DSM-5: Forensic applications (Part II of II)

Courts cling to DSM as "bible"

As alluded to yesterday, in Part I, mental health professionals know not to take the DSM (or the ICD, for that matter) too seriously. It's just convenient fiction, or at best "useful constructs," mainly used to attain insurance reimbursement.

Only, there's this curious phenomenon: In the legal system, where the consequences of error can be grave, DSM diagnoses have taken on a mantra of grand truth. Increasingly, I find myself being asked during court testimony about some nit-picky little criterion or another (such as the six-month specifier for pedophilia) as if it is sacred gospel, rather than the arbitrary creation of some idiosyncratic back-room committee.

One bold colleague, when asked on the witness stand to confirm that the DSM is indeed "the bible of psychiatry," answers with a resounding "YES!" But, he adds, "Bible is Greek for 'book,' and the DSM's are a collection of books or chapters submitted by sundry subcommittees and approved or not based on politics. As with the Christian Bible, some known books (like the Book of Thomas) did not make the cut."

I don't recommend that tactic unless you are well grounded in theological studies. I myself cannot state under oath that the DSM is "the bible," when the attorney is really seeking to have me confirm its status as a learned treatise, that is, sufficiently authoritative that it should be relied upon in court. It may be the only game in town, but it's hardly known for its empirical fidelity. The text's assortment of vague generalities are not even referenced, so we don't know where they came from. If you are going to testify about a specific mental condition, such as delusional disorder, I recommend relying on empirical research from reliable sources that you can cite. 

Turning now to specific changes in the DSM-5 of most potential relevance to forensic work....

The good news is that some of the more outlandish proposals -- such as parental alienation syndrome and hebephilia -- got a resounding thumbs-down. So, here's my first-glance summary of what's new and different. 

Sexual paraphilias

An attempt by an ambitious minority to add a slew of new sexual disorders fell flat. So, you won’t find hebephilia, paraphilic coercive disorder or hypersexuality in the DSM-5. They didn’t even make the appendix for "conditions for further study" (which is populated by such non-starters as caffeine use disorder, internet gaming disorder, and the more worrisome attenuated psychosis syndrome).

These defeats are a big blow for the civil commitment industry, which lobbied for them to replace the shady "not otherwise specified" diagnoses being used to justify indefinite detention of offenders who don't have legitimate mental illnesses.

The section does, however, contain a few pesky little wording changes that may come into play in forensic cases. Each  disorder except pedophilia in the paraphilias chapter now has two remission qualifiers. If the person has not been impaired for five years, the disorder can be said to be "in full remission." This is a nod to the reality that sexual kinks often come and go over time. But there's a catch: The remission must be while the person was "in an uncontrolled environment." Otherwise, a new remission specifier of "in a controlled environment" can be applied. I anticipate that government evaluators in sexually violent predator trials may use this language to argue that a prisoner whose predicate offense was decades in the past is still disordered and at risk today, despite no objective evidence of such.

Another important change is in the text accompanying sexual sadism disorder, which now reads more like it was written for adversarial deployment. There are now two types of sadists -- "admitting individuals" and deniers. For deniers, the fact of having "inflicted pain or suffering on multiple victims on separate occasions" may be sufficient for a diagnosis. As a "general rule," the text instructs, recurrent can be interpreted to mean "three or more victims on separate occasions."

As discussed yesterday in Part I, the DSM-5 does not provide citations to empirical research to back up its recommendations. This is especially problematic in the case of sexual sadism, because even most chronic rapists are not necessarily aroused by a victim's suffering; rather, the victim's suffering fails to inhibit their arousal as it would for other men. The fact of inflicting pain or suffering also says nothing about what is going on in the mind of the inflicter, and three is just an arbitrary number pulled from a hat. These new guidelines will only complicate a problematic diagnosis with abysmally poor reliability and no predictive validity.

Antisocial personality disorder

Early buzz was that this pejorative label -- which can be applied to essentially any chronic offender -- would be revised to more closely align it with the even more pejorative and controversial construct of psychopathy. But the APA abandoned all proposed personality disorder changes (including a radical move to drop half of them altogether and to place the rest of them on a dimensional spectrum), so this diagnosis remains unchanged.

The real news here comes from the field trials. In regard to reliability, antisocial personality disorder came in at the bottom of the barrel, down there with the new mixed anxiety-depressive disorder with a kappa reliability rating of only 0.2. Historically, kappas below 0.4 have been considered poor. Although DSM-5 chief statistician Helena Kraemer is arguing that lower kappas should be deemed "acceptable," a 0.2 essentially means that even trained professionals cannot agree on whether a given individual has a disorder. This makes antisocial personality disorder far too unreliable for use in court.

Speaking of empirically dubious disorders, intermittent explosive disorder got a change worth noting. Whereas the aggressive outbursts at the core of this disorder used to require physical aggression, now "verbal aggression" suffices. If you've ever reviewed psychiatric hospital charts, you know that this is how hospital technicians chart episodes of disquiet among patients. For example, I recently saw a chart notation that "John Doe was verbally aggressive" stemming from an incident in which the involuntarily hospitalized Mr. Doe muttered profanities at hospital orderlies who had barged into his room while he was sleeping and confiscated the gauze pads he was using for an acute injury. In short, look for upticks of this disorder wherever the powerless are concentrated.

Posttraumatic stress disorder

Psychologist Richard Samuels checks his DSM
"bible" during testimony in Jodi Arias murder trial

PTSD got some significant tweaking in the DSM-5, mostly in directions that could increase its prevalence. The requirement of experiencing “fear, helplessness or horror” in reaction to the trauma was eliminated. There are now four "symptom clusters" rather than three. A new symptom of "reckless or self-destructive behavior" has been added, and the symptom of irritable behavior or angry outbursts has some added language, "typically expressed as verbal or physical aggression toward people or objects" and "with little or no provocation" (have fun explaining that one in court!).

In clinical practice, these changes won’t much matter. As Greenberg noted, "Mostly we’re content to find a label that matches people in some vague way and then get on with the business of helping them figure out what's going on in their lives that landed them in our offices." However, in court the devil is in the details. Difference between an "and" or an "or," or a three-month versus a six-month time specifier, can be critical. Unfortunately, there are no side-to-side charts with the changes from DSM-IV to DSM-5 highlighted or crossed out. The biggest benefactor of all this tweaking will be psychological test companies, whose psychometric tests for PTSD will have to be revamped. So get out your pocketbooks now.

Intellectual functioning and the death penalty

Last but not least, changes to the developmental disabilities section could make more criminals eligible for execution. Under the U.S. Supreme Court's Atkins standard, an IQ score of below 70 had been like a magic line in the sand, below which one becomes ineligible for capital punishment. However, the DSM-5's intellectual developmental disorder (renamed from mental retardation) drops IQ scores in favor of the more subjective construct of adaptive functioning, or the ability to live independently in the world.

"There are a lot of courts that are hostile to the basic legal doctrine the Atkins case established," death penalty lawyer David Dow told Reuters. "When you replace a test that is one part objective, one part subjective with a solely subjective test, it becomes easier for courts that are hostile to the constitutional principle of Atkins to evade that criterion."

"We believe that we are providing the courts with a more fine-grained means to consider adaptive functioning more comprehensively and more meaningfully," countered James Harris, of the DSM-5 work group.

Other specified or unspecified disorder

As I just mentioned, the devil is in the details. When a person does not meet minimum criteria for a diagnosis, clinicians can choose between the new categories of other specified disorder and unspecified disorder (the listed example being the unwieldy "other specified depressive disorder, depressive episode with insufficient symptoms"). These quick-and-dirty options are meant for use in the emergency department, where clinicians have little time and not much background information to go on. But the DSM-5 authors open the door for forensic misuse by stating their desire for "maximum flexibility for diagnosis." How's this for a loophole large enough to drive a Mack truck through:

"When the clinician is not able to further specify and describe the clinical presentation, the unspecified diagnosis can be given. This is left entirely up to clinical judgment."

Look to shady evaluators to misuse these "other" and "unspecified" labels to create nonexistent disorders for forensic use. That won't be anything new; it's essentially the same phenomenon we now see in sexually violent predator proceedings with the deployment of the DSM-IV-TR classifier "paraphilia not otherwise specified (NOS)," which these new categories replace. Such improper diagnosis may be legal, but that doesn't make it ethical.

Forensic caveat

One welcome change in the new manual is that the old cautionary statement about use of the DSM in forensic contexts gets more prominent play. Rather than being buried in the introduction, it's got its own little page in the DSM-5:

"... In most situations the clinical diagnosis of a DSM-5 mental disorder ... does not imply that an individual with such a condition meets legal criteria for the presence of a mental disorder or a specified legal standard...."

But when push comes to shove, judges and juries are going to do what they want to do, forensic cautions or no. As Texas lawyer Susan Orlansky -- whose client is slated for execution despite a lower-than-70 IQ -- told Reuters, "If the Texas court system is willing to ignore the DSM-IV, I don't know why they wouldn't be just as willing to ignore the DSM-5."

By all means take a moment to familiarize yourself with the changes in the new diagnostic manual that are relevant to your work. Just don't be conned into taking this whole diagnostic enterprise too seriously. After all, that's what the American Psychiatric Association is counting on to keep itself financially solvent.

I welcome comments, especially if you know of other changes of potential forensic relevance that are not listed here, or if you have a different take on the changes I highlighted.

And, if you are planning to attend the American Psychological Association convention in Honolulu, I invite you to my full-day CE training on psychiatric diagnosis in legal settings on July 31.

DSM-5: Much ado about nothing? (Part I of II)

Ambitious "paradigm shift" fizzles 

By now, you've seen the bad press about the American Psychiatric Association's new diagnostic codebook: Media pundits are labeling it "a manual run amok," so ambitious in scope that almost everyone qualifies for some mental illness or another.

But browsing through my crisp new copy, I find myself curiously dispassionate. Sure, it's even more bloated than the DSM-IV. But mainly, they just moved the chapters around and renamed a diagnosis here and there (dysthymia, for example, is now persistent depressive disorder). Even the typefaces will look familiar.

It's downright anticlimactic.

Remember when they first announced work on the new DSM? It was going to be a revolutionary "paradigm shift," aligning diagnoses with modern science. Disorders were going to be dimensional rather than categorical. All kinds of novel proposals were in play: Parental Alienation Syndrome. Paraphilic Coercive Disorder. Psychosis Risk Syndrome.

Then came the backlash. Prominent work group members walked out over the lack of science in the revision process. Petitions were launched. Special interest groups lobbied. ("Aspies," for example, were furious that psychiatry had bequeathed them an identity and were now taking it back.) The field trials fell apart. Even the National Institute of Mental Health announced it was breaking away from the DSM's diagnostic schema (although switching to its biology-worshipping Research Domain Criteria is like jumping from the frying pan to the fire).

Ultimately, the psychiatrists retreated. With both drug money and membership numbers down, the last thing the American Psychiatric Association needed was more negative flak. Especially when the DSM rakes in a steady profit, $5 to $6 million per year, giving them "fabulous riches" over time.

So, you'll find a few notable changes: There’s disruptive mood dysregulation disorder, a belated effort to undo the damage wrought by overdiagnosis of childhood bipolar disorder. Hoarding disorder and the Big-Pharma-inspired premenstrual dysphoric disorder made the cut. But overall, it's just business as usual.

In the short term, the new manual will give the APA's coffers a big boost. The book alone retails for $130 or more, and -- like a blockbuster Disney movie -- there will be ancillary products including cell phone apps, how-to guides, trainings, and such.

Eventually, however, the DSM will become increasingly irrelevant. It's already being superseded by the World Health Organization's International Classification of Diseases, which even on the APA's home turf of the United States is now required for insurance reimbursement. While some tout ICD codes as preferable, the only real advantage of the ICD is that it is freely available online.

By design, the DSM codes are almost precisely parallel to the ICD's. And the entire diagnostic enterprise, as psychotherapist Gary Greenberg explores in The Book of Woe, is an elaborate fiction -- a shell game perpetrated by psychiatrists on patients, insurance companies, and (most critically for our purposes here) the courts. Greenberg spent two years mucking about in the DSM-5 development trenches, where work group members frankly acknowledged that psychiatric diagnoses are just "fictive placeholders" or "useful constructs" rather than real conditions that carve nature at its joints.

Tomorrow, in Part II, I will highlight some specific changes (and non-changes) potentially relevant to forensic practice. 

If you are planning to attend the American Psychological Association convention in Honolulu, I also invite you to my full-day CE training on psychiatric diagnosis in legal settings on July 31.

Military sexual assault scandal unearths "illegal" psychiatric diagnoses

If you haven't been following the sexual assault scandals in the U.S. military, tune in: It’s yet another arena where bogus psychiatric diagnoses are playing a sordid role.

Women soldiers who report sexual assault are diagnosed with psychiatric conditions such as borderline personality disorder or bipolar disorder that get them drummed out. Not only are their careers ruined, but they are denied benefits and sometimes must even repay any bonuses they got for enlisting.

Because the symptoms of these "preexisting" disorders overlap with the emotional sequelae of trauma -- anger, fear, depression, anxiety, avoidance -- it can be hard to tell the difference.

Women in every branch of the U.S. military are being disproportionately discharged with personality disorders, according to an investigative series, Twice Betrayed, in the San Antonio (Texas) Express-News. The Air Force has the widest disparity: Women make up 20 percent of the force, but 35 percent of personality discharges.

Sometimes, as in one case featured in the Express-News series, military psychologists and psychiatrists are being influenced by officers in the accused's or accuser's chain of command to view accusers as mentally unstable and/or sexually promiscuous.

In a report on "illegal" psychiatric diagnoses, the Vietnam Veterans of America say that in addition to rape victims, many combat soldiers with organic brain trauma or posttraumatic stress disorder continue to be drummed out of the military with bogus personality disorders and adjustment disorders that block their disability benefits, despite Congressional efforts to crack down on this abuse (for example, by requiring that the diagnoses be issued by psychiatrists or PhD-level psychologists).

It was a bit incongruous to find myself sitting in an Air Force courtroom, consulting on a sexual assault case, when the news broke that the chief of the Air Force's Sexual Assault Prevention and Response program had been arrested for sexually assaulting a female stranger in a parking lot.Talk about the fox guarding the hen coop.

That bizarre twist came on the heels of a headline-grabbing survey documenting skyrocketing rates of sexual assault in the military: An estimated 26,000 soldiers were sexually assaulted in 2012, up from 19,000 the year before. Women in the military face about twice the risk of sexual assault as civilian women (one in three versus about one in six). And only a tiny fraction of assaults -- 3,374 last year-- are reported.

That's likely due to the fact that women who do report rape are shunned, disbelieved, and retaliated against, and their assailants are rarely punished. The seven-month investigation by Karisa King of the San Antonio Express-News found that only about 10 percent (302 of 2,900) of the accused were court martialed, with only 177 sentenced to confinement. (The airman in my case was one of those rare few, but then again he was a low-level airman, not an officer. And it probably didn't help his case that all of these scandals were busting out that very week.)

It’s no coincidence that the San Antonio paper ran the series: Outside that city sits the sprawling Lackland base, the Air Force's basic training center for enlisted personnel. In an unfolding investigation there, at least 33 training instructors are suspected of sexually assaulting 63 or more trainees.

If this latest scandal isn't enough to convince people of the link between sexual violence and a climate of hostile masculinity (as researchers such as Neil Malamuth have been arguing for decades), I don't know what is. On the other hand, if psychologists in the sex offender treatment industry got their hands on these training officers, they'd probably label them with some fictional disorder like "paraphilia not otherwise specified (nonconsent)" that decontextualized their behaviors beyond recognition. 

Consulting in a military court martial one week and a sexually violent predator civil commitment hearing the next, I can't help but notice how mental illness strikes in clusters, afflicting sexual assault victims in one setting and offenders in the other. The clue that situational exigency is in play is that in neither case is the diagnosis about helping the supposed sufferer. It's all about punishment, with diagnosis as the weapon.

I highly recommend the series, Twice Betrayed. An in-depth report by the The Vietnam Veterans of America on the misuse of psychiatric diagnoses in the military, Casting Troops Aside, is HERE.

Miracle Village: A leper colony for bogeymen

Almost 750,000 Americans are now on sex offender registries, and the numbers just keep growing. Because the truly dangerous are mixed in with the far more numerous low-risk offenders, registries are useless from a public safety perspective. But they do have a pernicious effect on ex-offenders, who -- like the lepers of yore -- oftentimes find themselves with nowhere to go and no hope of ever reintegrating into society.

Enter "Miracle Village" in Florida. Built in 1964 for sugar cane workers (some of whom still live there), it was transformed into a haven by an evangelical pastor and his wife (both of whom, ironically, were sexually molested as children). It's now home to about 100 convicted sex offenders, a place they can be among others like themselves and feel a bit more human. Since the community was established in 2009, there has not been one reported sex crime, according to the local sheriff's office.

But it's only a drop in the bucket. The demand is extraordinary; more than 100 people per week apply for the limited housing.

The short video Sex Offender Village was put together by two people who come from what might be seen as opposite ends of the spectrum: Documentary filmmaker Lisa Jackson has spent years examining sex crimes from the victim’s point of view; David Feige is a former chief public defender from the Bronx turned TV writer. But they agree on one thing: U.S. sex offender laws are "doing more harm than good":

In the past 25 years, the laws governing sex offenses have gone from punitive to draconian to senseless. The term 'sex offender' simply covers too wide a range now, painting the few truly heinous crimes and the many relatively innocuous ones with the same broad brush. This overly broad approach wastes resources that could be better spent, for instance, on clearing the huge and unforgivable backlog of untested rape evidence kits. We see even deeper problems: the explosion of sex offender registries, stringent yet demonstrably ineffective residency restrictions, and the bizarre world of 'civil commitment,' where we punish what someone might do rather than what he or she has done. All of this suggests that our entire approach to dealing with sex offenders has gone tragically off the rails.

CLICK ON ABOVE IMAGE TO VIEW THE 5-MINUTE VIDEO AT THE NEW YORK TIMES OP-ED WEBSITE.

Attorney-client privilege trumps child abuse reporting law, court rules

Elijah W. ruling clarifies thorny issue in California

Forensic psychologists are split as to whether we must breach confidentiality when a criminal defendant divulges child abuse or threatens physical harm to others.

On the one hand, here in California a psychologist can be criminally prosecuted under the Child Abuse and Neglect Reporting Act (CANRA) for failure to report suspected child abuse. On the other hand, a psychologist hired as a defense consultant assumes a legal duty to maintain attorney-client confidentiality.

But a welcome appellate ruling this week at least partially resolves this vexing dilemma. A psychologist hired by a criminal defense attorney is bound by the same rules as the attorney, and must uphold the client's Constitutional right to confidentiality rather than report child abuse, the court held.

"In the absence of clear legislative guidance, we decline to read into CANRA [the Child Abuse and Neglect Reporting Act] a reporting requirement that contravenes established law on confidentiality and privilege governing defense experts and potentially jeopardizes a criminal defendant’s right to a fair trial," ruled the Second Appellate District.

The question of whether, or how, to report threatened violence (as mandated under Tarasoff and related case law) remains a bit vaguer; in some cases, warning the retaining attorney might discharge the duty to protect, but in other cases it might not. 

The appellate ruling also does not clarify the reporting requirements of psychologists retained by litigants in child custody or civil cases. However, an attorney colleague said it likely extends to any situation in which the psychologist is hired to consult on a privileged matter, such as in civil or child custody cases. The colleague's opinion was based in part on the fact that the court specifically declined to decide the issue on Constitutional grounds, basing its decision instead on California laws regarding attorney-client privilege. In contrast, under California's Evidence Code (Section 1017), there is no privilege if the expert is appointed by the court as a neutral expert. Also, if the psychologist shifts from the consultant role to become a testifying expert, once-privileged information is no longer protected.

The ruling is good news for forensic practitioners in that it reduces the ethical tension between protecting the privacy rights of the accused and protecting our own skins. Psychologists who fail to report suspected child abuse may be subject to criminal and civil penalties and are often treated very harshly by licensing boards.

The ruling puts California in the lead among U.S. states in clarifying psychologists' duties in navigating a confusing mishmash of reporting laws. Maryland is an exception to the general vagueness; that state's Attorney General issued an opinion that defense-retained psychiatrists in criminal cases are exempt from mandated reporting.

Judge had nixed child's request for independent expert

The case involved Elijah W., a 10-year-old Los Angeles boy arrested on an arson charge. When the defense team requested an expert to help prepare the fourth-grader's defense, the juvenile judge limited them to a member of the local juvenile competency to stand trial (JCST) panel. However, panel members had told Elijah's attorneys that they would report to authorities any information that Elijah revealed about suspected child abuse or neglect.

In contrast, a member of the local superior court's regular panel of psychiatrists and psychologists, Dr. Catherine Scarf, had assured the defense team she would respect attorney-client privilege and only report threats or child abuse to Elijah's counsel. The judge refused to appoint Dr. Scarf, scoffing at the defense team's concerns as "merely academic" because the judge could not recall any juvenile disclosing reportable information during a competency evaluation. 

Los Angeles created the juvenile panel in response to a recent California law mandating that juvenile competency evaluators have special training and experience in child development and juvenile forensic issues. The Los Angeles court's juvenile protocol allows a minor's defense counsel to obtain an assessment and not disclose it unless a doubt is declared as to the minor's competency. 

Elijah's attorney argued that appointment of a defense expert who would not defer to lawyer-client privilege violated Elijah's Constitutional right to effective assistance of counsel.

The appellate court agreed, noting that child abuse reporting requirements might interfere with full and open communication between a minor and his defense team.

"It is certainly plausible, for example, that a young child accused of setting fires is acting out following some form of traumatic experience, perhaps even child abuse…. Similarly, if the child is warned of the defense psychologist's intention to disclose information concerning child abuse or neglect prior to the assessment ... disclosures necessary for effective representation may be inhibited."

The appellate court also considered whether the attorney-client privilege trumps the so-called Tarasoff warning, or psychologists' duty to protect reasonably identifiable victims from threatened violence. The justices wrote favorably of Dr. Scarf's position that notifying the defense attorney would discharge the duty; in California, an attorney may reveal confidential information if necessary to prevent a criminal act likely to result in death or great bodily harm:

"We cannot evaluate in advance whether Dr. Scarf's intended notification of Elijah's attorney will insulate her from liability in any particular situation…. But her position is certainly reasonable, and her willingness to safeguard the confidentiality of Elijah's communications at the risk of personal liability should not have been discounted by the juvenile court."

Bottom line: The appellate court ordered that the juvenile court approve Dr. Scarf's appointment.

Practical implications

Forensic psychologists in California will want to carefully review this ruling for themselves, and tailor their consent forms based on the nature of the case and who the client is -- the court, the defense, or the prosecution. In preparing one's informed consent documents, consulting with an attorney knowledgeable in this tricky area is certainly not a bad idea.

Likewise, the case serves as a reminder for practitioners outside of California, who should determine the relevant statutes and case law in the jurisdictions in which they practice. In their book Evaluation for personal injury claims, Kane and Dvoskin opine that in jurisdictions in which attorneys are mandated to report child abuse, expert consultants likely must report as well. (The American Bar Association has an online chart listing state-by-state laws pertaining to attorneys' child-abuse reporting requirements.)

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The published case, Elijah J. versus Superior Court of Los Angeles County, can be found HERE. 

Related resources available online include: 

• Forensic evaluations and mandated reporting of child abuse, Kapoor and Zonana (2010), Journal of the American Academy of Psychiatry and Law

• Expert Opinion: Does mandatory reporting trump attorney-client opinion? Connell, Golding, Morgan and Niland (2004), American Psychology-Law Society News  

 
Hat tip: Adam Alban, PhD, JD

Spring reading recommendations -- forensic and beyond

Marauding bands of juvenile killers. Gang rapist-kidnappers. Wife beaters.

We’re talking elephants, dolphins and parrots, respectively. That's my forensic psychology angle on Animal Wise, a fascinating new book by nature journalist Virginia Morell.

Not long ago, it was taboo in science circles to claim that animal have minds. But the burgeoning field of animal cognition, having broken out of the strait jacket imposed by 20th-century behaviorism, is now mounting a full-on challenge to the notion of an evolutionary hierarchy with humans at the top. Morell, a science writer for National Geographic and Science magazines, traveled around the world interviewing animal scientists and observing their research projects on everything from architecturally minded rock ants and sniper-like archerfish to brainy birds, laughing rats, grieving elephants, scheming dolphins, loyal dogs, and quick-witted chimpanzees.

She found cutting-edge scientists who not only regard animals as sentient beings, but even refer to their study subjects as trusted colleagues. Professor Tetsuro Matsuzawa in Kyoto, for example, has set up his lab so that when the chimpanzees "come to work" each morning, they enter on elevated catwalks and sit higher than the humans, which makes them feel more comfortable. He cannot understand why humans feel so threatened by his discovery that chimpanzees are capable of holding much more information in immediate memory than can we humans.

"I really do not understand this need for us always to be superior in all domains. Or to be so separate, so unique from ever other animal. We are not. We are not plants; we are members of the animal kingdom." 

 

 

YouTube video of Alex the parrot showing his cognitive skills

Animal researchers are realizing that not only do all animals have individual personalities, but some -such as chimpanzees and dolphins - even develop cultures. This engaging and thought-provoking book can be read on many levels. It is highly informative while also being quite entertaining. But on a deeper level, it probes the moral dimensions of science.

Morell’s 2008 National Geographic article in from which the book grew is HERE. Her Slate article, "What are animals thinking?" is HERE.  My Amazon review (if you are so inclined, click on "yes," this review was helpful) is HERE.


The Signal and the Noise

If you haven't yet read Nate Silver's important The Signal and the Noise, it’s past time to grab a copy. Silver’s analytic method is central to forensic psychology. Best known for his spot-on predictions of U.S. presidential races, Silver argues that accurate predictions are possible in some (limited) contexts -- but only when one learns how to recognize the small amount of signal in an overwhelming sea of noise. And also when one approaches the prediction using Bayes's Theorem. This is one of those engrossing books that really stays with you, and has very practical applications in forensic assessments. I find it especially useful in writing reports. Plus, it helps one understand current events involving prediction, like the story of six Italian scientists being sent to prison for failing to predict a deadly earthquake. (Earthquakes are inherently unpredictable, and Silver explains why.) 

* * * * *

Speaking of forensic report writing, if you want to tune up your own report writing skills, or you are teaching or supervising students, I highly recommend Michael Karson and Lavita Nadkami's book, Principles of Forensic Report Writing, due out at the end of this month. Karson and Nadkami take an innovative and thoughtful approach, helping us to think outside of the box about this essential aspect of our trade.


Other  recommendations

Beyond forensics, here a few other worthwhile books I've read recently:

If American history interests you, check out bestselling author Tony Horwitz's Midnight Rising, about John Brown's ill-fated raid on Harpers Ferry and its role in the abolitionist movement, or Tim Egan's The Big Burn, about the massive fire in the U.S. Northwest that helped change the political landscape and establish the national Forest Service. Both are engrossing and educational; I listened to the audio versions during lengthy road trips.

* * * * *

If you are into dystopic fiction, I recommend Hillary Jordan's When She Woke. In the not-distant future, the government has gone broke, and can no longer afford to maintain its massive prison system. So, instead of incarceration, law-breakers -- in a modern-day riff on The Scarlet Letter -- are dyed bright colors for the length of their sentences. In a globally warmed Texas ruled by Christian fundamentalists, Hannah Payne wakes up bright red, for the crime of aborting her baby. This edge-of-your-seat tale isn't too far-fetched, given current trends, as laws are being passed in Oklahoma and elsewhere to criminalize abortion, and as the public shaming of sex offenders (who in the novel are "melachromed" blue and killed on sight by vigilantes) becomes more and more entrenched.

* * * * *

Finally, I'm just launching into Gary Greenberg's hot-off-the-press book on the DSM, The Book of Woe: The DSM and the Unmaking of Psychiatry, and I can already tell it's going to be a doozy. More on that soon, time permitting....

Forensic practice: A no-compassion zone?

Murder trial prompts professional dialogue

Do empathy or compassion have a place in a forensic evaluation? Or should an evaluator turn off all feelings in order to remain neutral and unbiased?

That question is at the center of a controversy in the murder trial of Jodi Arias that I blogged about last week, with the prosecutor accusing a defense-retained psychologist of unethical conduct for giving a self-help book to the defendant.

Under heavy-artillery fire, Richard Samuels* denied prosecutor Juan Martinez's accusation of "having feelings for" the defendant, who killed her ex-boyfriend and is claiming self defense. Samuels testified he gave Arias a book because he is a "compassionate person" and thought the book would help her, but that his objectivity was never compromised. The exchange prompted a juror to ask Samuels:  "Do you believe absolutely that it is possible to remain purely unbiased in an evaluation once compassion creeps in?"

Martinez called a rebuttal witness to testify that gift-giving is a boundary violation and unethical. Newly minted psychologist Janeen DeMarte, testifying in court for only the third time, testified that a forensic evaluator should never feel compassion for a defendant, as such feelings compromise integrity (a position she modified under cross-examination).

Given these starkly divergent positions, I was curious what other forensic psychologists think. So, I initiated a conversation with a group of seasoned professionals, publishing two brief video excerpts of the relevant testimony on YouTube (click on the images below to watch the excerpts) to guide the conversation.

View the Richard Samuels excerpt (18 minutes) by clicking on the above image.

View the Janeen DeMarte excerpt (10 minutes) by clicking on the image.

Gift-giving: A bad idea

Contrary to the prosecutor’s insistence, our Code of Ethics does not prohibit gift-giving. Nor do the Forensic Psychology Specialty Guidelines (which are aspirational rather than binding). It's an ethical gray area.** As with much involving ethics, it all depends. But still, the consensus was that giving a book to a defendant is a mistake. Whether or not it affects one's objectivity, it gives the appearance of potential bias. And in forensic psychology, maintaining credibility is essential. "Gift giving," as one colleague put it, "gives the appearance of either a personal or therapeutic relationship with the defendant."

Samuels's error lay in failing to think through his action, and recognize how his blurring of boundaries could damage his credibility and thus undermine his testimony. Ultimately, by discrediting his own work, he potentially caused harm to the very client whom he was attempting to help.

The nature of the book itself further undermined the expert's credibility in this case. As another colleague pointed out, what good is a self-help book, Your Erroneous Zones: Step-by-Step Advice for Escaping the Trap of Negative Thinking and Taking Control of Your Life, going to do a woman who is in jail and facing the death penalty for stabbing and shooting someone to death?

On the other hand, although gift-giving is a slippery slope, there are times when only a curmudgeon would not give. For example, if you are conducting a lengthy evaluation and you decide to buy yourself a drink or a snack from the vending machines, do you refuse the subject a soda, for fear it would undermine objectivity or lend an appearance of bias? How rude!

Empathy: It's only human 

The general consensus was that, without some measure of empathy, one cannot hope to understand the subject or the situation. One is left with "an equally problematic perspective that dehumanizes and decontextualizes the evaluation,' in the words of another psychologist.

"There is an orientation toward forensic work that is strikingly cold," noted yet another colleague. "I have seen some highly experienced forensic examiners who use their 'objectivity' with icy precision and thereby fail to establish the kind of rapport necessary to obtain a complete account of the offense or other important information…. The absence of empathy can be just as biasing as too much of it."

Or, as Jerome Miller wrote, in one of my favorite quotes from the forensic trenches, "It takes unusual arrogance to dismiss a fellow human being’s lost journey as irrelevant."

In other words, without empathy, any claim to objectivity is illusory, because there is no true understanding. And that, too, is dangerous. DeMarte's extreme position thus errs in the opposite direction from Samuels', in advocating for forensic psychologists to be automaton-like technocrats.

Indeed, the main danger of empathy as discussed by leaders in our field, such as Gary Melton and colleagues in Psychological Evaluations for the Courts, is not that it biases the evaluator, but that it potentially seduces vulnerable subjects into revealing too much, thus unwittingly increasing their legal jeopardy. For this reason, Daniel Shuman, in a minority position in the field, argues that using clinical techniques to enhance empathy is unethical because this can -- wittingly or unwittingly -- cause harm to evaluatees. 

After all, our training as therapists makes us good at projecting understanding, and at least the illusion of compassion. Our subjects often let down their guard and experience the encounter as therapeutic, even when we clearly inform them that we are not there to help them in any way, and even when we remain vigilant to control our expressions of empathy.

"The best forensic evaluations bring all the clinical skills learned to promote self-disclosure and emotional emitting (empathy, reflective comments, attention to feelings, suspension of moral judgment, etc.)," a colleague commented. "We know how to get people to talk about things that they might otherwise wish to hide from others and themselves. Most defendants feel understood or at least feel they have been heard at the conclusion of an assessment."

Behaviors, not emotions, can be unethical

A third general consensus emerging from our professional dialogue was that feelings themselves are "almost never unethical." Which is fortunate, as we can never know for certain what another person is thinking or feeling. Rather, it is the behavior that follows that can be problematic; we must remain alert to what feelings a subject is evoking in us, lest they lead us astray. Sticking close to the data, and being transparent in our formulations, can keep us from behaving incompetently or problematically in response to our feelings, whether of empathy and compassion or -- at least as problematic -- dislike or revulsion. 

Bottom line: Do not check your empathy at the jailhouse door. You need it in order to do your job. And also to remain human.

Thanks to all of the many eloquent and insightful colleagues who contributed to this conversation.

NOTES:

*Samuels has taken down his website (svpexpertwitness.com), so I am providing a link to an old cached version.  

**Psychology ethicist Ofer Zur has written more on gift-giving in psychotherapy, with links to the gift-giving provisions of various professional ethics codes.

Diagnostic controversies: Registration open for my Hawaii workshop

A shameless plug for my upcoming training workshop in Honolulu, sponsored by the American Psychological Association. CE's in paradise; what's not to like? To register (or get more information), click HERE.

'Digital lynch mob' assaults expert witness in televised murder trial

Imagine you are testifying in a high-profile murder case being live-streamed over the Internet. Suddenly, an angry mob swarms all over you. More than 10,000 people sign an online petition urging a boycott of your lecture contracts. Your book gets a thousand negative hits on Amazon. You are stalked, and a photo of you dining with the trial attorney is posted on Facebook, implying unethical conduct. You even get death threats.

That is the social media-coordinated avalanche that hit domestic violence expert Alyce LaViolette, testifying for the defense in the capital murder trial of Jodi Arias. The unrelenting cyber assaults so rattled LaViolette that she suffered an anxiety attack that landed her in the emergency room.

But the ER visit may only encourage the cyber-stalkers, who revel online over her discomfiture and obvious emotional deterioration over the course of seven grueling days of court testimony.

This type of Internet mobbing, in which cyber-posses enforce social norms through public shaming, is becoming more and more commonplace. One of the most widely known examples of such Internet vigilanteism was the 2005 case of "Dog Poop Girl," a South Korean woman who gained infamy after she refused to clean up after her dog on a Seoul subway; the harassment eventually escalated to the point that she was forced to quit her university job. 

But what was LaViolette's crime?

The domestic violence counselor had the audacity to opine that Jodi Arias was a victim of domestic violence -- that she was dominated and abused (physically, emotionally and sexually) by the man she eventually killed. Such an opinion bolsters Arias's claim that she killed her ex-boyfriend in self defense.

Murder tragedies as entertainment

Unfortunately for LaViolette, her analysis runs counter to the dominant narrative in a gendered morality play produced by media conglomerate Turner Broadcasting and distributed through its cable channels HLN, CNN and In Session. In this good-versus-evil melodrama, Arias is a psychopathic female who killed a morally righteous man in a fit of jealous rage. Period. End of story. Airbrushed out are all the nuances, the shades of grey inevitably present in any such violent tragedy. 

The burgeoning infotainment industry has perfected a profit-making formula of sensationalized true-crime "reporting" that plays on viewers' emotions, whipping audiences into a frenzy of self-righteous indignation in which they clamor for guilty verdicts -- very often against female transgressors. Nancy Grace's shrill ranting over the Casey Anthony murder acquittal garnered HLN a record of almost three million viewers. More recently, HLN went after another woman, Elizabeth Johnson, suspected in the mysterious disappearance of her baby. 

The Arias case seems Heaven-sent for this voyeuristic style of entertainment, in which vulturous pundits mete out tantalizing morsels of crime "facts" to their addicted audience. Travis Alexander provides titillation from the grave via thousands of graphic emails, instant messages, texts and phone chats in which he degrades his paramour as a "whore," "slut," "corrupted carcass" and "three-hole wonder" whom he can sexually violate at will. For her part, Arias is a demonstrable liar. When her ex-boyfriend was found with a gunshot wound to the head, a slit throat, and more than two dozen stab wounds, she initially claimed innocence. After police demolished her alibi defense, she then claimed that two intruders broke into the home and killed Alexander, before finally admitting to the killing but claiming self defense.

Cast in the starring role of swashbuckling hero in this sordid drama is prosecutor Juan Martinez, a dapper man with a quick mind and an acerbic style, whose meteoric rise from the son of Mexican immigrants to a top government attorney is the stuff of American legend. Women line up outside the Maricopa County, Arizona courthouse, swooning at the sight of him as they jockey for photographs and autographs.

"This is murder trial as entertainment," Josh Mankiewicz, a correspondent for NBC's Dateline program (which ran two segments on the case), told reporter Michael Kiefer of the Arizona Republic. "This is not a trial like O.J. (Simpson's) that sheds new light on society. This is not about race or money. It's a perfect tabloid storm. It is occurring in the absence of any other tabloid storm."

Nancy Grace, "Dr. Drew" and the other pundits capitalizing on such trials foster a false sense of intimacy by calling everyone by first names. They encourage vicarious audience participation on Facebook, Twitter, online polls and other social media. But this is no value-neutral production. This is an archetypal trope that requires a guilty verdict; as one insightful media critic noted, acquittals do not produce the desired catharsis.

Public shaming run amok

In such an emotionally charged climate, anyone affiliated with the defense automatically becomes a villain. However, it is interesting to observe the disparate treatment of LaViolette as compared with a male expert witness, psychologist Richard Samuels. The prosecutor aggressively attacked them both. Playing not only to the jurors but to his sizeable out-of-court fan base, Martinez paced back and forth like a tiger smelling blood, demanding of his cornered prey that they give only "yes or no" answers to his myriad questions. Under his withering cross-examination, both witnesses came across as defensive and evasive. Both were vulnerable due to their confirmatory biases -- a failure to seek out evidence that might disconfirm their case theories. But, objectively, Samuels would seem to invite at least as much criticism as LaViolette, due to his bumbling style, his test scoring errors, and his questionable case formulation (he diagnosed posttraumatic stress disorder using a rating scale on which Arias endorsed a fictitious trauma, of witnessing Alexander's murder at the hands of imaginary intruders).

However, the public's palpable fury against LaViolette far outstrips that targeting Samuels. Consistent with the Turner Network's gendered narrative of criminal villainy, the cyber-posse is fueled by a potent combination of misogyny and homophobia: The expert witness in their crosshairs is "emasculating," "a bull dyke," "a man-hater," "fat," "buck-teethed," "a bitch."

The Internet fosters this culture of hate. Its cloak of anonymity is disinhibitory, emboldening people to spew bile with impunity. In The Cult of the Amateur, Andrew Keen warns that the deluge of anonymous online content is altering public debate, manipulating opinion, blurring the boundaries between experts and the uninformed and weakening the vitality of professional media -- newspapers, magazines, music and movies.

The proliferation of bottom-feeders on Twitter and YouTube is one thing. But it is quite another thing when cyber-bullying seeps into the courtroom, intimidating witnesses and threatening the presumption of innocence.

Can inundated jurors remain unbiased?

Legal experts worry that a virtual deluge of unreliable and biased information -- readily available at the click of the mouse or a TV remote -- is undermining jurors' neutrality. In their off hours, curious jurors in the Arias case can tune in not only to the cable TV and social media debacle, but can watch the defendant's entire videotaped police interrogation -- including excised portions -- as well as a police interview with Arias's parents, in which they speak of her mental problems. Pro- and anti-Arias websites have sprung up. And it's not just outsiders who are furiously Tweeting, texting and blogging about the case.  Witnesses are watching the trial from home and texting the prosecutor with suggestions for cross-examination. Jodi Arias herself is tweeting from the jail, through a friend. ("HLN is an acronym for Haters Love Negativity," she tweeted.)

It would be naive to suppose that the Arias jury is immune to the inflammatory rhetoric swirling around the Internet. Some of the more sarcastic questions that jurors submitted for the expert witnesses sounded scripted by Nancy Grace. For example, one juror asked psychologist Samuels whether a bad haircut could induce posttraumatic stress disorder (PTSD), Samuels's diagnosis for Arias.

Yet trial judge Sherry Stevens -- who allowed cameras into the courtroom in the first place -- is now relying on the honor system rather than regaining control by sequestering the jury.  Complained defense attorney Kirk Nurmi: "The court asks the question of the jurors every morning, 'Have you seen anything on the media?' No one raises their hand... It is a fairy tale to assume that this jury is not hearing any of this. It is all over the news."

Kiefer, the Arizona Republic reporter who broke the story of witness LaViolette's cyber-bullying, gave examples of juror social-networking misconduct in other cases: A Michigan juror who posted a Facebook preview of her verdict ("Gonna be fun to tell the defendant they're GUILTY"); a juror in Britain who polled her social-media "friends" as to whether she should find a defendant guilty.

With more and more successful appeals of verdicts due to such Internet or social-media interference, according to a Reuters Legal survey, an appeal of any guilty verdict in the four-month Arias trial is a virtual certainty.

But any appeal will not mend the reputations of the expert witnesses called by the defense. As a retired Maricopa County Superior Court judge told Michael Kiefer, the Arizona Republic reporter, "it's the electronic version of a lynch mob."

Sree Sreenivasan, a journalism professor at Columbia University, told Kiefer he had never seen anything like the attack on LaViolette, but that it likely will become "standard operating procedure in prominent cases" -- witness intimidation taken to its logical extreme in a public culture of shaming and vilification.

If so, experts may think long and hard before about accepting referrals in high-profile cases. That, in turn, could have a chilling effect on defendants' rights to a fair trial.

Michael Kiefer's insightful Arizona Republic reports on the social media debacle are HERE, HERE and HERE. A full collection of the live-streamed trial videos is located HERE.

Upcoming trainings: Assessment; personal injury; sexual violence; ethics in diagnosis

If you are planning to be in or around Florida, New Jersey, Hawaii or London over the next few months, here are some recommended forensic trainings on the horizon:

April 19 and onwards: Sexual violence workshops (London) 

Building on the success of the 2011 sexual violence workshops sponsored by the British Psychological Society (at which I spoke), Middlesex University is hosting another round of BPS-sponsored workshops on various aspects of sexual violence. Multiple-perpetrator rape is the topic of the first workshop, coming right up on April 19. (Also check out the new book, the first-ever text on this topic.) Next up are a June 27 workshop on "negotiating ethical sexual relationships," a Sept. 17 workshop on "intersectionality and sexual violence," and a fourth workshop on the investigation and prosecution of rape (date yet to be decided). All the workshops will be held at Middlesex University's Hendon Campus. More details are HERE.

April 20: Assessing Emotional Damages in Personal Injury and Employment Discrimination Cases (New Jersey)

William Foote, president of the American Psychology-Law Society (APA Division 41), will be presenting a five-stage model for assessing psychological damages in personal injury and workplace discrimination cases at the spring conference of the New Jersey Psychological Association. To find out more about this all-day training, click HERE.

May 3-5: New Directions in Forensic and Clinical Assessment (Florida)

Many big names in forensic psychology will descend upon Miami for this training sponsored by Division 42 (Psychologists in Independent Practice) of the American Psychological Association. The three-day conference will feature trainings on risk assessment, malingering, trial consultation, the DSM-5, intellectual disability, and much more. Information and registration can be found HERE. 


July 31: Controversial Psychiatric Diagnoses in Legal Settings (Hawaii) 

Yours truly is the trainer at this all-day continuing education workshop at the American Psychological Association's annual conference, along Honolulu's idyllic Waikiki Beach. I will focus on the scientific and practical limits of psychiatric diagnoses in forensic cases, and provide ethics guidance on how to present diagnostic testimony in court. Details are HERE; I'd love to see you there!

Risk screening worthless with juvenile sex offenders, study finds

Boys labeled as 'sexually violent predators' not more dangerous

Juveniles tagged for preventive detention due to their supposedly higher level of sexual violence risk are no more likely to sexually reoffend than adolescents who are not so branded, a new study has found.

Only about 12 percent of youths who were targeted for civil commitment as sexually violent predators (SVP's) but then freed went on to commit a new sex offense. That compares with about 17 percent of youths screened out as lower risk and tracked over the same five-year follow-up period.

Although the two groups had essentially similar rates of sexual and violent reoffending, overall criminal reoffending was almost twice as high among the youths who were NOT petitioned for civil commitment (66 percent versus 35 percent), further calling into question the judgment of the forensic evaluators.

Because of the youths' overall low rates of sexual recidivism, civil detention has no measurable impact on rates of sexual violence by youthful offenders, asserted study author Michael Caldwell, a psychology professor at the University of Wisconsin and an expert on juvenile sex offending.

The study, just published in the journal Sexual Abuse, is one in a growing corpus pointing to flaws in clinical prediction of risk.

It tracked about 200 juvenile delinquents eligible for civil commitment as Sexually Violent Persons (SVP's). The state where the study was conducted was not specified; at least eight of the 20 U.S. states with SVP laws permit civil detention of juveniles, and all allow commitment of adults based on offenses committed as a juvenile.

As they approached the end of their confinement period, the incarcerated juveniles underwent a two-stage screening process. In the first phase, one of a pool of psychologists at the institution evaluated them to determine whether they had a mental disorder that made them "likely" to commit a future act of sexual violence. Just over one in every four boys was found to meet this criterion, thereby triggering a prosecutorial petition for civil commitment.

After the initial probable cause hearing but before the final civil commitment hearing, an evaluator from a different pool of psychologists conducted a second risk assessment. These  psychologists were also employed by the institution but were independent of the treatment team. Astonishingly, the second set of psychologists disagreed with the first in more than nine out of ten cases, screening out 50 of the remaining 54 youths. (Only four youths were civilly committed, and a judge overturned one of these commitments, so ultimately all but three boys from the initial group of 198 could be tracked in the community to see whether or not they actually reoffended.)

Evaluators typically did not rely on actuarial risk scales to reach their opinions, Caldwell noted, and their methods remained something of a mystery. Youths were more likely to be tagged for civil detention at the first stage if they were white, had multiple male victims, and had engaged in multiple instances of sexual misconduct in custody, Caldwell found.

However, no matter what method they used or which factors they considered, the psychologists likely would have had little success in predicting which youths would reoffend. Even "the most carefully developed and thoroughly studied" methods for predicting juvenile recidivism have shown very limited accuracy, Caldwell pointed out. This is mainly due to a combination of youths' rapid social maturation and their very low base rates of recidivism; it is quite hard to successfully predict a rare event.

Indeed, a recent meta-analysis revealed that none of the six most well-known and best-researched instruments for appraising risk among juvenile sex offenders showed consistently accurate results. Studies that did find significant predictive validity for an instrument were typically conducted by that instrument's authors rather than independent researchers, raising questions about their objectivity.

"Juveniles are still developing their personality, cognitions, and moral judgment, processes that reflect considerable plasticity," noted lead author Inge Hempel, a psychology graduate student in the Netherlands, and her colleagues. "There are still many possible developmental pathways, and no one knows what causes persistent sexual offending."

Caldwell agrees with Hempel and her colleagues that experts' inability to accurately predict which juveniles will commit future sex crimes calls into question the ethics of civil commitment.

"From the perspective of public policy, these results raise questions about whether SVP commitment laws, as written, should apply to juveniles adjudicated for sexual offenses," he wrote. "If SVP laws could be reliably applied to high risk juvenile offenders, the benefit of preventing a lifetime of potential victims makes for a compelling case. However, the task of identifying the small subgroup of juveniles adjudicated for sexual offenses who are likely to persist in sexual violence into adulthood is at least extremely difficult, and may be technically infeasible."

* * * * *

The articles are:

Michael Caldwell: Accuracy of Sexually Violent Person Assessments of Juveniles Adjudicated for Sexual Offenses, Sexual Abuse: A Journal of Research and Treatment. Request it from the author HERE.

Inge Hempel, Nicole Buck, Maaike Cima and Hjalmar van Marle: Review of Risk Assessment Instruments for Juvenile Sex Offenders: What is Next? International Journal of Offender Therapy and Comparative Criminology. Request it from the first author 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.