MnSOST-R actuarial instrument critiqued

More questions about validity of controversial SVP tool

WARNING: This post is technical, and meant as a heads-up to professionals working in the SVP field, especially those who are still encountering (or using) the MnSOST-R. I would advise readers and subscribers who do not work in this area to skip this post – and have a nice 4th of July Holiday.

The current issue of the preeminent forensic psychology journal Law & Human Behavior has a scathing critique of the Minnesota Sex Offender Screening Tool – Revised (MnSOST-R) by University of Minnesota Professor William Grove and graduate student Scott Vrieze. Through a series of statistical analyses, the authors argue that this instrument does not result in more accurate prediction of sex offender recidivism than simply knowing the base rate for such recidivism. The instrument fails to meet basic evidentiary standards and should be excluded from SVP civil commitment trials, they argue.

Despite the fact that the MnSOST-R is used in at least 13 of the 17 states that have SVP civil commitment laws, there is little published information on its reliability or validity. The authors review the available information, which in and of itself makes the article imperative for those using the instrument.

Another contribution is the authors' critique of the recently popularized technique of using AUC's (the Area Under the Curve, from signal detection theory) as a measure of test accuracy. Recidivism rates of sex offenders would have to be about seven times higher than they are in order for AUC estimates to be reliable, the authors argue:

"An AUC statistic … can lull the clinician into thinking that, if the AUC is suitably high, the test will perform satisfactorily…. This is far from necessarily so…."

In the same issue of the journal, Douglas Mossman offers a rebuttal: "Contrary to what Vrieze and Grove suggest, ARAIs (actuarial risk assessment instruments) of modest accuracy yield probabilistic information that is more relevant to legal decision-making than just ‘betting the base rate.' "

The Vrieze and Grove critique follows a series of similar, statistically based critiques of the MnSOST-R and similar actuarials by Richard Wollert. These include:

• Wollert, R. (2002). The importance of cross-validation in actuarial test construction: Shrinkage in the risk estimates for the Minnesota Sex Offender Screening Tool- Revised. Journal of Threat Assessment. 2(1), 89-104.

• Wollert, R. (2002b). Additional flaws in the Minnesota Sex Offender Screening Tool- Revised. Journal of Threat Assessment. 2(4), 65-78

• Wollert, R. (2006) Low Base Rates Limit Expert Certainty When Current Actuarials Are Used to Identify Sexually Violent Predators: An Application of Bayes's Theorem. Psychology, Public Policy, and Law. Feb Vol 12(1) 56-85

These articles are not light reading; they amount to complicated battles among statisticians. But forensic psychologists are expected to be aware of these debates when they testify about the use of actuarial instruments in SVP proceedings.

The Vrieze and Grove abstract is here; the Mossman rebuttal abstract is here. For the full articles you either have to pay or have access to a university database. A handy medical primer on ROC/AUC statistics, complete with slidable graphics, is here.

Video voyeurism: Wisconsin appellate case

"Does agreeing to get naked with someone mean it is lawful for them to film you in the buff without your consent? That's the issue before the Wisconsin Court of Appeals in a case brought by a man convicted of secretly taping his girlfriend in the nude at her home.

The Madison Wisconsin Capital Times has the full story.

Arson: New frontier for exonerations?

Arson Screening Project launches this week

Shortly before Cameron Todd Willingham’s execution four years ago in Texas for a house fire that killed his three young daughters, four arson experts called into question the scientific evidence underlying his conviction.

"There's nothing to suggest to any reasonable arson investigator that this was an arson fire," wrote expert Gerald Hurst in his report. "It was just a fire."

Texas' governor ignored the report, and Willingham was executed on Feb. 17, 2004.

Although it was too late for Willingham, two years later fellow Texan Ernest Ray Willis was exonerated after a panel of fire experts working pro bono for the Innocence Project concluded that both fires were accidental. (Their full report is here.)

"Bad science" exposed

In their peer review, the fire scientists noted that many of the "indicators" of arson that were taught in fire investigation courses up into the 1990s have since been "scientifically proven to be invalid." Yet many so-called experts remain woefully uninformed on the current state of the science. Worse, others deliberately distort science, behaving "as if constant repetition would make [their false] assertion true."

The report echoes a 2004 Chicago Tribune investigation of the Willingham case that found that "many of the pillars of arson investigation that were commonly believed for many years have been disproved by rigorous scientific scrutiny."

Based on my former experience as a criminal investigator, I have no doubt that these problems are real, and are likely the tip of the iceberg. I saw many a case in which fire investigators quickly jumped to the conclusion that a fire had been deliberately set based upon the bad character of their prime suspect rather than reliable evidence.

With DNA exonerations starting to max out due to the small fraction of cases in which DNA evidence is collected, the Innocence Project is expanding into other causes of wrongful convictions, including what they call "inexact sciences" and pseudoscientific methods. Old arson convictions are likely to be at the forefront of this new area of scrutiny.

An Arson Screening Project launched just yesterday by the John Jay College of Criminal Justice will lead the charge, scrutinizing the backlog of arson cases compiled by the Innocence Project. Part of the Center for Modern Forensic Practice, the project will collect and evaluate claims of wrongful conviction "based on the use of a faulty, folk-science of fire indicators over the past 20 years."

One of the main dangers of bad science is that jurors tend to trust expert witnesses and to fall for such "science" hook, line, and sinker.

As one of the jurors who sentenced Willingham put it, "Maybe this man was innocent. Now I will have to live with this for the rest of my life."

Among the goals of the new project will be to create a pool of nonpartisan fire experts who can help avoid this outcome by disseminating information about the " 'bad science' arson experience" to other professionals and the public.

Hat tip: Grits for Breakfast

Commission recommends major reforms to California death penalty system

California's death penalty system is costly, ineffectual, and on the verge of collapse, according to a just-issued report of the California Commission on the Fair Administration of Justice.

California has the longest delays in executions of any state. Of the 813 people sentenced to die since the death penalty was reenacted in 1977, only 13 have been executed. That's fewer than have killed themselves (14) or died of natural causes (38). Despite the fact that death verdicts are decreasing (last year, only 20 people were sentenced to death in the populous state), the number of people awaiting execution is at an all-time high of 670. The logjam is so great that "California would have to execute five prisoners per month for the next 12 years just to carry out the sentences of those currently on death row," the Commission stated.

A major reason for the long delays is a shortage of competent attorneys at every stage of the process. A condemned prisoner sits on death row for 3 to 5 years before getting a lawyer, waits another 2 years before his first, "automatic" appeal is heard by the state Supreme Court, and waits more years before getting state habeas counsel (291 inmates don't have that attorney assigned yet). That's before even reaching the federal level, where more delays ensue at every stage.

To address the attorney shortage, the Commission is recommending big increases in the stable of state Public Defenders and attorneys at the California Habeas Corpus Resource Center. Such massive funding increases are unlikely, in my opinion, given the current budget crisis and the national trend of slashing defense expenditures (see my June 26 blog post.)

The Commission also recommends more funding at the trial level. The report points out that most death penalty verdicts are getting overturned by federal courts, causing expenditures for costly retrials. The leading cause of such reversals is trial attorneys' failure to adequately investigate potential mitigating evidence, as required under Wiggins v. Smith (539 US 510, 2003).

Part of the reason for that abysmal record, according to the Commission, is that many counties are paying private attorneys a flat fee. This discourages them from hiring investigators and expert witnesses, because the money comes out of their own pocket. The Commission urged the state Supreme Court to increase funding for privately appointed lawyers so that they are paid enough to ensure "high quality legal representation" and so that they obtain the necessary expert services.

The Commission's recommendations to pour massive additional funding into a faulty system are sure to be controversial. The Commission mentions less costly alternatives, including getting rid of the death penalty altogether (as some other states have done) or at least reducing its scope so that only the "worst of the worst" are eligible.

One very sound recommendation is to eliminate felony murder as grounds for death. (see the New York Times editorial by Adam Liptak, "American Exception: Serving Life for Providing Car to Killers," for an excellent discussion of the felony murder rule.)

Narrowing the death penalty's scope to five especially heinous grounds would reduce the current death row population to 368, the Commission said.

The comprehensive report also addresses geographic variations in death penalty implementation. Researchers have found that rural counties in California with high proportions of whites impose death at a higher rate, and - perhaps not coincidentally - people who kill African Americans are less likely to receive the ultimate punishment.

The Commission, created in 2004 to recommend reforms to make the state's criminal justice system fairer, heard from 72 witnesses over a six-month period. In addition to the majority recommendations, the downloadable, 145-page report contains dissenting statements from police and prosecutor members as well as a call for death penalty abolition by commission members from the defense bar.

The Commission is composed of law enforcement, prosecutors, defense attorneys, judges, and citizens. It has already issued a series of unanimous recommendations on other criminal justice issues, including eyewitness identification, false confessions, jailhouse informants, scientific evidence, and wrongful conviction remedies. (See my previous blog post (here) for links to those reports.

San Francisco Chronicle coverage of the report is here. The American Bar Association's study on the death penalty in eight states is here. Critical analysis of the U.S. death penalty by Time and Newsweek magazines are here and here.

Interesting issue of forensic psychiatry journal

The latest issue of the Journal of the American Academy of Psychiatry and Law is now available online. The theme is ethics in forensic psychiatry practice.

I found Cheryl Wills' article (here) especially intriguing:

Post-Katrina Juvenile Competency Determinations: A Tale of Two Systems

Natural disasters such as Hurricane Katrina have resulted in the displacement of families to locations throughout the nation. Juvenile courts have been affected by this mass migration of youths. Postdisaster recovery has been slow. Consequently, a cohort of youths has aged out of the juvenile justice system before their juvenile competency hearings could be held. Some of these young adults now face charges as adults in criminal courts. The author explores what happens when youths awaiting juvenile competency determinations age out of the system and face charges as adults. The evolution of the problem, the current situation, case examples, and possible solutions are reviewed.

Amnesia and crime

The June issue also includes a point-counterpoint debate on assessing amnesia and crime. Should the approach be neuropsychiatric, as argued by Hal Wortzel and David Arciniegas (here), or psychiatric-clinical, as argued by Dominique Bourget and Laurie Whitehurst (here)?

Review of Campbell's Assessing Sex Offenders

Michael Harlow writes a critical review (here) of the new (second) edition of Terrence W. Campbell's Assessing Sex Offenders: Problems and Pitfalls. (To see the new edition itself at Amazon, click here.)

Legal case summaries

And, last but not least, we get summaries of interesting recent court cases on:

• Miranda Waiver in a Juvenile

• Mental Retardation and the Death Penalty

• Competence to Stand Trial

• Methamphetamine-Induced Psychosis and Diminished Capacity

Click here for the full table of contents.

Indigent defendants face loss of attorneys

"Starve the Beast" decimating public services

Crumbling schools, shuttered hospitals, unemployment, homeless elderly, the demise of medical and mental health services. It is hard for me to grasp that the catastrophic collapse of America's infrastructure is part of a deliberate, 25-year strategy.

But there is not much doubt that the current crisis is the result of the "Starve the Beast" doctrine of slashing government services through tax cuts, especially for the corporations and the rich. Taxes in the United States are far lower than in almost any other advanced country, while war costs skyrocket.

In the criminal justice system, budget cuts are making a mockery out of the Constitutional right to legal representation. With plea-bargains the norm, trials are becoming an endangered species. In one rural Mississippi county, more than 4 out of 10 indigent defendants plead guilty at arraignment, on the day that they first meet their court-appointed contract lawyers.

The public defenders I work with are staggering under crippling caseloads. Around the country, budget cuts are forcing layoffs of trial lawyers. In some counties, public defense agencies are responding by refusing to handle misdemeanors and even, in some cases, serious felonies.

• In Florida, the Miami-Dade County Public Defender is withdrawing from all felony cases except murder and child rape. Bennett Brummer said this week that his office cannot ethically accept more cases than his attorneys have time to properly handle. A court hearing is set for Friday.

• In Minnesota, the state Public Defender Office is laying off 16 percent of its attorneys (72 of 440), and will stop representing parents in child welfare cases and defendants in some drug court cases.

• In Kentucky, the Department of Public Advocacy will drop about 10,000 to 20,000 cases per year, including involuntary civil commitments and family court cases. The chief justice of the Supreme Court called it an impending legal crisis: "Without adequate defense counsel, the public simply cannot be confident that persons are not being wrongfully convicted of crimes."

• In Atlanta, Georgia, the state public defender is closing one office and laying off lawyers, leaving 1,850 defendants without lawyers. A class-action lawsuit brought by several of the suspects and their attorneys claims the firings will replace adequate representation with “lawyers who meet, greet and plead their clients in as little time as possible."

If public defenders refuse a case, the courts may appoint private contract attorneys. In Atlanta, the proposal is to pay these private lawyers $200 for each plea bargain and $600 for each trial. It is hard for me to see how this meager payment could possibly engender adequate legal representation.

The crisis bodes poorly for forensic psychologists who make their living in the criminal justice sector. Unqualified attorneys who are simply collecting checks have little incentive to contract for necessary investigation or psychological evaluations for their indigent clients. As in the rural Mississippi county described above, the only way they can make a buck is by strong-arming guilty pleas at arraignment.

More importantly, it bodes poorly for those who are actually innocent. Based on DNA exonerations, Scott Henson over at Grits for Breakfast estimates there are probably about 2,300 to 5,000 innocent people locked up in Texas prisons alone. If the current crisis continues, that number is bound to grow.

The Wall Street Journal's Law Blog, ABC News, and the New York Times have more on the crisis. Hat tip to Bruce for telling me about the conservative "Starve the Beast" doctrine.

CA Study: Shockingly low sex offender recidivism

New research in California shows that only a tiny fraction - 3.38 percent - of released sex offenders are convicted of a new sex offense within 10 years of release. The study followed 3,577 prisoners who were released between 1997 and 2007 after serving time for sex offenses.

In an even larger parallel study by California's Sex Offender Management Board, tracking 4,204 paroled sex offenders, only 3.21 percent were convicted of a new sex offense within 5 years of release.

In both studies, almost all of the recidivism came within the first year post-release. Sex offenders were returned to custody for parole violations at a lower rate than other paroled prisoners, despite the fact that they were supervised more intensely. And they were more likely to be rearrested for crimes other than sex offenses.

The findings are consistent with a smaller study two years ago of recidivism by civilly committed Sexually Violent Predators. Of 93 such high-risk offenders released from Atascadero State Hospital without completing treatment, only 4.3 percent reoffended within six years.

The data call into question the dramatically higher recidivism rates cited by state evaluators at Sexually Violent Predator (SVP) civil commitment trials. Those data are based on Canadian research with an actuarial instrument called the Static 99. The Static 99 recidivism base rates are 18 percent after five years and 21.3 percent after 10 years, many times higher than the California data.

The statistical procedure of survival analysis may explain some of this discrepancy, but is unlikely to account for most of it. In survival analysis, an offender who dies or is reimprisoned is removed from the data pool, so that only offenders who are at risk of reoffending are calculated.

Rates of detected recidivism among sex offenders have dropped precipitously in recent years. In a 10-year period, sexual assaults against adolescents age 12-17 dropped by 79 percent; substantiated sexual abuse cases involving children dropped 39 percent in the same period. Possible reasons for the decline include greater public awareness and more severe punishments.

The data are a bit hidden at the California Sex Offender Management Board's website, so I have made them available HERE (5-year study) and HERE (10-year study).

How will Edwards affect competency evaluations?

Imagine yourself in this situation:

You have no money or family resources. You are arrested for a serious crime you did not commit. You are assigned an overworked and inexperienced lawyer. You repeatedly call his office, but he is never there. On the eve of trial, he briefly visits you at the jail. He is not familiar with your case. He has done no investigation. He brushes aside your claims of innocence and urges you to plead guilty. You talk to other prisoners. They say this attorney is notorious for falling asleep during trials. Frantic, you ask the judge for a different lawyer. He refuses.

This situation is far from fantasy. The quality of court-appointed counsel is abysmal in many jurisdictions. Indigent defense agencies are understaffed and underfunded, creating a pressing demand to extract guilty pleas from their clients. Appellate courts have consistently ruled that inexperience, falling asleep, and heavy drinking do not necessarily constitute ineffective assistance of counsel.

Your choices: (1) Watch this inept attorney railroad you to prison, (2) plead guilty to a crime you did not commit, or (3) represent yourself.

That latter choice may be your best option. According to the only empirical study to date, pro se defendants were more likely to win acquittals than were defendants with attorneys. Of course, only a tiny proportion of defendants, about 0.3% to 0.5%, represent themselves, often when they are backed into a corner as in the above vignette.

So how does this relate to yesterday's U.S. Supreme Court ruling in Indiana v. Edwards?

In Edwards, the high court carved out a special niche for mentally ill defendants, subordinating autonomy for ostensible fairness. The ruling establishes two levels of competency: the current (low) level for competency to stand trial, and a higher one for competency to represent oneself. But it provides no guidance on what this higher level is.

Although only a small proportion of pro se defendants are mentally ill, a request to represent oneself is likely to trigger a competency evaluation. Indeed, of the 22% of pro se defendants who were screened for competency in the above-cited study by law professor Erica Hashimoto, most (59%) were screened only after they sought to dismiss their counsel. Judges and prosecutors are likely to seek such evaluations because failure to do so might cause a conviction to be overturned.

Expansion of parens patriae doctrine

The underlying problem is that the standard for competency to stand trial is very low, and the courts have consistently refused to raise the bar. But how many judges want an inexperienced, potentially disruptive defendant mucking up their courtroom? So, my prediction is that mentally ill defendants will be found competent, but forced to accept an attorney - and a defense - that they may not want.

Indeed, this was at the crux of Justice Antonin Scalia's lengthy dissent:

"Once the right of self-representation for the mentally ill is a sometime thing, trial judges will have every incentive to make their lives easier … by appointing knowledgeable and literate counsel."

And since the U.S. trial system gives "full authority" to the attorney to conduct the defense as he or she sees fit, a defendant who has not consented to legal representation is stripped of the right to present his own defense.

"The facts of this case illustrate this point with the utmost clarity," Scalia wrote. "Edwards wished to take a self-defense case to the jury. His counsel preferred a defense that focused on lack of intent. Having been denied the right to conduct his own defense, Edwards was convicted without having the opportunity to present to the jury the grounds he believed supported his innocence."

The other side of this argument, of course, is that allowing floridly psychotic defendants to represent themselves sanctions court-assisted suicide in that conviction is almost always assured. This is especially so in serious cases, including death penalty cases.

As the high court held in the half-century-old case of Massey v. Moore, "No trial can be fair that leaves the defense to a man who is insane, unaided by counsel, and who by reason of his mental condition stands helpless and alone before the court."

Slippery slope

As Scalia noted, the Edwards ruling is "extraordinarily vague." It leaves unanswered the question of what level of competence is sufficient to represent oneself, and how that decision will be made.

It also leaves unclear what happens when a defendant has an attorney, but seeks to testify at trial. Will there be an intermediate standard of competency for this situation, in which a certain degree of rational thinking and articulation skills are necessary?

Undoubtedly, the murkiness of the new standard will increase the complexity of these evaluations for forensic psychologists and psychiatrists. This is especially problematic in that court-appointed experts are grossly undercompensated, which attracts inexperienced and poorly trained professionals willing to perform what one attorney I know refers to as "drive-by competency evaluations."

I see the potential of depriving the mentally ill of a right to counsel as a potentially slippery slope. Where does one draw the line? Indeed, in its amicus brief, the American Psychiatric Association noted the need for pro se defendants to have both "oral communication capabilities" and "written-communication abilities."

So, might perceived low intelligence or even low education be a sufficient bar to self-representation? And, how about ideological extremism? Could those labeled "terrorists" be barred from representing themselves in order to air their political beliefs?

This linkage is not a remote possibility, as it turns out. One of the key issues in the Guantanamo prosecutions has been whether the detainees (who are not protected by the U.S. Constitution) will be allowed independent counsel. The initial tribunal rules refused to allow competent detainees to represent themselves. Now, detainees may decline government-appointed lawyers, but the tribune may force counsel onto any detainee who does not fully participate in his defense.

More nuanced approach

On the brighter side, the high court refused to overturn Faretta v. California, as the state of Indiana had sought. That 1975 case established the right of defendants to represent themselves so long as they made this choice "voluntarily and intelligently."

In addition, the ruling may whittle away at the unilateral view of competency espoused by the court in Godinez v. Moran, the only other Supreme Court case that has considered competence within the context of self-representation. In that 1993 opinion, written by Justice Clarence Thomas, the court engaged in convoluted reasoning to hold that no higher level of competency was required to waive counsel.

"There is no reason to believe that the decision to waive counsel requires an appreciably higher level of mental functioning than the decision to waive other constitutional rights," held the Court in Godinez. "The competence that is required of a defendant seeking to waive his right to counsel is the competence to waive the right, not the competence to represent himself."

In contrast, the Edwards opinion cites the empirical research conducted by the MacArthur group to assert that competency is not a single, unitary construct. Rather, understanding, reasoning, and appreciation of one's circumstances are separable aspects of functional legal ability, the court held.

We can only hope that this recognition of the complexity of competency, and the implicit endorsement of formal competency assessment tools such as the MacCAT-CA, signals an important shift in thinking.

In preparing this essay, I came across many good resources, some of which are listed here.

The ruling in Indiana v. Edwards is here. All of the various supporting and opposing briefs are available here and here. The American Psychiatric Association brief is here.

Erica Hashimoto's research on pro se defendants, Defending the Right of Self-Representation: An Empirical Look at the Pro Se Felony Defendant, 85 NC Law Review 432 (2007), is available for download here. An essay by her at the Concurring Opinions blog is here.

The New York Times, the Christian Science Monitor, and Legal Times have coverage of the ruling. Commentary is available at Scotusblog, Crim Prof blog, Simple Justice, the Legal Ethics Forum, and Court-O-Rama.

Mentally ill: No constitutional right to self representation

A few months ago, I blogged about an important case out of Indiana, pertaining to whether the mentally ill have a right to represent themselves in court. As many of you may recall, this Constitutional right led to the farcical and ironic spectacle of a railroad killer railroading himself straight to prison.

That was Colin Ferguson (satirized by Saturday Night Live here). We have witnessed similar spectacles in other cases of floridly psychotic people acting as their own attorneys. Another example that I blogged about several times was Scott Panetti, who rambled insanely at his 1995 murder trial and tried to subpoena Jesus Christ, John F. Kennedy, and other dead people.

It's an easy conviction for the prosecution, of course. But it is hardly fair. And certainly not dignified.

In today's 7-2 ruling in the case of Indiana v. Edwards, the U.S. Supreme Court held that the mentally ill do not have the same constitutional rights as everyone else. Even though someone may be competent to stand trial with the help of a lawyer, a judge may force the defendant to accept an attorney if the trial might otherwise be a farce.

"The Constitution permits states to insist upon representation by counsel for those competent enough to stand trial ... but who still suffer from severe mental illness to the point where they are not competent to conduct trial proceedings by themselves," Justice Stephen Breyer wrote for the majority.

Proponents of allowing mentally ill defendants to represent themselves despite questionable understanding and judgment cite the Sixth Amendment's right to self-representation. Legal scholar Michael Perlin calls this argument a "pretextual" rationalization for injustice.

Today's decision involved Ahmad Edwards, a delusional schizophrenic man whom a trial judge ruled was competent to stand trial for a robbery-shooting but incompetent to represent himself. Edwards had an attorney but was convicted anyway, prompting his appeal. This ruling will likely reinstate his conviction.

The imposition of a higher standard for self representation than for other facets of competency to stand trial seems at odds with the high court’s earlier holding in Godinez v. Moran. Clarence Thomas, the author of that 1993 opinion, dissented in Thursday's ruling, as did fellow conservative jurist Antonin Scalia.

"In my view, the Constitution does not permit a state to substitute its own perception of fairness for the defendant's right to make his own case before the jury," Scalia said.

The full opinion in Indiana v. Edwards (07-208) is available here. USA Today has more here. My previous blog post on the case is here. Photo credit: afsilva, "The Railroad Ahead" (Creative Commons license).

More on the McInerney antigay murder case

Defense may use emerging science of adolescent brain development

Greg Herek, a prominent scholar in the field of prejudice studies, wrote a good summary today about the case of 14-year old Brandon McInerney. As I noted yesterday, the 14-year-old will be arraigned Thursday on charges of murdering his gay classmate, 15-year-old Lawrence King.

Herek's post, which you can read at the UC Davis researcher's "Beyond Homophobia" blog, mentions the possibility of a defense based on emerging neuroscience technology, suggesting that the adolescent brain is not fully developed.

McInerney's attorney, Ventura County Public Defender William Quest, has said he will do everything he can to invoke the science of the developing brain at McInerney's trial. Quest maintains that immature brain development might mitigate the intent to kill.

"The crux of homicide is you have this intent to kill. It's thought out and coherent. If there is something that, given your brain development, puts you in a state that is not coherent, it mitigates that intent," he is quoted in the Ventura County Star as saying.

Quest may have a tough time convincing jurors that McInerney did not form the legally required intent to kill, in that the Young Marines member brought a gun to school and shot Lawrence King not once but twice in the head.

If a neuroscience defense emerges as a centerpiece of the nationally publicized case, it will likely draw attention to the current conflict in the field over whether the budding science is well enough established for the courtroom. (For more on that debate, see the Law & Neuroscience Project website and the Law and Ethics of Brain Scanning resources brought to you by the Sandra Day O’Connor College of Law at the University of Arizona.)

That controversy aside, it will be good news if Quest backs away from his earlier focus on blaming the school for the tragedy. Quest had publicly stated that administrators of the middle school where the killing took place were partly responsible because they allowed the victim to openly display his gender nonconformity.

Tom Kisken of the Ventura County Star has a lengthy summary of the neuroscience debate as it pertains to McInerney's case, available online here. Greg Herek's blog post is here.

What caused middle school tragedy?

14-year-old Brandon McInerney to be arraigned Thursday

The facts are deceptively simple:

• Lawrence "Larry" King was a 15-year-old who loved art, chess, and entomology. Since moving to a home for abused children, he was becoming more open about his sexuality and had taken to sporting high heels and makeup.

• Larry was relentlessly teased at his Southern California middle school. His response was to dish it back at his tormentors, who included among them the popular and hypermasculine Brandon "Bear" McInerney.

• An escalating conflict between the two boys ended on Feb. 12, when Brandon marched into E.O. Green Middle School and shot Larry in the head. Brandon will be arraigned later this week in Ventura County on a charge of murder with a hate crime enhancement.

But beyond these superficial case facts, questions swirl:

• What provoked Brandon to the point that he committed murder? And should he be prosecuted as an adult?

• Does the school bear any responsibility? Should administrators have realized the danger and intervened before lethal violence exploded?

• What can and should be done to improve the safety of gender-nonconforming youth in the schools?

Prosecution as an adult

On the front burner is the question of whether Brandon will be tried as an adult. In California, the minimum age at which a juvenile can be transferred to adult court is 14. Brandon had turned 14 just a few weeks before the offense.

In an ironic twist, a coalition of 27 sexual minority groups has urged the District Attorney not to try Brandon in adult court, where he would face a punishment of 50 years to life in prison. "We call on prosecutors not to compound this tragedy with another wrong,” wrote the coalition. "We support the principles underlying our juvenile justice system that treat children differently than adults and provide greater hope and opportunity for rehabilitation." The letter cites research by the Centers for Disease Control and Prevention finding that children tried as adults are more likely to commit another crime than those tried as juveniles.

The prosecutor's office is likely to ignore the coalition's eloquent plea. After all, Brandon showed premeditation by bringing a gun to school a day after a lunchtime argument with Larry.

School's responsibility debated

In the wake of the tragedy, many fingers are pointing at the school - but from different sides.

On one side is Brandon's public defender, William Quest. He blames the school for being too gay-positive, and letting Larry come to school wearing feminine accessories. Administrators should have intervened when Larry openly flirted with Brandon, he says.

On the other side are lesbian and gay activists, who point out that despite significant progress the schools remain a dangerous place for gender-deviant youth. Four out of five sexual minority youth report being harassed at school, according to a recent national survey.

The oxymoronic "No Child Left Behind" movement, with its myopic focus on standardized testing, has also decimated many anti-bullying programs. "A lot of educators are frustrated because they understand the importance of addressing some of these larger [social] efforts, but when they try to they're told, 'You've just got to get the math scores up,' " said educator Kevin Jennings.

Still, there are dramatic signs of change. Many young people are coming out at earlier ages, are finding acceptance among peers, and are feeling good about themselves. This year, more than 7,500 schools nationwide participated in a student-led Day of Silence dedicated to Larry King.

The annual Day of Silence is sponsored by the Gay Straight Alliance (GSA) movement. School-based GSA clubs are one of the most promising methods of improving school safety, and they are increasingly common at the high school level. Larry's middle school did not have one.

Gay Panic Defense?

The accusations leveled by Brandon's public defender raise the possibility of a Gay Panic Defense, in which the defense might claim that Brandon had no choice but to defend himself and his masculinity from Larry's aggressive sexuality.

In my own research with antigay hate crime perpetrators, I found that many young men believe they have a right to physically assault gay men whom they perceive as flirting with them.

In my research, I conceptualized antigay violence as existing on a continuum. At one end are verbal taunts that are ubiquitous and which, sadly, remain socially acceptable among many adolescents. At the other end are severe acts of violence. These tend to be committed not necessarily by those with the most hostile attitudes toward gay people but, rather, by those with the most severe histories of violence or abuse.

Brandon's case fits this model. Brandon was just one among many of the students at E.O. Green who routinely teased and taunted Larry, according to an account in the Ventura County Star:

"A lot of people picked on him," said Madison Norton, 12. "Some people would walk up to him, and he'd say something back. It would be random, like at lunch - 'What's with the makeup' - weird stuff like that."

Hailey Day, 13, said she regularly heard Brandon calling Larry derogatory names the week before the shooting. She would tell him to stop, and Brandon would walk away.

But Brandon, as the product of a volatile home environment, had the potential for more extreme violence. Court records reveal a childhood dominated by family violence and drug addiction, according to a report in the Ventura County Star newspaper. Indeed, right around the time of his conception his father shot his mother in the elbow. Thus, throughout his life Brandon had seen violence modeled as a method of solving problems.

If students had an open channel of communication to school administrators, and if administrators could effectively respond, this tragedy might have been averted. Just the day before the killing, at a lunchtime confrontation between Brandon and Larry, another boy reportedly shouted at Larry: "You better watch your back."

Did anyone take the threat seriously? Perhaps only Larry.

The day of the shooting, Larry looked upset, friends told the Star. "He came to school looking different. Gone were the boots and makeup. He wore regular tennis shoes and had his hair gelled and carefully combed to the side."

"I said, 'Dude, what's wrong?' " his friend Matthew Hernandez recalled. "He said, 'Nothing.' "

Yesterday, NPR's All Things Considered ran a 5-minute segment on the case, including chilling audio from a 911 call. (Listen here.) More background is online at Wikipedia, the Advocate, and the Los Angeles Times.

Hat tip: Greg Herek

"Locked in Limbo"

Expose on Minnesota's civil commitment system

Minnesota is the heartland of America, and it could also be considered Ground Zero for the Sexually Violent Predator movement that has swept America in the past two decades. Minnesota brought us the MnSost-R, one of the first of the wave of controversial "actuarial" instruments used to measure sex offender recidivism risk. The state civilly commits a greater proportion of its sex offenders than any other state, and so far it's proven to be a life sentence for all.

This weekend is the start of an in-depth series in the Minneapolis Star-Tribune that explores the the history, the mounting costs, and some of the controversies surrounding the Minnesota Sex Offender Program (MSOP), where 554 men and one woman have been committed. To date, 24 "patients" have died in the program, while not a single person has been successfully treated and released. The series features an online slide show and profiles of several offenders.

Check it out here.

Hat tip: Kirk Witherspoon

Seattle mistrial highlights complexity of insanity law

On the one side, the defense: Naveed Haq was in a manic, psychotic state and was prompted to commit his rampage at the Jewish Federation of Greater Seattle on July 28, 2006 by hearing God tell him he was on a mission.

On the other side, the prosecution: Haq was a frustrated, chronically unemployed, and awkward man whose killing of one woman and wounding of five others was an attempt to commit "suicide by cop."

Faced with these dueling positions, jurors threw up their hands Wednesday after many days of grueling deliberations and declared that they could not decide whether Haq was insane. Haq will be retried.

During the nationally televised trial, James Missett, MD, Ph.D. testified for the defense that Haq thought he was on a mission from God and thought he could bring peace to the Middle East. Haq believed God approved of his mission because God was talking to him during the shooting and he felt like something was controlling his trigger finger, Missett testified. Missett is a prominent forensic psychiatrist from Menlo Park, California, who is affiliated with Stanford University's Center for Psychiatry and the Law.

However, Under the Washington case of State v. Potter (68 Wn. App. 134), just believing that he was acting on a mission from God would not be enough to establish legal insanity; he would still have to show that he was unaware that his act was legally and morally wrong.

Missett testified that Haq was unable to perceive the nature of what he was doing or tell right from was wrong. Under Washington law, Haq was insane if he was "unable to perceive the nature and quality of the act" or "unable to tell right from wrong" due to a mental disease or defect. The burden is on the defense to prove insanity by a preponderance of the evidence.

Countering Missett’s testimony was J. Robert Wheeler, Ph.D., a forensic psychologist in Washington who specializes in sex offender treatment and evaluation. He testified for the prosecution that Haq was depressed, angry, and suicidal - but not psychotic or manic - in the days leading up to the shooting.

He testified that Haq told him, "I was very lonely. My family was always on my case. I had monetary problems. I was enraged all the time. I had no friends. This whole Jewish Federation thing was kind of an escape, you know - it was a suicide attempt.' " On cross-examination, however, Wheeler acknowledged that Haq did tell him, "It was like something had taken hold of me, some other force, on my hand, on my body, on my brain."

As evidence of Haq's capacity to plan and premedite, Wheeler pointed out that Haq purchased three guns and test-fired them before the shooting.

The dueling experts did not differ significantly on Haq's diagnosis: Missett diagnosed him with bipolar disorder, while Wheeler diagnosed schizoaffective disorder, a psychotic disorder similar to schizophrenia but with mood swings.

The jury spent more than seven days struggling over the starkly competing versions of Haq's mental state at the time of the offense before finally announcing that they were hopelessly deadlocked.

"We deliberated with tears, and to the best of our ability," said one juror. "I have great compassion for the victims and their families, as well as everyone involved in the case. ... We were all very, very sad at the end."

The Seattle Times and the Seattle Post-Intelligencer have extensive coverage of the case. In April I also blogged (here) about some of its interesting evidentiary issues.

Case study on malingering diagnosis

I was excited when I picked up my mail today to find an advance copy of the latest issue of the Journal of Forensic Psychology Practice, with a long overdue article by me on malingering. As you can probably guess from the title, "Malingering as a Dichotomous Variable: Case Report on an Insanity Defendant," the article evolved out of a forensic case in which I was retained. I testified as an expert witness on the issue of insanity. The article critiques certain practices at an unnamed but easily identifiable state hospital.

Here is the abstract:

Malingering in forensic contexts has garnered increased attention in recent years. As a result, the past two decades have seen the development of more than a half dozen instruments to assess response styles. Although these instruments are gaining unprecedented popularity among forensic practitioners, there is little research on how closely practitioners adhere to the published guidelines for administration or interpretation. This article provides a case study of the use of one popular instrument, the Structured Inventory of Reported Symptoms, in an insanity case. Misinterpretation of the defendant’s scores contributed to the misclassification of malingering, which was used to bolster the government’s case at trial. This case suggests the need for better training and more caution when using instruments to assess response styles in forensic contexts.

No right to competence at SVP trial, court holds

You all know what a "Catch-22" is, right?

In the novel by the same name, that was the military catch that kept any airman from avoiding a combat mission. More broadly, it is a double bind in which a government bureaucracy achieves its goals through circular logic that in reality is both illogical and even immoral at times.

For a perfect, modern-day example, read last week's appellate opinion in the Wisconsin case of Ronald D. Luttrell (available here).

Luttrell is (or at least was) a pretty bad man. Back when he was 29 years old, he raped and killed an 83-year-old woman after breaking into her home. He is now 53 and because his prison term has ended, the state wants to lock him in a hospital so he cannot commit any future crimes.

What the appellate opinion boils down to is this: Luttrell does not have the right to be found competent before being tried as a Sexually Violent Predator. But the opinion is a great example of a Catch-22 because of its circular reasoning, geared not toward justice but toward achieving the state's utilitarian goal of incapacitation.

In the first catch, the court says that Luttrell is not being punished: He is facing civil commitment only to protect the public. Because he is not being punished, criminal protections do not apply. That is despite the fact that SVP "patients" face far more dire consequences than most criminal defendants. Here in California, for example, with one prior "qualifying offense" and an easily demonstrated risk to the public, you can get what amounts to a life sentence at a state hospital.

Second, the court argues, Luttrell must by definition be mentally ill or he could not be civilly committed. That is because, in order to be legal under U.S. Supreme Court holdings, a civil commitment must be based upon a diagnosed "mental abnormality" that makes the person "likely" to commit future sexually violent acts.

This is another great Catch-22. The mental illnesses that most frequently cause incompetence to stand trial are the big ones, like Schizophrenia and Mental Retardation. In SVP cases, people are assigned controversial diagnoses like Pedophilia, "Paraphilia NOS," and Antisocial Personality Disorder (see my previous posts, here and here). These conditions do not scramble the brain such that a person would be legally incompetent.

Competency is not some quirky technicality, by the way. It is a fundamental right in the criminal justice system in most countries. The idea, descended from British common law, is that it is patently unfair to put someone on trial when he is too crazy to defend himself. Not only that, but it makes the government look bad. The requirements for competency are also pretty basic. You need only a rudimentary understanding of your legal situation, and a minimal ability to assist your attorney in preparing a defense.

Contrary to what many people - including some defendants - think, being found incompetent in a criminal case does not necessarily get you off. You go to a state hospital, where you may spend more time incarcerated than if you had pleaded guilty and gone to jail.

However, there are limits. Back in the 1960s, a "feeble-minded" deaf-mute named Theon Jackson was found incompetent and received what amounted to a life sentence for two petty thefts totaling $9. His case triggered reforms that cap how much time a person can be hospitalized for competency restoration treatment. In Wisconsin, for example, a criminal defendant who is not likely to "become competent" within one year must be released from confinement unless he is eligible for the regular kind of civil commitment due to grave disability or dangerousness.

And that is precisely the worry of the Wisconsin court as to Sexually Violent Predators. Although they are dangerous under SVP definitions, most would not meet the criteria for dangerousness under the regular civil commitment laws, which require evidence of a recent act or threat to do serious bodily harm. Luttrell, for example, would not qualify because he committed his crime almost a quarter of a century ago.

But, hey, compared to the innocent children victimized in Operation Wagon Train or the Yearning for Zion raid, it's hard to muster a whole lot of sympathy for a guy who raped and murdered an 83-year-old woman in her own home. Even if it was a long time ago.

Hat tip: Luis Rosell. Photo credit: "Gilbert" (Creative Commons license).

Major ruling on forensic neuropsychology

Flexible wins epic
Battle of the Batteries

The Democrats have Obama versus Clinton. American Idol has the battle of the two Davids. But whoever heard of the battle between the fixed and the flexible batteries?

The New Hampshire Supreme Court, for one. And in that more obscure battle in the field of neuropsychology, the court this week handed a resounding victory to the flexible battery. Although I haven't seen anyone dancing in the streets, it's a victory that forensic psychologists and neuropsychologists should be celebrating.

A bit of background: The "fixed" battery approach involves rigid administration of a fixed set of tests. The most popular such batteries are the Halstead-Reitan and the Luria. The flexible or "Boston Process" approach, in contrast, involves administering a core set of tests, supplemented by extra tests chosen on the basis of specific case factors and hypotheses.

When I was a neuropsychology intern, I was trained in the Boston Process Approach. As it turns out, the overwhelming majority of neuropsychologists in a recent survey - 94% - said they use some type of flexible battery approach. As the New Hampshire Supreme Court pointed out, that makes it the standard of practice in the field.

The case involves the alleged lead poisoning of Shelby Baxter, now 13, when she was a toddler. The civil case against Ms. Baxter's landlord, whom the Baxters claim knew the apartment was contaminated, was dismissed after the trial judge excluded neuropsychological evidence using the Boston Process approach as not scientific. The case will now go forward.

The plaintiffs' neuropsychologist, Barbara Bruno-Golden, Ed.D, had substantial experience with lead-exposed children, and each individual test in her battery was published, tested, and peer reviewed, as befitting reliable science under the legal standard of Daubert and New Hampshire statutory law.

At a 6-day Daubert evidentiary hearing, the defense called controversial neuropsychologist David Faust, Ph.D., who testified that although Dr. Bruno-Golden's approach was generally accepted in clinical practice, it was not so in a forensic setting. The plaintiff's experts, as well as the American Academy of Clinical Neuropsychology in an amicus brief, correctly countered that there is no separate standard for forensic practice.

In its exhaustive and thoroughly reasoned opinion, the Supreme Court soundly rejected Faust's reasoning, issuing a monumental blow to the minority of forensic neuropsychologists who staunchly cling to the fixed battery approach.

"Under the defendants' position, no psychologist who uses a flexible battery would qualify as an expert, even though the flexible battery approach is the prevalent and well-accepted methodology for neuropsychology," the court pointed out. "Therefore, the implication … is that no neuropsychologist, or even psychiatrist or psychologist since, in their view, all combinations of tests need to be validated and reliable, could ever assist a trier of fact in a legal case."

The court held that any weaknesses in Bruno-Golden’s methodology - if indeed such existed - were properly handled through cross-examination and counterbalancing evidence in the adversarial trial process.

The case, Baxter v. Temple, is online here. A news article is here. A blog commentary at Traumatic Brain Injury is here.

Photo credit: 02ma (Creative Commons license)

"Fake Bad Scale": Lawyers advocate exposing in court

When a controversial test is being used against their client, attorneys may weigh the following questions:

• Should I seek an evidentiary hearing (under Frye or Daubert) and try to exclude the test?

• Or, should I let the test come in as evidence, and educate the jury about weaknesses in the underlying science?

This question regularly comes up at Sexually Violent Predator trials, regarding the controversial Static-99 risk assessment tool. Now, it is coming up in civil personal injury trials, regarding the MMPI-2's "Fake Bad Scale" (which I blogged about here back in March).

Increasingly, attorneys are choosing the second option when the science underlying a test is weak. They are openly critiquing the test and its findings, and allowing jurors to form their own conclusions. Yesterday's Lawyers USA features an article on how plaintiffs' attorneys are "turning the tables" on the Fake Bad Scale:

Although plaintiffs' attorneys are unanimous in despising the Fake Bad Scale, there is a mini-debate about whether it is more effective to exclude the test before trial or allow it in and discredit it while cross-examining the defense expert.

"It's a tough call, frankly," said Dorothy Clay Sims, a founding partner of Sims, McCarty, Amat & Stakenborg in Ocala, Fla., who has won three hearings over excluding the test.

"Frye and Daubert hearings are tough, but courts don't seem to like this test, so it's difficult to give up a hearing that you have a good chance of winning," she said. "On the other hand, once the Fake Bad Scale is demystified for the jury, and you pierce through it, they look at the defense doctor and say 'Oh, come on.' "

The article features the case of Sarah Jenkins, a medical receptionist who suffered tissue injuries and cognitive problems after her pick-up truck was hit by a delivery truck. She scored in the faking range on the Fake Bad Scale.

Rather than fighting to exclude the test, experienced trial attorney Dean Heiling made it a centerpiece. He cross-examined the defense expert at length about the test, and through his own expert exposed the controversy in the field about the test's validity.

Most interestingly, he put his client on the stand in rebuttal, and had her go through each test item and her answer with the jury.

Jurors deliberated only three hours before awarding a verdict of $225,749.

The lesson to forensic psychologists: Know your tests, and know their weaknesses.

The full story, by Sylvia Hsieh, is here, although it is only available to subscribers. For more on the controversy over the scale, see my previous post here.

Hat tip: Ken Pope

Scarface idolatry: Evidence of violence?

I was driving past an abandoned gas station where vendors usually sell fresh strawberries and oranges from the back of a pickup truck. This day, the vendors were selling Scarface posters instead. Framed ones, all different poses of the cultural icon.

The sight harkened me back to a young drug trafficker I evaluated. Although he had no known history of violence, federal agents found a Scarface poster along with a loaded handgun in his home. The poster, argued federal prosecutors, showed a propensity for violence.

I don't know how many young drug traffickers hang Scarface posters on their walls, but after last month's appellate decision in U.S. v. Marin I can say that it is not a good idea. Antonio Marin of Massachusetts was caught under very similar circumstances to the young man I evaluated. Charged with possessing a firearm in furtherance of drug trafficking, he said no, he simply had a "casual," innocent interest in guns. At trial, the government rebutted that defense by presenting a Scarface shadow box found in Marin's apartment. The display case contained (among other items) a picture of Al Pacino aiming a machine gun, a replica gun, and a cigar.

An appellate court upheld the use of the Scarface memorabilia against Marin, saying its probative value outweighed its potentially prejudicial impact.

That's where expert testimony might have proven helpful. As I wrote in my report in the similar case, research has established certain factors as correlated with violence. Scarface idolatry, no matter its intuitive appeal, is not one of them. If it was, the crime rate would be much higher: Scarface is one of the most popular DVD's on Amazon, and the Internet has dozens of Scarface-related sites and hundreds of spin-off products, including music tapes, posters, and T-shirts.

Researchers have studied the effects of violent media on aggression for decades, generating hundreds of studies on this topic. Although the debate continues to rage, there is general consensus that no direct link exists between violent cinematic imagery and real-life violence. Watching large amounts of violent movies or TV shows might encourage violence in those already so inclined, but fantasy violence is neither necessary nor sufficient to trigger real-life violence.

Interestingly, the potentially unfair prejudice of Scarface memorabilia was acknowledged in a second case last month, this time when the defense tried to introduce it at a trial.

High school students Jean Pierre Orlewicz and Alexander Letkemann of Michigan were on trial for a gruesome beheading-murder of a 26-year-old man named Daniel Sorensen. To bolster their claim of self defense, the teenagers sought to introduce images from Sorensen's MySpace page of - you guessed it - Scarface.

No can do, the judge ruled. The photos "would tend to move the jury to decide the matter on an improper basis such as inflamed passions and emotions."

Sorensen is not the only murder victim whose MySpace site was scoured for the low-down on his personality and proclivities. Indeed, that is one of the first places police (as well as people like me) will look for uncensored (if sometimes exaggerated) self portrayals when someone gets caught up in a crime. That potential reality is far from the minds of young people as they immerse themselves in the semi-public world of social networking.


Take the case of University of California Berkeley fraternity member Christopher Wootton. He was killed this month in a drunken, late-night brawl. His loyal friends and family insist he was a peaceable guy who must have been trying to defuse the combatants. On his MySpace site just a week earlier, however, he had bragged about grinding another man's face into the pavement during an unrelated drunken fight.

Will this admission be allowed in court, to bolster the 20-year-old murder defendant's contention that he acted in self defense? Only time will tell.

One thing is certain: If either of these young men had a Scarface poster on their wall, we will hear about it on the local news. And then those street-corner vendors might have to go back to selling fruit. So far, no one has tried to link strawberries to violence.

Hat tip: Colin Miller at EvidenceProf

Who will write the next DSM?

Would you believe: Pfizer, Eli Lilly, Wyeth, Merck, AstraZeneca and Bristol-Myers Squibb?

Or, at least, those are some of the BigPharma corporations with whom members of the task force charged with creating the 5th Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders have contracts.

It shouldn't come as a surprise. But it ought to alarm the public, given BigPharma's enormous and growing influence in so many spheres of public life all around the world.

More than half of the experts involved in the previous edition of the psychiatric bible also had monetary relationships with drug makers, according to a Tufts University study. The percentage was up to 100 percent for experts working on certain severe mental illnesses, such as schizophrenia. (The New York Times story on that 2006 research is here.)

A just-published book, The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders, has more on this construction of difference as illness. Trends that author Peter Conrad notes include the medicalization of "male" problems such as baldness and sexual impotence, and the pathologizing of children's behavior and appearance (short kids now have idiopathic short stature which requires synthetic human growth hormone).

Another new book, The Rise of Viagra, further documents the pathologizing of sexual variation, including an effort by BigPharma's spin doctors to create public hysteria and a new market for medicines to treat Female Sexual Dysfunction."

Meanwhile, as I've blogged about elsewhere, the sex offender industry is lobbying for new diagnoses to medicalize illegal sexual conduct, including "hebephilia" for men who are sexually attracted to teens, and "Paraphilia Not Otherwise Specified-Nonconsent" for men who rape.

Look for all these, and more, as possible candidates for the new and expanded DSM-V. Each edition of the DSM contains more diagnoses than its predecessor, and each diagnosis is supposedly treatable with meds. DSM-I (1952) listed 106 mental disorders, DSM-II (1968) had 185, DSM-III (1980) had 265, and DSM-IV (1994) has 357. That's an average of about 84 new diagnoses per edition, so the DSM-V should have 440 or more diagnoses.

Hopefully, this week's blog post by New York Times health writer Tara Parker-Pope about the conflict of interest signals that the public will be kept informed.

The consumer watchdog group Integrity in Science, a project of the Center for Science in the Public Interest, is also following the scent of money. See my Amazon book list, Critical Perspectives on Psychiatry, for other books on the DSM and the construction of illness.