March 29, 2010

Teen sexting resources

"Sexting" is a hot topic these days, especially in the wake of this month's U.S. Third Circuit Court of Appeals ruling in Miller v. Mitchell that it is unconstitutional to prosecute teens for child pornography solely based on their cell phone photos. The highly publicized Pennsylvania case illustrated the unintended consequences of current sex offender hysteria. The district attorney's office in Wyoming County had threatened to prosecute a teenage girl on felony child pornography charges unless she underwent mandatory reeducation. An appellate court barred the prosecutor from retaliating against young Ms. Doe for invoking her constitutional right not to attend the education program.

Related resources:
  • A TV news video of forensic psychology students speaking about teen sexting at a state government hearing in Connecticut

March 28, 2010

Canada: Parent complaints deterring custody evaluators

Speaking of censorship...

Fear of complaints by disgruntled parents is deterring professionals from working in the child custody arena, creating a "major social and legal problem," according to a group of lawyers and forensic evaluators in Canada. The group is urging the Canadian government to change the law in order to restrict disciplinary complaints.

A plea signed by 11 psychologists, psychiatrists, lawyers and social workers “urges changing the rules so disciplinary bodies can only consider complaints from such parents if they have been first approved by the judge in the case or by the other, winning parent, or have been screened to weed out frivolous grievances,” according to an article in the National Post. As reporter Tom Blackwell explains it:
Experts are appointed jointly in custody cases to interview, observe and sometime conduct psychological testing on family members to help determine who is best able to care for the children of divorces. The work can take months and cost the parties up to $75,000. The lobby group is not looking to gain "immunity" for assessors from disciplinary charges, only to curb the high number of spurious complaints, said Nick Bala, a Queen's University law professor.
Hat tip: Ken Pope

March 27, 2010

UK: Lie detection critic silenced by lawsuit

Hearing voices lately? If not, that could be because corporate interests are using the legal system to keep critical voices from speaking out about controversial new tools in our field, according to European scholars.

A Swedish phonetics professor says when he challenged the premises underlying an Israeli voice risk analysis (VRA) lie detection system that the British government has spent 2.4 million pounds pilot testing, the manufacturer threatened his publisher into withdrawing a manuscript from press. The government wants to employ voice stress analysis to detect benefits fraud; here in the United States, police frequently use similar technologies in criminal interrogations.

Francisco Lacerda, the Stockholm University professor, said the censorship "showed how English law was damaging science abroad as well as in the UK," according to an article in the Times of London.

Responding to a series of similar high-profile defamation actions against scientists, a group called the Libel Reform Coalition is campaigning for changes in Britain's law. A Coalition petition, signed by about 44,000 people when I last checked, is online HERE; I encourage you to check out the group's website and sign the petition.

March 25, 2010

"DSM-5 and sexual disorders: Just say no"

Psychology urged to oppose psychiatric monopoly

When one introduces new chickens into an existing flock, the flock establishes a pecking order. The older birds peck the new ones into submission. With lower status, the new birds feel -- to anthropomorphise a bit -- inferior.

That's what happened when the upstart field of psychology pushed its way into the bastions of psychiatry. Psychiatrists bristled at the intrusion. Psychologists of necessity submitted to psychiatric authority. Now, years later, psychologists vastly outnumber higher paid psychiatrists in many mental health niches, but as a profession we still have an inferiority complex. Thus, we let a single psychiatric association in the United States dictate how mental functioning and impairment are conceptualized.

As the chorus of critical voices over the American Psychiatric Association's poorly drawn draft DSM-5 manual grows ever louder, some are urging psychology to issue a formal opposition paper. For example, Stephen Diamond, a clinical and forensic psychologist in Los Angeles, writes in Psychology Today that our profession's apathy "is a big part of the problem":
While clinical psychology has to some extent leaped onto this same biological bandwagon driven by contemporary psychiatry, seeking prescription privileges, some psychologists and other non-medical mental health professionals have practically written off the value and importance of psychodiagnosis today -- in part precisely due to its inherent medicalization, biological bias, dehumanizing labeling, and notorious inaccuracy…. [I]t is time for the leadership of the American Psychological Association to take a far more active and public role in the revision and direction of the DSM-5…. What, if anything, [is] the American Psychological Association is doing about DSM-V? Or about the hypermedicalization of psychology?
Allen Frances, the psychiatrist who chaired the DSM-IV task force, has become one of the most vocal critics of the manual's proposals. He too is calling on organized psychology to step up before it is too late. Taking his campaign directly to psychology and the general public, he hosts a "DSM5 in distress" column in the popular magazine Psychology Today that shines a spotlight by turn on various problematic aspects of the draft manual. In his recent call for an organized response from psychology, he writes that:
the American Psychiatric Association (APA) came to hold the DSM franchise only by historical accident…. Now that the DSMs have attained such importance, there have been repeated questions about the appropriateness of its continued sponsorship by more than just one professional organization…. The numerous problems that have bedeviled the development of DSM5 again raise the question whether the American Psychiatric Association should be sole steward of an official diagnostic system that impacts on all mental health disciplines…. Individual psychologists and the professional associations within psychology can play an important role in pointing the way forward for DSM5 and in protecting it from costly mistakes.
Perilous forensic consequences

Frances is increasingly focusing on the monumental potential for negative and unintended consequences in the forensic realm of the proposed changes:
The most obviously detrimental suggestions are in the paraphilia section, where the proposed change to the definition of paraphilia and the likely suggestion to introduce a new diagnosis of "paraphilic coercive rapism" will greatly compound the significant mischief already initiated by a seemingly trivial change in DSM-IV. More generally, even small changes in wording can result in large forensic confusion once parsed by lawyers in their peculiarly rigorous and tendentious fashion. The wording of every suggested option in DSM5 needs careful review by forensic experts.
"DSM-5 sexual disorders make no sense"

In a more recent column, Frances specifically targets the Big 3 sexual disorders that I have extensively blogged about. Of all of the DSM-5 work groups, he writes:
the Sexual Disorders Work Group has strayed furthest off the reservation. It has made a series of radical and dangerous suggestions that need to be dropped.... Each of the Work Group's suggestions is based on the thinnest of research support-usually a handful of studies often done by members of the committee making the suggestion. None has been subjected to, or could possibly survive, anything resembling a serious risk/benefit or forensic analysis.
As he points out, there are few researchers and little good research on sexuality. Consensus on the bounds of "normalcy" does not exist, and cultural bias plays a major role in what is defined as pathological (a point cogently made by Richard Green in his critique of the proposed hebephilia diagnosis). Especially important for my readers, "decisions regarding the diagnosis of sexual disorders can have profound and unanticipated forensic ... implications."

Regarding the three paraphilia proposals that will have the most impact in civil commitment proceedings in the United States, Frances had the following to say:

"Paraphilic Coercive Disorder"
This proposal was explicitly rejected for DSM IIIR and was given no serious consideration for DSM IV. The problem is the impossibility of reliably distinguishing between the small group of hypothesized "paraphilic" rapists (who would be given a mental disorder diagnosis) and the much larger group of rapists who are simple criminals.

The distinction has taken on huge significance because [of] SVP statutes mandating indefinite (usually in practice lifelong) inpatient civil psychiatric commitment for individuals who have (1) completed their prison sentence for a sexually violent crime, (2) have a diagnosed mental disorder, and (3) are deemed likely to repeat.... Although the SVP statutes have twice passed Supreme Court tests, they rest on questionable constitutional grounds and may sometimes result in a misuse of psychiatry.

Most disturbingly, an ad hoc and idiosyncratic suggested diagnosis -- Paraphilia Not Otherwise Specified -- has become a frequent justification for the psychiatric commitment of rapists who are really no more than simple criminals. Raising this diagnosis to official status would greatly compound this misuse of civil psychiatric commitment.
"Hypersexuality Disorder"
This is the strangest of constructs.... The fundamental problem with "hypersexuality" is that it represents a half baked, poorly conceptualized medicalization of the expected variability in sexual behavior.... The authors are trying to provide a diagnosis for the small group whose sexual behaviors are compulsive -- but their label would quickly expand to provide a psychiatric excuse for the very large group whose misbehaviors are pleasure driven, recreational, and impulsive. The offloading of personal responsibility in this way has already captured the public and media fancy and would spread like wildfire. Making an official mental disorder category of "hypersexuality" would also have serious unintended forensic consequences inthe evaluations of sexually violent predators (SVP).
"Pedohebephilia"
This new category would extend the traditional definition of Pedophilia ... to include pubescent teenagers. Clearly, sex with underage teenagers is reprehensible and deserves appropriate punishment under the penal code. It is, however, anything but clear when (and if) sexual behaviors with teenagers should qualify as a mental disorder. This diagnosis would be subject to the same misuses in SVP cases as has been described above.
With such widespread and vigorous opposition, it's hard to imagine these nutty proposals slipping into the DSM-5. But, stranger things have happened in the field of psychiatry.

Related article:

DSM-5 and "Psychosis Risk Syndrome": Not Ready For Prime Time
Dr. Frances' latest piece, in Psychiatric Times, is on Psychosis Risk Syndrome, one of the scariest diagnostic proposals. If adopted, it would likely lead to a wave of false-positive errors in which teenagers are wrongly identified as future schizophrenics and placed on dangerous antipsychotic medications.
Hat tips: Ken Pope, Andrew H.
Graphics credit: Raul Crimson (Creative Commons license 2.0)

March 24, 2010

Excellent overview of insanity evaluations

I just finished Ira Packer's new book, Evaluation of Criminal Responsibility, from the Best Practices in Forensic Mental Health Assessment series. I found it to be an excellent summary manual, and affordably priced to boot. Here is the start of my review; click HERE for the full review:
This crisply written manual provides a balanced summary of the case law, empirical research, and developing practice standards for conducting insanity evaluations. Ira Packer, an award-winning scholar and long-time leader in the field of forensic psychology, brings a wealth of wisdom and experience to this topic. His discussions of controversial topics, such as whether to provide an “ultimate issue” opinion and how to approach the possibility of malingering, are especially balanced and nuanced.

Criminal responsibility evaluations are difficult endeavors both because of their retrospective nature, and also because we can never know for sure what was going on in someone else’s head, especially when that person may have understandable reasons to distort....
My full review is HERE. (Please be sure to click on "yes" if you find the review helpful; that boosts my Amazon ranking.)

March 21, 2010

Forensic fallout of revamping personality disorders

What is a personality disorder?

Your answer likely depends on whether you are a mental health professional, a layperson, or a member of the legal profession, where the term can have a highly scripted meaning with weighty implications.

In fact, the Supreme Court of Washington just ruled that the precise definition is so critical that a judge's refusal of a defense request to define it for a jury invalidated a civil detention order. That's because in Washington, a convicted sex offender cannot be civilly committed to a state hospital unless he has either a personality disorder or a "mental abnormality" that makes him more likely than not to commit sexually predatory acts in the future. The legal distinction between these two conditions derives from the DSM's axial system, under which most illnesses are listed on Axis I but personality disorders are categorized as "Axis II," because they are conceptualized (not always accurately) as more chronic and enduring than acute Axis I disorders.

At the trial of Curtis Pouncy, the prosecution-retained psychologist, Richard Packard, had testified that Curtis Pouncy had both conditions. The jury ultimately found Pouncy to be a Sexually Violent Predator (SVP), but it did not state whether this finding was on the basis of a personality disorder, a mental abnormality, or both. Explained the Supreme Court in overturning the commitment:
"The phrase 'personality disorder' is not one in common usage and is beyond the experience of the average juror. It is a term of art under the DSM that requires definition to ensure jurors are not 'forced to find a common denominator among each member's individual understanding' of the term…. We have no way of knowing from the verdict whether the jury found that Pouncy was an SVP because he suffered from a mental abnormality or a personality disorder. And, if the jury agreed Pouncy suffered from a personality disorder, we have no way of knowing what definition the jury used in reaching this conclusion…. We cannot say the failure to instruct on the definition of 'personality disorder' in no way affected the final outcome of the case; accordingly, it was not harmless. A new trial is required."
The government of Washington is so interested in the precise meaning of the term that in 2009 it actually codified the definition for purposes of SVP civil commitment. Tagging off of the definition in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the Revised Code of Washington Section 71.09.020(9) now defines a personality disorder as:
"an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has onset in adolescence or early adulthood, is stable over time and leads to distress or impairment. Purported evidence of a personality disorder must be supported by testimony of a licensed forensic psychologist or psychiatrist."
As Constance Holden reports in the current edition of Science magazine, "Personality disorders are hard to pin down. They don't have a common defining mood or behavior, people don't get hospitalized for having one, and a drug won't cure one."

If that sounds tricky, wait until the American Psychiatric Association adds layer upon layer of new complexity, and in the process completely scraps the definition as reified by government entities such as the Washington state legislature. Under a draft proposal rolled out last month for the new DSM-5* (due out in 2013), the old personality disorders are barely recognizable and some have disappeared altogether.
  • First off, the overarching definition will be new. Now, personality disorders are defined more briefly as:
"the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual's cultural norms and expectations."
Both self-identity and interpersonal functioning are then further defined. For example, poor interpersonal functioning involves failure to develop empathy, intimacy, cooperativeness, or "complexity and integration of representations of others."
  • Next, one rates the person on a set of six traits (negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy) to determine whether the general adaptive failure is "associated with extreme levels of one or more" of these.
  • Finally, there are the specific personality "types," whittled down from the current 10 to only five: Schizotypal, Borderline, Obsessive-Compulsive, Avoidant, and Antisocial/Psychopathic. Note that psychopathy will make its grand debut, while narcissistic exits stage left.
In his erudite competency opinion in the Brian David Mitchell case, Judge Dale Kimball leaned heavily on narcissistic personality disorder as an explanation for the defendant's presentation. If the Personality Disorders Work Group for the DSM-5 gets its way, that diagnosis will go the way of of hysteria and melancholia. Of course, as the judge wisely pointed out, DSM diagnoses are not directly applicable to ultimate legal issues:

"[I]t is not particularly necessary for the court to determine a specific diagnosis in determining competency.... [E]ither an Axis I or Axis II condition could potentially render a defendant incompetent. And, on the other hand, a defendant could have an Axis I and/or Axis II condition and still be competent."
So, what do you get when you combine five personality types with six crosscutting traits? "A camel -- a horse made by committee," psychologist Drew Westen of Emory University told Science magazine.

And in forensic contexts, how will terms such as "culturally adaptive," "empathy," "cooperativeness," "negative emotionality," and "antagonism" be operationalized? Based on research into how forensic evaluators decide about other value-laden constructs such as psychopathy and risk, dare I predict partisan allegiance will rear its ugly head?

Paul A. Siciliano at Basically Law has more on the Pouncy decision. Psychologist Simone Hoermann has commentary on the DSM-5 personality disorders revamp at her Personality Disorders blog.

*The current DSM and all previous editions are designated by Roman numerals, but the APA has decided to use Arabic numerals starting with the fifth edition.

Photo credits: (1) Vagamundos (Creative Commons license 2.0); (2) Kaptain Kobold (Creative Commons license 2.0)
 

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DSM-5 POSTSCRIPT: Following much brouhaha, the American Psychiatry Association ultimately did not adopt the more radical proposed changes to the personality disorders for the DSM-5, nor did it remove Narcissistic Personality Disorder (much beloved in some psychiatric quarters) as one of the types. However, the entire axial system (i.e., the distinction between Axis I mental disorders versus Axis II personality disorders) was eliminated. Meanwhile, contemporary research is suggesting that personality disorders -- for example Borderline and Antisocial disorders -- are not nearly as enduring or lifelong as the DSM definitions continue to suggest.