Another severe attack at Napa Hospital

Less than two months after a psychiatric technician was strangled to death, another staff member has been beaten unconscious at Napa State Hospital, California's largest psychiatric hospital. Already abysmal staff morale is sinking lower as tensions rise among the captive patients, whose privileges have been curtailed since October's slaying.

Four years ago, the U.S. Attorney General's Office negotiated a consent decree mandating sweeping changes aimed at improving patient care and reducing suicides and assaults at the troubled hospital. A federal probe had revealed widespread civil rights violations, including generic "treatment" and overuse of seclusion and restraints. Napa, the only state psychiatric hospital in Northern California, houses defendants undergoing competency restoration treatment and those found not guilty by reason of insanity.

Earlier this year, another scandal hit the hospital, when its executive director was arrested on 35 felony charges stemming from the alleged molestation of a foster son. He was suspected of molesting at least four other boys going back to the 1970s.

Lee Romney of the Los Angeles Times, who has provided the best coverage of California's troubled state hospital system over the past few years, reported that patients at Napa are increasingly agitated in the wake of greater restrictions on their movement, exacerbating an already bleak picture:

Since 2006, the state's mental hospitals have been under a federal court order to improve conditions for patients. Yet safety for both patients and staff has deteriorated markedly at Napa State Hospital over the last year, data show. The other state hospitals subject to the federal consent judgment have also experienced a rise in violence since the state began implementing changes in care.

In case you need a job, by the way, the hospital is hiring.

Hat tip: Kathleen

News flash: Epic trial ends with sanity verdict

It took a jury only five hours to decide that Brian David Mitchell does not meet Utah's legal definition of insanity, and to find him guilty of all charges in the 2002 kidnapping of Elizabeth Smart.

The high-profile case teems with issues of import to forensic psychology and psychiatry, including malingering and the boundary between delusions and extreme religious beliefs.

The trial, as in the many past hearings, featured dueling experts. On one side was prominent New York City psychiatrist Michael Welner, who said Mitchell was sane and malingering a mental disorder to escape criminal liability. Defense attorneys criticized both Welner's fees, a whopping $750,000 (no, that's not a typo), and his methods. For example, he had FBI agents conduct about 30 interviews on his behalf, according to an Associated Press report by Jennifer Dobner.

On the other side was psychologist Richart DeMier, who evaluated Mitchell for 45 days at a federal prison in Missouri in 2008 and diagnosed him with paranoid schizophrenia. During his full day of testimony, DeMier was vigorously questioned about the sometimes-muddy distinctions between delusions and extreme religious views, a central issue throughout this case. He testified that the distinction is not an exact science, and that mental illness is not always black and white, according to a report in the Deseret News.

Experts also dueled ferociously at Mitchell's competency hearing last year. At one point during testimony by Jennifer Skeem, a forensic psychologist from California who grew up in Utah, the proceedings "seemed less about issues relating to Mitchell's competency and more about what she believed was 'character assassination' " by Welner, according to a Deseret News report. "I'm not a hired gun who intentionally collaborated with an unethical defense team," Skeem told the court.

Crazy or not, the self-styled prophet maintained his typically bizarre behavior during the reading of the verdict, loudly singing the hymn, "He Died, the Great Redeemer Died."

Judge Kimball’s 149-page competency ruling, which I highly recommended to any of you who do competency work, is HERE.

My previous coverage of this fascinating case, with links to other reports, includes:

• Mitchell to plead insane (July 6, 2010)
• Mitchell labeled as malingerer, ruled competent (March 1, 2010)
• "Legal pointillism": New approach to competency (Dec. 8, 2009)
• Record-breaking fee for competency report? (Dec. 4, 2009)
• Utah court: OK to forcibly medicate accused kidnapper (Dec. 17, 2007)

Graphics credit: Scott Snow, KSL

Crazy Like Us: The Globalization of the American Psyche

A successful virus is adaptive. It evolves as needed to survive and colonize new hosts. By this definition, contemporary American psychiatry is a very successful virus. Exploiting cracks that emerge in times of cultural transition, it exports DSM depression to Japan and posttraumatic stress disorder to Sri Lanka.

Journalist Ethan Watters masterfully evokes the heady admixture of moral certainty and profit motive that drives U.S. clinicians and pharmaceutical companies as they evangelically promote Western psychiatry around the globe. On the ground in Sri Lanka following the tsunami, for example, hordes of Western counselors hit the ground running, aggressively competing for access to a native population "clearly in denial" about the extent of their trauma. Backing up the foot soldiers are corporations like Pfizer, eager to market the antidepressant Zoloft to a virgin population.

Watters has done his homework. Each of his four examples of DSM-style disorders being introduced around the world is rich in compelling historical and cultural detail. Despite their divergences, each successful expansion hinges on the mutual faith of both the colonizers and the colonized that Western approaches represent the pillar of scientific progress.

My review of Crazy Like Us, an engaging and enlightening book that I highly recommend, continues HERE.

Watters' Jan. 8, 2010 essay in the New York Times, "The Americanization of Mental Illness," is HERE.

Age tables improve sex offender risk estimates

First, how old is the bus driver?

If 30 people are riding on a bus, and 30 more people board the bus, how old is the bus driver?

The answer, many second-graders will assure you, is 60. (They know your question involves numbers, but they don't quite get the concept.)

Clinical psychologists are a bit like that. Most of us were not drawn to the field by a deep and abiding passion for numbers. This puts some in a quagmire when they jump into forensic work, and courts order them to predict future events with a high degree of mathematical precision.

Illusion of certainty, certitude in illusions

Since passage of the Psychologist Full Employment Act,* I have observed a growing group-think among government sex offender evaluators in particular. At the annual meetings of the Association for the Treatment of Sexual Abusers (ATSA), crowds flock to hear self-appointed gurus give the latest in a series of ever-changing instructions about how to use their pet formulas, freely available online, that promise to take the guesswork out of risk assessment.

Psychologists who lack statistical sophistication are especially likely to swoon over fancy-sounding terms such as receiver operating characteristics (ROC) and to overlook the gaping flaws in current actuarial methodology. Instead of deriving from sound scientific principles such as random sampling, the tools are strung together from a motley collection of random data, much of it never published or subjected to peer review. As I have reported in the past, the Static-99 family of instruments are not very accurate, and tend to err in the direction of overestimating risk.

So, what about that bus driver?

Getting back to the bus driver: Let's say the second-graders happened to be right, and he really is 60 years old. What are the odds that he will be arrested for a sex crime, given that he recently served time for sexual assault? (I know, I know. What bus company would have hired him? But, play along with me here.)

If you asked a randomly selected passenger aboard the bus, the answer would be close to 100%.

But as you know, the public drastically overestimates sex offender recidivism rates. Let’s say that in reality, the average sex offender who scores in the low range on actuarial risk instruments has a 5% chance of sexual recidivism, while the average high-scoring offender has a 29% risk. Obviously, without knowing more about the bus driver, all you can say is that his risk of reoffense is somewhere between 5% and 29%.

But that too would be wrong. Because of his age, the bus driver's recidivism risk over the next eight years is more in the range of 2.7%.

Which is probably lower than the risk of a passenger getting trampled if you hollered out, “Eek! Sex offender!”

Good news: Age-stratified tables improve accuracy

The single most robust finding of two centuries of criminological research is that desistance from crime is near universal. As they age, criminals stop offending. This holds true across all eras, cultures, and offender groups. Sex offenders are not exempt from this pattern. As their libidos decline, they too settle down or burn out. Unfortunately, this “age invariance effect,” as it has been called, has trouble filtering down into the muddy waters of the sex-offender industry. (See my online review of the book Desistance in the Open Access Journal of Forensic Psychology for more discussion of this.)

When age is not properly taken into accounting in estimating risk, the risk for older offenders -- such as our bus driver -- is overestimated, while the risk of younger offenders is underestimated.

Now, a collaboration by scholars from the United States, New Zealand, and Australia reveals that the accuracy of sex offender risk prediction can be significantly improved by using age-stratified tables to calculate risk.

The researchers tapped into an electronic database of all sex offenders in New Zealand who were released from prison over a 15-year period. They combined the data on those 5,880 offenders with recidivism data on 3,425 offenders published by Static-99 developer Karl Hanson in 2006, to develop what they call a "Multisample Age-Stratified Table of Sexual Recidivism Rates" (MATS-1).

Using Bayes's Theorem, the researchers were able to calculate likelihood ratios for different levels of risk. (Bayes's Theorem speaks to the probability of an event, taking into account both the phenomenon's base rate and the accuracy of a test. Cognitive scientists regard the Bayesian method as the gold standard, often using it synonymously with rational reasoning.)

Overall, the recidivism base rate of their combined international sample was 9% over a 10-year period, which is consistent with other reported research. Dividing offenders into three levels of risk based on their scores on actuarial risk instruments, the researchers found that those with low risk scores had an average 5% risk of reoffense within eight years, as compared with 12% for medium-risk offenders and 29% for offenders with high scores. By dividing sex offenders into various age groups, they were able to come up with more precise estimates of risk (see below table).



Evaluators should use this type of age-stratified procedure when giving estimates of recidivism risk, particularly for older offenders, the researchers advise. Estimating an offender's probability of recidivism based on the observed proportion of recidivists in a population is more accurate than relying on a set of untested assumptions. It is also much simpler and easier to explain to a trier of fact.

I highly recommend the article, published in the current issue of Sexual Abuse, which goes into a great deal of detail about the method and its superior stability and accuracy. The authors are Richard Wollert of Washington State University and the Mental Health Law and Policy Insitute at Simon Fraser University in Canada, Elliot Cramer, a statistician and professor emeritus from the University of North Carolina-Chapel Hill, Jacqueline Waggoner of the University of Portland, Alex Skelton of the New Zealand Department of Corrections, and James Vess of Deakin University in Australia. Request reprints from the first author (HERE).

Related blog posts:

• Delusional campaign for a world without risk (April 3, 2010)
• Static redux: Sandgropers jumping off rickety ship (Sept. 23, 2010)
• SVP industry sneak peek: Problems in Actuaryland (Oct. 4, 2009)
• New study: Do popular actuarials work? (April 20, 2010)
• Study: Actuarials fail to predict sexually violent recidivism (March 5, 2010)

For a good introduction to Bayesian reasoning, see Eliezer Yudkowsky's tutorial, "An Intuitive Explanation of Bayes' Theorem."

*The Psychologist Full Employment Act is the label conferred on the Sexually Violent Predator (SVP) laws by a leading psychology-law scholar in a recent plenary address.

Prison overcrowding: Chickens coming home to roost

U.S. Supreme Court to hear critical California case

When is the last time you heard of prisoners and prison guards teaming up in a legal case?

They are united on the same side in a case set to be argued in front of the U.S. Supreme Court on Tuesday.

The case concerns prison overcrowding in California, where about 164,00 prisoners are crowded into facilities designed to hold less than half that number. The state is fighting a federal district court that the massive population must be cut by 40,000 to allow for minimally adequate mental health and medical treatment.

“The case is being widely watched across the U.S, as other states grapple with California-style problems: tough sentencing laws that filled up prisons even as the economy battered state budgets,” write Joanna Chung and Bobby White in today’s Wall Street Journal. Eighteen states have filed briefs backing California in the case of Schwarzenegger vs. Plata, arguing that releasing prisoners would threaten public safety.

The issue of inadequate mental care in California prisons has been in the courts since 1991, when Ralph Coleman filed a lawsuit that was eventually merged with prisoner Marciano Plata’s similar lawsuit of 2001. The district court appointed an independent expert to oversee prison health care. That expert, law professor Clark Kelso, believes the court-ordered reductions in the prisoner population are needed to achieve "sustainable constitutional health care" in the face of continued prison construction.

As Chung and White report:

The rare alliance of California's powerful prison guard union and the inmates illustrates the severity of the situation, legal experts say. "It should not be a surprise to anyone that the chickens have come home to roost after a series of disastrous policy choices that has landed California in this position," says David Fathi, director of the American Civil Liberties Union's National Prison Project, which has filed a brief on behalf of the inmates….

Tough sentencing laws enacted by the state during the 1990s, including the three-strikes-and-you're-out law, as well as a parole crackdown that's returned violators to return to prison even for minor infractions, fueled the dramatic rise of California's prison population….

When Edmund G. "Jerry" Brown Jr. first was governor in the 1970s, California's prisons housed more than 20,000 inmates. When Mr. Brown, who won back his old job in this month's elections, returns to office in January, he will oversee more than 160,000….

The California Correctional Peace Officers Association, the 30,000-strong prison guard union, says the state's current strategy of building more prisons at home and shipping overflow inmates to out-of-state private penitentiaries won't solve the long term trend. Ryan Sherman, an association spokesman, says: "You can't build your way out of this.... We need real reform, not a numbers game."

Mr. Sherman wants the state to invest in more medical staff and equipment to address the poor conditions that instigated the lawsuits. While the prison population rose dramatically over the last few year he says the state never kept pace with investments in doctors and nurses and better health facilities.

Meanwhile, the state California faces a $6 billion shortfall for the current fiscal year ending June 30 and a $19 billion shortfall for the next fiscal year, according to the nonpartisan state Legislative Analysts Office.

"The way that California ends up dealing with this problem will be an example for other states with massive budget problems and overcrowded prisons to watch and learn from," says Anthony S. Barkow, head of New York University law school's center on criminal law, which filed a brief on behalf of the inmates.

Hat tip: Kathleen

Postscript: An update on Tuesday's hearing can be found HERE. Meanwhile, as reported HERE, California is responding to the threat of a population cap by frantically shipping prisoners to private prisons in other states. Medical and mental health care is much worse in these privately run institutions, where violence is not only tolerated but may be encouraged, according to an Associated Press news story (with video of an incident in a private prison in Idaho). (By the way, did you know that the private prison industry, hankering for more captive bodies, helped author Arizona's anti-immigrant law? That fascinating story is HERE.) KALW radio has some good background on the crisis, including an audiotaped report on medical care at San Quentin.

The Psychology of jury voir dire

How many times have you debriefed jurors after they rendered their verdict and been surprised by what they told you? Jurors don't deliberate based on facts and argument. They deliberate based on their perception of the facts and arguments. And it is the juror's belief system that accounts for the varying way that jurors perceive facts and arguments.

That is the start of an informative how-to piece in The Jury Expert by psychologist Matthew L. Ferrara, a trial consultant based in Austin, Texas.

The current issue of The Jury Expert has several other interesting articles, including:

• Police deception during interrogation and its surprising influence on jurors' perceptions of confession evidence by Krista D. Forrest & William Douglas Woody

• Do we need Einsteins in the jury box? The role and impact of juror IQ by Alison Bennett

• What the literature tells us about the jury foreperson by Traci Feller

Photo: "The Jury," John Morgan, 1861 (Public domain; source: Wikimedia commons)