Friday, July 31, 2009

Lane on "diagnostic madness of DSM-V"


To linger anxiously, even bitterly, over job loss is all too human. To sigh with despair over precipitous declines in one's retirement account is also perfectly understandable. But if the APA includes post-traumatic embitterment disorder in the next edition of its diagnostic bible, it will be because a small group of mental-health professionals believes the public shouldn't dwell on such matters for too long.

That's a sobering thought -- enough, perhaps, to make you doubt the wisdom of those updating the new manual. The association has no clear definition of the cutoff between normal and pathological responses to life's letdowns. To those of us following the debates as closely as the association will allow, it's apparent that the DSM revisions have become a train wreck. The problem is, everyone involved has signed a contract promising not to share publicly what's going on.
That's a snippet from Christopher Lane's latest essay on the upcoming DSM-V, in Slate magazine. Lane is an English professor and author of Shyness: How Normal Behavior Became a Sickness, a wonderful expose of how the DSM-III came to be.

Related article: Wrangling over psychiatry's bible, Los Angeles Times

Thursday, July 30, 2009

New sex offender studies

The booming sex offender industry is producing lots of literature these days. A few current studies of interest, all with negative findings:

Child porn use not linked to contact crimes

Men who use internet child pornography are not at high risk of committing hands-on sex offenses, especially if they do not have a prior criminal record of such activities, suggesting that other risk factors must be taken into account to identify potential offenders.

The article, The consumption of Internet child pornography and violent and sex offending, by scholars in Switzerland and Germany, is available online for free, through the open-access site BioMed Central.

Actuarials fail to predict juvenile recidivism

There's a lot of demand these days for tools to predict which juvenile sex offenders will reoffend. The recidivism rates are very low, which makes this task especially difficult. In this study, Jodi Viljoen of Simon Fraser University and colleagues tested four widely used instruments, and found that none of them significantly predicted sexual reoffending. The instruments were the ERASOR (Estimate of Risk of Adolescent Sexual Offense Recidivism), the Youth Level of Service/Case Management Inventory (YLS/CMI), the Psychopathy Checklist: Youth Version (PCL:YV), and the Static-99.

The abstract of Assessment of Reoffense Risk in Adolescents Who Have Committed Sexual Offenses: Predictive Validity of the ERASOR, PCL:YV, YLS/CMI, and Static-99 is available through Criminal Justice and Behavior's "online first" website, but you need a subscription to see the whole article.

Adam Walsh: Only an illusion of safety

This project used a sample of sex offenders in New York State who are registered under the federal Adam Walsh Child Protection and Safety Act (AWA), to perform the fist empirical assessment into whether the Act's implementation is likely to increase public safety. The answer, unsurprisingly, is a resounding no. As it turns out, the offenders classified as lowest risk (Tier 1) reoffended at higher rates than those classified as moderate (Tier 2) to high risk (Tier 3).

Again, you can see the abstract of this study, The Adam Walsh Act: A False Sense of Security or an Effective Public Policy Initiative? by Naomi J. Freeman and Jeffrey C. Sandler, at Criminal Justice Policy Review's "online first" site, but the article requires a subscription.

Tuesday, July 28, 2009

Top confession expert barred from testifying

Over the past few decades, police have developed a set of sophisticated procedures to get suspects to confess to crimes. Most suspects who succumb to the so-called "Reid" tactics of manipulation and deception are actually guilty. But some minority -- the exact proportion is unknown -- are not.

How can judges and jurors tell the difference?

The short answer is, they generally cannot. False confessions can look amazingly real. In the Central Park jogger case, for example, juveniles who falsely confessed to gang-raping a woman energetically demonstrated their (false) actions on videotape. Five juveniles were convicted on the basis of the false videotaped confessions, despite no physical evidence linking them to the crime. It wasn't until years later that the true culprit (a lone sexual predator) was identified.

To jurors, judges, police, and other members of the public, confession evidence is overwhelmingly powerful evidence of guilt. After all, it goes against common sense to think that someone would confess to a crime he did not commit.

Luckily, researchers have laboriously combed through confessions that later turned out to be false, and have found markers of unreliability. Among the markers are lengthy and intense interrogations, "contamination" through police feeding of crime facts to suspects, and a lack of guilty knowledge on the part of the suspect. Certain individual factors (such as youth, low intelligence, naivete, and acquiescence to authority) also put some suspects at heightened risk.

A leading expert in this area is Richard Leo, a law professor at the University of San Francisco and author of Police Interrogation and American Justice. Because laypeople lack the expertise to tease out telltale markers of unreliability, Leo has educated jurors and judges about this science.

That is just what he was slated to do in the Michigan case of Jerome Kowalski, who confessed on videotape to the 2008 shooting deaths of his brother and sister-in-law. Leo was prepared to testify about how Kowalski might have come to believe he committed the crime despite having no recollection of it.

Typically, expert witnesses are allowed to testify when they can provide information that is beyond the common knowledge of jurors, and will assist such "fact-finders" in arriving at the truth. Leo believed his testimony could "be important at trial to help the jury understand police interrogation methods and 'how some methods can lead to a false confession,' " according to a report in today's Livingston Daily Press and Argus.

But, in a ruling that shocked the defense attorneys and has created some hubbub among forensic psychologists around the country, a judge barred both Leo and a clinical psychologist from testifying, saying jurors can use their common sense to determine whether the confession is valid.

"We have no defense at this point," attorney Walter Piszczatowski told a newspaper reporter after the hearing. He asked Judge Theresa Brennan to put the case on hold while he appeals, but she denied that request too. The trial is set to start in October.

Further resources:

" 'I'd know a false confession if I saw one': A comparative study of college students and police investigators," by Saul M. Kassin, Christian A. Meissner, and Rebecca J. Norwick, Law & Human Behavior (2005).

Livingston
Daily Press and Argus coverage of this case is HERE.
My review of Leo's
Police Interrogation and American Justice is HERE.
A related blog post, "Canada: How false confessions occur," is HERE.

A book with chapters by psychologists Sol Fulero and Bruce Frumkin on the admissibility of this type of confession testimony is expected out later this year from the American Psychological Association press. The book,
Interrogations and confessions: Research, practice, and policy, is being edited by Christian Meissner and G. Daniel Lassiter, both of whom have extensive expertise in this field.

On police, profiling, and Henry Gates

Guest essay by Sam Sommers*

When it comes to matters of race, the problem with asking how much progress we've made is not that there isn't a right answer. It's that there are two. Ask White Americans about race relations, and most focus on how far we've come. Ask Black Americans, and you're more likely to hear how far we still have to go.

Have we made strides when it comes to racial profiling? Sure. The practice now has a well-known name, jurisdictions keep statistics to track it, and commissions have been established to eradicate it. But what the arrest of Dr. Gates crystallizes is that we still have a ways to go. Whether the neighbor who called police or the officer who arrived on the scene consciously considered race is beside the point. What we know from scores of studies is that race influences our mental calculus -- sometimes when we aren't aware of it, when we don't want it to, and even on the police force.

In psychological research, participants exposed to subliminal photos of Black men are quicker to identify ambiguous images as weapons. Respondents in police simulation studies -- including actual officers -- are more likely to mistake innocuous items for guns when held by a Black man. These are basic human tendencies to which many of us fall victim, yet they aren't inevitable with proper vigilance or training.

That's what makes knee-jerk denials that race played a role in Gates' arrest so disappointing. I'm not arguing that race was the only reason things went down as they did. I wasn't there; details remain fuzzy. But let's be honest: White Harvard professors just don't get charged with disorderly conduct in their own homes. And when Black men of less renown are arrested under similar circumstances, we don't hear about it on the news.

Sure, it's dangerous to read too much into the anonymous comments of web users and the incendiary efforts of bloggers who seek to draw attention (and web traffic) to themselves. But to me, one of the most striking aspects of this story is how angry some White people seem to be in response to it, as if the mere suggestion that race had anything to do with Gates' arrest is a) ridiculous, b) offensive, and c) an indcitment of the American way of life. Check out, for example, some of the initial reader responses to the on-line story of the arrest in my hometown Boston Globe.

I've said it before, and I'll say it again: there are few things White Americans find more aversive than talking about race. But to dismiss out of hand the relevance of race to Gates' arrest flies in the face of empirical data, not to mention good, old-fashioned, common sense. You don't have to be an expert to understand that things like this just don't happen to White professors at Harvard.

*From the New York Times, posted with the written permission of Sam Sommers. For the entire Times on-line forum, featuring invited essays by seven leading experts, click HERE. Sommers has also written a further update on the case, More Gates Fallout, at his informative blog, Science Of Small Talk.

Sommers is an award-winning social psychologist at Tufts University in Massachusetts who has testified in murder trials as an expert witness on racial bias. My prior posts about his work include:

Monday, July 27, 2009

Professionals behaving badly

Mistrial in psychiatrist molestation case

Remember the case of the San Francisco Bay Area psychiatrist whom the juvenile courts kept sending boys to for at least 16 years after allegations of molestation first surfaced?

Disappointingly for the prosecutor and the alleged victims, the jury trial of 77-year-old William Ayres ended in a mistrial today, after nine days of deliberations.

Ex-patients, now men in their 20s and 30s, had testified that the prominent psychiatrist molested them in his private, soundproof office under the guise of giving them medical exams.

"Much of the testimony during the trial centered on whether Ayres followed acceptable psychiatric practices when he gave the exams, which [the prosecutor] argued were merely a ruse to give the doctor a reason to fondle boys," according to a San Francisco Chronicle report. "While the details varied, Ayres' former patients told authorities similar scenarios: Ayres would direct them to undress, then conduct a physical where he fondled their genitals or masturbated them for several minutes."

Juvenile court judges continued to send new victims to Dr. William Ayres until 2003, long after the first of multiple complaints against him by boys and their parents. Several dozen men accused Ayres of molesting them as boys dating back almost four decades. Economic class disparities between the accusers and the accused likely influenced the failure to prosecute until the chance intervention of a freelance writer from New York.

Although Ayres is elderly and ill, a retrial is likely.

Tuesday postscript: A writer who attended the trial tells me that the jury was leaning 10-2 and 11-1 for guilt; the main holdout was a young woman who recently graduated from law school and who did not believe the alleged victims.

My original blog post is HERE; the blog Psych Watch ("Documenting Psychiatrists Behaving Badly") has a special "William Ayres Watch" page devoted to in-depth coverage of the case.

Lawsuit in forensic psychologist voyeurism case


Meanwhile, in another case involving alleged sexual misconduct by a forensic mental health professional, an employee of Stuart Greenberg has sued the estate of the once-prominent forensic psychologist.

The ex-employee alleges that she was fired after discovering the video camera that Dr. Greenberg allegedly used to spy on women in his office bathroom. A former president of the American Board of Forensic Psychology and a consultant for the Seattle Archdiocese, Dr. Greeberg committed suicide after the voyeurism allegations surfaced. In her civil suit, the woman alleges that Dr. Greenberg confessed to her that he had videotaped her and two other women as they used the bathroom.

The Seattle Post-Intelligencer story is HERE.

Sex crimes prosecutor charged with rape

And, finally, back in court today is a prosecutor in Contra Costa County, California, who has been fired pending trial for the alleged gunpoint rape of a female colleague. In one of the more chilling aspects of the case, the woman alleges that the sex crimes unit where she and former supervisor Michael Gressett worked together was a highly sexualized place where prosecutors "bantered about rough sex and directed gallows humor toward the crime victims they represented," according to a San Francisco Chronicle article.

And they wonder why some rape victims balk at reporting the crime. Talk about a perception of revictimization!

Photo credit: Kristopher Skinner, Contra Costa Times

Hitting the top 40

I was honored to return from vacation and find this blog featured on Psyblog's Top 40 list of "Superb Psychology Blogs." Psyblog is a fabulous site out of the UK, well worth checking out. The work of Jeremy Dean, a researcher at University College London with backgrounds in both law and the Internet, it bursts with scientific psychology information presented via a clean, intuitive Wordpress format. Features include synopses of Schachter's memory research, attention research, and 10 "brilliant social psychology studies." If you've got a bit of time on your hands (or you're procrastinating on your work projects), you might want to check out some of the other Top 40 psychology sites and set up some bookmarks or feeds for future reference. They include a wealth of information.

Friday, July 17, 2009

PTSD: Pandemic like swine flu?

Just about every week, an attorney calls me wanting a client evaluated for PTSD. Virtually everyone in forensic practice has probably seen highly dubious diagnoses of PTSD, deployed for obvious secondary gain. But even outside the courtroom, our cultural obsession with trauma and victimization may be creating an epidemic of wrongful PTSD diagnoses, at a public cost of billions of dollars.

Such is the controversial position that is "splitting the practice of trauma psychology and roiling military culture," writes science writer David Dobbs in a lucid analysis in Scientific American Magazine.

Critics contend that both the larger American culture and the medical culture within the Veterans Administration (VA) reflexively regard all bad memories, nightmares, and other signs of distress as evidence of Posttraumatic Stress Disorder (PTSD). Returning soldiers are encouraged to create a "trauma narrative" to explain their problems. This, unfortunately, gives them monetary benefits in the short term, but sucks them down a dead-end path that will mire them in chronic disability and "a psyche permanently haunted."

"This has nothing to do with gaming or working the system or consciously looking for sympathy," says Harvard University psychologist Richard J. McNally, an authority on memory and trauma and a leading critic. "We all do this: we cast our lives in terms of narratives that help us understand them. A vet who's having a difficult life may remember a trauma, which may or may not have actually traumatized him, and everything makes sense."

Unlike most psychiatric diagnoses, PTSD as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) must be caused by a traumatic event. However, the tie is really to the memory of an event. And, as research shows, memory is highly unreliable and malleable: "We routinely add or subtract people, details, settings and actions to and from our memories. We conflate, invent and edit."

Unfortunately, the fuzziness of the PTSD construct makes it very hard to distinguish from other disorders with overlapping symptoms, including depression and traumatic brain injury, increasingly common among soldiers returning from Iraq.

And giving treatment for PTSD (typically, controlled exposure to trauma triggers) may make other problems worse:

"If a depressed person takes on a PTSD interpretation of their troubles and gets exposure-based CBT [cognitive behavioral therapy], you're going to miss the boat," McNally says. "You're going to spend your time chasing this memory down instead of dealing with the way the patient misinterprets present events."

Critics such as McNally are calling for revisions in the upcoming edition of the DSM, due out in 2012, to better distinguish depression, anxiety and phobia from true PTSD.

They are also calling for an overhaul in the VA's disability system, to "remove disincentives to recovery and even go the extra mile and give all combat veterans, injured or not, lifetime health care."

Such changes, of course, are unlikely, given our entrenched "cultural obsession with trauma."

Interestingly, military historian Ben Shephard posits that the PTSD diagnosis benefits American society by absolving it of moral responsibility for the Vietnam war. As Dobbs summarizes it, American society gained:

"a vision of war's costs that, by transforming warriors into victims, lets us declare our recognition of war's horror and absolves us for sending them for we were victimized, too, fooled into supporting a war we later regretted. We should recognize war's horror. We should feel the soldier's pain. But to impose on a distressed soldier the notion that his memories are inescapable, that he lacks the strength to incorporate his past into his future, is to highlight our moral sensitivity at the soldier's expense."

Shephard, in his book A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century, is not arguing that PTSD does not exist. Indeed, "shell shock" or "battle fatigue" was recognized long before PTSD became a formal diagnosis in the wake of the Vietnam War. Rather, he argues that the construct overemphasizes permanent psychic damage when resilience is actually more common among humans exposed to traumatic stress.

It is this capacity to recover that is lost when combat veterans (and others) are encouraged to take on the identity of chronically broken men and women.

Photo credit: "Helplessness" by Dr. S. Ali Wasif (Creative Commons license)

Hat tip: Tim Derning

Tuesday, July 14, 2009

Dueling experts: Farcical spectacle that should be abolished?

Dueling psychiatric experts are an appalling farce and "a travesty of the profession and the law," according to an op-ed in yesterday's Boston Globe.

The opinion piece comes in the wake of the high-profile sanity trial of Christian Karl Gerhartsreiter (GAYR'-hahrtz-ry-tur), a German con artist who used a string of fake identities (including "Clark Rockefeller") to establish himself in wealthy circles in New York, Boston and Los Angeles. Last month, a jury rejected the defense theory of insanity and convicted him in the kidnapping of his 7-year-old daughter. He was sentenced to four to five years in prison.

Psychiatrist Stephen Bergman (who writes fictional parodies of psychiatry under the pen name Samuel Shem) critiqued the various experts for, respectively:

  • charging too much money (one expert got $10,000, which ain't a whole lot these days)
  • giving opinions on TV ahead of the trial
  • spending only 2.5 hours with Gerhartsreiter
  • not having prior experience testifying in court
The prosecution's expert, psychiatrist James Chu, diagnosed narcissism and sociopathy. He testified that Gerhartsreiter exaggerated his symptoms and knew what he was doing was wrong.

Two defense experts, forensic psychologist Catherine T.J. Howe and forensic psychiatrist Keith Ablow, a Fox News commentator, both testified that Gerhartsreiter suffered from delusional disorder (grandiose type) and narcissistic personality disorder, and was insane when he fled to Baltimore with his daughter during a custody dispute.

Bergman saved most of his vitriol for the DSM diagnostic enterprise, which is so tainted by profiteering and bias that a "circus atmosphere" is almost inevitable when it is brought into court:
"The lucrative link between a diagnosis and a drug to treat it, when diagnosis itself is culture-bound and often subjective, pollutes the impartiality of the 'Diagnostic and Statistical Manual.' … If psychiatric diagnoses and treatments have an element of fuzziness, how could doctors paid by one side or the other not come up with a diagnosis wanted by their employer?"
His solution?

Do away with experts that are paid by either side. Instead, have a neutral panel whose opinions are binding.

Bergman makes some legitimate points, especially about how flaws in the system of psychiatric diagnosis impact forensic cases. (See my new article on this topic HERE.) And, some of his criticisms of these particular experts may be legitimate (although, ironically, he got their roles backwards*). Indeed, the defense appeal argues that the government's expert was unqualified and applied the wrong legal standard for criminal responsibility.

But, overall, Bergman misses the forest for the trees.

The adversarial system entitles each side to present its best case in court. To foreclose that option just because experts sometimes differ would be fundamentally unfair. After all, as a colleague of mine put it, disagreements are not unique to psychiatry: "Engineers routinely disagree in court over the cause of a collapsed bridge, just as chemists disagree in court over the nature of a substance."

And just because they disagree, that doesn't mean that the experts are dishonest or lack integrity, as Bergman implies.

Unfortunately, high-profile insanity trials like this one skew the perceptions of the public and pundits like Bergman. In reality, insanity (which varies by jurisdiction but generally requires that the defendant did not know the difference between right and wrong) is rarely invoked as a defense, and is even more rarely successful. One eight-state study found that the defense was used in less than 1% of cases, and was successful only about one-fourth of the time. In 90% of the successful cases, the offender had been psychiatrically diagnosed prior to the crime.

Even when the defense is invoked, the "dueling experts" phenomenon is rarer than people think. The vast majority of insanity cases are resolved behind the scenes because the experts for both sides are in substantial agreement. In such cases, a trial -- with its attendant publicity -- never takes place. (See Before and After Hinckley: Evaluating Insanity Defense Reform.)

Another public misconception is that successful use of the insanity defense allows people to "get off" for the crime. In reality, most insanity acquittees are sent to locked state hospitals that look very much like prisons. They often spend more time locked up than if they had been convicted of their crime.

Bottom line: A defendant's right to the best possible defense should not be foreclosed just because of errors or hype in the rare celebrity case.

----------
* Bergman wrote: “For the prosecution: one psychiatrist, famous from Fox TV and psychiatric thrillers, was paid $10,000 for his expertise as part of an 'insanity defense,' testimony that was challenged by his offering opinions about Rockefeller on TV in advance of the trial; a prosecution psychologist agreed with his diagnosis, basically of a narcissistic character who was 'delusional' -- that is, insane. For the defense: a psychiatrist who had seen the accused once for 2 1/2 hours and had never before testified in court came up with the diagnosis of narcissism and sociopathy -- that is, not insane." In reality, the two experts he said were prosecution witnesses were actually defense-retained, and the expert he labeled as "for the defense" was actually the prosecution's.

Monday, July 13, 2009

Diagnostic reification in court

Good psychologists think in shades of gray. But the inside of a courtroom is painted black and white. One side wins, the other loses. Here, I discuss an ethical dilemma posed by this disjuncture between scientific uncertainty and the law's pull for absolutes. This dilemma concerns diagnostic labeling in court.

So begins my new "Ethics Corner" column in the July/August issue of the California Psychologist, available HERE.

Monday, July 6, 2009

Diagnosing Michael Jackson

You have probably seen some of the postmortem efforts to pin psychiatric diagnoses on Michael Jackson, in the wake of his untimely demise. It's a pedantic enterprise, with no shortage of diagnostic contenders: Pedophilia, anorexia, body dysmorphic disorder, and a dual diagnosis (that's a psychiatric disorder plus a substance abuse disorder). Most recently, we've got J. Michael Bailey, the man transgender activists love to hate, wading into the fray with erotic identity disorder and a paraphilia called autogynephilia.

"Whoa, folks! Not so fast!" say others.

Calling for a little reflection on this whole paraphilia-hebephilia-whateverphilia diagnostic craze is Scientific American columnist Jesse Bering, a research psychologist at Queen's University Belfast:

Would you really have wanted Oscar Wilde euthanized as though he were a sick animal? Should André Gide, whom the New York Times hailed in their obituary as a man 'judged the greatest French writer of this century by the literary cognoscenti,' have been deprived of his pen, torn to pieces by illiterate thugs? It's complicated. And although in principle we know that all men are equal in the eyes of the law, just as we did for Michael Jackson during his child molestation trials, I have a hunch that many people tend to feel (and uncomfortably so) a little sympathy for the Devil under such circumstances.
I highly recommend Bering's muse, "Pedophiles, Hebephiles, and Ephebophiles, Oh My: Erotic Age Orientation" (which, by way of full disclosure, cites yours truly).

 
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