Top forensic psych’s shameful secrets: A cautionary tale

An investigative report on the secret life of a prominent forensic psychologist is generating controversy on professional listservs. Some want to let sleeping dogs lie. Others, including this blogger, believe the sordid tale contains valuable lessons for the field.

Photo credit: Seattle Times

Stuart "Stu" Greenberg was at the pinnacle of a highly successful career when he committed suicide in 2007 after being caught using a secret camera to spy on women – including fellow psychologists -- in his office bathroom.

Greenberg was a respected leader in forensic psychology. Former president of the American Board of Forensic Psychology, he had functioned as a professional gatekeeper in heading the committee that wrote a national certification exam for the field. He was a sought-after speaker who published articles on ethics in peer-reviewed journals. In court, his opinion could decide the fate of a parent seeking custody of her child. Charging $450 an hour, he had amassed an estimated $1.7 million in personal worth and owned at least two houses and a boat.

But in last weekend's Seattle Times, investigative reporters Ken Armstrong and Maureen O'Hagan reveal new details of Greenberg's less savory side. They go so far as to paint the Seattle psychologist as a "toxic force -- a poison coursing through the state's court system," who destroyed lives while building a career based on "hypocrisy and lies."

Previously sealed records dug up by the newspaper -- including a 1990 disciplinary case -- attest to Greenberg's power and "cunning," the reporters write:

His word could determine which parent received custody of a child, or whether a jury believed a claim of sexual assault, or what damages might be awarded for emotional distress…. [The records] show how he played the courts for a fool. He played state regulators for a fool. He played his fellow psychologists for a fool. And were it not for a hidden camera, he might have gotten away with it.

The report describes how Greenberg coerced Washington state's Examining Board of Psychology into sealing public records of a 1990 disciplinary action against him. The case involved alleged misconduct in four separate child custody cases. The Board imposed a three-year ban on his conducting such evaluations. But "within a year of getting his disciplinary history sealed, Greenberg was giving seminars to other psychologists on the ethics of parenting evaluations," the report says.

As an example of the destruction wrought by Greenberg, the reporters interviewed the complainant in one of the four cases. Surgical nurse Cathy Graden said she had no fears of losing custody of her 4-year-old son after her divorce. What she didn't know was that Greenberg and the lawyer for her ex-husband were limited business partners in a speculative investment venture:

The report Greenberg filed in court eviscerated Graden. It said she posed a grave danger to her son; that she was "probably" sexually abusing him; that she was psychologically unstable and possibly paranoid….In court, testifying, Greenberg described Graden as "quasi-psychotic," but said the diagnosis was tricky, because Graden might appear "quite normal." She would likely deny doing anything wrong to her son, Greenberg said, or alternatively, she "might genuinely not remember."

By the time Greenberg finished, Graden, out in the hallway, had been stripped of all defenses -- and without a clue to what had just happened. If she appeared normal -- well, Greenberg said she would. If she denied hurting her son -- that was part of her disorder. If she challenged Greenberg's work or motives -- she was paranoid. At the end of the hearing … the judge ordered the boy turned immediately over to his father, with Graden allowed to visit only if supervised by a therapist.

Graden finally got her son back when he was nine years old, but only because his father was killed in a work accident.

"Inscrutable field with immense power"

The Seattle Times piece is slanted. It castigates the entire field for the alleged criminal and unethical conduct of one individual. As we all know, there are honorable and dishonorable people in all professions. In my locale, the FBI is investigating a group of rogue police who allegedly sold drugs, ran a brothel and took money from a lawyer to make staged arrests of fathers in child custody cases. Yet the media do not paint all law enforcement with that same dirty brush. And some of the supposed misdeeds for which the reporters lambast Greenberg, such as lacking the clairvoyance to know that a priest he evaluated was lying about the extent of his sexual misconduct, are hardly evidence of turpitude. Nowhere is a spokesperson for our field given space to clarify or comment about the implications.

But in calling forensic psychology "an inscrutable field with immense power," the reporters tap into a popular conception with a kernel of truth.

Power is a corrupting force. Just as Greenberg wielded immense power over the fates of parents and children, forensic psychologists today abuse their power and destroy lives when they invent diagnoses to further pretextual goals, present personal opinion and prejudice masked as science, or testify that they know with mathematical certainty that a person will commit a future crime. Such misconduct is common in certain forensic contexts. In fact, its routine nature presents an obstacle to intervention. I know of one colleague whose attempts to complain about psychologists' improper opinions in court were rebuffed by a licensing board on the grounds that the opinions -- while improper -- were not sufficiently unusual.

Greenberg's tale may thus serve as a cautionary one about why the field should not collectively look away when we see colleagues abusing their power. Individually or as a group, it is our ethical duty to intervene when we see colleagues misbehaving -- stepping beyond the bounds of science, engaging in activities that seem biased, or (as in Greenberg's case) mistreating women or others with less social currency. Perhaps if Greenberg's superficial aplomb had not blinded colleagues to his faults, he could have been redeemed and this public tragedy averted.

Professional condemnation of Greenberg's misconduct serves other purposes. It demonstrates respect for the members of the public who were negatively affected, as well as for our own women colleagues who allegedly suffered sexual exploitation and betrayal by a colleague whom they trusted. It may encourage exploration in our professional literature about the existence of corruption, which always creeps into situations involving power and authority, and how this problem might be addressed.

It may also be useful for each of us to reflect personally on the lessons here. Many of us work largely alone. Without professional accountability, it is easy to go astray. The stakes are high, the material troubling, the settings adversarial. In these difficult circumstances, it is incumbent upon all of us to behave honorably and ethically, to avoid even the appearance of bias, to be transparent in explaining the basis of our often-consequential opinions, and to admit the limits of our knowledge.

In other words, to recognize the inherent power imbalances, and to strive for humility and honesty.

A collection of primary documents and news reports on Greenberg's case can be found at The Liz Library. Also at that site are direct quotes from psychologists' (supposedly) internal debates on the case as culled from two professional listservs. (Note that the presentation is biased and misleading; by publishing mainly one side of a vigorous debate, they misrepresent psychologists as overwhelmingly opposed to public airing of this troubling case. But it's still worth checking out.)

Sexual violence prevention: Recommended journal issue

The current issue of the International Journal of Law and Psychiatry features an excellent collection of diverse scholarship on the prevention of sexual violence. Papers address the empirical and moral foundations of prevention from the perspectives of law, psychiatry, criminology, psychology, and public policy. Here's a preview of a couple of the articles I've read so far….
 

Paraphilia battle pivotal to future of U.S. civil liberties

Jerome Wakefield, a professor at New York University and an influential theorist of mental disorder, provides a searing analysis of the messy paraphilia debacle that the DSM-5 task force has waded into. After providing a brief history, he dissects the current proposals to show how their conceptual invalidity will open the door to widespread abuse in forensic practice:

 

Needless to say, prosecutors availing themselves of civil commitment processes and wishing to keep offenders from release find it in their interest to argue for the most expansive possible interpretation of the DSM criteria for paraphilic disorders -- lending enormous weight to the details of the diagnostic criteria…. The convenience of these criteria in forensic evaluations seems more than offset by the potential for prosecutorial abuse and the long-term undermining of the credibility of the distinction – sanctioned by the Supreme Court as a constitutionally crucial one – between mental disorder-driven behavior and other motives for criminal behavior.

Wakefield joins the ranks of other respected figures to recognize the high stakes involved in the battle over whether sex crimes equate to mental disorder. As he bluntly puts it, the struggle over how sexual paraphilias are defined is “tactically central to the future of civil liberties in our country.” If the government can indefinitely detain men who have served prison time for sex crimes based on bogus psychiatric labels that supposedly impair their volitional control, it's only a matter of time before other groups are rounded up, too. 

Of all of the controversial paraphilias, Wakefield asserts, the “most flawed and blatantly overpathologizing” is pedohebephilia, which would expand pedophilia to encompass attraction to pubescent minors. Arguments by its proponents are both weak and misleading, he writes:

The first argument for the expanded category is that hebephilia is similar to pedophilia in that both involve attraction to physically immature individuals. This is about as valid an argument as saying that both dyslexia and illiteracy involve difficulties reading, thus illiteracy should be considered a disorder. The kind of immaturity involved in pubescence is vastly different from the kind in prepubescence from the specific perspective of its ability to trigger normal sexual interest, so in fact the dissimilarity is more important than the similarity…. The other two arguments – that some prosecutors are currently using the diagnosis “Paraphilia Not Otherwise Specified (Hebephilia)” and that the ICD [the World Health Organization’s diagnostic system] allows sexual preference for early pubescence as a disorder – ignores the critical question of whether these uses are valid…. Hebephilia as a diagnosis violates the basic constraint that disorder judgments should not be determined by social disapproval. This is a case where crime and disorder are being hopelessly confused.

Although the sexual disorders work group has backed down on two of its three most controversial proposals, it is clinging tenaciously to pedohebephilia, the brainchild of the Canadian laboratory that employs two members of the work group. Hopefully, a newly established scientific review committee for the DSM-5 will heed the increasingly strong warnings emitting from mainstream social scientists and psychology-law practitioners such as Wakefield, and have the common sense to squelch this ridiculous proposal. Otherwise, as Wakefield puts it, “the forensic tail [will be] wagging the validity dog, and we are likely to get criteria that possess a misdirected pseudo-validity that will not serve us in the long run and set a dangerous precedent for future tensions between civil liberties and civil commitment for mental disorder.”

Inevitable recidivism: An urban legend

Tamara Rice Lave, a law professor at the University of Miami, tackles the essential premise underlying current social policy toward sex offending: that apprehended sex offenders (especially child molesters) will continue to re-offend. As Lave shows, the courts and the public accept this premise with an unquestioning and almost religious fervor, ignoring a growing body of empirical evidence to the contrary.

Inevitable recidivism has saturated the media, political and popular discourse, and thus it has become the dominant frame due to its availability…. This sets up a dialectical process in which the public believes that sex offenders inevitably recidivate; the media write stories that bolster this belief, and politicians pass laws that are responsive to this belief. The effect is to have inevitable recidivism become a socially constructed fact.

When actual evidence of sex offender recidivism is examined, a huge gap exists between what is assumed and what the data actually shows because most sex offenders do not in fact recidivate. Thus there is a galaxy of sexually violent predator laws and an entire branch of Supreme Court jurisprudence that is founded upon a demonstrable urban legend.

The special issue, Beyond Myth: Designing Better Sexual Violence Prevention, was co-edited by professors Eric Janus (author of Failure to Protect, an essential text on sex offender law and policy) and John Douard. Both are, like myself, firm believers that we should be focusing scarce resources on primary prevention of sexual violence rather than on misguided campaigns rooted in moral panic and hysteria. Such campaigns are not only ineffectual, but they may actually increase the very problems they are aimed at solving.

The articles are:

Jerome C. Wakefield:  DSM-5 proposed diagnostic criteria for sexual paraphilias: Tensions between diagnostic validity and forensic utility [request from author HERE]

Tamara Rice Lave: Inevitable recidivism: The origin and centrality of an urban legend  [full text available online HERE]

A preview of all of the articles in the special issue, Beyond Myth: Designing Better Sexual Violence Prevention, is HERE. Clicking on a preview of an article allows one to email the author to request a reprint.

Brits: American psychiatry needs new theoretical frame

Ever since the American Psychiatric Association launched its multi-million dollar diagnostic industry with the publication of the DSM-III in 1980, the approach to successive editions has been to tinker, fiddle, and tweak: Change a diagnostic threshold here; reword a criterion there; remove an outdated label and add two or three more in its place.

Meanwhile, the underlying structure is so shoddy and out of touch with reality that the best thing to do would be to tear the whole thing down and start over. That's the message of the British Psychological Society, the UK’s 50,000-member professional body for psychologists, responding to the latest draft of the Diagnostic and Statistical Manual. The APA had invited the Society to comment on the DSM-5, currently due out in 2013.

The Society is concerned that clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation…. The putative diagnoses presented in DSM-5 are clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements, with little confirmatory physical 'signs' or evidence of biological causation. The criteria are not value-free, but rather reflect current normative social expectations.

The Society critiqued a range of proposed changes in the DSM, including major changes to the personality disorders as well as (of particular relevance to forensic practitioners) the sexual paraphilias. Particular concern was expressed over a proposed "attenuated psychosis syndrome." This proposal is "very worrying" to the British psychologists, as it will "stigmatize eccentric people" and lower the threshold for prescribing potentially harmful antipsychotic medications.

More broadly, the Society commented, the DSM diagnostic system's limited focus leads practitioners to ignore the relational and environmental contexts for psychological problems:

The Society recommends a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with 'normal' experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly evidenced causal factors.

Retreat from diagnostic labeling urged

Rather than "applying preordained diagnostic categories," the Society recommends cataloging specific symptoms or complaints, such as "hearing voices" or "feelings of anxiety."

Statistical analyses of problems from community samples show that they do not map onto past or current categories…. While some people find a name or a diagnostic label helpful, our contention is that this helpfulness results from a knowledge that their problems are recognized, … understood, validated, explained (and explicable) and have some relief. Clients often, unfortunately, find that diagnosis offers only a spurious promise of such benefits. Since – for example – two people with a diagnosis of 'schizophrenia' or 'personality disorder' may possess no two symptoms in common, it is difficult to see what communicative benefit is served.... We believe that a description of a person’s real problems would suffice…. There is ample evidence from psychological therapies that case formulations (whether from a single theoretical perspective or more integrative) are entirely possible to communicate to staff or clients. We therefore believe that alternatives to diagnostic frameworks exist, should be preferred, and should be developed with as much investment of resource and effort as has been expended on revising DSM-IV.

The 26-page statement is available HERE.

Violence risk meta-meta: Instrument choice does matter

Despite popularity, psychopathy test and actuarials not superior to other prediction methods 

The past couple of decades have seen an explosion of interest in forensic assessment of risk for future violent and sexual recidivism. Accordingly, evaluators can now choose from an array of more than 120 different risk assessment tools. But should this choice be based on individual preference, or are some instruments clearly superior to others?

Several systematic reviews and metaanalyses have addressed this question, but their conclusions often conflict. In the first systematic review of these reviews (called a “meta-review”), Jay Singh and Seena Fazel of Oxford University found that methodological shortcomings may contribute to the confusion. Problems they identified in the 40 metaanalyses and reviews they studied included authors' failure to adequately describe their study search procedures, failure to check for overlapping samples or publication bias, and failure to investigate the confound of sample heterogeneity.

The Oxford scholars, along with Martin Grann of Sweden's Centre for Violence Prevention, set out to rectify this problem via a more methodologically rigorous meta-review, using optimal data analyses and reporting procedures. For this purpose, they used the Preferred Reporting Items for Systematic Reviews and Metaanalyses, a 27-item checklist designed to enable a transparent and consistent reporting of results.

For their meta-meta (a metaanalysis of the metaanalyses), they collected data from 68 studies involving about 26,000 participants in 13 countries, focusing on the accuracy of the nine most commonly used forensic risk assessment instruments:

• Psychopathy Checklist (PCL-R)
• Static-99
• Historical, Clinical, Risk Management-20 (HCR-20)
• Violence Risk Appraisal Guide (VRAG)
• Sexual Violence Risk-20 (SVR-20)
• Level of Service Inventory (LSI-R)
• Sex Offender Risk Appraisal Guide (SORAG)
• Spousal Assault Risk Assessment (SARA)
• Structured Assessment of Violence Risk in Youth (SAVRY)

Big differences in predictive validity

As it turns out, these widely used instruments vary substantially in predictive accuracy. Performing the best was the SAVRY, a risk assessment instrument designed for use with adolescents. At the bottom were the Level of Service Inventory and the Psychopathy Checklist. This is not too surprising, as the LSI-R is used with a wide variety of general offenders, and the PCL-R was not designed for risk prediction in the first place.

The present metaanalysis would therefore argue against the view of some experts that the PCL- R is unparalleled in its ability to predict future offending.

Statistical method matters: DOR outperforms AUC

The researchers compared several different methods of measuring predictive accuracy. They found that a popular statistic called the Area Under the Curve (AUC) was the weakest. Use of the AUC statistic may help to explain why some metaanalyses were unable to find significant differences among instruments, the authors theorize.

Better methods for comparing instruments’ predictive accuracy include calculating positive and negative predictive values and also using something called the Diagnostic Odds Ratio, or DOR. This is the ratio of the odds of a positive test result in an offender (true positive) relative to the odds of a positive result in a non-offender (false positive). The authors’ summary performance scores pooled results from all four statistical methods.

Actuarials not superior; race also matters

The poor performance of the Psychopathy Checklist (PCL-R) was not the only finding that may surprise some forensic evaluators. The researchers also found no evidence that actuarial tools – such as the widely touted Static-99 – outperform structured clinical judgment methods like the HCR-20 or the SVR-20.

They also found that an offender's race is critical to predictive accuracy. Risk assessment instruments perform best on white offenders, most likely because white offenders predominate in the underlying studies. This is consistent with other research, including a study by Dernevick and colleagues finding that risk assessment instruments are poor at predicting misconduct in terrorists.

Caution is therefore warranted when using any risk assessment tool to predict offending in samples dissimilar to their validation samples, the authors stress.

This systematic review appears to be the most methodologically rigorous such study to date, in a rapidly evolving field. I recommend obtaining both articles (see below for author contact information) and studying them carefully. The stakes are high, and it behooves us to use the instruments that are the most accurate for the specific purpose at hand.

The studies are:

• Singh, J.P., et al., A comparative study of risk assessment tools: A systematic review and metaregression analysis of 68 studies involving 25,980 participants, Clinical Psychology Review (2011), doi:10.1016/j.cpr.2010.11.009. [Contact the author.]

• Singh, J.P. and Fazel, S., Forensic Risk Assessment: A Metareview, Criminal Justice and Behavior (2010) [Contact the author.]

Psychiatrist: Time to drop “silly” hebephilia once and for all

"Striking new evidence" should place the nail in the coffin of a "poorly conceived" proposal to turn sexual attraction to pubescent minors into a new mental disorder, says the chair of the DSM-IV Task Force in a new blog post at Psychology Today.

Allen Frances, professor emeritus at Duke University, has vocally opposed efforts to expand psychiatric diagnoses in the upcoming edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), due out in 2013.

In the wake of the DSM leadership's recent abandonment of a controversial new diagnosis for rapists, Frances says it is also past time to relegate "hebephilia" to "the obscurity it has so long and so justly deserved":

'Hebephilia' is a medical-sounding term for what is a purely legal issue--the statutory rape of pubescent youngsters aged 11-14. This is a crime deserving punishment, not a mental disorder deserving psychiatric hospitalization…. The 'hebephilia' proposal was always a poorly thought out, obvious non-starter. It failed on conceptual grounds, was unsupported by scientific evidence, and would create disastrous forensic problems. 

Four strikes and you're out

Frances lists four “strikes” against the proposal. In the first place, he points out, attraction to pubescent teenagers is biologically “hard-wired,” not deviant. Second, the research literature is “pathetically thin, methodologically flawed, and mostly completely irrelevant to whether it should be considered a mental disorder.” Third, the construct is a “forensic nightmare” that is already being abused in Sexually Violent Predator (SVP) civil commitment proceedings.

Lastly, Frances lambasts the claim that the number of sex crimes an individual has committed can be the basis for an accurate diagnosis. According to Frances, an independent data analysis just accepted for publication by Behavioral Sciences and the Law debunks that assertion. The article, by Richard Wollert and Elliot Cramer (online HERE), delivers "a piercing nail to seal the coffin" on hebephilia, writes Frances:

Reanalyzing the original raw data with appropriate statistical methods, they found that (contrary to the original report) there was an extremely high false positive rate in identifying 'hebephilia.' This had been obscured by an obvious statistical error in the original analysis--the highly selective sampling of subjects at the poles of the continuum, arbitrarily excluding those in the middle.

Frances’s full essay, at his Psychology Today blog DSM in Distress, is HERE.

New review of sex offender treatment text

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