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

Oldest condemned man dies at 94

Elderly outlaw's competency remained at issue

Like so many Depression-era outlaws, the infamous Clyde Barrow and Bonnie Parker met early deaths, gunned down in a police ambush at the ages of 26 and 23. Among the few from that era to beat the hangman's noose was Viva Leroy Nash, the oldest death row prisoner in the United States, who died last week of natural causes.

Imprisoned for most of his adult life, Nash lived long enough to become both psychotic and demented, according to his lawyers; he was also deaf and almost blind. At the time of his death, his competency to participate in post-conviction habeas proceedings was on appeal to the U.S. Supreme Court.

Forensic psychiatrist Barry Morenz of the University of Arizona had evaluated Nash and opined that the old outlaw suffered from a delusional disorder. His symptoms included paranoid and grandiose delusions as well as auditory hallucinations. Dr. Morenz also noted worsening cognitive problems and memory impairment.

In the landmark case of Oscar Gates (formally known as the Rohan case), the 9th U.S. Circuit Court of Appeals ruled in 2003 that a death row prisoner has a right to be competent during post-conviction appeals, so that he may advise and consult with attorneys regarding issues that might arise. The standard is somewhere between the higher level of competency required to stand trial and the very low, so-called "Ford" competency standard required for execution.

In 2007, the appellate court applied this holding to Nash's case, granting a death penalty stay until Nash's ability to communicate rationally with his counsel could be evaluated and litigated. The government was appealing that ruling when Nash died.

A lengthy account in Phoenix' New Times last year was skeptical of Nash's incompetence claim. It described the self-educated convict as "intelligent and well read" and "a consummate jailhouse lawyer" who in the 1960s won "certain procedural safeguards for inmates" in a ruling that almost made it to the U.S. Supreme Court.

But then again, maybe advancing age and years of supermax confinement finally did him in. After all, more than one out of three people in their 90s has a dementia. And long confinement in solitary housing eventually drives even the strongest mind "stir crazy."

Life at Nash's final residence, the austere supermax Arizona State Prison Complex-Eyman, is an invisible form of torture. With Arizona "at the vanguard of the country's correctional zeitgeist in stripping away inmate privilege," according to a critical report in The Tucson Weekly, long-term lockdown in the unit is the state's "version of a straitjacket." Devoid of human connection, prisoners in such environments not uncommonly take to self-stimulating behaviors that is rare in other contexts -- sculpting figurines out of feces, masturbating in public view, or gouging their flesh and playing with it.

Craig Haney, an expert on the psychological effects of long-term solitary confinement, called the Arizona supermax one of the most severe. "Solitary confinement has been around for a long time," Haney told the Weekly. "What's different about these supermax units is that the technology of the modern correctional institution allows for a separation, almost a technological separation, of inmates from the social world around them in ways that really weren't possible in the past."

Under these conditions, if a condemned prisoner's appeals drag on long enough, it is almost inevitable that his mind will deteriorate to the point that he needs a forensic evaluation of his competency to rationally communicate with his attorney. So, if other Depression-era outlaws had survived long enough, we forensic practitioners may have gotten a chance to glimpse back into a bygone era through their eyes as well.

A wild and colorful life

It surely would have been interesting to interview this old man who talked like he had just stepped out of an Old West movie. Born in Salt Lake City's rural south side in 1915, during Prohibition, the "wild child" dropped out of school in the seventh grade and embarked on a life of crime.

During the Roaring Twenties he and a gang of other boys burglarized warehouses. In his mid-teens, armed with a gun, he caught an outbound boxcar and, like millions of other dispossessed young men during the Great Depression, set off "to seek his fortune," according to a laudatory 2005 account in the New Criminologist that referred to him as "a living legend." The account was based in part on more than 200 pages of handwritten memoirs.

By age 17, he was serving time at an industrial school for juveniles in Ohio for car theft. He escaped, did an armed robbery, and was sentenced to 30 months at Kansas' notorious Leavenworth Penitentiary, where he has said that a Mafia don tutored him in jewelry store heists.

Paroled in 1934, he fathered his only child (who died 21 years ago) and resumed his life of crime, with robbery sprees in Utah, Georgia, Alabama, and who knows where else. He was imprisoned in 1936 after a bungled robbery with his younger brother. Next arrested in 1946 in Alabama for check-kiting, he escaped from jail and reportedly fled to Mexico with a large sum of stolen money.

But his outlaw ways were catching up to him, and he spent most of his ensuing years in prison. He did a 25-year stretch for the 1947 shooting of a Connecticut police officer (who lived). In 1977, he was sentenced to two life terms for a robbery-murder. Somehow, he was placed on a prison work crew from which he escaped in 1982. Just three weeks later, he did the crime for which he was sentenced to die in 1983 -- a robbery-murder at a Phoenix coin shop.

Although his appeals have focused on his poor legal representation at his 1983 trial, given his litany of crime and the callous way that he executed his final victim it is doubtful than any jury would have voted to spare his life. Yet he managed to outlive men who were sent to death row long after he arrived, and ultimately he managed to die of natural causes.

Some have intimated that the state itself was dragging its heels, to avoid the spectacle of killing a dottering old man. With California and Alabama getting flak for recent executions of a 76-year-old and 74-year-old, respectively, just think of the clamor over the killing of a blind, deaf, crippled, demented and mentally ill 94-year-old.

So ends another chapter in America's love-hate relationship with capital punishment.

Hat tip: Kathleen

Photos: Bonnie Parker, circa 1932, credit Wikipedia Commons; Nash about 20 years ago, credit Arizona Department of Corrections; Arizona State Prison at Eyman, courtesy Department of Corrections

Skeem to give psychopathy training in Oregon

Save the date: Friday, April 9

On the heels of a hugely successful training featuring Stephen Hart of Simon Fraser University on sex offender risk assessment, Alexander Millkey and Michelle Guyton at Northwest Forensic Institute in Portland are doing it again. This time, they've scored Jennifer Skeem of the University of California at Irvine, who will provide advanced training on the controversial construct of psychopathy.

As many of you know, Dr. Skeem is an eminent scholar who has received the prestigious Saleem Shah Award for Early Career Excellence from the American Psychology-Law Society (APA Div 41) and the Distinguished Assistant Professor Award for Research at UC Irvine. She has published more than 70 scientific articles, chapters, and books, and is co-editor and an author of the excellent new book, Psychological Science in the Courtroom: Consensus and Controversy. Her research areas include psychopathy, violence risk assessment, and effective supervision strategies for individuals mandated for psychiatric care.

In this training, she will challenge prevailing assumptions that psychopathy is a unitary and homogeneous construct or something that can be reduced to a score on the Psychopathy Checklist-Revised (PCL-R). She will also present data challenging the deeply entrenched idea that people with psychopathic traits are incurable cases that should be diverted from treatment settings to environments where their behavior can merely be monitored and controlled.

The all-day training is on Friday, April 9 at Portland State University, and is followed by a networking reception with Dr. Skeem. Registrants will receive six hours of continuing education credits. The cost is only $175, or $75 for students.

For more information and to register, go to the Institute's website.

DSM-V: Get ready, get set . . . here it comes!

The American Psychiatric Association plans to launch its new DSM-V website tomorrow, February 10, publicly airing the long-anticipated diagnostic revision proposals and their criteria. I understand that two of the controversial forensic-related diagnoses I have blogged about extensively -- paraphilic coercive disorder and pedohebephilia -- are among those that made the draft manual.

Simultaneously, controversies grow on multiple fronts. On the one hand, we've got psychiatrists arguing that it's time to wrest the discipline back from all of those pesky non-psychiatrist interlopers. Writing over at the Psychiatric Times, Steven Moffic says the DSM-V should include an express clause saying only psychiatrists are qualified to use the manual.

Don't hold your breath. As long as psychiatrists keep charging many times the fees of other mental health practitioners, I guarantee that economic forces will keep Dr. Moffic's wish from coming true. Talk about trying to close the barn door after the horses are long gone!

Meanwhile, on the other side of the fence, the Association for Women in Psychology is saying, "Who wants it?" The Association has launched a new web site devoted to concerns about bias in the DSM-V diagnostic system. The site features a veritable link fest of criticisms, with articles on specific areas of diagnostic bias that will inordinately affect women, including anorexia nervosa, borderline personality disorder, female sexual dysfunction, and gender identity disorder.

Of particular relevance to forensic practitioners is an article critiquing parental alienation syndrome, proposed for the DSM-V, as well as articles on racism and social class bias in the diagnostic system.

Check it all out, folks. And if you disagree with anything you see, be sure to speak up now, before it's too late. The new manual, originally slated for publication in 2012, has been pushed back to May 2013, which may seem far away. But you only have two short months -- until April 20, 2010 -- to view the draft and make comments; after that, the website "will be available for viewing only." So much pseudoscience, so little time.

It's easy to register and make your comments. Whether the psychiatric gurus will listen is another story. But if you don't try, you'll never know.

Related resources:

Peter Aldhous, the award-winning science reporter covering the DSM debacle for New Scientist magazine, will be following up on his widely disseminated article, Psychiatry's Civil War, with a critical report on the latest developments. He is the guest on Michael Krasny's Forum on KQED radio on Wednesday (February 10); you can download the audio of "Updating Psychiatry's Bible" HERE.

What is a gang?

A group of violent thugs? A social club? Troubled, homeless losers who are "hard to love"?

And what is gang membership? Is it a fixed identity, or something fluid, which urban youngsters claim or don't claim according to external circumstances and the flow of their lives?

How can we explain why, even in the roughest neighborhoods, at most 10 percent of youths belong to street gangs? Who are the other nine out of ten, and how do they negotiate survival without affiliation?

For answers to these complex questions, and more, I recommend a new book from New York University Press, Who You Claim, written by John Jay College of Criminal Justice sociology professor Robert Garot based on ethnographic researcher at a continuation school in Southern Calfornia.

Garot's nuanced analysis is a refreshing antidote to the kind of simplistic categorization that we see in corrections and in forensic practice, where young people being processed through the system are treated as if the label of gang member explains everything that we need to know about them.

His bottom-line message: Beware reifying gangs as fixed and essential components of identity, when even their members do not see them as such. As urban centers create increasingly fluid possibilities for identity -- exemplified by Polish-Brazilian and Mexican-Korean cuisines -- identity is becoming much more malleable and flexible than such a narrow and pejorative focus would lead us to believe.

My complete review, at Amazon, is HERE.

The "juvenile sex offender": Myth in the making?

Book describes harmful effects of labeling and treatment

In the past 30 years, a vast cottage industry has sprung up to treat and warehouse juvenile sex offenders. Whereas in 1982 the United States had 20 programs to treat such youths, by 2002 that number had skyrocketed to upwards of 1,300 specialized programs, most of them private, for-profit residential centers. What is especially startling about the continuing expansion of this fledgling industry is that rates of serious offending, including sex offending, by juveniles is staying steady or even declining.

In The Perversion of Youth, forensic psychologist Frank DiCataldo says this new field may be harming both youth and society, by labeling typical delinquents as sexual monsters and thereby forcing them down a deviant path from which there is little hope of escape. In other words, our very process of labeling and treatment may breathe life into the bogeyman of our cultural imagination.

Like many failed social experiments, this one is driven by good intentions. But its underlying premises are based not on scientific evidence but on misguided faith and lore. DiCataldo, a psychology professor at Roger Williams University, meticulously presents the empirical evidence suggesting that the "juvenile sex offender" is not a natural category distinct from other delinquents. Rather, youths so labeled are typical delinquents whose offending happens to include a sex offense. And their sex offenses stem not from sexual deviance, but from a panoply of developmental factors, including sexual experimentation, thrill-seeking, poor social skills, emotional neediness, and rigid gender scripts that encourage sexual conquest as proof of masculinity.

In the past, many of the so-called sex offenses for which even young children are now being locked up and subjected to treatment would have been regarded as sex play, experimentation, or -- more seriously -- evidence of general criminality. In the overwhelming majority of cases, the natural course is for youths to mature out of sexual misconduct and other delinquency as they become adults, the data show.

Since only a tiny handful of youths who commit a sex offense are budding sexual deviants, the dominant treatment -- a one-size-fits-all, deviancy focused relapse prevention model -- is not helpful. In fact, by labeling normal adolescent boys as deviants, it may be very harmful, encouraging them to see themselves as the very monsters that the label makes them out to be.

DiCataldo is not peering down from an ivory tower. Long-time director of the Forensic Evaluation Service for the Massachusetts Department of Youth Services, he devotes special attention to the practices in the treatment trenches. Instead of taking the time to really see the individual adolescent for who he is, well-intentioned but dogmatic clinicians administer manualized treatment based on a “mind-boggling” array of unsupported global beliefs:

All adolescents who have committed an inappropriate sex act must receive this particular form of treatment; all juvenile sex offenders have a history of sexual victimization, and if you look deep enough, you will find it; adolescents must admit that their sexual abuse was traumatic and damaging; their denial must be broken down with persistent in-your-face confrontation; they must admit to deviant fantasies or hidden perversions and are provided fantasy logs in which to record them; … they must make their offense fit a stock, prefabricated dynamic involving the need for power and control or the presence of perversion or deviancy; they must face the fact that they have an incurable condition, like a chronic disease….

Ironically, he points out, the only empirically supported treatment for juvenile sex offenders, Multisystemic Treatment (MST), does not endorse these unproven tenets. Indeed, it does not even directly address sexual deviancy, instead focusing on client strengths and environmental supports in the family and community.

Like the misguided treatment programs, efforts to design instruments that will accurately predict which juvenile will go on to reoffend are also doomed to failure. It is not the fault of the instruments themselves, the author contends. Rather, because the base rates of sexual recidivism are so low (an estimated 5% to 15% across many studies), the most reliable prediction for any individual boy is that he will NOT commit a future sex offense.

In warning of the siren call of the sex offender narrative, DiCataldo echoes scholars such as James Kincaid and Philip Jenkins who have written about its alluring promise to simplify simplify the world and safely contain its dangers. But unlike in previous historical cycles of moral panic and sexual hysteria, he points out, this time around the pathologizing discourse of deviance is more securely embedded in systems such as the schools and the juvenile justice system. The ever-expanding and lucrative cottage industry devoted to juvenile sex offending has so firmly entrenched itself as a part of modern culture that, absent some serious attention to the lack of underlying science, it is unlikely to fade away anytime soon.

The author could have benefited from a good editor, as the presentation becomes repetitive. Still, in meticulously summarizing virtually all of the existing research and case law pertaining to juvenile sex offending, this well-researched book is an essential one-stop resource for anyone interested in understanding the contemporary phenomenon of juvenile sex offending.

So, here's a modest idea:

In recent years, a small-scale civil rights movement has emerged among mental patients, former mental patients, and their allies. One of their aims is to remove mental illness as the core construct of a person's identity. As such, they recommend not using terms such as "schizophrenic" as nouns to describe a person. Rather than calling someone "a schizophrenic," they would say: "A person with schizophrenia" or, even better, "a woman who has had some bouts of psychosis." I would love to see this applied in the sex offender field. Instead of calling a child "a juvenile sex offender," why not call him "a 15-year-old who engaged in sexual misconduct" or "a boy with a sex offense arrest"? As DiCataldo so thoroughly explains, within the current legal and treatment climate, the mere act of labeling a child as "A SEX OFFENDER" can effectively derail that person's life, potentially forever.

* * * * *

And, finally, I leave you with a related book recommendation:

The Trauma Myth, by Susan Clancy. The New York Times book review is HERE.

Related Amazon book reviews:

• Failure to Protect: America's Sexual Predator Laws and the Rise of the Preventive State

• Evaluation of Sexually Violent Predators (Best Practices for Forensic Mental Health Assessment)

• Mistakes Were Made (But Not by Me): Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts

• Rape and the Culture of the Courtroom
  

• Shyness: How Normal Behavior Became a Sickness

Photo credit: SOL Research