What I Learned Part II

Psychiatry residents on the APA listserv were surveyed about their experiences with social media. 9.7% of residents had gotten friend requests from patients. The remaining residents were asked what they would do if they got such requests. 85% of residents said they would automatically ignore them. 15% said they would discuss the request with the patient, then decline it. Less than 3% of residents received any training about proper social media use in residency. Half admitted googling their patients.

One poster presented the results of a one year study of four major media outlets: the New York Times, the LA Times, USA Today and Fox News. The outlets were culled for articles related to mental illness and violence. The stories were scored according to how many contained one of the follow true facts about mental illness and violence:
1. The majority of mentally ill are never violent.
2. People with mental illnesses are more likely to be victims of violence than perpetrators
3. People with mental illnesses are more likely to be violent against themselves than against others
4. When violent, they are more likely to victimize family than strangers.
Fewer than five percent of the articles contained any of these facts.

The state of New York has successfully used electronic monitoring and regular clinician feedback to reduce the use of polypharmacy in the state prison system.

All state prison systems were surveyed regarding their policies regarding pornography. Of 43 responding states, all banned material that represented a risk to institutional safety and security. There was high variability regarding allowed visual or verbal depictions of sexual acts. There is no published data to support any policy link between prison safety and the presence of pornography.

Crisis intervention training for police is thought to be helpful to reduce incidents of violent outcomes when responding to acutely mentally ill people, but the content of the training varies between program and lacks consistency. There also needs to be more outcome studies to learn if these programs do actually divert mentally ill people out of the criminal justice system.

The PCL-R is coming under pressure as a risk prediction tool. There was a great pro-con debate about this presented by a panel of Broadmoor Hospital psychiatrists. Although interrater reliability is 0.8, there is still significant variance in scores and this could be enough to cause inconsistency when using cutoff scores to determine readiness for release from their severe personality disorder program. It stood out as a risk prediction tool in the 1990's because it was the only one of its kind, but newer tools are being developed with better ROC-AUC scores.

Lastly, multiple personality disorder is coming back. In spite of recent books such as Sybil Exposed, Creating Hysteria and I'm Eve, which document the role the therapist played in the creation or course of the disorder, one presentation today still featured a criminal defendant thought to suffer from multiple personality disorder. This presentation would have been much more effective had there been another expert presenting the potential pitfalls of examining criminal defendants for this disorder. The psychiatrist in this presentation fell into many of those pits: he presented a videotape of the interview in which he asked probing and leading questions (admitting at one point he had to "dig" for symptoms for 20 minutes before the defendant reported any!), and occasionally referring to the defendant as a "patient" rather than as a defendant---clear evidence of bias. The redeeming feature of the presentation was an overview of case law regarding competency and insanity and MPD.

In 2006 there were 4000 civilly committed sex offenders in the US. In this panel they took maps of several large cities in New York, overlaid a map of schools and school bus stations, then overlaid a map of available housing. Finally, the last overlay was a map of legal exclusion zones---boundaries of areas that were legally "off-limits" to convicted sex offenders. This illustrated, at least in Buffalo, New York, that there was literally no place for a sex offender to legally live within city limits. Then they overlaid a map of reported home addresses of sex offenders: 90% were living in restricted areas. There is increasing evidence to suggest that sex offender registration and living restrictions may increase recidivism.

So that's the second conference day. I also enjoyed the computer committee's presentation, which was a two hour geek-fest off all things tech and forensic. It's something you just have to witness to appreciate, sorry. Lots of cloud-based software for document management and report-writing. Not relevant to most Shrink Rap readers but fun for me.

What I Learned Part I

Regular readers know that every year I tweet and blog from the conference of the American Academy of Psychiatry and Law. This group of forensic psychiatrists consists of about 1800 of the country's practitioners. Topics are quite diverse and sometimes rather unusual. It's a lot of fun. Here's just a small smattering of factoids I picked up yesterday:

• The "sovereign citizen" defense can prompt a competency eval, but is not a delusion. The sovereign citizen movement is a recognized subculture of people who believe the government has no jurisdiction over them.
• Of 200 defendants cleared by DNA, one-fourth had confessed to the crime.
• According to FBI uniform crime reports, between 2001 to 2009 2.2% of police murders took place while responding to calls involving a mentally ill person.
• The collection and selling of serial killer memorabilia is also a venue for potential fraud.
• President Peter Ash gave an interesting and useful Presidential address about juvenile violent offenders. Persistent juvenile offenders tend to become more impulsive with age, not less. They commit an average of 30 to 70 previous offenses before they are caught for the index violent offense. They differ from adult violent offenders in that they tend to act in groups rather than alone, they commit impulsive rather than planned violence, and their criminal activities tend to be more diverse than adults. There is a .3 correlation between juvenile psychopathy scores and later adult psychopathy, but this only accounts for ten percent of the variance. Translation: most violent juvenile offenders do not become violent adults. Nobody knows for sure why.
• There was frequent discussion of the hazards and pitfalls of involvement in social media, including discussion about using it to impeach or undermine witness credibility. So far though, when questioned nobody had actually seen this happen to an expert witness. Concern seems to be out of proportion to reality.

HIGHLIGHT OF THE DAY:

My favorite part of this first conference day was the luncheon speech by Pete Earley. Mr. Earley is a former Washington Post report and New York Times bestselling author who's son has a serious mental illness. His book Crazy is required reading in my training program. The book is a description of life inside of one state's broken forensic mental health system. He is passionate and compassionate, and a vigorous and outspoken advocate. The audience was clearly captivated by what he had to say, and at sometimes it was frankly hard not to stand up and shout 'amen'! when he made his points. (Take home quotes for me: "Never give up hope! People get better!" and "A single person can change the system.") I was thrilled to finally meet this very warm man whom I admire. And I'm not just saying this because he wrote a blurb for our book!

SUB-HIGHLIGHT:

I attended a presentation about psychiatrists in the media. The panel presented an interesting categorization of activities: psychiatrist as scientist (presenting and interpreting studies), educator, storyteller, celebrity commentator and curbside therapist. I was surprised and flattered to see the home page of Shrink Rap, and the cover of the book, as an example of "psychiatrist as educator" in the media. I'm glad to see we seem to be accomplishing something helpful.


So that's the first day. You can follow me on Twitter (see the sidebar). If you're here at the conference and want to #OccupyAAPL, drop me a note!

What I Learned Part III

• More on social media and medicine today. One survey of a surgery department showed half of residents and faculty had public Facebook accounts and a third posted professional information.
• People are using "mindfulness" therapy to treat sex offenders. No studies on efficacy.
• Offenders with bipolar and psychotic disorders are twice as likely to have more than two additional arrests than non- SMI offenders.
• Some criminal defendants try to claim that the government is a corporation, and that they should be tried under contract law rather than criminal law. This is sometimes called a "straw man defense" and may prompt judges to request a competency assessment.
• Defendants who graduate from mental health courts demonstrate improved life circumstnaces with regard to housing, quality of life, symptoms and compliance. Some studies have shown mental health courts to result in improvement for as many as 78% of defendants.
• Court ordered custody evaluators are more likely to recommend paternal custody if the mother is poor or has a history of psychiatric admissions. They are more likely to recommend maternal custody if the father has a history of arrests.
• No suicide prediction tool has a predictive validity greater than 3%.
• Forty percent of patients given opioids for non-cancer pain misuse their meds, 5% become addicted.
• In the UK people with ASPD may be subject to multiagency public protection agreements, sharing information between government agencies.

Coming up tomorrow:
      Correctional risk management and the forensic sciences sampler. Good luck to everyone without power in the snow!