Forensic fallout of revamping personality disorders

What is a personality disorder?

Your answer likely depends on whether you are a mental health professional, a layperson, or a member of the legal profession, where the term can have a highly scripted meaning with weighty implications.

In fact, the Supreme Court of Washington just ruled that the precise definition is so critical that a judge's refusal of a defense request to define it for a jury invalidated a civil detention order. That's because in Washington, a convicted sex offender cannot be civilly committed to a state hospital unless he has either a personality disorder or a "mental abnormality" that makes him more likely than not to commit sexually predatory acts in the future. The legal distinction between these two conditions derives from the DSM's axial system, under which most illnesses are listed on Axis I but personality disorders are categorized as "Axis II," because they are conceptualized (not always accurately) as more chronic and enduring than acute Axis I disorders.

At the trial of Curtis Pouncy, the prosecution-retained psychologist, Richard Packard, had testified that Curtis Pouncy had both conditions. The jury ultimately found Pouncy to be a Sexually Violent Predator (SVP), but it did not state whether this finding was on the basis of a personality disorder, a mental abnormality, or both. Explained the Supreme Court in overturning the commitment:

"The phrase 'personality disorder' is not one in common usage and is beyond the experience of the average juror. It is a term of art under the DSM that requires definition to ensure jurors are not 'forced to find a common denominator among each member's individual understanding' of the term…. We have no way of knowing from the verdict whether the jury found that Pouncy was an SVP because he suffered from a mental abnormality or a personality disorder. And, if the jury agreed Pouncy suffered from a personality disorder, we have no way of knowing what definition the jury used in reaching this conclusion…. We cannot say the failure to instruct on the definition of 'personality disorder' in no way affected the final outcome of the case; accordingly, it was not harmless. A new trial is required."

The government of Washington is so interested in the precise meaning of the term that in 2009 it actually codified the definition for purposes of SVP civil commitment. Tagging off of the definition in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the Revised Code of Washington Section 71.09.020(9) now defines a personality disorder as:

"an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has onset in adolescence or early adulthood, is stable over time and leads to distress or impairment. Purported evidence of a personality disorder must be supported by testimony of a licensed forensic psychologist or psychiatrist."

As Constance Holden reports in the current edition of Science magazine, "Personality disorders are hard to pin down. They don't have a common defining mood or behavior, people don't get hospitalized for having one, and a drug won't cure one."

If that sounds tricky, wait until the American Psychiatric Association adds layer upon layer of new complexity, and in the process completely scraps the definition as reified by government entities such as the Washington state legislature. Under a draft proposal rolled out last month for the new DSM-5* (due out in 2013), the old personality disorders are barely recognizable and some have disappeared altogether.

• First off, the overarching definition will be new. Now, personality disorders are defined more briefly as:

"the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual's cultural norms and expectations."

Both self-identity and interpersonal functioning are then further defined. For example, poor interpersonal functioning involves failure to develop empathy, intimacy, cooperativeness, or "complexity and integration of representations of others."

• Next, one rates the person on a set of six traits (negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy) to determine whether the general adaptive failure is "associated with extreme levels of one or more" of these.

• Finally, there are the specific personality "types," whittled down from the current 10 to only five: Schizotypal, Borderline, Obsessive-Compulsive, Avoidant, and Antisocial/Psychopathic. Note that psychopathy will make its grand debut, while narcissistic exits stage left.

In his erudite competency opinion in the Brian David Mitchell case, Judge Dale Kimball leaned heavily on narcissistic personality disorder as an explanation for the defendant's presentation. If the Personality Disorders Work Group for the DSM-5 gets its way, that diagnosis will go the way of of hysteria and melancholia. Of course, as the judge wisely pointed out, DSM diagnoses are not directly applicable to ultimate legal issues:

"[I]t is not particularly necessary for the court to determine a specific diagnosis in determining competency.... [E]ither an Axis I or Axis II condition could potentially render a defendant incompetent. And, on the other hand, a defendant could have an Axis I and/or Axis II condition and still be competent."

So, what do you get when you combine five personality types with six crosscutting traits? "A camel -- a horse made by committee," psychologist Drew Westen of Emory University told Science magazine.

And in forensic contexts, how will terms such as "culturally adaptive," "empathy," "cooperativeness," "negative emotionality," and "antagonism" be operationalized? Based on research into how forensic evaluators decide about other value-laden constructs such as psychopathy and risk, dare I predict partisan allegiance will rear its ugly head?

Paul A. Siciliano at Basically Law has more on the Pouncy decision. Psychologist Simone Hoermann has commentary on the DSM-5 personality disorders revamp at her Personality Disorders blog.

*The current DSM and all previous editions are designated by Roman numerals, but the APA has decided to use Arabic numerals starting with the fifth edition.

Photo credits: (1) Vagamundos (Creative Commons license 2.0); (2) Kaptain Kobold (Creative Commons license 2.0) 

 * * * * *

DSM-5 POSTSCRIPT: Following much brouhaha, the American Psychiatry Association ultimately did not adopt the more radical proposed changes to the personality disorders for the DSM-5, nor did it remove Narcissistic Personality Disorder (much beloved in some psychiatric quarters) as one of the types. However, the entire axial system (i.e., the distinction between Axis I mental disorders versus Axis II personality disorders) was eliminated. Meanwhile, contemporary research is suggesting that personality disorders -- for example Borderline and Antisocial disorders -- are not nearly as enduring or lifelong as the DSM definitions continue to suggest.

Jury rejects Samenow’s lone insanity opinion

During one of my stints as a prison clinician, I had the unfortunate experience of being supervised by a psychologist who believed that prisoners were monsters bent on manipulation, and who thus tried to thwart my attempts to provide treatment. That psychologist's favorite book: Stanton Samenow's Inside the Criminal Mind.

"Criminals think differently" is the basic premise of the well-worn treatise. Samenow rejects out-of-hand most mainstream sociological, environmental, traumatogenic, developmental, biological, and psychological theories of crime, labeling them as absurd, simplistic, or even plain "kooky":

[C]riminals are not mentally ill or hapless victims of oppressive social conditions…. Despite a multitude of differences in their backgrounds and crime patterns, criminals are all alike in one way: how they think…. [A]ll regard the world as a chessboard over which they have total control, and they perceive people as pawns to be pushed around at will…. Some of their most altruistic acts have sinister motives.

Samenow promotes this popular rhetoric on national TV and radio shows such as Good Morning America and the Larry King show. In court, the well-known psychologist has testified for many decades in insanity cases, being called exclusively by the prosecution to attack defendants' claims of insanity. Over time, this one-sidedness started working to defense attorneys' advantage; they were able to rebut his testimony simply by telling juries that Samenow always testified against insanity. (Here is a recent example.)

This month, however, Samenow broke with tradition and for the first time opined in court that a defendant met the legal standard for insanity. He picked a rather unusual case. Unlike most defendants who plead insanity, Evan D. Gargiulo, being prosecuted in Virginia for the shooting death of a cab driver, had no history of psychiatric disorder. The competitive swimmer and former college swim team coach was an engineer for Lockheed Martin and a lieutenant in the National Guard when he shot Mazhar Nazir in the back of the head with his 9 mm pistol.

Gargiulo testified that he shot Nazir in self defense when the Pakistani-born cabbie tried to grab him. He said that after getting a taxi ride home from a nightclub, he realized he had lost his wallet. He went into his apartment, retrieved his gun and car keys, and had Nazir drive him to his car. Once there, he realized he had also lost a roll of cash so could not pay his $130 fare. It was at that point, he claimed, that Nazir became angry and reached over the seat to grab him, making him fear for his safety. The hapless driver died from a single gunshot to the back of his head.

Samenow testified that Gargiulo had led such a sheltered life, and had developed such an exaggerated paranoia, that he could not distinguish right from wrong at the time of the crime. As Tom Jackman of the Washington Post reported it:

Samenow said Gargiulo's dismay at being robbed and his "enormous fear" of Nazir caused him to shoot without thinking of the consequences. "I haven't encountered somebody with this level of fear," Samenow said. He said there is no formal definition of Gargiulo's mental condition in the Diagnostic and Statistical Manual of Mental Disorders, the accepted reference book for courts trying to parse mental illness and criminal culpability.

Samenow said later that his first appearance for the defense in an insanity case in 40 years showed that he has an open mind after decades of examining mentally ill defendants and finding them criminally responsible. He testified that he was paid $25,000 by the defense, which rested with Samenow as its only witness.

The jury didn't buy either the self defense or insanity defenses. After six hours of deliberations, it convicted Gargiulo of second-degree murder and sentenced him to 15 years in prison. To the disappointment of the victim's family, that was 25 years less than the maximum the jury could have imposed.

Gargiulo photo courtesy Fairfax County (Virginia) Police Department

Training update: March 25 in Seaside, California

Ethics and forensic diagnosis

For you Californians, I’ve got some good news on the training that I am giving at the Forensic Mental Health Association conference March 24-26 in Seaside. The organizers have just doubled my time slot: I will now be presenting for the entire afternoon of Thursday, March 25. If you are free that day, there is still time to sign up. Registration information is online HERE.

My topic is Ethical Considerations in Psychiatric Diagnoses in Forensic and Correctional Settings. I will give an overview of ethics issues in the use of diagnostic labels in court and in correctional settings before focusing specifically on controversial diagnoses that are often invoked in adversarial legal contexts. Diagnoses of focus will include Antisocial Personality Disorder and the sexual paraphilias, including pedophilia and the novel diagnoses being proposed for the upcoming DSM-5 (e.g., "Paraphilic Coercive Disorder" and "Pedohebephilia").

Please note that the time listed in the program brochure for my training is incorrect. My new, expanded time slot is from 1:30 to 5:00 p.m.

This year's legal track, focusing on competency to stand trial in California (see my previous blog post), has also been expanded and will include some exciting new presenters.

All types of continuing education credits are being offered for professionals in the fields of mental health, law, and law enforcement.

New critique of proposed hypersexuality disorder

Although the construct of hypersexuality is becoming popular with clinicians, strong empirical evidence for its validity is lacking, according to a new critique in the Archives of Sexual Behavior. The author, Jason Winters, is a research psychologist involved with the High Risk Sex Offender Program of the Forensic Psychiatric Services Commission in Vancouver, BC.

As with other disorders being proposed for DSM-5, due out in 2013, the boundary between normalcy and supposed pathology is fuzzy and arbitrary, writes Winters. Findings from a recent Internet survey he conducted suggest that more than four out of every ten men and one out of five women might meet the "excessive sexuality" criterion, operationalized as an average of seven or more orgasms per week.

And if behaviors that interfere with other responsibilities are evidence of pathology in the sexual realm, why not create formal mental disorders for other types of preoccupations? For example, why not pathologize a tenure-track professor who prioritizes academic work over family and friends? (I was glad Winters did not mention excessive blogging as an example of a potential mental illness, but then I remembered that Internet Addiction has already been proposed for the DSM.)

The criterion of engaging in sexual behavior to enhance mood is similarly problematic:

[I]f we are to accept that repeatedly engaging in sexual behaviors to enhance mood is symptomatic of a distinct sexual disorder, then we must also be willing to accept that repeatedly engaging in non-sexual rewarding behaviors for a similar effect is symptomatic of other corresponding mental disorders…. [But] the DSM does not include disorders of watching too much television, or shopping, exercising, or working too much.

As Winters points out, an unstated bias against sexual expression outside of a traditional monogamous marital dyad seems the basis for calling some sexual behaviors -- such as one-night stands, anonymous sex, and multiple partners -- evidence of disease.

Ultimately, he concludes that while excessive sexuality may be problematic and distressing for some, and in such cases merits clinical attention, a new diagnosis may be of "dubious value."

Except, I might add, to the civil commitment industry, increasingly desperate for new diagnoses to justify the civil commitment of sex offenders who do not qualify for recognized mental illnesses.

Police interrogations: AP-LS issues landmark white paper

Boy's "psychological torture" points to need for reform

In 1998, the Crowe family in Escondido, California awakened to their worst nightmare. Twelve-year-old Stephanie was lying in a pool of blood on her bedroom floor, dead from multiple stab wounds. Police quickly zeroed in on a suspect -- Stephanie's 14-year-old brother Michael. After a series of grueling interrogations, Michael ultimately admitted he may have killed his sister. He and two friends were arrested for murder.

Only through serendipity were the boys' charges dismissed more than a year later, when DNA evidence proved that a mentally ill transient had committed the murder. That man, Richard Tuite, was ultimately convicted of manslaughter.

Now, the Ninth U.S. Circuit Court of Appeals has reinstituted the families' civil rights case against the police, dismissed by a federal judge several years ago. Writing for the three-judge panel, Justice Sidney R. Thomas described the shocking nature of the interrogations:

One need only read the transcripts of the boys' interrogations, or watch the videotapes, to understand how thoroughly the defendants' conduct in this case "shocks the conscience." Michael and Aaron [Houser] -- 14 and 15 years old, respectively -- were isolated and subjected to hours and hours of interrogation during which they were cajoled, threatened, lied to, and relentlessly pressured by teams of police officers. "Psychological torture" is not an inapt description.

"Psychological torture" and "brutal and inhumane" were descriptions given by a juror in the real killer's criminal trial after he viewed the videotaped interrogations. (I show the heartwrenching video, which is no longer available commercially, in my forensic courses.) Dr. Richard Leo, an expert in coerced confessions and author of Police Interrogation and American Justice (read my review HERE), echoed the juror's sentiments, describing Michael's interrogation as "the most psychologically brutal interrogation and tortured confession that I have ever observed." So did Dr. Calvin Colarusso, Director of Child Psychiatry Residence Training Program at the University of California, San Diego, who evaluated Michael and described the interrogation as "the most extreme form of emotional child abuse that I have ever observed in my nearly 40 years of observing and working with children and adolescents."

The appellate victory will allow the families' federal civil rights case to move forward to a jury trial or a settlement. In an interesting angle, the justices also reinstated the claim against a psychologist whom police consulted during the interrogation. The plaintiffs allege that Dr. Lawrence "Deadlift" Blum, a police psychologist, conspired with Escondido police, helping them formulate a "tactical plan" that they followed in their interrogation. Blum admitted in a deposition that he told a police detective that 15-year-old Aaron Houser, Michael's friend, was a "Charlie Manson wannabe."

The ruling coincides with publication of a landmark article sponsored by the American Psychology-Law Society (AP-LS) on the scientific status of coerced interrogations and false confessions. The article, written by leading scholars Saul M. Kassin, Steven A. Drizin, Thomas Grisso, Gisli H. Gudjonsson, Richard A. Leo, and Allison D. Redlich and published in this month's Law & Human Behavior after an extensive process of vetting and review, is only the second such paper authorized by AP-LS in its 42-year history. The first was a 1998 white paper on eyewitness identification. As William C. Thompson, criminology and law professor at the University of California at Irvine, notes in the introduction to the special issue:

That paper (Wells, Small, Penrod, Malpass, Fulero, & Brimacombe, 1998) proved extremely influential in subsequent policy debates about line-ups and other eyewitness identification procedures. By providing an intellectual framework for analysis of systemic factors that affect eyewitness accuracy, and by distilling specific policy recommendations from a broad array of research, it set the agenda for policy discussion and channeled those discussions in productive directions. The paper was the foundation for a subsequent National Institute of Justice policy paper. Many of its recommendations, such as procedures for composing line-ups and instructing witnesses, are beginning to be implemented nationwide.

The AP-LS hopes the current review article will have a similar effect on the field. After methodically reviewing the state of the science, the authors make a number of critical recommendations for reform aimed at reducing the number of false and/or coerced confessions. These include:

• Mandatory electronic recording of interrogations, with the camera angle focused equally on the suspects and detectives
• Limits on the duration of interrogations
• Limits on the presentation of false information and evidence
• Special protections for vulnerable suspects, including juveniles and those with cognitive and/or psychiatric impairments
• Scrutiny of "minimization" tactics, in which police pursue "themes" that minimize suspects' perceived moral, psychological, and/or legal culpability
  

Michael Crowe's exoneration came about as a result of what author Edwin Borchard described in a 1932 tome on wrongful convictions as "sheer good luck." The scholars who collaborated on this white paper hope that their recommendations will reduce the role of such serendipity, by giving police, prosecutors, judges, and juries the scientific information necessary to reduce egregious injustices like the one in Escondido 12 years ago.

Images: (1) Michael Crowe's interrogation, (2) Richard Tuite, the real killer, (3) Michael Crowe with his sisters; Stephanie is on the left.

Hat tip: Adam Alban

Brian David Mitchell will pursue insanity defense

In the wake of last week's competency finding, a date of Nov. 1 has been set for Brian David Mitchell's federal trial in the kidnap-rape of Elizabeth Smart of Utah. The defense has indicated it plans to mount an insanity defense. As reported by the Associated Press today, a parallel case in state courts has stalled over the question of Mitchell's competency.

I'm still wading through Judge Kimball's 149-page ruling on competency, which I highly recommended to any of you who do competency work. In describing Mitchell as a cunning malingerer, the decision has plenty of implications for the insanity trial as well.

Latest hebephilia critiques: Point-counterpoint

I've just updated my Hebephilia and the DSM-5 Controversy resources page with two new articles in the Archives of Sexual Behavior critiquing the proposed diagnosis of pedohebephilia.

Green: Moral standards masquerading as science

In his boldly titled "Sexual Preference for 14-Year-Olds as a Mental Disorder: You Can’t Be Serious!!," prominent psychiatrist and sexologist Richard Green pulls no punches. Green, who teaches at the Imperial College of London, served on the Gender Identity Disorders subcommittee for DSM-IV. Back in the 1970s he was a forceful advocate for removing homosexuality from the manual of mental illnesses, a struggle he references in his current critique:

The parody of science masquerading as democracy made a laughing stock of psychiatry and the APA when it held a popular vote by its membership on whether homosexuality should remain a mental disorder. Decreeing in a few years time that 19-year-olds who prefer sex with 14-year-olds (5 years their junior) have a mental disorder … will not enhance psychiatry’s scientific credibility.

As he points out, the age of legal consent in several European countries falls within the range that the proposed pedohebephilia disorder would make pathological for the older participant:

If the general culture is accepting of participation by the younger party, but psychiatry pathologizes participation by the older party, then the mental health profession pronounces a moralistic standard and, if successful, becomes an agent of social control.

Green goes on to catalog "biased terms" and "logically frail arguments" in the proposal. In this, he joins a growing chorus of voices sounding the alarm about myriad problems with the proposed pedohebephilia diagnosis.

O'Donohue: Let's go even further

Coming at it from the opposite angle of most critics is William O'Donohue, a psychology professor at the University of Nevada at Reno and co-editor of the second edition of the widely consulted text Sexual Deviance.

O'Donohue argues for keeping it simple: "any sexual attraction to children … is a pathological, abnormal condition." His proposed diagnosis reads as follows: "The person is sexually attracted to children or adolescents under the age of 16" as evidenced by (1) self report, (2) laboratory findings, and/or (3) past behavior. Whether the person has acted on his or her attractions would not matter. The number of victims would not matter. And internal distress would not be required.

O'Donohue expresses a lack of concern over the inevitable false positive errors that such a broad net would ensnare. He argues that we should be more concerned about false negative errors -- pedophiles who escape diagnosis when the criteria are too narrow, for example when more than one known victim is required. And he applauds the move to expand pedophilia to include hebephilia, or attraction to pubescent minors.

Prosecution-retained evaluators in U.S. civil commitment cases will be salivating at the prospects for this one. But consider the source. O'Donohue is the psychologist who has argued for subjecting gay and lesbian parents to special scrutiny in child custody evaluations. (Respected child custody experts Jonathan Gould, David Martindale, and Melisse Eidman wrote an outstanding counterpoint, summarizing the empirical research as indicating that "sexual orientation is not a pertinent factor when considering the best psychological interests of children." In the interest of full disclosure, I share that view, as I wrote in an article published in the same journal a few years earlier.)

And, despite his support for diagnostic expansion, even O'Donohue concedes that the psychometric properties of the proposed diagnosis remain unknown. In other words, neither its reliability nor its validity have been empirically established. A wee problem, that.

A list of published articles on the hebephilia debate, with links to the publisher's web pages, is HERE. For the newest additions, look for the "NEW" icon towards the bottom of the page.

Stalker slain -- "WWBD?"

You evaluate a man who engaged in repetitive stalking of a high school girl. He spied on her, followed her around (rationalizing it as “for her own good”), and even climbed in her bedroom window at night and watched her sleep. He acknowledges a powerful desire to kill her.

Ominous, right? When we encounter men like this, they raise our hackles.

But in pop culture -- movies, music, and videos -- this possessive, condescending, and downright creepy behavior is often glorified as "true love." Such is the case with Edward in the blockbuster Twilight movie series, marketed with great fanfare to young teenage girls.

Appalled by the sexually predatory behavior modeled by Edward in Twilight, freelance Web designer Jonathan McIntosh of Rebellious Pixels asked himself, "What would Buffy do?" Buffy, of course, being the strong woman heroine of the popular TV series Buffy the Vampire Slayer.

If you haven’t seen the resultant video mashup, stop whatever you're doing and take the six minutes to watch it.



The brilliant and hilarious video has been translated into 16 languages and watched by millions of people worldwide. As reported in the L.A. Times, Buffy v. Edward reveals Edward’s supposed charm for the creepy stalker behavior it is:

[T]he Slayer has little patience for the expertly coifed Edward, dazzling or otherwise. "Being stalked isn’t a big turn-on for girls," Buffy tells him. When Edward tries to explain that he's on "a special diet," Buffy replies, "What are you doing? Here, at this table, talking to me like we're some kind of talking buddies?"

McIntosh's essay explaining his project is HERE.

Study: Actuarials fail to predict sexually violent recidivism

In a new prospective study out of Austria, none of the actuarial instruments commonly used to predict sex offender recidivism were able to predict sexually violent recidivism among a group of sex offenders released from prison after treatment.

The interesting study, just published in the International Journal of Offender Therapy and Comparative Criminology, was designed to validate German versions of commonly used actuarial tools, including the Static-99, RRASOR, SORAG, and SVR-20. It followed about 400 Austrian prisoners for an average of three years in the community.

The main problem obtaining significant results was that recidivism was so rare. Obviously, the less likely an event is to occur, the harder it is to accurately predict. Only seven offenders in the entire sample committed a new hands-on offense during the followup period, and most of those were extrafamilial child molesters. Recidivism base rates were especially low for rapists and incest offenders.

The results echoed findings in two other recent studies in which the actuarials failed to demonstrate good predictive validity for predicting sexually violent reoffending.

Most of the instruments did better when recidivism was defined more broadly, to include all sexual reconviction, even hands-off offenses such as voyeurism or exhibitionism that is not typically defined as sexually violent under civil commitment laws. Even including these lesser offenses, the overall base rate for all sexual recidivism among this sample was still quite low, 4.3% (12% among extrafamilial child molesters, 1.7% among rapists, and about 1% among incest offenders).

When extrafamilial child molesters -- the group most likely to reoffend -- were examined separately, all of the instruments except the RRASOR had some predictive utility, with the SVR-20 doing the best. Still, neither the Static-99 (the most widely used actuarial tool) nor the RRASOR could significantly predict sexually violent reoffenses even for that relatively higher-risk group.

"From the results of these studies and of the present study, the actuarial prediction of some reoffence categories in at least some offender subtypes is less accurate than generally assumed,” the authors concluded. "One major aim of most criminal justice systems is to calculate risk by predicting the probability of severe sexual crimes. This goal obviously is not yet achieved satisfactorily by actuarial risk assessment, because results are far from ideal, especially when time-at-risk periods are relatively short."

An important implication of this study is that evaluators need to consider offender subgroups separately, rather than lumping all types of sex offenders together. Recidivism varies tremendously by type of offender (e.g., rapists versus child molesters) and by how recidivism is defined, with the various instruments doing better at some types of predictions than others. Furthermore, so little outcome research exists on certain groups (such as hands-off offenders, juveniles, the intellectually disabled, and offenders with only adult male victims) that the actuarials may be inappropriate to use at all.

The study is:

Rettenberger, M., Matthes, A., Boer, D.P., & Eher, R. (2010). Prospective Actuarial Risk Assessment: A Comparison of Five Risk Assessment Instruments in Different Sexual Offender Subtypes. International Journal of Offender Therapy and Comparative Criminology, 54 , 169-186.

Hat tip: Jeffrey Singer

FURTHER READING: For those of you interested in the actuarials, I also recommend "More prejudicial than probative?," a stastical critique by David J. Cooke, a forensic psychology professor in Glasgow who is an expert scholar and trainer on violence risk assessment. Cooke argues that the actuarials are compelling because they are simple to use by paraprofessionals and have a scientific veneer, but "the scientific basis for actuarial scales, as applied to individuals, may be more illusory than real." The article, in the journal of the Law Society of Scotland, is available online. It also includes useful references to other sources.

Furor over France’s "pornographic" anti-smoking ads

A French anti-smoking campaign comparing smoking to sex slavery is being accused of everything from dissemination of pornography to insensitivity to child sexual abuse victims.

The ads -- set to be published in newspapers and posted in bars -- feature teens smoking cigarettes in such a way that they look like they might be performing oral sex on a man in a suit. The caption reads, "Smoking means being a slave to tobacco."

"Traditional advertisements targeting teens don't affect them. Talking about issues of health, illness or even death, they don't get it," a spokesperson for the Association for Nonsmokers' Rights told AP in explanation. "However, when we talk about submission and dependence, they listen."

The 16-year-old who alerted me to the controversy thought it was quite a hoot. But the family minister of France is not laughing. She is calling for a ban on the ads as "indecent exposure" and "an affront on public decency." Likewise, a child welfare group called the ads cruel and insensitive toward young child abuse victims. Tobacco company representatives are also incensed at being compared to pedophiles. "It's no longer prevention, but out of place provocation," one tobacco association said on its web site.

Ironically, the advance uproar is giving the anti-smoking campaign so much publicity that it will make the formal ad campaign unnecessary.

Hat tip: Greg

UK may end controversial "dangerous and severe personality disorder" program

In what could signal a seismic shift against civil commitment based on pretextual mental disorder, England is rumored to be considering an end to its controversial "Dangerous and Severe Personality Disorder" (DSPD) program.

The program was launched in 1999 and has so far cost an estimated 200 million pounds (more than $300 million USD), with little evidence of efficacy in identifying dangerous criminals or curbing violent crime. The four DSPD units -- two at Broadmoor and Rampton high security hospitals and two at Whitemoor and Frankland prisons -- house about 300 offenders. Critics say the label Dangerous and Severe Personality Disorder is a political invention, not a true psychiatric disorder.

According to an exclusive report by London's independent Channel 4 News, the Ministry of Justice is considering a halt to the program based in part on a report that concludes that the program "has been largely ineffective and should now be abandoned." The report, co-authored by former government advisor Peter Tyrer, is under review for the journal Medicine, Science and The Law, published by the British Academy of Forensic Sciences.

The report follows on the heels of another critical analysis that I recently blogged about, due to be published in the International Journal of Law & Psychiatry. That study, "Dangerous and severe personality disorder: An investigation of the construct," by authors Ullrich, Yang, and Coid, found a very high rate of false positives -- that is, people categorized as DSPD and at high risk of serious reoffending when they actually did not reoffend when tracked in the community.

Ullrich and colleagues found that 26 DSPD offenders would need to be civilly committed to prevent one major violent act. In regard to sex crimes, the researchers found that most were committed by offenders who were NOT categorized as DSPD, undermining the UK Home Office and Department of Health assumption that offenders at the highest risk for future sex offending would be categorized as DSPD.

If Britain does indeed eliminate the DSPD program, it will be a major blow for those who advocate for civil commitment as a viable means of increasing public safety. Not only is it exorbitantly expensive, but also the civil liberties implications of wrongfully detaining people who are not truly dangerous based on unreliable prediction tools are ominous.

It will also be a blow against the creation of dubious new diagnoses to justify civil commitment on the grounds of purported mental disorder, as is being done here in the United States.

Finally, this scientific setback may also help to discourage those who seek to extend civil commitment to other populations, such as juveniles.

More prominent voices join chorus of DSM5 critics

With the unveiling of the draft DSM5, the chorus of well-aimed criticisms flying in from all sides is becoming truly spectacular. The latest voices are prominent scholars writing in the eminently respectable Wall Street Journal, Los Angeles Times, and Washington Post.

All three focus on what most critics agree is an especially troubling aspect of the proposed manual -- the "wholesale medical imperialization" that eventually will label nearly every human being with one or more psychiatric pathologies. The authors of the DSM, critics assert, have appointed themselves as the arbiters of what is normal and what is not.

Wall Street Journal: Psychiatry in demise

Edward Shorter, a University of Toronto professor and preeminent scholar of the history of medicine, gives a historical overview of the DSM's development to support his verdict that the latest draft manual illustrates a discipline in demise.

To flip through the latest draft of the American Psychiatric Association's Diagnostic and Statistical Manual, in the works for seven years now, is to see the discipline's floundering writ large. Psychiatry seems to have lost its way in a forest of poorly verified diagnoses and ineffectual medications. Patients who seek psychiatric help today for mood disorders stand a good chance of being diagnosed with a disease that doesn't exist and treated with a medication little more effective than a placebo.

Los Angeles Times: Overdiagnosis gone berserk

Allen Frances, chairman of the DSM-IV task force, has been sounding the alarm over this new manual far and wide of late. This latest essay is perhaps his most eloquent to date, and of direct relevance to forensic practice in that it focuses on the proposed sexual disorders that will be used pretextually in civil commitment proceedings:

The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day -- despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.

The sexual disorders section is particularly adventurous. "Hypersexuality disorder" would bring great comfort to philanderers wishing to hide the motivation for their exploits behind a psychiatric excuse. "Paraphilic coercive disorder" introduces the novel and dangerous idea that rapists merit a diagnosis of mental disorder if they get special sexual excitement from raping….

Frances urges the public to pay attention and voice opposition to psychiatry's "recklessly expansive suggestions" before the juggernaut becomes unstoppable:

This is a societal issue that transcends psychiatry. It is not too late to save normality from DSM-V if the greater public interest is factored into the necessary risk/benefit analyses.

Washington Post: George Will weighs in

Finally, prominent political columnist George F. Will weighed in on the moral implications of the proposed diagnostic expansions. Will expressed worries about the legal consequences of excusing amoral conduct as a symptom of uncontrollable illness.

The 16 years since the last revision evidently were prolific in producing new afflictions. The revision may aggravate the confusion of moral categories.

Today's DSM defines "oppositional defiant disorder" as a pattern of "negativistic, defiant, disobedient and hostile behavior toward authority figures." Symptoms include "often loses temper," "often deliberately annoys people" or "is often touchy." DSM omits this symptom: "is a teenager." …

[C]onfusion can flow from the notion that normality is always obvious and normative, meaning preferable. And the notion that deviations from it should be considered "disorders" to be "cured" rather than stigmatized as offenses against valid moral norms.

Now that just about every major news outlet in the United States has run highly critical analyses, the question becomes: Will the American Psychiatric Association listen? Or, like an individual in the throes of a manic episode, will it continue its pell-mell rush to diagnose all human behaviors, creating an ever-broader assortment of bizarre pathologies?

Hat tip: Bruce

Breaking news: Mitchell labeled as malingerer, ruled competent

Checking for updates on the Elizabeth Smart case for tonight's lecture on competency restoration, I see that the judge ruled just moments ago that Brian David Mitchell is competent to stand trial.

In an opinion that went on for a hefty 149 pages, U.S. District Judge Dale Kimball agreed with prosecution psychiatrist Michael Welner that Mitchell is a psychopath who is faking mental illness to avoid criminal responsibility. The 56-year-old alleged kidnapper "does not presently suffer from a mental disease or defect that impedes his rational and factual understanding" of the proceedings against him, the judge ruled.

The decision came after a 10-day competency hearing at which Dr. Jennifer Skeem testified that Mitchell suffered from a delusional disorder and was incompetent.

Judge Kimball's 149-page ruling is online HERE.
Today's Associated Press coverage is online HERE.
My previous coverage of the case includes:

• "Legal pointillism": New approach to competency
• Epic competency hearing continues
• Record-breaking fee for competency report?
• Mitchell slated for epic competency hearing
• Utah court: OK to forcibly medicate accused kidnapper

DSM: Paraphilia controversy escalating

Brouhaha hits Land Down Under

Last week, I reported on a scathing denunciation by Allen Frances, MD, chair of the DSM-IV Task Force, of the draft proposal for the 5th edition of the diagnostic manual. Frances was particularly critical of the proposed sexual disorders, calling pedohebephilia "one of the most poorly written and unworkable" proposals to surface.

Now, Kenneth Zucker, chair of the DSM-V Sexual Disorders Work Group, has fired back in a letter to the Psychiatric Times. Defending not only pedohebephilia but also the other two controversial diagnoses of Hypersexual Disorder and Paraphilic Coercive Disorder, Zucker accused Frances of shooting from the hip, and "fir[ing] off criticisms as quickly as his grandchildren might tweet to their friends."

Frances fired right back, reiterating critics' central concern that these disorders lend themselves to "a grave misuse of psychiatry by the legal system in the handling of sexually violent predators”:

Every new diagnosis suggested for DSM5 requires (but has not yet received) a searching risk/benefit analysis and a thorough forensic review. I am confident that none of the suggestions for new diagnoses made by the Sexual Disorders Work Group would stand up to such scrutiny.

Today, experts in the Land Down Under chimed in with concern over Paraphilic Coercive Disorder. "Fears proposed new illness will be misused in court by rapists," reads the headline in the Sydney Morning Herald.

The reemergence of a proposal that was soundly rejected as a diagnosis in the 1980s "has come as a surprise to some psychologists," Nick Miller reports.

Lisa Phillips, a senior lecturer in psychological sciences at the University of Melbourne, echoes Frances' concerns over the potentially far-reaching legal implications of pathologizing rape as a mental disorder. Reiterating the concerns of feminists back in the 1980s, she said it could be used by rapists to avoid criminal responsibility for their acts.

This point fits with an intriguing insight by the brilliant legal scholar Eric Janus, who has written and lectured extensively on sex offender civil commitment and psychology-law topics more generally for the past couple of decades.

In Failure to Protect: America's Sexual Predator Laws and the Rise of the Preventive State (a book I highly recommend), Janus argues that the "tabloid model of gender violence" epitomized in sexually violent predator laws has -- perhaps accidentally -- become a powerful force for the politically conservative agenda of dismantling hard-fought feminist rape reforms. Like the newly proposed diagnoses, these laws favors biological and psychological explanations over sociocultural ones, and supports the patriarchal rape myth that rapists "lack control" over their sexual impulses.

Imagine the dustup if feminist psychiatrists and psychologists take note of these ersatz diagnoses and link up in opposition with legal scholars and psychologists concerned about their pretextual uses in civil commitment proceedings. And that's before transsexuals, furious over the Work Group's Gender Identity Disorder proposals, join the vocal chorus.

Napa Hospital chief arrested for sexual assault

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

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

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

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

Blogosphere recommendations

Mind Hacks

I have been checking out Mind Hacks since it featured a really nice review of my blog. The blog evolved out of the 2004 book by the same name, in which authors Tom Stafford (a cognitive neuroscientist) and Matt Webb (an engineer and designer) provide 100 exercises that teach readers neuroscience theories through games and tricks.

Among the scientists who contributed "hacks" is Vaughan Bell, who seems largely responsible for keeping the blog alive through his quirky and eclectic posts. Dr. Bell is a psychologist currently working in Medellín, Colombia and also a visiting research fellow in the Department of Psychological Medicine and Psychiatry at the Institute of Psychiatry, King's College London.

Just to give you an idea of some of his near-daily offerings, he recently posted on everything from decorative skull shaping to dream smoking (that's when you dream about cigarettes after you quit smoking) to new research on cave paintings. I particularly enjoyed his link to an amazing Russian website that features historical art by and about the mad. It reminded me of when I was living in Paris at age 10 and was influenced by an exhibit of art by schizophrenics that my mother took me to at the Louvres museum. More somberly, the prolific Bell reported on a new study in the Journal of Adolescent Health finding that it's a myth that teens think they are invincibile; actually, they greatly overestimate their chances of dying soon. I found it interesting, because the behaviors that result from either thinking error could look very similar.

The psychology of the angry American

Elsewhere in the blogosphere, my forensic psychology colleague Paul G. Mattiuzzi in Sacramento has an interesting analysis at his Everyday Psychology blog of the psychology of the pilot who intentionally crashed his plane into an IRS building in Austin, Texas on February 18.

Dr. Mattiuzzi based his analysis on the diatribes that Joe Stack wrote before taking his last flight. Although Mattiuzzi doesn't specifically reference the so-called Tea Party Movement, his comments on the "lunatic fringe" seem to apply to these disaffected white Americans:

There is in this country today, it seems to me, a gathering storm of mindlessly angry people who are "fed up" for reasons they can barely explain. There are people in the media who are telling them they should be angry, and perhaps more importantly, that they should be afraid….

[These] people have come to identify the government as an enemy of the people. They are grandiose in their belief that they understand it all better than anyone else. They are self-righteous in their indignation and in their resentment. They express a sense of entitlement, arguing that they have a right not just to their own opinions, but also to their own facts. They shout until no one can hear them and then complain that no one is listening. They expect their individual voice to prevail and then complain that they have been denied representation. They do not wish to contribute to the common good, but demand all the benefits they have been promised. Like Stack, they bemoan corporate greed while demanding that greed be unfettered.

Dr. Mattiuzzi hopes that acts like Joe Stack's do not inspire copycats. As he concludes (in my favorite lines from his essay):

Joe Stack wanted us to believe that in his abject failure, he had achieved success. It's as if he listened to only part of what Bob Dylan once sang ("there's no success like failure"), without bothering to stick around and hear the end of the lyric: "and failure's no success at all."

Mind Hacks is HERE. Everyday Psychology is HERE.

Calif.: Legal training on competency assessment

March 24-26 conference to offer MCLE credits

I've gotten a surge in queries from psychologists interested in being supervised as they embark into the tricky area of court-ordered competency-to-stand-trial assessments. With that need in mind, I'm excited that the Forensic Mental Health Association is featuring a special "legal track" on competency at next month's conference. It won't adequately train folks in the nuts and bolts, but they can get the lay of the land and become aware of some of the pitfalls and controversies.

One of the sessions that looks is especially interesting is on "Expert Qualifications and the Adequacy of Court-Ordered Evaluations." Having seen plenty of deficient, drive-by evaluations caused by a combination of the courts' low standards and low pay, I am happy to see this area getting some much-needed attention. The co-presenters are Judge Kurt Kumli of Santa Clara County, a nationally recognized expert in juvenile law and policy, and attorney David Meyer of USC's Institute of Psychiatry and Law.

The opening session of the legal track will address practical issues of enforcing court orders for competency restoration in state hospitals, jails, and conditional release programs. Again, this is a topic ripe for attention, as many competency restoration programs are sorely deficient.

Other sessions of the competency track will focus on juvenile competency, procedural changes in assessing trial competence in California, and the assessment of malingering. In addition to the usual continuing education credits for mental health practitioners, the track will offer MCLE credits to attorneys.

In addition to this special legal track on competency to stand trial, the March 24-26 conference features other high-caliber offerings:

• Judge Stephen Manley of Santa Clara County will present a keynote address on collaborative courts in California

• Stephen Behnke, JD, PhD and director of the APA Ethics Office, will review evolving conceptions of clinicians' duty to protect under Tarasoff

• Stephen Miles, a professor of medicine at the University of Minnesota, will muse on lessons prison clinicians can learn from the involvement of psychologists and physicians in abusive interrogations in war-on-terror prisons

Your faithful blogger, Karen Franklin, is also presenting at the conference, on one of my favorite topics, "Ethical Considerations in Psychiatric Diagnoses in Forensic and Correctional Settings."

Finally, I just have to mention the most bizarre session I came across: "A psychiatric-legal analysis of a case of lycanthropy in a 19th-century serial killer" (presented by doctors J. Arturo Silva and Douglas Tucker). Yee-gads! With pop culture's current fascination with all things supernatural, that's one session I just must attend!

Registration is still open for the March 24-26 conference, although the "early-bird rate" ends March 1. Joining the FMHA earns you an additional $25 discount off the cost of registration. The conference is down in Seaside, California (by Monterey), so it's a scenic venue for those of you who might want to bring family. More information and the registration form are HERE.

Illustration: 18th century engraving, courtesy Wikipedia

DSM-V: Will shoddy manual implode years before launch date?

The DSM-V debacle continues to expand like a mushroom cloud following a nuclear explosion. Media pundits right and left are commenting critically on the draft manual, published online after years of cloak-and-dagger secrecy.

As most of you know by now, the American Psychiatric Association has granted the public a very brief window in which to comment online on the draft proposals. I haven't seen an explanation of how public input will be tallied or used. Will a popularity contest influence psychiatric diagnosis? We've seen how well citizen input works here in California, where the initiative process has brought government to a standstill. Can you imagine neurologists setting up a website to get lay input on a new diagnostic scheme for brain tumors? This debacle only underscores the point that the DSM is more politics than science.

Among the best commentaries I've seen this week are Sally Satel's op-ed in the Wall Street Journal and Allen Frances' piece in Psychiatric Times. Science magazine also has an interesting analysis of the proposed behavioral disorders, which would medicalize harmful habits like gambling, overeating, and down the line perhaps "Internet Addiction." All three articles touched on the negative forensic consequences of the radical proposed changes.

"Prescriptions for Psychiatric Trouble"

Psychiatrist Sally Satel, a resident scholar at the American Enterprise Institute, lecturer at Yale University School of Medicine, and a brilliant thinker, critiqued psychiatry's endless drive to expand mental disorder, placing ever-larger "swaths of the population under the umbrella of pathology." As Satel points out, the DSM-V continues the troubling tradition, launched 30 years ago with publication of the manual's third edition, of elevating reliability over validity:

[J]ust because two examiners concur that a person qualifies for a particular diagnosis does not mean that he has an authentic mental illness. How do we know, for example, that a person diagnosed with major depressive disorder (the formal designation for pathological depression) is not actually suffering from a bout of natural if intense sadness brought on by a shattering loss, a grave disappointment or a scathing betrayal?

The manual will not help us here. In fact, a number of changes proposed for the DSM V (e.g., new diagnoses for binge eating, hoarding and hypersexuality) are likely to inadvertently place large swaths of normal human variation under the umbrella of pathology.

Both she and Allen Frances, former chair of both the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, believe that Psychosis Risk Syndrome may be the scariest example of overinclusion. Hundreds of thousands of young people, especially the poor and minorities, could be given this highly stigmatizing label and medicated with extremely dangerous drugs, even though these medications are not very effective and the broad majority of these youngsters would not go on to develop psychoses if left alone.

In his critique in Psychiatric Times, aptly titled "Opening Pandora's Box," Frances notes that the DSM-V "would create tens of millions of newly misidentified false positive 'patients.' " Not only could almost anyone qualify for at least one of the new diagnoses (which include such nebulous constructs as Mixed Anxiety Depressive Disorder, Minor Neurocognitive Disorder, Temper Dysfunctional Disorder with Dysphoria, and -- in a big nod to America's 12-Step religion -- Addiction Disorder), but thresholds are being lowered for many existing disorders as well.

Forensic applications: Disastrous unintended consequences

One of the DSM-V developers' most troubling weaknesses is their profound "insensitivity to possible misuse in forensic settings," Frances notes. As an example, he cites Pedohebephilia, "one of the most poorly written and unworkable" proposals in the draft:

Expanding the definition of pedophilia to include pubescent teenagers would medicalize criminal behavior and further the previously described misuse of psychiatry by the legal system. Certainly, sex with under-age victims should be discouraged as an important matter of public policy, but this should be accomplished by legal statute and appropriate sentencing, not by mental disorder fiat.

Two other potential "forensic disaster[s]" are Hypersexuality Disorder and Paraphilic Coercive Disorder, both of which will be used to expand the pool of sex offenders eligible for indefinite civil commitment on the basis of purported mental disorder.

In Frances' opinion, based on having worked on the three previous editions of the DSM and knowing many of the drafters of the current version, critics are missing the mark by focusing on alleged financial and/or professional conflicts of interest. Rather, the DSM-V work group members are sincere and well meaning, but have a natural, "and seemingly irresistible," tendency to expand the boundaries of diagnoses in order to identify and treat all potential sufferers. This "diagnostic imperialism" produces a fatal blind spot:

Unfortunately, Work Group members … [miss] the fact that every effort to reduce the rate of false negatives must inevitably raise the rate of false positives (often dramatically and with dire consequences). It is inherently difficult for experts, with their highly selected research and clinical experiences, to appreciate fully just how poorly their research findings may generalize to everyday practice -- especially as it is conducted by harried primary care clinicians in an environment heavily influenced by drug company marketing…. [T]he DSM5 suggestions display the peculiarly dangerous combination of nonspecific and inaccurate diagnosis leading to unproven and potentially quite harmful treatments.

Frances strongly argues that the time to weed out implausible and even "incoherent" proposals is now, not after the proposed field testing:

I feel it is my responsibility to raise clear alarms now because the past performance of the DSM5 leadership does not inspire confidence in its future ability to avoid serious mistakes.... Field trials are arduous and expensive and make sense only for testing the precise wording of criteria sets that have a real chance of making it into the manual -- not for the many poorly written and far out suggestions that have just been posted. It seems prudent to identify and root out problems now lest they sneak through in what will likely be an eventual mad rush to complete DSM5....

Because of the secretive and closed nature of the DSM5 process, the expectable enthusiasms of the experts who comprise the Work Groups have not been balanced, as they must always be, with real world practical clinical wisdom and a careful risk/benefit analysis of the possible unintended consequences of every suggestion.

It would be reckless now to rely on the complacent assumption that all these problems will eventually come out in the wash. By its previous actions and inactions, the DSM5 leadership has sacrificed any "benefit of the doubt" faith that their process will be self-correcting in a way that guarantees the eventual elimination all of the harmful options.

Note: If you want to read Sally Satel's op-ed, do it now; after seven days, Wall Street Journal articles are only available by subscription. I highly recommend that forensic experts and attorneys carefully review Frances' article, and note his recommendation for greater forensic oversight. At minimum, if new diagnoses without established validity are included in the manual, the DSM should add a caveat that they are never to be used as grounds for civil commitment.

Special hat tip to the ever-helpful JANE

Forensic psychiatrist: Courts fostering "POLITICAL DIAGNOSIS"

After sex offenders, who will be next?

More leading experts are starting to notice and voice alarm over the pretextual use of psychiatric diagnoses in SVP civil commitment cases. In an editorial this week, a prominent forensic psychiatrist quotes the late Michael Crichton, calling it "bad science 'tricked out' for public policy ends."

Writing in the Psychiatric Times, James Knoll, psychiatry professor at SUNY-Syracuse and director of a forensic fellowship program, critiques both the questionable diagnoses and the shaky risk assessment techniques being used to civilly commit Sexually Violent Predators:

A variety of instruments have been developed (PCL-R, Static-99, Phallometry, Minnesota Sex Offender Screening Tool, etc.); however, these tests are often challenged in courts as not meeting legal standards for expert evidence and testimony. So while the research database has grown, the question remains: is it reliable enough to be proffered as expert testimony? Experts in the field continue to have serious reservations, and express caution about the (mis)use of these instruments for expert testimony.

Turning to the questionable diagnoses being used in SVP cases, Knoll puts the onus squarely on the U.S. Supreme Court for creating a tautological and "politico-legal" definition of "mental disorder or abnormality" for use in these civil commitment proceedings:

[T]he courts may use our diagnoses when they choose to, and they may ignore them and/or devise their own if it suits public policy…. Since it is forensic mental health professionals who are tasked with SVP evaluations, they have attempted to give this term meaning within the confines of their science. Have these attempts reached a consensus? It would appear that they have not. There continues to be substantial disagreement….

When psychiatric science becomes co-opted by a political agenda, an unhealthy alliance may be created. It is science that will always be the host organism, to be taken over by political viruses…. [P]sychiatry may come to resemble a new organism entirely -- one that serves the ends of the criminal justice system.

If we want to know where all this is headed if someone doesn't slam on the brakes, Knoll points us across the Atlantic to the United Kingdom, where offenders are indefinitely committed on the basis of a nebulous "Dangerous and Severe Personality Disorder" (DSPD):

Given the similarities between our SVP laws and the UK’s DSPD laws, is it too outrageous to speculate that a psychopathy (or DSPD-equivalent) commitment law might be on the U.S. horizon? Remember, the driving force behind such initiatives is usually only one highly publicized, egregious case away.

Related resource:

For an empirical study on the scientific problems with determining future violence under the UK's "Dangerous and Severe Personality Disorder" law, see: Ullrich, S., Yang, M., & Coid, J. (2009), "Dangerous and severe personality disorder: An investigation of the construct," International Journal of Law & Psychiatry (in press). The ultimate conclusions are strikingly similar to the issues posed by Knoll.

The study found a high rate of false positives -- that is, people categorized as DSPD and at high risk of serious reoffending when they actually did not reoffend when tracked in the community: 26 DSPD offenders would need to be civilly committed to prevent one major violent act.

When tracking sex crimes, which are of particular public concern, the researchers found that most new sex offenses were committed by offenders who were NOT categorized as DSPD, undermining the UK Home Office and Department of Health assumption that offenders at the highest risk for future sex offending would be categorized as DSPD.

After critiquing the accuracy of actuarial techniques, the article concludes:

"Bearing in mind the inaccuracy of DSPD criteria in identifying high risk individuals ... the construction of medico-legal terms, as in the case of DSPD, appears highly questionable.... [M]any determinants of violence are circumstantial and situational, and will invariably change over time, rather than related to some inherent characteristics of the perpetrator.... [F]ar more research is necessary ... before attempting to integrate a psychiatric condition into a legal system."

Heed these warnings, folks. The way things are headed in the U.S. criminal justice system, I expect to hear expansion of civil commitment to other groups -- violent offenders, juveniles, and others -- being proposed any minute now.

Photo credit: SUNY Office of Public Affairs