Europeans first to shoot down controversial paraphilia

Resounding 100-to-1 vote against "pedohebephilia"

I was impressed by the unanimity of opposition to the sexual paraphilias among forensic psychiatrists at their annual conference last week in Tucson, Arizona.

But as it turns out, the sex experts of Europe had the Americans beat, both in numbers and timing.

At last month's meeting of the International Association for the Treatment of Sexual Offenders (IATSO) in Oslo, Norway, the vote was approximately 100 to 1 against the controversial diagnosis of "pedohebephilia," according to two reliable sources. The lone dissenting voice was a member of the DSM-5 committee.

I hope the DSM revisers are listening. If not, they are going to end up the laughingstock of the world.

Richard Green, MD: "Hebephilia is a Mental Disorder?"

The vote at the IATSO conference, where European psychiatry is strongly represented, came after a talk by Richard Green, a prominent psychiatrist, sexologist, and professor at the Imperial College of London. Green served on the Gender Identity Disorders subcommittee for DSM-IV, and was a leading advocate for removing homosexuality from the DSM back in the 1970s. In a published critique of the hebephilia proposal, he pointed out the parallels:

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

He has also pointed out that the age of legal consent in several European countries falls within the range that the proposed disorder would make pathological for the older participant.

A separate audience poll at the IATSO conference on the proposed diagnosis of hypersexuality was more mixed, with about a third favoring the diagnosis, a third opposing it, and a third undecided, according to one of my sources.

NPR report on AAPL debate

Meanwhile, National Public Radio has reported on Saturday's AAPL vote against the paraphilias. Reporter Alix Spiegel blogged about it on NPR's health blog, "SHOTS," under the heading "Forensic Psychiatrists Don't Favor Some Proposed Sexual Diagnoses."

These negative votes will have no a direct impact on the DSM-5, now due out in 2013. In the case of the controversial sexual paraphilias, one Canadian research group is dominating the process and most of the upcoming field trials will be done at government detention facilities where insular opinion runs heavily in favor of the diagnoses.

Proponents of the paraphilia revisions are urging supporters to lobby the DSM committee. It seems that, as we have seen in the past, lobbyists may have an inordinate impact, overshadowing valid science.

But if the American Psychiatric Association kowtows to this special interest niche and ignores the broader consensus of psychiatrists and other mental health professionals around the world, this will certainly reduce the credibility of the manual in years to come.

UPDATE: My Psychiatric Times coverage of the debate, "Forensic Psychiatrists Vote No on Proposed Paraphilias," is online HERE.

Psychiatrists vote no on controversial paraphilias

By an overwhelming majority, a group of seasoned forensic psychiatrists who work with sex offenders voted last night against three controversial new sexual disorders being proposed for the DSM-5.

The votes were 31-2, 31-2, and 29-2, respectively, against Paraphilic Coercive Disorder, Pedohebephilia, and Hypersexual Disorder. The votes came at the end of a debate at the annual meeting of the American Association of Psychiatry and Law (AAPL) in Tucson, Arizona.

The rejection is symbolic, but sends a strong message to the DSM-5 developers. One of the six debate panelists, Richard Krueger, is a member of the Paraphilias SubWorking Group. Two other panelists serve as advisors to the committee. In the audience were prominent forensic psychiatrists who took stances regarding similar proposals during previous revisions of the DSM.

The American Psychiatric Association, to which most forensic psychiatrists belong, publishes the influential Diagnostic and Statistical Manual of Mental Disorders, now in its fourth edition. But psychiatrists have not played a central a role in the 20-year-old sex offender civil commitment industry, which is lobbying for these new diagnoses. Much of the planned field testing will be done at civil commitment sites.

The debaters

Arguing for and against Hypersexual Disorder were two prominent psychiatrists with decades of experience in assessing sexual disorders. Richard Krueger, on the "pro" team, is a Columbia University professor and medical director of the Sexual Behavior Clinic at the New York State Psychiatric Institute. John Bradford, an advisor to the DSM-IV and past president of AAPL, is a Distinguished Fellow of the APA, last year earning its prestigious Isaac Ray Award. The University of Ottawa professor is founder and clinical director of the Sexual Behaviors Clinic in Ottawa. He expressed concern about how clinicians would determine how much sexual preoccupation is excessive, and voiced worry that homosexual men might be disproportionately given the label.

Two Wisconsin psychologists debated "Paraphilic Coercive Disorder," which would apply to rapists. Thomas Zander took the "con" position while David Thornton of the Sand Ridge Secure Detention Center for sexually violent predators was "pro." This is the third time that the American Psychiatric Association has considered such a diagnosis.

Tackling Pedohebephilia were two Northern Californians, forensic psychiatrist Douglas Tucker ("pro") and your faithful blogger ("con"). The controversial proposal would expand pedophilia from its current definition, in which the target of sexual attraction must be prepubescent, to young pubescents as old as 14.

The debate was organized by forensic psychiatrist Lynn Maskel, a clinical professor at the University of California-San Diego.

Clinical versus forensic utility?

The three-member "con" team focused on two main themes:

• All three proposed diagnoses lack a sufficient scientific basis.

• They are highly likely to be misused in the forensic context, the primary site for their application.

The "pro" debate team repeatedly insisted that these diagnoses are being proposed based on their scientific merit, not their utility to government evaluators in civil commitment cases. They said these new diagnoses are needed so people suffering with these conditions can get adequate treatment.

The clinical needs argument is a red herring. Clinicians are not turning away patients with problematic sexual behaviors because the proper billing code is missing from the Diagnostic and Statistical Manual of Mental Disorders. Rapists will not flock in for needed treatment when they hear that a Paraphilic Coercive Disorder label is now available for them.

The audience of forensic psychiatrists clearly did not buy the clinical justification. As more than one audience member asked the panel, If the rationale is strictly clinical, why are attorneys serving as advisors to the work group?

Back in 1986, the last time Paraphilic Coercive Disorder was proposed for the DSM, it was defeated in large part due to the opposition of forensic psychiatrists (not pesky feminists, as the historical revisionists would have it). Hopefully, history will repeat itself with respect to all three of these poorly conceptualized and dangerous proposals.

The debate was audiotaped, and will be available for purchase from AAPL. The texts of the proposed diagnoses can be viewed at the DSM-5 website. My resource page on Hebephilia is HERE. Thomas Zander’s article, Inventing Diagnosis for Civil Commitment of Rapists, is online HERE.

Photo: (L to R) John Bradford, Karen Franklin, Thomas Zander, David Thornton, Douglas Tucker, Richard Krueger. Photo credit: Luis Rosell.

UPDATE: My Psychiatric Times coverage of the debate, "Forensic Psychiatrists Vote No on Proposed Paraphilias," is online HERE.

Arson probe: "Revenge of the scientists"

Perhaps the single most compelling exemplar of problems with the U.S. death penalty is the case of Cameron Willingham of Texas. Willingham, whom I have blogged about before, was executed in 2004 for a house fire in which his three daughters perished. But, as it turned out, the fire may not have been arson after all.

An ongoing probe is fostering rebellion by scientists against pseudoscientific evidence in arson cases. Some are even calling for a re-examination of all arson convictions in Texas from the past 20 years, according to a report by Dave Mann of the Texas Observer, who has covered the case extensively.

PBS Frontline's has a new documentary on the case, "Death by Fire," which I recommend you keep an eye out for. (It's also available on DVD.) The PBS website has great background, online videos, and interactive links. PBS' Hari Sreenivasan has additional commentary and case-related links at his news blog.

Related blog posts:

• Will Texas arson case change death penalty debate? (Sept. 2, 2009)
• Arson: New frontier for exonerations? (July 2, 2008)
  

Is Good Lives only for sex offenders?

A reader asked:

How applicable is the Good Lives Model (book review HERE) to working with people who have transgressed in ways other than sex offending?

Answer:

The theory was not developed for sex offenders in particular. It is being adopted for use with sex offenders under the premise that their patterns of desistance from crime are similar to those of other criminal offenders. Many types of rehabilitation programs are turning to the Good Lives Model and other positive psychology approaches. By way of illustration, here is a testimonial from a Canadian psychologist who uses it with men who have engaged in family violence:

We have been using the Good Lives Model (GLM) in a family violence program for men who batter for the past year. The framework allows us to maintain all the traditional processes one might typically see in an offender program. It also supports the use of a variety of strategies pulled from narrative therapy, solution focused therapy, zen psychology, biofeedback, cognitive behavioural, learning theory, etc. while maintaining a cohesive theoretical perspective.

The GLM approach supports a stronger focus on offender engagement. We find that the men are more able to see what their role is in therapy. We have been conducting exit interview with clients as they complete the program. It is interesting to hear how the values embedded in the program are translated into their narratives. I rarely heard this kind of ownership of change from men when we were teaching a relapse prevention-style group.

I found that shifting to the GLM from a purely cognitive-behavioral, relapse prevention, risk-needs-responsivity approach allowed me to align my understanding of what constitutes good therapy from the effective counselling literature (i.e., the therapeutic engagement of the client). At times I have found the strict manualized approaches to treatment to be more "psycho-educational" than therapeutic.

Our population is largely non-convicted, self-referred men where drop out rates are typically very high. People are finishing this program. Our outcome measures suggest clients experience an increase in self-monitoring, emotional self-regulation, and cognitive flexibility, with reductions in perceived levels of anger and aggression.

I did relapse-prevention sex offender programming for many years and continue to integrate those materials and strategies into the current curriculum. We just get to add a lot more and have the theoretical underpinning to back up our efforts.

Thanks to Ann Marie Dewhurst, Ph.D. of Edmonton for giving me permission to post this example of the Good Lives Model in action.

Systems failure or black swan?

New frame needed to stop "Memorial Crime Control" frenzy

It's the same thing again and again:

• A rare but horrific tragedy befalls a high-status victim, usually a child

• Media pundits point fingers and place blame

• A supposed flaw in the legal system is pinpointed

• Opportunistic politicians enact knee-jerk legislation to "fix" the "hole"

This process explains wave after wave of "memorial crime" laws, such as Jessica's Law, the AMBER Alerts, Three Strikes, and Megan's Law. Borne on a tide of moral panic, the symbolic laws are costly, have no impact on crime or public safety, and sometimes even backfire.

These laws are implictly driven by "Routine Activities" logic. Under the Routine Activities theory of crime, crime results from a convergence of: (1) motivated offenders, (2) available targets, and (3) the absence of a capable guardian. So, goes the theory, you can stop heinous behavior by reducing opportunity.

But this is an upside-down approach to rare events that are anything but routine, argue criminologists Timothy Griffin and B. Grant Stitt of the University of Nevada in an intriguing article in Critical Criminology. Far more logical and productive would be to interpet these events as statistical inevitabilities or -- as Nassim Nicholas Taleb calls them -- "Black Swans."

Good public policies and sensible lifestyle choices can minimize the risk of serious criminal victimization, but not absolutely. Unfortunately, current American public policies such as child protection legislation are driven not by the realization of this apparently simple truth, but by its denial….

If public officials could embrace the grim reality that a certain number of certain types of crimes are inevitable, it could move the public discourse away from a futile search for a misguided solution and toward a mindset of rational problem management. The policy implication of random activities theory is that public safety officials and the general public need to be prepared to accept the fact that, for some categories of crime, there are few if any "‘solutions’" beyond what we are currently doing, and that our visceral reaction to 'Black Swan crimes' in the form of memorial crime control legislation is futile and possibly self-defeating….

[T]he proper application of random activities theory, rather than resulting in a depressing resignation toward tragic crime, could actually ... be liberating. Random activities theory could be a powerful heuristic in the public discussion of crime control because it enables experts to identify and categorize a class of crime that have stubbornly resisted repeated public attempts at suppression. It is a rhetorical tool that can defuse at least some of the excessive attention lavished on unavoidable crimes and allow the public discourse to move toward the preponderance of crime which is more amenable to public policy remedy….

In times of inexplicable tragedy, people cannot be faulted for taking what solace they can in whatever beliefs and comforts they can muster, but these are the arenas of religion, philosophy, and personal reflection -- not the justice system. The history of memorial crime control in the United States shows that whatever catharsis it provides is always short-lived. There will always be one more "Black Swan crime" to fuel reactionary demands for legislative response, and the failed policy cycle continues….

The message might lack visceral appeal, but most people do have, at some level, an intuitive appreciation of "‘acts of God," "adversity," or just plain bad luck.

Unfortunately, while I am by nature an optimist, the brazen assault on rationality that is taking place in the United States at this moment in history may belie the authors' optimism in appeals to common sense. Citizens who cling en masse to superstition, stubbornly reject established science, and believe that our president is a Muslim are proving themselves fairly unamenable to sane discourse.

I still recommend the article.

The abstract of the article, "Random Activities Theory: The Case for 'Black Swan' Criminology," is HERE. Request a copy of the article from the authors by clicking HERE (for Timothy Griffin) or HERE (for B. Grant Stitt).

Hat tip: David Stubbins

Exciting new sex offender treatment model

Today, dear readers, is an exciting day. It marks the official release of a groundbreaking new book on sex offender treatment, one that may signal a pivotal turning point away from punitive practices toward a recognition of offenders' essential human dignity and the universality of crime desistance.

Scholars D. Richard Laws and Tony Ward have taken on a huge task in Desistance from Sex Offending: Alternatives to Throwing Away the Keys. They hope to bring mainstream criminological theories about crime desistance to an insular, risk-obsessed fringe of forensic psychology that has remained remarkably uninterested in the fact that offenders desist from crime, or the process through which that occurs.

Desistance provides a superb, highly readable overview of the criminological literature on desistance, the age-crime curve, and offender reintegration research, focusing heavily on the seminal works of Sampson and Laub and Shadd Maruna. The authors propose the Good Lives Model as a theory that can bridge the looming chasm between desistance theory and forensic psychology practice with sex offenders.

The voices of dissent against the dominant, pathologizing discourse of deviance are growing louder. The publication of this trailblazing book is yet another in a series of signals that the reign of penal harm may be losing steam, creating opportunities for implementing progressive reforms.

Desistance is essential reading for clinicians, researchers, academicians, attorneys, and anyone interested in the application of contemporary social science theory on desistance to sex offender rehabilitation.

The timing is propitious, coinciding as it does with next week's annual conference of the Association for the Treatment of Sexual Abusers (ATSA) in Phoenix, Arizona. At least one conference seminar, by Pamela Yates, Ph.D., will focus on applying the Good Lives Model to sex offender treatment. If you are attending the conference, buy this book early before it sells out.

We can only hope that the spirit of reform embodied in Desistance truly catches on, rather than being coopted by the entrenched forces of risk management.

NOTE: I am writing more detailed and formal reviews of Desistance for publication, and will link to those as soon as they are available. Also see my online review at Amazon (and please, as always, remember to click on “yes” if you like the review).