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.
Diagnostic reification in court
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). Read More...
Monday, July 6, 2009
DSM-V: Urgent warning and call to action
Predicting a flawed manual that "will haunt psychiatry for many years to come," the chair of the DSM-IV Task Force has issued an urgent call to the American Psychiatric Association to change course on its revision process for the Diagnostic and Statistical Manual of Mental Disorders (DSM) before it is too late.
Allen Frances' strongly worded appeal in the Psychiatric Times predicts the DSM-V -- scheduled for publication in May 2012 - will usher in a flood of new mental disorders that will medicalize normality, producing "a bonanza for the pharmaceutical industry but at a huge cost to the new false-positive patients caught in the excessively wide DSM-V net.""In my experience, experts on any given diagnosis always worry a great deal about missed cases but rarely consider the risks of creating a large pool of false positives—especially in primary care settings. The experts' motives are pure, but their awareness of risks is often naive. Psychiatry should not be in the business of inadvertently manufacturing mental disorders."
Frances makes special note of the potential for "unpredictable and consequential" unintended consequences in forensic settings:"Years after the DSM-IV was completed, we learned about the enormous unintended impact of a seemingly slight wording change we made only for technical reasons in the section on paraphilias. A misreading of our intentions in making the change had led to great confusion -- with forensic evaluators using the diagnosis of paraphilia not otherwise specified to justify the sometimes inappropriate lifetime psychiatric commitment of rapists who had no real mental disorder."
This prediction is prophetic in light of current lobbying efforts by the paraphilias subworkgroup to create a new "pedohebephilic disorder" category that could vastly expand sex offender diagnosis, proving a bonanza for the sexual offender civil commitment industry.
Frances is highly critical of the "inexplicable secrecy and the lack of openness to outside influence and criticism" surrounding the DSM-V revision process."Restricting the free flow of ideas creates enormous blind spots that greatly increase the risk of damaging unintended consequences…. The advisory group is far too small and select to reduce, rather than encourage, heated debate. In producing a new edition of the DSM, your harshest critics eventually turn out to be your best friends because they are most likely to help you avoid pitfalls."
He is urging the American Psychiatric Association to create an external committee to review what is going on with the DSM and make recommendations to avoid serious negative consequences in the future.
Frances' important article, A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences, is available HERE.
An accompanying Q&A, DSM-V Badly Off Track, is HERE.
Some of my related blog posts are HERE.
Wednesday, July 1, 2009
Despondex: Is psych mania overreaching?
First, click the image above to watch this ad for Despondex, the first-ever prescription depressant. It brilliantly captures how the pharmaceutical industry pathologizes human conditions, mints formal diagnoses to label them, and markets lucrative medications to treat them.
Take bipolar disorder in children.
It has gone from a rare condition to a common diagnosis. In an 8-year period (1994-2002), the number of children diagnosed as bipolar increased by 4,000 percent. Yes, that's right. Four thousand percent. As with the ADHD craze a few years ago, with the diagnostic labeling has come medications for about two-thirds of the newly bipolar. Medications that cause severe long-term health consequences, such as obesity and diabetes.
Now, show me a child who doesn't have radical mood swings. As Christopher Lane describes in Shyness: How Normal Behavior Became a Sickness, the steps to creating a disorder are straightforward:
- Conduct a study.
- Discover a previously overlooked problem.
- Label it.
- Create a formal diagnosis.
- Promote a treatment.
- Marginalize the critics.
Through this process, the prevalence of a disorder can be made to "rise and fall as erratically as the stock market" (to quote Kutchins & Kirk from Making Us Crazy) through adjustments to the wording, symptom duration, and the number of criteria required for diagnosis.Indeed, we are witnessing this manufacturing process in the current effort to create a bizarre new diagnosis of "pedohebephilia" for the DSM-V, as I have blogged about more than once.
But has the psychiatric-pharmaceutical juggernaut gone too far? I am probably being overly optimistic, but I find this past week's developments mildly encouraging.
First came the research study published in the June 17 issue of the Journal of the American Medical Association, announcing flaws in the much-touted 'Depression Risk Gene' study upon which so much of our popular culture's notion of mental illness rests.
That followed exposes, such as one in the Miami Herald, of pharmaceutical drugmakers' use of ghostwriters to produce ''a huge body of medical literature that society can't trust.''
Just today came two more entries in the series of critical articles about psychiatric diagnosis and the pharmaceutical industry, in newspapers on separate continents -- the London Times and the San Francisco Chronicle.
The Chronicle's lead story focused on the diagnosis of bipolar disorder among children. The London Times article promotes a new book by the brilliant Richard Bentall (whose 1994 book, Madness Explained, deservedly won the British Psychological Book Of The Year award).
Doctoring the Mind: Is Our Current Treatment of Mental Illness Really Any Good? pulls no punches: It "paints a stark picture of a mental health system riddled with corruption and incompetence, in which shrinks live it up on pharmaceutical company cash while patients are disrespected, dehumanised and drugged to the eyeballs."
Bentall isn't some foaming-at-the-mouth anti-psychiatry extremist. He offers rational argument and scientific evidence to back up his claims about the ineffectiveness of modern psychiatric "treatment" and the weaknesses in its underlying biomedical model.
Bentall is not optimistic about change, though, because psychiatry and drug companies "have a vested interest in keeping things are they are."
I am afraid he may be right. Even in the midst of critiques pointing out the long-term harm, more people than ever are popping pills and allowing their children to pop them too. The latest rage, bipolar disorder, has so inundated popular and youth culture that it's even become an aggressive verb on the playground, as
in:"You don't watch out, man, I'm gonna go bipolar on you!"
If we don't watch out, that will be the newest mental defense to violent crime.
Photo credit: Mike "Dakinewavamon" Kline (Creative Commons license)
Read More...
Tuesday, June 23, 2009
Hebephilia struck by third blow
Down but not out?
It may be too soon to call it the death knell, but this week's ruling by a federal judge in Massachusetts certainly dealt a reeling blow to the highly contested pseudo-diagnosis of hebephilia and its ever-more-marginalized adherents.
In the third of three back-to-back decisions in federal court, U.S. District Judge Joseph Tauro said hebephilia just doesn't pass muster as a basis for civilly committing someone as a "sexually dangerous offender."
Hebephilia -- sexual attraction to adolescents -- certainly exists in nature, but the Government failed to meet is burden of establishing by clear and convincing evidence that it amounted to "a serious mental illness, abnormality, or disorder" as required for civil commitment, wrote the judge. Simply put, "hebephilia is not generally recognized as a serious mental illness by the psychological and psychiatric communities."
The case involved Todd Carta, who was due to be released from federal prison after serving time for computer-based child pornography. Carta has a lengthy history of sex with underage males, ages 13 on up, and has acknowledged an attraction to adolescent boys.
The Government's expert, psychologist Amy Phenix, diagnosed Carta with "Paraphilia Not Otherwise Specified: Hebephilia," which she defined as a sexual preference for "young teens . . . 'till about age seventeen."
Phenix's position was countered by psychologist Leonard Bard, who testified that Carta had no diagnosable mental disorder. Bard identified numerous problems with the diagnosis of hebephilia, including its absence from the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the prevalence of sexual attraction to adolescents among normal men.
The judge got it. In a thorough and well reasoned decision, he deconstructed the legal use of this nebulous diagnosis brick by brick. Perhaps most impressive was his clearly articulated understanding of the importance of adequate empirical research to support a diagnosis:"Most importantly, the Government has failed to demonstrate that a diagnosis of hebephilia or paraphilia NOS: hebephilia is supported by research in the field of psychology…. Most of the articles put forward by the Government were published by coauthors Dr. Blanchard and Dr. Cantor. Dr. Bard criticized the work of Dr. Blanchard and Dr. Cantor, testifying that they are both on the editorial board of the journal that publishes their findings, which has at least the potential to damage the integrity of the peer-review process. Dr. Bard also criticized the research underlying their conclusions for failing to include a control group and for eliminating a large portion of the samples, among other problems. The five replies criticizing Dr. Blanchard's recent article proposing inclusion of hebephilia in the DSM-V suggest that Dr. Blanchard's work is not widely accepted. Dr. Bard testified that 'it’s the same group that is published over and over again trying to justify [a diagnosis of hebephilia], and they have failed.' "
The judge acknowledged that by ordering Carta's release he was not suggesting the convicted sex offender is a model citizen, but just drawing a line in the sand between criminality and mental disorder: Absent a widely recognized mental disorder it is Unconstitutional to "order indefinite commitment on the basis of the offensiveness of Respondent's conduct alone."
This is the third federal ruling in a row against hebephilia. The only other federal courts to address its use both rejected it as a basis for civil commitment. Those cases were U.S. v. Shields and U.S. v. Abregana, both decided last year.
Normally, this might be a "Three Strikes and You're Out" situation. Put the tired old construct to bed.
But fans are frantically trying to rehabilitate and rejuvenate hebephilia by getting it added to the next edition of the DSM (DSM-V). This would get around at least one of the many concerns expressed by Judge Tauro and others, over "the lack of any clear criteria" for making the diagnosis. Spearheading the DSM-V effort is Raymond Blanchard of the Centre for Addiction and Mental Health in Canada, who not only sits on the editorial board of the journal that published his research (as Judge Tauro pointed out in his opinion), but also serves on the DSM-V Sexual and Gender Identity Disorders Work Group. From that influential position, he is lobbying for the addition of hebephilia or a newly minted term – pedohebephilic disorder (what a mouthful!) to the diagnostic bible.
With the DSM-V work groups stacked (see my related posts HERE), we may just have to wait and see. But in the meantime, All Hail to Massachusetts, for landing a solid blow against pseudoscience in the forensic arena.
Judge Tauro's decision is HERE. A list of articles on "Hebephilia and the DSM-V Controversy" is HERE; for more on hebephilia see my essay, "Invasion of the hebephile hunters: Or, the story of how an archaic word got a new lease on life."
Photo credit: Noel Kerns' "Closed," Creative Commons license (entrance to the defunct Mission Four Outdoor Theatre in San Antonio, Texas)
Saturday, June 6, 2009
Embitterment disorder: The latest from DSM-V
My regular readers know all about the DSM-V revision controversies (click HERE for more), and the efforts of some psychiatrists to make the manual ever-more-expansive, until just about nearly every human condition becomes a formal pathology.
But, really, folks. Post-traumatic embitterment disorder? Isn't that going a bit far?
The L.A. Times' Shari Roan has the story of how some psychiatrists want to create a formal label for embittered people bent on revenge. We all know them; now we'll have a handy-dandy acronym -- PTED -- by which to refer to them.
The article is part of Ms. Roan's ongoing coverage of the heated DSM debates at the American Psychiatric Convention in San Francisco. Today's coverage is here.
MORE DSM NEWS: A letter in the current New England Journal of Medicine on the pharmaceutical influence over the DSM-V development process, and the resultant "crisis of credibility" in psychiatry, is online HERE. The authors are Lisa Cosgrove, Ph.D., of the University of Massachusetts; Harold J. Bursztajn, M.D., of Harvard Medical School; and Sheldon Krimsky, Ph.D., of Tufts University.
Wednesday, May 27, 2009
Salon on Army PTSD diagnosis scandal
Many of my forensic psychology students have signed up with the military after getting their graduate degrees. A main reason is to get the student loan monkey off their back; the military will forgive their massive debts. That is hard to resist. But at what price service?
Today's Salon features an audiotape of civilian psychologist Douglas McNinch explaining to a combat veteran the pressure the military puts on treatment providers not to diagnose Posttraumatic Stress Disorder:
(CLICK ON THE IMAGE ABOVE TO LISTEN TO THE AUDIOTAPE)
"I will tell you something confidentially that I would have to deny if it were ever public. Not only myself, but all the clinicians up here are being pressured to not diagnose PTSD and diagnose anxiety disorder NOS [instead]."The audiotape, secretly recorded by a patient labeled "Sgt. X," confirmed what "wounded soldiers and their advocates have long suspected -- that the military does not want Iraq veterans to be diagnosed with PTSD."
Why not? Because Posttraumatic Stress Disorder would require paying for expensive, intensive treatment, including possibly lifelong disability payments. Large numbers of vets suffering from severe trauma might also dampen public enthusiasm for war, and make recruitment even more difficult than ever.
After the tape surfaced, the Senate Armed Services Committee refused to investigate, and the Army conducted its own internal investigation that cleared itself of any wrongdoing. What a surprise.
Perhaps some of you have seen Michael Moore's award-winning documentary, Fahrenheit 9/11, which shows predatory recruiters prowling shopping malls in poor communities scouring for fresh meat. Or the harrowing movie Stop-Loss, about how hard it is for some to get out of the Army once they have served their time.
Many young people come home damaged or destroyed, with invisible but severe traumatic brain injuries (as I blogged about two years ago) or severe psychological trauma. After the military chews them up and spits them out, psychologists like my former students are supposed to put them back together again.
But, hey, it's really not that bad. It's only Anxiety Not Otherwise Specified. How hard can that be to treat?
"COMING HOME" is the title of the excellent Salon investigative series about U.S. Army troops who have returned from Iraq. Focusing on troops at Fort Carson, Colorado, Salon reporters reviewed more than two dozen incidents of suicide, suicide attempts, prescription drug overdoses and murder, much of which "could have been avoided if the Army did a better job of recognizing and treating the symptoms of post-traumatic stress disorder."
Those of you who are attending next week's Forensic Training Institute in Oakland, California, will get to hear more about diagnostic shenanigans and the controversy over forensic use of the PTSD diagnosis. (Hopefully it's not too late to sign up, if you haven't done so already.) Read More...
Thursday, April 9, 2009
We're All Mentally Disordered: College-Age Edition
All of the diagnoses were made according to DSM-IV criteria using the National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule–DSM-IV version, a valid and reliable fully structured diagnostic interview designed for use by professional interviewers who are not clinicians.
If the interviewers are not clinicians, on what basis are they trained to understand what makes for truly significant distress that might justify a mental health diagnosis versus someone who is suffering from more mild symptoms that do not comprise a mental disorder? Here's some information from a different study that used a different slice of the same overall dataset on which the December 2008 study was based:
Approximately 1800 lay interviewers from the US Bureau of the Census administered the NESARC using laptop computer–assisted software that included built-in skip, logic, and consistency checks. On average, the interviewers had 5 years’ experience working on census and other health-related national surveys. The interviewers completed 10 days of training. This was standardized through centralized training sessions under the direction of NIAAA and census headquarters staff.
So the figures that will be trotted out in the media ad infinitum about the shoddy mental health of American youth are based on laptop-assisted interviews conducted by people who apparently have no formal training in mental health. Maybe mental health and related disability are really so easy to assess that we don't need experienced, formally trained interviewers. If that's the case, maybe we should just have Census Bureau interviewers provide initial mental health assessments in clinical care settings -- after all, if they are such good mental disorder detectors, couldn't we just train a bunch of interviewers rather than spend millions of dollars training and paying mental health professionals? Think of the savings!
I mean no disrespect toward the Census Bureau interviewers. They are performing important work that in many instances helps us to better understand the health of the nation. All I'm saying is that we might want to avoid uncritically accepting judgments of our nation's mental health based on interviewers who lack mental health training and experience.
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