to see that cognitive behavioral therapy tops the list, followed by intensive drug treatment. Strong marriages and ties to work also help parolees reintegrate into society.

The entire book is available for free online from the National Academies Press.

Should jails be designated "treatment facilities"?

When criminal defendants are found incompetent to stand trial, they go to state hospitals for competency restoration treatment. But hospitals around the country have run out of beds, forcing psychotic defendants to linger in county jails for many months.

In response to this crisis, California is proposing to designate county jails as "treatment facilities" that can provide pretrial defendants with competency restoration treatment for up to six months.

Under Senate Bill 568, jails will gain the authority to forcibly medicate incompetent defendants. (This is a complicated area of law governed by the 2002 U.S. Supreme Court case of U.S. v. Sell. For background, see: www.jaapl.org/cgi/reprint/32/1/83.pdf.)

Forensic psychologists are voicing concern about this move.

First of all, jails are unlikely to do much more than administer antipsychotic medications, in some cases without proper legal review and oversight. Jail psychiatric services tend to be minimal and underfunded. They are not set up to provide effective competency restoration training.

A second concern is that the jail environment is not conducive to mental health. Prisoners with severe (and often complex) mental disorders need around-the-clock services from highly trained professionals in a therapeutic setting in order to become competent to stand trial.

The bill, backed by the sheriff’s departments that run county jails, appears to be in response to a recent Sacramento court ruling that incompetent defendants must be transferred quickly to state hospitals for treatment. A competing bill, Assembly Bill 1121, would require that defendants be transferred to state hospitals within 14 days of being found incompetent.

If SB 568 passes, other states with similar crises will likely try this solution as well, foisting their fiscal burdens onto cash-strapped county governments. It’s all part of the trickle-down effect of the criminalization of the mentally ill that began in the 1970s with the defunding of community mental health programs and escalated with the prison boom of the 1980s and 1990s.

Thanks to Robert D. Canning, Ph.D., Paul G. Mattiuzzi, Ph.D., and Philip J. Davis, Ph.D. for their contributions to this analysis.

Senate Bill 568 is available at: http://tinyurl.com/37rl53

Assembly Bill 1121 is available at: http://tinyurl.com/39cn6

Can school shootings be prevented?

Everyone’s got an opinion about Seung-Hui Cho and how his Virginia Tech rampage could have been prevented. The university administration should have done something. The police should have done something. And where the heck were his parents?

Such acts never occur out of the clear blue sky. There are always signs. With new details emerging rapidly about Cho Seung-Hui's history, we know that Cho gave off a great many signs. And some around him noticed those signs.

At least one teacher was so disturbed that she reported him to academic authorities and to police. Police investigated his “stalking” of female students and even had him briefly hospitalized. His parents called campus administrators to voice their concerns about his mental health. Fellow students say they even wondered aloud whether Cho could be a school shooter.

The problem, in terms of violence prediction, is that many people – and especially many adolescent and young adult men – are troubled. Many are severely depressed. Many express disturbing, violent fantasies. But, fortunately, only a tiny fraction commit lethal acts against others.

In other words, hindsight is 20/20. It is far easier to realize that a young man is depressed or disturbed than to accurately predict whether he will become violent. Prior to his rampage, Cho may not have seemed all that out of the ordinary to college counselors and police.

A national study of 95,000 college students last year found that in the previous year 16% had felt so depressed that they found it difficult to function. More than 9 percent had seriously considered suicide, and one in every 100 had tried to kill themselves that year. And more and more students are seeking treatment at college counseling centers. The counseling center at Virginia Tech treats about 2,000 students a year, according to its director.

In an interview with The Chronicle of Higher Education, the incoming president of the Association for University and College Counseling Center Directors said that many of Cho’s signs are not at all unusual among college students.

At Cornell University, where he is director of counseling services, Gregory Eells said it is “fairly common” for a professor to call counseling services to ask what they should do when a student writes a disturbing essay.

“Would you hospitalize Quentin Tarantino?” Eells asked. “There are all sorts of writers who write about dark, violent themes, but most of them are not dangerous to themselves and others.

“It's always easy to look back and say the friend was concerned, a faculty member was concerned, they had a previous hospitalization…. But to make a jump and say that everyone who exhibits those signs is going to become the perpetrator of the worst shooting in American history is not a logical jump. That possibility is always there, but a million times that is not what is going to happen.”

The director of the counseling center at Virginia Tech agreed, pointing out that the types of stalking complaints made by the two women against Cho are not uncommon on college campuses.

"It is very difficult to predict when what someone perceives as stalking is stalking, and then how it might translate into violence later," Dr. Chris Flynn of the Virginia Tech counseling center told the Associated Press. "Clearly, if anyone had any warning about a violent incident, people would have stepped in and acted."

After a disaster such as this, some people will likely lobby for stricter laws. Laws reducing psychologist-patient confidentiality. Laws making involuntary hospitalization easier. But such laws would cast too wide a net. In the end, it may prove impossible to predict which troubled young man will become violent.

Instead, we might want to look for ways to reduce the alienation and rage felt by so many young men today. To improve school climates. To reduce the bullying, the ostracization, and the glorification of hypermasculinity that provide the social backdrop for school shooting rampages.

For an interesting perspective by educator ira Socol, go to: http://www.insidehighered.com/views/2007/04/20/socol