Violence risk in schizophrenics: Are forensic tools reliable predictors?

The high-profile cases of Jared Lee Loughner and Anders Behring Breivik have contributed to high public demand for accurate prediction of violence potential among the mentally ill. While the number of risk assessment tools designed for this purpose has exploded in the past two decades, no systematic review has been conducted to investigate how accurate these tools are for predicting risk in individuals with schizophrenia.

But never fear: Jay Singh of the University of Oxford and colleagues (whose recent meta-review questioned overbroad claims about the accuracy of actuarials in risk assessment) have stepped into the breach, this time examining whether existing tools have proven efficacy for this task.

Reporting in this month's special issue of Schizophrenia Bulletin on violence and schizophrenia, the authors state that despite the existence of at least 158 structured tools for predicting outpatient violence risk, only two studies have measured instruments' predictive validity in discharged patients diagnosed with schizophrenia.

Instead of reporting on instruments' accuracy for specific patient groups, most studies report predictive validity estimates for heterogeneous groups of psychiatric patients. This forces clinicians and the public to assume that these group-level data apply to any individual diagnostic group.This assumption turns out to be a problem, due in part to the large differences in base rates of violence in psychiatric patients. We know, for example, that individuals with substance abuse disorders are more prone to violence, in general, than those diagnosed with major depression.

Examining the psychometric and predictive features of 10 widely used tools for assessing risk in mentally disordered offenders and civil psychiatric patients, the authors found "little direct evidence to support the use of these risk assessment tools in schizophrenia, specifically."

Overall, schizophrenics have low base rates of violence, with an estimated prevalence of between 10 and 15 percent. As I've discussed here in the context of sex offenders, the rarer a behavior is, the harder it is to successfully predict, leading to erroneous predictions of high risk in people who are not truly dangerous. The authors quote another research finding that in order to prevent one stranger homicide by a schizophrenic, governments would need to detain a whopping 35,000 patients.

That sounds to me like a black swan problem.

As in their previous meta-meta-analysis, the authors critique the almost exclusive use of the area under the curve (AUC) statistic to validate risk assessment instruments. Proponents of the AUC like it because it measures predictive utility independent of the base rate of the behavior in question. But this is as much a weakness as a strength, leading to a false sense of confidence in our ability to accurately predict the risk of individuals in heterogeneous groups of patients:

"High" AUC values for heterogeneous groups of psychiatric patients may have led researchers, clinicians, and policymakers to believe that instruments perform well for all diagnostic groups. However, it is problematic to suggest that structured instruments would be able to identify high-risk individuals with the same accuracy in groups with higher and lower base rates of violence.

In another interesting finding, Singh and colleagues found that the item content of violence risk tools varies markedly, with many tools including unique factors not contained in other instruments. This is a problem, unless these items are truly correlated with risk.

The authors call for updated reviews of the risk and protective factors underlying violence in different psychiatric groups -- including, for example, executive dysfunction in schizophrenics -- before additional risk assessment tools are constructed.

The review is available by contacting Dr. Singh (click HERE), who shortly will be coming to America to accept a post with the Mental Health Law and Policy Department of the University of South Florida.

Related blog post: Violence risk meta-meta: Instrument choice does matter (June 19, 2011)

Brick wall blocking progress on sexual violence

Forty years after the women’s rights movement brought attention to the widespread nature of sexual violence, the overwhelming majority of offenses still go unreported. Even when a brave victim does come forward, prosecution is rare and conviction even rarer.

That unpleasant reality was the starting point for this week's international conference on sexual violence at Middlesex University in London. Delegates from around the world -- including from Europe, Turkey, Israel, Australia, Canada and the United States -- met to brainstorm next steps in the battle against this catastrophic pandemic.

The consensus among delegates seemed to be that the legal system -- despite the best of intentions of many within it -- is ill equipped to rectify the "justice gap" between sexual violence perpetrators and their victims.

The "brick wall" (in the words of criminologist Betsy Stanko of "the Met," London's Metropolitan Police) blocking progress is built of so-called "rape myths" that make women unwilling to come forward, and impede successful prosecution when they do.

Myth Number One is that only bad and/or crazy men rape. As I explored in my opening keynote address, the promotion of this fiction by a powerful sex offender treatment industry has had the paradoxical effect of making the everyday rapist and child molester even less recognizable than ever by jurors and judges.

Myth Number Two is that men cannot control their sexual impulses. The corollary of this is to blame women for rape: Why did she get drunk? Why did she go with him? Why did she act (or dress) that way? Women have internalized these messages and so - unlike, say, burglary victims -- feel deeply humiliated and ashamed when they are raped.

Conference organizers Jackie Gray, Miranda Horvath,
and Susan Hansen (Photo credit: The Times)

These myths are so universal in Western cultures that even feminist women working at a women's health clinic communicate them in private, informal conversation, according to new research by one of the conference's organizers, Susan Hansen of Middlesex University. (The other two organizers were Miranda Horvath and Jackie Gray.)

Compounding the problem is the fact that rapists tend to target vulnerable women who do not fit the profile of a virtuous victim, so do not make good witnesses. In the "vast majority" of London cases tracked by the Met, around 85 percent, victims were (1) seriously intoxicated at the time of their assault, (2) involved in an intimate relationship with the perpetrator, (3) mentally ill, and/or (4) minors, Stanko reported. These are not ideal victims, from the standpoint of successful prosecution.

What to do?

As noted by long-time activist Liz Kelly, chair of the Child & Woman Abuse Studies Unit of London Metropolitan University, sexual violence exists on a continuum, from predatory leers, touches and verbal harassment -- to which virtually all women are subjected -- on up to illegal sexual assault. Direct confrontation of the male entitlement undergirding this entire spectrum of behaviors will be critical to meaningful progress against sexual violence, speaker after speaker emphasized.

In other words, delegates argued for reintroducing gender into the professional discourse. As Moira Carmody of the University of Western Sydney in Australia pointed out, gender-based analysis of sexual victimization is often perceived as too threatening. So it is replaced with gender-neutral discourse about interpersonal conflict, in which the gender of perpetrator and victim become interchangeable.

I had witnessed this dynamic in action the previous day, at the international consortium on multiple-perpetrator rape. As so frequently occurs in these types of professional gatherings, someone brought up the topic of female perpetrators, sidetracking discussion onto this tangential topic. I say tangential, because the reality is that group rape is an overwhelmingly male activity. Even on the exceedingly rare occasions in which women or girls are present, they are almost always auxiliaries, for example the wife of a sexual deviant, or a female gang member pressured to help her boyfriend procure a victim.

In addition to addressing the gender hierarchies and other power imbalances that facilitate victimization, we need to empower young people so that they perceive of themselves as active agents who have choices and practical tools for negotiating complex social situations.

Stieg Larsson, the author of the popular Millennium trilogy, did not feel this power when he was 15 years old. Thus, he did not intervene during a group camping trip, as three of his friends raped a 15-year-old girl. "Her screams were heartrending, but … his loyalty to his friends was too strong," writes longtime friend and biographer Kurdo Baksi. "He was too young, too insecure." Larsson struggled with guilt for the rest of his life, even naming the heroine of his novels after the rape victim, Lisbeth.

To empower young people in these types of situations, Carmody has developed an educational program that trains participants both in how to behave ethically in their own sexual encounters, and how to be "ethical bystanders." The curriculum, funded by the Australian government, has been successfully introduced with boys, girls, men and women from a variety of backgrounds, from rugby players to Maoris in New Zealand to gay men and lesbians.

New Zealand is using this ethical bystander approach in an innovative public health campaign to combat an expected rise in sexual assaults during the Rugby World Cup. An eight-minute video, "whoareyou," pushes the idea that everyone is responsibility for the safety of those around them.

A first step in primary prevention, then, is teaching and training young people to behave ethically toward each other.

On a larger level, we will need to directly challenge the rape myths undergirding an entire spectrum of intimate intrusions by men and boys against those with less social currency. Only then will victims feel empowered to step forward, and will judges and jurors be able to recognize and condemn the everyday offender who stands before them.

Knocking down that brick wall will be no small task.

Group rape getting long-overdue spotlight

Groups of men and boys have been raping lone, vulnerable girls and women since time immemorial. (Read Judges 19 in the Old Testament for one chilling account.) In fact, group rape is woven so tightly into the fabric of Western civilization that hardly anyone ever stops to think about it. Until now, that is.

When I did my first literature review of the topic back in 2003, for an article conceptualizing it as a theatrical production of hegemonic masculinity, I was astonished by the paucity of research. That is starting to change, thanks in large part to the tireless efforts of two prolific young scholars in the UK, Miranda Horvath of Middlesex University and Jessica Woodhams of the University of Birmingham.

Horvath and Woodhams secured funding from the British Psychological Society to put together an international consortium of researchers, academics and practitioners to further study the topic. We’re collaborating on an edited volume, which I’m pretty sure will be the first book in the history of the world on the topic of multiple-perpetrator rape. (It’s due out from Routledge in February 2013.)

I’m here in London giving a talk on the role of masculinity and culture in multiple-perpetrator rape, at the second of three research seminars. As I found in an analysis of international media coverage (which I will present in the upcoming book), Western societies display a cultural schizophrenia toward this phenomenon: Even as the public at large condemns group rape, contradictory messages permit and even reinforce it, fueling a cycle of masculine misconduct. 

London after the riots

Piccadilly Circus, 2011 (by K. Franklin)

London is a fitting backdrop for a seminar on group violence. Even as the city frenetically prepares to host the 2012 Olympics, it struggles to regain equilibrium in the wake of last month’s severe and economically costly rioting. 

Yesterday, I watched live BBC coverage of a government hearing into the police response to the rioting. Although the hearing covered a broad range of issues, Britain’s popular media latched onto a quote by Justice Secretary Ken Clarke, blaming the rioting on a "feral underclass." With coded racial language like that, it's no surprise that the rioting has led to increased racial prejudice and xenophobia among the British public, according to a just-released study. A greater number of respondents who felt that British society and culture were under threat are now expressing hostility toward Muslims, blacks and eastern Europeans.

London 2011 (K. Franklin)

Bolstering the racialized image in the public's mind is the much-ballyhooed statistic that three-quarters of those convicted of riot-related crimes had prior criminal records.  Of course, as the police were the first to admit during yesterday’s hearing, those with prior criminal histories were easiest to find, and so were rounded up after the riots. In other words, if you weren’t a known criminal you were less likely to get arrested, thereby producing a misleading statistic.

More broadly, why would anyone be surprised that members of an unemployed and disenfranchised underclass would be the first to rise up in protest over a police killing? Or that the have-nots would seize any opportunity to steal from the haves? Britain's confronting the problem today, but the rioting should serve as a wake-up call to every nation with severe economic and social disparities.

Ironically, by seizing upon the isolated quote and statistic, the popular media distorted what the justice secretary and other government leaders were saying. They were actually promoting the concept of rehabilitation. Calling the penal system "broken," the Secretary commented:

It's no good just punishing them. We're failing to make sure that those that are capable of being reformed are reformed and are actually sorting out their drugs, their drink, given a slightly more sensible approach to the values of society so that at least fewer of them will start causing trouble again the next time they have a chance.

Next up: Sexual violence conference

Stay tuned: Tomorrow I will be giving the opening keynote at a conference on sexual violence prevention, also here at Middlesex University in North London. Time allowing, I'll have more to report from my visit.

Jury deadlocks in gay panic trial

After a closely watched trial, a jury ultimately failed to agree on whether teenager Brandon McInerney should be punished for murder in the killing of classmate Larry King. The final vote was five for murder, and seven for the lesser crime of voluntary manslaughter.

The defense had played on gay panic, blaming 15-year-old King for being too provocative. Forensic psychologist Donald Hoagland, who spent 17 hours interviewing and testing McInerney, testified that when the cross-dressing victim said, “What’s up baby” to McInerney the day before the killing, it threw the 14-year-old into a fit of homicidal rage.

Hoagland further testified that when King said he was changing his name to Leticia, that triggered a dissociative state, causing McInerney not to realize what he was doing at the time of the shooting, according to the Ventura County Star.

The fatal flaw with that theory is that McInerney made advance plans to kill King. He acquired and loaded the gun, and announced his plan to several people the day beforehand, according to testimony during the eight-week trial. He shot King twice in the back of the head during a first-period class.

The only juror to speak to the media said that what really swayed the jury was not the gay panic defense, but the fact that the defendant was only 14 years old at the time of the 2008 crime. Prosecutors repeatedly rejected widespread pleas from the public -- including from a coalition of gay and lesbian groups -- to try the boy as a juvenile. He faced 51 years to life in prison if convicted in adult court.

Enough is enough, say the editors of the Star, which has provided excellent blow-by-blow coverage of the case since the outset; the prosecution needs to be reasonable:

That division among the jurors reflects the deep divide that also exists in the community at large regarding the appropriate way to punish a boy who committed an act of horrific violence that demands severe punishment, yet who had turned 14 just two weeks before the shooting, whose home life failed to provide the support and guidance that a child needs, and who was in a turbulent situation at school where there was equally little support evident.

The District Attorney's Office could refile murder charges against Brandon, but The Star believes the wisest course of action now is to take a sufficient amount of time for a good, hard look at the case that the prosecution presented and carefully consider what the jury's reactions revealed.

For starters, this trial showed it will be hard if not impossible to convince a jury that a sentence of 50 years to life in prison — which is mandatory for a first-degree murder conviction — represents justice in this criminal case, in which the defendant was prosecuted as an adult rather than in Juvenile Court.

Related blog posts:

Gay panic defense: Slain boy accused of provocation (August 10, 2011)

Don't ban gay panic defense (August 51, 2009)

What caused middle school tragedy? (June 10, 2008)

More on the McInerney antigay murder case (June 11, 2008)

Dangerous People: An international discourse

Dangerous People marks an important moment in risk discourse. Leading scholars from around the Western world join together to discuss the problematic science, ethics and morality underlying contemporary approaches to populations deemed high risk. These include not only sex offenders (the focus of this week's New York Times op-ed) but also suspected terrorists, illegal immigrants, violent youth, and the mentally ill.

Not surprisingly, contradictions over risk prediction play out even within the pages of this international and interdisciplinary work. Consider these offerings:

• Forensic psychologist David Cooke and statistician Christine Michie of Scotland issue their strongest warning yet about the fraud being perpetrated by proponents of “actuarial” risk prediction, whose illusion of scientific certainty camouflages predictions that are highly inaccurate and misleading:

At the heart of the matter is the fact that simple linear models cannot explain complex behavior…. Individuals are violent for different reasons: any one individual may be violent for different reasons on different occasions. This inherent complexity dooms simple-minded statistical prediction.... The only way to deal with this complexity is to think psychologically, not statistically.

• Lorraine Johnstone, another Scot, warns that the actuarials' inaccuracies are dangerously magnified with juvenile offenders, who present a "moving target" because they are still in the process of developing.

• Yet, on the other side of the fence, law professor Christopher Slobogin of the USA continues in his vociferous campaign for preventive detention of a litany of groups -- including the mentally ill, enemy combatants, violent juveniles and persons who spread communicable diseases -- based on these very same faulty statistical methods.

Meanwhile, legal scholars Eric Janus and John La Fond continue to shine a spotlight on the United States' costly experiment with civil detention of sex offenders.

Janus's intriguing theory is that the Sexually Violent Predator (SVP) laws are a tool of conservative ideologues to roll back feminist gains in the struggle against sexual violence and gender inequality. He advocates for a return to an empirically guided, public-health approach as the sanest way to combat sexual violence while also safeguarding tax dollars from waste.

"Predictably," agrees La Fond, "the American SVP experiment has been an abysmal and costly failure. Other countries should learn from our terrible mistakes."

Overviews of practices in other Western nations -- including Australia, England and Canada -- suggest that despite this warning, various U.S.-style detention schemes based on remote future risks are gaining traction internationally.

Several chapters in the volume, however, focus on a somewhat different model out of Scotland, the Order for Lifelong Restriction (OLR). This order, rendered at the time of initial sentencing, involves the imposition of an indeterminate sentence to be followed by lifelong supervision. To maximize consistency, risk assessors are accredited by a special Risk Management Authority. Although Scotland abides by the European Convention on Human Rights, which contains a guarantee against arbitrary detention, concerns have been raised about lengthy detention and lifelong sentences for juveniles. Additionally, as the volume editors point out, "it is too early to say whether the Scottish system has been successful in reducing violent and sexual recidivism."

On a somewhat different note, Jennifer Skeem, Jillian Peterson and Eric Silver challenge the widespread assumption that mental illness is a direct cause of criminality in mentally ill offenders. Rather, they say, many mentally ill people may engage in criminal behavior because they are poor, and therefore exposed to contextual risk factors for crime. We should stop regarding mental illness as a master status, they argue, in favor of a more nuanced approach to mentally ill offenders.

Many of the chapters in this timely collection -- edited by Australian legal scholars Bernadette McSherry and Patrick Keyzer -- will no doubt prove prophetic. The current state of fear-based hysteria, like all social movements, will wane in time. Politicians and the public will realize how costly and ineffective are many of the currently cherished practices and will reverse course. As the editors conclude:

What is clear from many of the chapters in this book is that schemes for imprisoning or detaining people for what they might do are costly, likely to contravene international human rights obligations, and have not proven to be effective in reducing crime, particularly sex offences. Detaining more and more people gives rise to the risk that detention regimes will collapse under the weight of numbers.

Yet in the short term, those who most need to hear this collective discourse -- including politicians, judges, prison officials, and even our very own misguided forensic practitioners -- are not listening. Isolated within a like-minded community, they are too busy searching for the magic potion that will make the world safe and appease a frightened public.

My Amazon review is HERE. If you appreciate this review, please go to Amazon and click "Yes" (this review was helpful). 

Trailblazing change in eyewitness ID rules

NJ ruling may reduce wrongful convictions; 

other jurisdictions likely to follow suit
x

As today's New York Times reports:

The New Jersey Supreme Court, acknowledging a “"troubling lack of reliability in eyewitness identifications," issued sweeping new rules on Wednesday making it easier for defendants to challenge such evidence in criminal cases.

The court said that whenever a defendant presents evidence that a witness's identification of a suspect was influenced, by the police, for instance, a judge must hold a hearing to consider a broad range of issues. These could include police behavior, but also factors like lighting, the time that had elapsed since the crime or whether the victim felt stress at the time of the identification. 

When such disputed evidence is admitted, the court said, the judge must give detailed explanations to jurors, even in the middle of a trial, on influences that could heighten the risk of misidentification. In the past, judges held hearings on such matters, but they were far more limited. 

The decision applies only in New Jersey, but is likely to have considerable impact nationally. The state's highest court has long been considered a trailblazer in criminal law, and New Jersey has already been a leader in establishing guidelines on how judges should handle such testimony.

Stuart J. Rabner, the court’s chief justice, wrote in a unanimous 134-page decision that the test for reliability of eyewitness testimony, as set out by the United States Supreme Court 34 years ago, should be revised.

The new rules come at a time of increased scrutiny of the eyewitness identification issue among lawyers, law enforcement officers and the scientific community. The opinion noted that task forces have been formed to recommend or put into effect new procedures to improve reliability. 

The State Supreme Court's ruling was seen as significant because it was based in part on an exhaustive study of the scientific research on eyewitness identification, led by a special master, a retired judge, who held hearings and led a review of the literature on the issue. The special master, Geoffrey Gaulkin, estimated that more than 2,000 studies related to the subject had been published since the Supreme Court’s original 1977 decision, the court noted. 

"Study after study revealed a troubling lack of reliability in eyewitness identifications," Chief Justice Rabner wrote. "From social science research to the review of actual police lineups, from laboratory experiments to DNA exonerations, the record proves that the possibility of mistaken identification is real. 

"Indeed, it is now widely known that eyewitness misidentification is the leading cause of wrongful convictions across the country."

The decision listed more than a dozen factors that judges should consider in evaluating the reliability of a witness’s identification, including whether a weapon was visible during a crime of short duration, the amount of time the witness had to observe the event, how close the witness was to the suspect, whether the witness was under the influence of alcohol or drugs, whether the witness was identifying someone of a different race and the length of time that had elapsed between the crime and the identification.

The Times report continues HERE.

Hat tip: Jane