Hebephilia flunks Frye test

Photo credit: NY Law Journal

In a strongly worded rejection of hebephilia, a New York judge has ruled that the controversial diagnosis cannot be used in legal proceedings because of “overwhelming opposition” to its validity among the psychiatric community.

Judge Daniel Conviser heard testimony from six experts (including this blogger) and reviewed more than 100 scholarly articles before issuing a long-awaited opinion this week in the case of “Ralph P.,” a 72-year-old man convicted in 2001 of a sex offense against a 14-year-old boy. The state of New York is seeking to civilly detain Ralph P. on the basis of alleged future dangerousness.

State psychologist Joel Lord had initially labeled Ralph P. with the unique diagnosis of sexual attraction to “sexually inexperienced young teenage males,” but later changed his diagnosis to hebephilia, a condition proposed but rejected for the current edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Under the Frye evidentiary standard, designed to bar novel scientific methods that are not sufficiently validated, a construct must be “generally accepted” by the relevant scientific community before it can be relied upon in legal proceedings.

Judge Conviser found that hebephilia (generally defined as sexual attraction to children in the early stages of puberty, or around the ages of 11 or 12 to 14) is being promoted by a tiny fringe of researchers and in practice is used almost exclusively as a tool to civilly commit convicted sex offenders. Under U.S. Supreme Court rulings, such offenders must have a mental disorder in order to qualify for prolonged detention after they have served their prison terms.

“It is not an accident, as Dr. Franklin outlined, that hebephilia became a prominent diagnosis only with the advent of SVP laws,” the judge wrote in his 75-page opinion. “It is also not a coincidence that each of the three expert witnesses who testified for the State at the instant hearing either work or formerly worked for state [Sexually Violent Predator] programs.”

Conviser’s ruling analyzed both the practical problems in reliably identifying hebephilia and the political controversies swirling around it: Without any standardized criteria, “clinicians are free to assign hebephilia diagnoses in widely disparate ways, many of which are just plainly wrong.” Using age as a proxy for pubertal stage is no guarantee of reliability because pubertal onset is highly variable. Ultimately, he concluded, whether erotic interest in pubescent minors is deemed "pathological" is more about moral values than science.

APA secrecy faulted

The judge was harshly critical of the American Psychiatric Association for its refusal to publicly explain why it rejected hebephilia from the DSM-5 in 2013. The diagnosis was aggressively promoted by a Canadian psychologist, Ray Blanchard, and fellow researchers from Canada’s Centre for Addiction and Mental Health (CAMH), who dominated the DSM-5 subcommittee on paraphilias.

Blanchard rewrote the DSM section on paraphilias (sexual deviances) in a broad way such that virtually all sexual interests other than a narrowly defined “normophilic” pattern became pathological. However, the APA rejected Blanchard’s proposal to expand pedophilia to pathologize adult sexual attractions to pubescent-aged (rather than just prepubescent) minors.

“The proposal was apparently rejected because it was greeted with a firestorm of criticism by the sex offender psychiatric community, which was communicated to the APA board…. As best as this Court can surmise, the APA rejected the pedohebephilia proposal because it was opposed by most of the psychiatrists and psychologists who worked in the field.”

“[S]trikingly,” wrote Judge Conviser, “the process through which proposed new diagnoses are approved or rejected is shrouded in a degree of secrecy which would be the envy of many totalitarian regimes…. With respect to hebephilia, the APA board’s actions will have a direct impact on both public safety and the fundamental liberty interests of hundreds or thousands of people.”

The APA forces those involved in the DSM revision process to sign nondisclosure contracts. That policy came in the wake of a series of published exposes – including Christopher Lane’s Shyness: How Normal Behavior Became a Sickness, Jonathan Metzl's The Protest Psychosis, and Ethan Watters’s Crazy Like Us (to name just a few of my favorites) -- that embarrassed the world’s largest psychiatric organization by shining a light inside the often subjective and political process of diagnosis creation and expansion.

“Overwhelming” opposition

Blanchard and his CAMH colleagues’ 2009 proposal to expand pedophilia into a new “pedohebephilia” diagnosis in the DSM-5 spawned a massive outcry, which mushroomed into at least five dozen published critiques.

In preparation for my testimony at this and similar Frye hearings in New York, I expanded on my 2010 article in Behavioral Sciences and the Law tracing hebephilia’s rise from obscurity, to produce an updated chart containing all 116 articles addressing the construct. If one tallies only those articles that take a position (pro or con) on hebephilia and are not written by members of the CAMH team, fully 83% are critical as compared to only 17% that are favorable. This, Judge Conviser noted, is strong evidence against the government’s position that hebephilia is “generally accepted” by the relevant scientific communities.

“The thrust of the evidence at the hearing was … clear: there was overwhelming opposition to the pedohebephilia proposal in the sex offender psychiatric community,” he wrote. “There is overwhelming opposition to the hebephilia diagnosis today.”

Courts scrutinizing nouveau diagnoses

With the APA’s rejection of hebephilia as well as two other proposed sexual disorders (one for preferential rape and another for hypersexuality), government evaluators continue to shoehorn novel, case-specific diagnostic labels into the catchall DSM-5 category of “other specified paraphilic disorder” (OSPD) as a basis for civil commitment.

Under a 2012 New York appellate court ruling in the case of State v. Shannon S., upon a defense request, a Frye evidentiary hearing must be held on any such attempt to introduce an OSPD diagnosis into a Sexually Violent Predator (SVP) case. That has triggered a spate of Frye hearings in the Empire State, affording greater scrutiny and judicial gatekeeping of scientifically questionable diagnoses.

Ironically, although the Shannon S. court upheld hebephilia by a narrow 4-3 margin, Shannon S. would not have met diagnostic criteria under the narrower definitions presented by the government experts at Ralph P.’s Frye hearing four years later, because his victims were older than 14.

“Assuming hebephilia is a legitimate diagnosis, Shannon S., like many SVP respondents, was apparently diagnosed with the condition not based on evidence he was preferentially attracted to underdeveloped pubescent body types but because he offended against underage victims,” Judge Conviser observed in his detailed summary of prior New York cases.

The three dissenting judges in Shannon S. were adamant that hebephilia was “absurd,” and an example of “junk science,” deployed with the pretextual goal of “locking up dangerous criminals” who had committed statutory rapes.

The opening of the Frye floodgates has led to a flurry of sometimes-competing opinions.

In 2015, in State v. Mercado, Judge Dineen Riviezzo ruled against “OSPD--sexually attracted to teenage females” as a legitimate diagnosis. However, she declined to rule on the general acceptance of hebephilia because it was not specifically diagnosed in that case.

A year later, relying on similar evidence, a judge in upstate New York ruled in State v. Paul V. that hebephilia was generally accepted, in large part because it was backed by the APA’s paraphilias sub-workgroup. Judge Conviser found that reasoning unpersuasive, pointing out that the subworkgroup was dominated by the very same CAMH researchers who were hebephilia’s primary advocates; it was therefore “not a valid proxy" for the scientific community.

In July, another court rejected both hebephilia and “OSPD--underage males” as valid diagnoses, in the cases of Hugh H. and Martello A. The court noted that hebephilia is inconsistently defined, was rejected for the DSM-5, and is primarily advanced by one research group; further, attraction to pubescent minors is not intrinsically abnormal.

Cynthia Calkins, a professor at John Jay College of Criminal Justice in New York, echoed those points in her testimony at Ralph P.'s hearing. She noted that in the United States, the main psychologists advocating for hebephilia are government-retained evaluators in SVP cases, who make up only perhaps one-fourth of one percent of psychologists and psychiatrists in the U.S. and so cannot be a proxy for “general acceptance” in the scientific community.

The government’s choice of experts illustrated Calkins’ point: Testifying for the government were Christopher Kunkle, director of New York’s civil management program for sex offenders, David Thornton of Wisconsin’s civil commitment center, and Robin Wilson, formerly of Florida’s civil commitment center and a protégé of Ray Blanchard’s.

The third expert called by Ralph P.’s attorneys was Charles Ewing, a distinguished professor at the University at Buffalo Law School who is both an attorney and a forensic psychologist and has authored several books on forensic psychology.

Defense attorneys Maura Klugman and Jessica Botticelli of Mental Hygiene Legal Service represented Ralph P. Assistant New York Attorney General Elaine Yacyshyn represented the state.

Ultimately, New York State’s highest court may have to weigh in to resolve once and for all the question of whether novel psychiatric diagnoses like hebephilia are admissible for civil commitment purposes. But that could be years down the road.

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The ruling in State v. Ralph P. is HERE. The subsequent order of Sept. 28, 2016 granting Ralph P.'s motion for summary judgment and dismissal of the civil commitment petition is HERE.

A New York Law Journal report on the case, "judge Rejects Diagnosis for Civil Confinement," is HERE.

A search of this blog site using the term hebephilia will produce my reports on this construct dating all the way back to my original post from 2007, "Invasion of the Hebephile Hunters."

Sex addiction: Science or pop fad?

Thirty-one years ago, when Patrick Carnes walked onto the Phil Donahue television show to promote his new book on sexual compulsivity as an addiction, his notion was – in his own words – “widely perceived as a joke.” 

But Carnes got the last laugh. With the mainstreaming of the addiction industry (eating, gambling, exercising and working are all potential addictions now), Carnes has risen to become guru of a lucrative empire with dozens of rehab centers staffed by thousands of paraprofessionals. Media outlets including Newsweek have uncritically jumped aboard, warning of a grim, pornography-fueled plague afflicting up to 5 percent of the U.S. population.  

With neuroscience all the rage, celebrities including Bill Clinton and Tiger Woods have been recast from mere cads to tragic victims of a progressive and often-fatal “brain disease.” The push for scientific legitimacy reached a zenith in 2013, with an unsuccessful bid to legitimize “hypersexuality” by adding it to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

So, what changed over the course of the last three decades that made the public more receptive to seeing sexual misconduct through the lens of addiction?

In their meticulously researched Sex Addiction: A Critical History, three cultural historians from the University of Auckland in New Zealand trace the rise of this social movement primarily to a politically conservative, sex-negative backlash against the sexual liberation movement of the 1960s and 1970s. 

One clue to its underlying cultural values, historians Barry Reay, Nina Attwood and Claire Gooder observe, is the movement's enduring strand of homophobia. Even before Carnes's 1983 book Out of the Shadows popularized sexual addiction, the term had been invoked by Lawrence Hatterer, a psychiatrist whose work in the 1950s-1960s focused on curing the “illness” of homosexuality. Heteronormativity remains prominent in the field, with gay men who violate heterosexual norms of sexuality labeled as sex addicts.

Unlike many purported disorders that are promoted by researchers or the pharmaceutical industry, sex addiction is a bottoms-up movement, with people self-diagnosing themselves via self-help books or quick-and-dirty Internet surveys. Its infiltration into popular culture owes in large part to the media’s abdication of its role as scientific gatekeeper, argue the authors of Sex Addiction. As the Columbia Journalism Review also pointed out in a critique of the Newsweek puff piece, “The problem with relying on therapists, as most of the articles over the years have done, rather than qualified experts in academia, is that they have a vested interest in promoting the idea that there’s a widespread problem. The more people believe it, the more money they make."


In contrast to the lay public, academic scholars have remained skeptical of a construct that is too broad and amorphous to have any scientific validity; everything from viewing pornography or having an illicit affair to feeling ashamed about one's sexuality can count toward a diagnosis. Indeed, research studies have found that people’s anxiety over their sexual behavior is tied more to their moral values and level of religiosity than to the actual intensity of their behavior.

It is findings such as these that open sexual addiction up to ridicule. One prominent critic, David Ley, author of The Myth of Sex Addiction, has mocked sexual addiction literature as "valley-girl science" -- a hodge-podge of anecdote and metaphor rather than any provable theory. As he told a Salon interviewer:

“All of these behaviors have been happening for millennium — people cheating, people having lots of sex…. There’s nothing new about this…. For every one of the behaviors they raise as addictive — whether it’s porn, strip clubs, masturbation, infidelity, going to prostitutes — I can present 10,000 people who engage in the exact same behavior and have no problems, and they can’t explain why that is.”

Historically, hysteria over sexual depravity is somewhat cyclical. Way back in the 1870s, a crusade against "smut" by a U.S. Postal Inspector and politician named Anthony Comstock resulted in thousands of arrests and the destruction of 15 tons of books. Interestingly, Comstock's passion for moral purity stemmed from his own personal demons; as a youth, he was said to have masturbated so compulsively that it almost drove him to suicide.

Treating a case of "Madness of the Womb" (1600s)

The pathologizing of female lust has a particularly long tradition, dating back hundreds if not thousands of years. In the late 1600s, women were diagnosed with nymphomania (a diagnosis that still exists in the World Health Organization's International Classification of Diseases, or ICD), or “madness of the womb," a disease said to be triggered by amorous courtings, lascivious books and dancing. As with today’s sexual addiction, the condition was considered progressive; if not promptly treated it would lead to “true and perfect madness.” Treatment included bleeding, cool baths with lettuce and flowers, marriage to "a lusty young man" or -- no kidding -- rubbing of the afflicted woman's genitals by "a cunning midwife."

Nowadays, as then, there is a common pattern in the way proponents of scientifically questionable new problems attempt to establish their legitimacy. First, they announce discovery of the problem; next, the problem’s lineage is traced back through time to show that it existed all along but was overlooked or neglected. Finally, and most critically, alarmist claims are made about a growing epidemic.

This pattern could be observed in the 2013 campaign to legitimize “hypersexuality” by making it a DSM disorder. For example, the claims-making process included articles by psychiatrist Martin Kafka  tracing hypersexuality’s lineage back to the pioneering sexologists of the 19th century. But in their first-rate scholarship, the Auckland historians scoured those primary sources – the writings of early sexology heavyweights such as Magnus Hirschfeld, Havelock Ellis, Richard von Krafft-Ebing and Iwan Bloch – and found that their descriptions of the sexually compulsive bore little resemblance to contemporary hypersexuality or sex addiction. Rather, the early sexologists described tortured souls who were both rare and bizarre, typically suffering from more global psychiatric or organic maladies rather than a primary sexual disorder. For example, writing in 1908 about the “sexually insane,” Iwan Bloch described him as resembling a “wild animal” who:

“rush[es] at the first creature he meets … to gratify his lust …. He seizes in sexual embrace any other living or lifeless object, and in this state may perform acts of paederasty, bestiality, violation of children, etc. In these most severe cases we can always demonstrate the existence of mental disorder, general paralysis, mania, or periodical insanity … as a cause.”

Judging from singular descriptions like this, the early hypersexual was an extraordinary creature, a far cry from the mundane individual proposed for the DSM-5. Indeed, the proposed operational definitions for contemporary hypersexuality are striking in their breadth. For example, one diagnostic criteria proposed for the DSM-5 was experiencing seven or more orgasms per week by any method. Based on one survey of the general population in Sweden, this arbitrary cutoff would have pathologized almost half of all men (44%) and more than one out of five women.

Despite official rejection of hypersexuality by the American Psychiatric Association in 2013, the ideology of sexual addiction is gradually seeping into forensic quarters. For example, in some civil detention sites for sex offenders, minimally trained "treatment providers" play the role of moral arbiters, determining what forms of sexual desire are "appropriate" based not on their illegality or potential harm but whether the providers find them "healthy."

To be deemed “healthy” in some such programs, captive patients are required to develop vanilla “masturbation fantasy scripts” that resemble a corny Hallmark card:

"My masturbation fantasy involves Amanda. She is 40* years old, with flowing auburn hair and large green eyes. We enjoy cuddling by the fireplace, taking long walks on the beach in the moonlight, and gazing into each other’s eyes by candlelight."

(*The fantasy object must be the same approximate age as the offender; if she is more than five years younger, he will be told to rewrite his script to make it more "appropriate.")

Despite the enduring popularity of teachers, nurses and -- especially -- librarians as objects of male fantasy, in the burgeoning sexual offender treatment industry, even these cultural tropes may be labeled as "deviant." In one case I was involved in, a man's fantasy of seducing a librarian was advanced as evidence of sexual danger, based on the notion that the library (even after hours) is a public setting.

Of course, this not-so-thinly veiled moralism masquerading as treatment has no empirical support as a method to reduce former sex offenders’ risk to the public. But it does comport with popular cultural notions of addiction and sexual compulsivity, however unproven -- even bizarre -- they may at times be.

* * * * *

Sex Addiction: A Critical History by Barry Reay, Nina Attwood and Claire Gooder is as well written as it is insightful; I highly recommend it. Also recommended is clinical psychologist David Ley’s thoughtful work, The Myth of Sex Addiction.  

“Pornography addiction”: Naked rhetoric?

No one actually knows what percentage of Internet use is sexually oriented, or how much money the porn industry is making. Many commonly cited figures are widely exaggerated, and the true statistics remain murky and contested. Yet it's safe to say that for some portion of the public, the easy accessibility leads to habitual use that interferes with other activities, such as family life, relationships, work or school.

But no worries. Treatment providers are standing by to help. A quick Google search produces dozens of residential treatment programs for pornography addicts.

What's not so easy to find is the price tag. The sites I surveyed require that you call them, or submit an online application for more information. That reticence is not surprising, given that costs average about $675 per day, or more than $180,000 for the nine-month minimum stay that some programs recommend.

This burgeoning pornography addiction treatment industry is the latest example of the therapeutic opportunism that has swept across the United States, selling snake oil remedies for alcoholism, drug addiction, overeating, adolescent rebellion, and so many more problems of modern living.

Unbeknownst to a gullible and desperate public, this new treatment industry is largely unregulated, and its grand claims have scant scientific support. Indeed, its underlying theory of sexual addiction has been widely repudiated by scientific researchers.

In a scathing new critique in Current Sexual Health Reports, authors David Ley and colleagues challenge the scientific basis for the sexual addiction industry. They argue that the pathologization of visual sexual stimuli (VSS), as they prefer to call it, is more reflective of religious and moral values than science.  

Chicken or egg?

There is no question that many people are discontented with their use of pornography. About one in 200 Americans reports problematic viewing habits, according to Ley and colleagues’s estimates. The ambiguity is whether pornography is a cause, or a reflection, of life dissatisfaction. Supporting the latter possibility, for example, is a large-scale Dutch study finding that lower life satisfaction predicted greater use of online pornography, not the other way around. Similarly, people with more severe psychological problems and drug and alcohol use are more likely to be heavy viewers of visual sexual stimuli.

It makes sense that people might escape into fantasy not only for sexual release but also to avoid negative mood states such as loneliness. We have only to look to the wave of relationship-phobic soshoku danshi (literally, "grass-eating boys") in Japan and the technosexuals like Davecat (whose YouTube video has gone viral) who prefer robots or blow-up dolls to "organic partners" to sense the breadth of interpersonal alienation in contemporary culture.

Thus, pornography consumption is perhaps more a symptom than a cause of angst, and targeting it for primary intervention might distract from the deeper issues at play.

Ley and colleagues go further, arguing that a skewed focus on negative effects, such as erectile dysfunction and relationship difficulties, hides potential positive health outcomes of "sexual visual stimuli" consumption. Of relevance to forensic practice, there is some evidence that pornography viewing may reduce risky sexual behaviors, especially among individuals who report high levels of sexual sensation-seeking.

Stigmatizing sexual minorities?

One of the more intriguing topics raised by Ley and colleagues is the religious tenor of many treatment programs and advocates of the addiction paradigm. High religiosity turns out to be one of the strongest predictors of treatment-seeking for sex addiction, suggesting that conflicts over personal values rather than the use itself may be driving dissatisfaction.

Taking this one step further, they argue that the anti-pornography movement serves an ideological function of promoting certain values while suppressing others. Individuals reporting addictive use of visual sexual stimuli tend to be non-heterosexual males with high libidos and high levels of sensation-seeking. The sexual addiction model, they claim, is an effort to exert social control over technological expressions of sexuality, suppress marginalized forms of sexuality, and stigmatize sexual minorities.

Intriguing as this argument is, I am disheartened by polemics that minimize the dehumanization and degradation of women, in particular, that are the mainstay of pornography. As revealed by scholars Miranda Horvath, Peter Hegarty and colleagues, the messages about women in British "lads mags" are indistinguishable from the rape-justifying statements made by convicted rapists. It's hard for me to see how this could be harmless, both to viewers and to society at large.

With the 12-step style pathologization of individual use ascending parallel to the rapacious and exploitive pornography industry, the porn and antiporn industries seem symbiotic and mutually reinforcing, each resting on an anemic foundation of hyperbole.

Meanwhile, the few who try to explore the deeper and more nuanced cultural implications of pornography find themselves attacked. I was shocked to hear  about a tenured sociology professor getting suspended a couple of years ago for showing a progressive critique, The Price of Pleasure, which delves into the seamy underbelly of the lucrative industry. (My first thought was “Whew! Glad I didn’t get any complaints when I showed that same film in my Sexual Violence course at San Francisco State University a few years ago.”) 

Ascendancy of the “sex addiction” model

Lest we forget, Ley and colleagues’ critique is not really new. It used to be pretty well accepted among serious scientists that "sex addiction" was a bogus pop psychology invention, yet another example of the quasi-religious 12-step model being grafted onto every conceivable behavior.

Detractors hail back as far as the late 1990s, when sex therapist Marty Klein, Ph.D. wrote his prophetic essay, "Why ‘Sexual Addiction’ Is Not A Useful Diagnosis -- And Why It Matters," dissecting the politics of this social movement. More recently, Forbes writers Matthew Herper, David Whelan and Robert Langreth tackled "The Shadowy Science Of Sex Addiction." British psychologist and sex educator Petra Boynton followed up with a 2008 critical essay, "Medicalising sexual behaviour" (which includes some good links and discussion of the parallel construction of "female sexual dysfunction”; see my review of Meika Loe's The Rise of Viagra for more on that topic). 

The media hype over the sexual peccadillos of golfer Tiger Woods (which had a lot to do with cultural angst over a Black man having lots of sex with white women, blondes no less) proved a huge boon to the fledgling industry. Also lending an aura of legitimacy was the ill-fated proposal to add "hypersexuality" to the DSM-5. A training announcement for sex offender professionals on "Sexual addiction and compulsivity -- the proposed DSM-5 diagnosis of hypersexuality” mustered a veritable grab-bag of 12-step pseudoscience: Patrick Carnes' "levels of hypersexuality"; the "family of origin of a sex addict" and "co-dependence and the co-addict spouse."  And now there’s even an academic journal with the trendy title Sexual Addiction and Compulsivity.

But unless and until the data come in to establish sexual addiction as a viable scientific construct, it’s yet another example of an over-eager industry putting the cart before the horse.

*****

NOTE TO READERS: To view or participate in a vigorous, critical discussion of this topic, go to the COMMENTS section of my mirror blog, "Witness," at Psychology Today (HERE). 

The article, "The Emperor Has No Clothes: A Review of the ‘Pornography Addiction’ Model," by David Ley, Nicole Prause and Peter Finn, is part of a topical collection on "current controversies" in Current Sexual Health Reports. It may be requested from the first author (HERE).  

Related blog posts:

• Pornography and contact sex offending (Guest essay by Jon Brandt, David S. Prescott and Robin J. Wilson), Jan. 16, 2013 
• Study: Lads’ mags sound identical to rapists, Dec. 15, 2011 
• New entry in porn-rape debate, June 3, 2009 
• Child porn use not linked to contact crimes, July 30, 2009

(c) Copyright Karen Franklin 2014 - All rights reserved

Research roundup

The articles are flooding in at an alarming rate, threatening to bury me under yet another avalanche. Before I am completely submerged, let me share brief synopses of a few of the more informative ones that I have gotten around to reading.

Assessor bias in high-stakes testing: The case of children’s IQ

I’ve blogged quite a bit about bias in forensic assessment, reporting on problems with such widely used tests as the Psychopathy Checklist and the Static-99R. As I’ve reported, some of the bias can be chalked up to adversarial allegiance, or which side the evaluator is working for, whereas some may be due to personality differences among evaluators. Now, researchers are extending this research into other realms -- with alarming findings.

In a study of intelligence testing among several thousand children at 448 schools, the researchers found significant and nontrivial variations in test scoring that had nothing to do with children’s actual intelligence differences. The findings, reported in the journal Psychological Assessment, are especially curious because scoring of the test in question, the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV), seems relatively straightforward and objective (at least as compared to inherently subjective tests like the Psychopathy Checklist, for example).

The article is:

• Whose IQ Is It? Assessor Bias Variance in High-Stakes Psychological Assessment.  McDermott, Paul A.; Watkins, Marley W.; Rhoad, Anna M. Psychological Assessment, Published online on Nov 4 , 2013. To request a copy from the first author, click HERE.

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Beware pseudo-precision in expert opinions

I’ve never forgotten a video I saw a long time ago, in which the filmmakers drove up to random strangers and asked for directions to a nearby landmark. Some of the good samaritans gave enthusiastic instructions that were completely wrong, while other people gave correct directions but in a more tentative fashion. The trouble is, the more confident someone appears, the more we judge them as knowing what they are talking about.  

One way we gauge a presenter’s confidence, in turn, is by their level of precision. In a new study, researchers found that participants were more likely to rely on advice given by people who provided more precise information. For example, they were more likely to trust someone who said that the Mississippi River was 3,992 miles long, rather than 4,000 miles long.

What this means in the forensic realm is that we should not make claims of false precision, when our evidence base is weak. For example, we should not claim to know that someone has a 44 percent chance of violent reoffense within three years. Such misleading claims-making lends an aura of confidence and expertise that is not warranted.

The article is:

• Show Me the Numbers: Precision as a Cue to Others' Confidence. Jerez-Fernandez, A., Angulo, A. N., & Oppenheimer, D. M. Psychological Science. Published online on 6 Dec. 2013. To request a copy from the corresponding author, click HERE.

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Ethics and the DSM-5

Speaking of avalanches, the volume of critical response to the DSM-5 is lessening now that the tome has been on the bookshelves for eight months. Trying to keep my finger on the pulse because of my training activities on the manual’s forensic implications, I found an interesting summary of the ethical dilemmas of the latest trends in psychiatric diagnosis.

The author, Jennifer Blumenthal-Barby, is an ethics professor at Baylor College of Medicine’s Center for Medical Ethics and Health Policy. In her critique, published in the Journal of Medical Ethics, she focuses on consequence-based concerns about the dramatic expansion of psychiatric diagnoses in the latest edition of the American Psychiatric Association’s influential manual. Concerns include:

• False positives, or over-diagnosis, in clinical (and I would add forensic) practice
• Risks associated with pharmacological treatments of new conditions
• Neglect of larger structural issues and reduction of individual responsibility through medicalization
• Discrediting of psychiatry through the trivialization of mental disorders
• Efforts to eradicate conditions that are valuable or even desirable

Although her discussion is fairly general, she does mention a few of the proposed diagnostic changes of forensic relevance that I’ve blogged about. These include the proposed hypersexual disorder and a proposal to eliminate the age qualifier (of 18 and above) for antisocial personality disorder, to make it consistent with all of the other personality disorders.

It’s a good, brief overview suitable for assignment to students and professionals alike.

The article is: 

• Psychiatry’s new manual (DSM-5): ethical and conceptual dimensions. Journal of Medical Ethics. Published online on 10 Dec. 2013. To request a copy, click HERE.

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Dual relationships: Are they all bad?

We’ve all seen the memo: Dual relationships are to be avoided.

But is that always true?

Not according to ethics instructor Ofer Zur.

Multiple relationships are situations in which a mental health professional has a professional role with a client and another role with a person closely related to the client. In a new overview, Zur asserts that, not only are some multiple relationships ethical, they may be unavoidable, desirable, or even -- in some cases -- mandated.

In delineating the ethics and legality of 26 different types of multiple relationships, Zur stresses that in forensic settings, most multiple relationships should be avoided.

The article, Not All Multiple Relationships Are Created Equal: Mapping the Maze of 26 Types of Multiple Relationships, is another good teaching tool, and is freely available online at Zur’s continuing education website.

By the way, if you are in California and are looking for more ethics training, Zur and two of my former colleagues from the state psychological association’s Ethics Committee -- Michael Donner, PhD and Pamela Harmell, PhD -- are co-presenting at an interactive ethics session at the upcoming California Psychological Association convention. The convention runs April 9-13 in Monterey, and the ethics conversation -- “Ethics are not Rules: Psych in the Real World” -- is on Saturday, April 12.

The psychic perils of forensic practice

John Bradford burst into tears. Hitting the road for the four-hour trek back to his home in Ontario, Canada, he could not stop crying and shaking.

An internationally renowned forensic psychiatrist, Bradford had been working around-the-clock on the high-profile case of Canadian Air Force Colonel Russell Williams, a decorated military pilot and commander of the country's largest military airbase who had spent his spare time torturing and murdering women.

Bradford's breakdown took him by surprise. Like other forensic practitioners, he had spent decades sitting across the table from rapists, murderers and sexual sadists. He was adept at emotionally distancing himself from their twisted psyches and wretched deeds. But the gruesome video of two young women screaming and begging for their lives (unsuccessfully, as he knew) proved a tipping point.

Descending into a very dark place, he was eventually diagnosed with posttraumatic stress disorder. He underwent lengthy therapy and drug treatment. Although he has now returned to his forensic practice, he is more cautious about the types of cases he will take on.

The profile by reporter Chris Cobb in the Ottawa Citizen, documenting Bradford's three-year struggle with vicarious traumatization, came as a complete shock to me. It was just three years ago that I served with Bradford on a team debating three controversial paraphilias being proposed for the DSM-5. Bradford, an advisor to the DSM-IV, was past president of the American Academy of Psychiatry and Law (AAPL), which hosted the debate. He holds numerous other accolades. He is a professor at the University of Ottawa, founder and clinical director of the Sexual Behaviors Clinic in Ottawa, and a Distinguished Fellow of the American Psychiatric Association, earning its prestigious Isaac Ray Award.

 Williams' victims, Jessica Lloyd and Marie-France Comeau

If he could fall apart, I wondered, who couldn’t?

Bradford described for the reporter how his mental state gradually morphed from calm and collected to irritable and angry, as he worked long hours on the Williams case. At one point, being cross-examined by a defense attorney in another case, he got so irritated by the attorney’s repetitiousness that he almost blurted out, "Why don’t you shut the f-- up, you a—hole?' "

It was then that he realized he was losing control.

"I knew there was something wrong but there was a lot of denial on my part," the 66-year-old Bradford told Cobb. "And that’s why it didn’t work when I first went into treatment. I was pessimistic and depressed, but if you’re a psychiatrist and a tough forensic guy you think you can blow anything off, right? And that’s what I did."

I was struck by the courage it must have taken Bradford to reveal his vulnerabilities to the world. I hope that his personal story can help stimulate conversation on the emotional dangers of this work. If Bradford can crumble, so can anyone, no matter how experienced, competent, or externally cool. Being part of a culture in which weakness is taboo, and can even be professional suicide, makes honest disclosure and help-seeking all the more difficult.

Confronting vicarious traumatization

Vicarious traumatization (also known as compassion fatigue, secondary trauma, or just plain burnout) has received some attention in professional circles in the past few years. There are books, journal articles, professional trainings, even websites.

The DSM-5 criteria for Posttraumatic Stress Disorder (PTSD) reflect this growing awareness. Criterion A, which lists the stressors that make one eligible for the diagnosis, now includes "experiencing repeated or extreme exposure to aversive details of the traumatic event(s)." To keep those who view disasters on TV from being diagnosed with PTSD, as happened after the 9/11 terrorist attack, the text clarifies that this applies to such people as "first responders collecting human remains or police officers repeatedly exposed to details of child abuse," and NOT to those exposed through the media, "unless this exposure is work related."

As this criterion implies, vicarious traumatization can strike not just forensic evaluators, but anyone who spends too much time rubbing up against trauma -- nurses, ambulance operators, child welfare workers, police, lawyers, judges, even jurors.

Studies on its incidence among forensic professionals are mixed. An unpublished survey by graduate student Julie Brovko and forensic psychologist William Foote of the University of New Mexico found low levels of vicarious traumatization among a convenience sample of 65 forensic psychologists. However, consistent with Bradford's case, more time in the field was correlated with more problems.

In contrast, a 2010 survey of 52 Australian clinicians providing treatment to convicted sex offenders found no evidence of compassion fatigue or burnout. The majority reported low stress and high levels of job satisfaction working with this challenging population. Ruth Hatcher and Sarah Noakes found that supervision and external social support helped clinicians avoid burnout.

One limitation of both of these studies is that they surveyed only those who remained active in the field. Anecdotal accounts suggest that some individuals leave forensic practice due to the emotional toll, which can produce feelings of estrangement, numbness, and hypervigilance.

An opposite danger?

Reflecting on Bradford's breakdown, I thought about the opposite tendency. Is it resilience that keeps other professionals from crumbling under the weight of witnessing constant perversion and misery? Or, might some be repressing their feelings in a manner that is not so healthy?

After all, to not be disturbed by graphic cruelty or stark oppression is in itself disturbing. Such psychic numbing whittles away at one's humanity.

In the memoir 12 Years a Slave (which I highly recommend), Solomon Northrup reflected on how the cruelty of slavery fostered casual violence not only toward slaves but also among white slaveholders. These men thought nothing of stabbing or shooting each other at the slightest provocation, the Southern "culture of honor" that remains with us today:

"Daily witnesses of human suffering -- listening to the agonizing screeches of the slave -- beholding him writhing beneath the merciless lash … it cannot otherwise be expected, than that they should become brutified and reckless of human life."

I've seen that phenomenon first-hand in institutions. Brutality breeds brutality, along with an indifference to brutality among institutionalized professionals that is equally troubling.

Mitigation?

Perhaps the first step in addressing the problem is for professionals to openly discuss the risk of professional burnout, vicarious traumatization, and psychic numbing. It’s very useful to have support and consultation groups where one can let one's guard down and be more vulnerable, debriefing after horrific case work with trusted colleagues.

Mindful meditation is so en vogue these days that I hesitate to join the bandwagon, but I do think it too can help reduce stress and emotional meltdowns.

Balance is also essential. Rest, relaxation, hobbies, exercise. It's not coincidental that Bradford broke down while working around-the-clock on a high-profile case. 

I'd be interested in others' thoughts on the emotional hazards of our work, and strategies or techniques for staying healthy.

Hat tip: Jeff Singer

Related resources:

• Brovko and Foote (2011), Vicarious Traumatization: Are forensic psychologists vulnerable to trauma exposure? (Presentation) 
• Culver, McKinney and Paradise (2011), Mental health professionals’ experiences of vicarious traumatization in Post-hurricane Katrina New Orleans, Journal of Loss and Trauma 16, 33-42 
• Harrison and Westwood (2009), Preventing vicarious traumatization of mental health therapists: Identifying protective practices, Psychotherapy Theory, Research, Practice, Training 46 (2), 203-219 
• Hatcher (2010), Working with sex offenders: The impact on Australian treatment providers, Psychology Crime and Law 16 (1-2) 
• Robertson, Davies and Nettleingham (2009), Vicarious traumatisation as a consequence of jury service, The Howard Journal 48 (1) 
• Tabor (2011), Vicarious traumatization: Concept analysis, Journal of Forensic Nursing 7, 203-208 
• Taylor and Furlonger, A Review of Vicarious Traumatisation and Supervision Among Australian Telephone and Online Counsellors, Australian Journal of Guidance and Counselling 21 (2), 225-235

Greetings from Bismarck, North Dakota

Here on the northern edge of the Great Plains, the local folk, of hardy Norwegian and Swedish stock, are strolling around as if it's a balmy day. Not me. Breathing steam into the 14-degree (-10 Celsius) air, I’m bundled up in a parka, ear muffs and gloves and still feel like an iceberg!

I’m up here at the behest of the state Supreme Court, giving a training to the judges on psychiatric diagnosis in court.

North Dakota is a sparsely populated state with the lowest crime rate in the nation, and the judicial community is tight-knit. Ninety percent of the state’s judges – from trial judges to Supreme Court justices – were crowded into the hotel ballroom.

It was hard to distill a day-long training into just two hours, but fortunately the well-informed and inquisitive judges brought up some of the omitted topics in the question-and-answer period. They seemed especially intrigued to learn of the reliability issues plaguing DSM-5 diagnoses, and the research on adversarial allegiance and psychopathy by Murrie and Boccaccini’s crew down in Texas and Virginia.

In 1997, North Dakota’s legislature jumped on the bandwagon and enacted a sexually violent predator law (here called a Sexually Dangerous Individual, or SDI, law), ushering in the circus of experts battling over diagnoses and risk assessment techniques that we see in the other 40 percent of U.S. states with such laws. So, naturally, someone asked about hebephilia, which testifying experts had falsely assured them would be in the DSM-5.

That reminds me: I just testified as a pure expert in a Frye evidentiary hearing in Washington on whether hebephilia was a generally accepted construct in the relevant scientific community. The judge ruled against hebephilia, but allowed an even-more-suspect "Paraphilia Not Otherwise Specified" diagnosis that the evaluator candidly admitted he had made up for that specific case.

North Dakota, by the way, holds the distinction of being the only U.S. state that has not adopted either the Daubert or Frye standard for evidence admissibility. It has its own unique rule that is very liberal. Still, as anywhere, judges bear the burden of being the evidentiary gatekeepers.

Talking with the judges after my session gave me a greater appreciation for the difficulties they face. Politicians pass laws, many ill-conceived, and then judges get stuck having to figure out how to enforce them, as best they can.