Assessing risk for sexual recidivism: some proposals on the nature of psychologically meaningful risk factors

Risk assessment and treatment for sexual offenders should focus on individual characteristics associated with recidivism risk. Although it is possible to conduct risk assessments based purely on empirical correlates, the most useful evaluations also explain the source of the risk. In this review, the authors propose that the basic requirements for a psychologically meaningful risk factor are (a) a plausible rationale that the factor is a cause of sexual offending and (b) strong evidence that it predicts sexual recidivism. Based on the second of these criteria, the authors categorize potential risk factors according to the strength of the evidence for their relationship with offending. The most strongly supported variables should be emphasized in both assessment and treatment of sexual offenders. Further research is required, however, to establish causal connections between these variables and recidivism and to examine the extent to which changes in these factors leads to reductions in recidivism potential.

Effectiveness of a mental health court in reducing criminal recidivism and violence

OBJECTIVE

In response to the large-scale involvement of people with mental disorders in the criminal justice system, many communities have created specialized mental health courts in recent years. However, little research has been done to evaluate the criminal justice outcomes of such courts. This study evaluated whether a mental health court can reduce the risk of recidivism and violence by people with mental disorders who have been arrested.

METHOD

A retrospective observational design was used to compare the occurrence of new criminal charges for 170 people who entered a mental health court after arrest and 8,067 other adults with mental disorders who were booked into an urban county jail after arrest during the same interval. A matching strategy based on propensity scores was used to adjust analyses for nonrandom selection into mental health court.

RESULTS

Propensity-weighted Cox regression analysis, controlling for other potential confounding variables (demographic characteristics, clinical variables, and criminal history), showed that participation in the mental health court program was associated with longer time without any new criminal charges or new charges for violent crimes. Successful completion of the mental health court program was associated with maintenance of reductions in recidivism and violence after graduates were no longer under supervision of the mental health court.

CONCLUSIONS

The results indicate that a mental health court can reduce recidivism and violence by people with mental disorders who are involved in the criminal justice system.

Adolescent development and the measurement of juvenile psychopathy

Researchers are currently seeking antecedents of psychopathy among children and adolescents. Instruments developed for this purpose are likely to be used in the future in ways that may have serious implications for youths in delinquency and criminal cases. In this regard, and because the concept and measurement of psychopathy have been developed in reference to adults, there is reason to be concerned about potential developmental sources of false positives when measuring psychopathic traits in juvenile offenders. We provide the basis for our concern, as well as standards regarding the types of research evidence that should be provided before psychopathy measures are accepted for use in juvenile forensic assessments.

Violence risk assessment and risk communication: the effects of using actual cases, providing instruction, and employing probability versus frequency formats

This article describes studies designed to inform policy makers and practitioners about factors influencing the validity of violence risk assessment and risk communication. Forensic psychologists and psychiatrists were shown case summaries of patients hospitalized with mental disorder and were asked to judge the likelihood that the patient would harm someone within six months after discharge from the hospital. They also judged whether the patient posed a high risk, medium risk, or low risk of harming someone after discharge. Studies 1 and 2 replicated, with real case summaries as stimuli, the response-scale effects found by Slovic and Monahan (1995). Providing clinicians with response scales allowing more discriminability among smaller probabilities led patients to be judged as posing lower probabilities of committing harmful acts. This format effect was not eliminated by having clinicians judge relative frequencies rather than probabilities or by providing them with instruction in how to make these types of judgments. In addition, frequency scales led to lower mean likelihood judgments than did probability scales, but, at any given level of likelihood, a patient was judged as posing higher risk if that likelihood was derived from a frequency scale (e.g., 10 out of 100) than if it was derived from a probability scale (e.g., 10%). Similarly, communicating a patient's dangerousness as a relative frequency (e.g., 2 out of 10) led to much higher perceived risk than did communicating a comparable probability (e.g., 20%). The different reactions to probability and frequency formats appear to be attributable to the more frightening images evoked by frequencies. Implications for risk assessment and risk communication are discussed.

From the lab to the police station. A successful application of eyewitness research

The U.S. Department of Justice released the first national guide for collecting and preserving eyewitness evidence in October 1999. Scientific psychology played a large role in making a case for these procedural guidelines as well as in setting a scientific foundation for the guidelines, and eyewitness researchers directly participated in writing them. The authors describe how eyewitness researchers shaped understanding of eyewitness evidence issues over a long period of time through research and theory on system variables. Additional pressure for guidelines was applied by psychologists through expert testimony that focused on deficiencies in the procedures used to collect the eyewitness evidence. DNA exoneration cases were particularly important in leading U.S. Attorney General Janet Reno to notice the eyewitness literature in psychology and to order the National Institute of Justice to coordinate the development of national guidelines. The authors describe their experience as members of the working group, which included prosecutors, defense lawyers, and law enforcement officers from across the country.

Using a general model of personality to identify the basic elements of psychopathy

In the present paper, we outline why we believe that factor analyses of the Hare Psychopathy Checklist Revised (Hare, 2003) are unlikely to yield the basic elements of psychopathy. As an alternative approach, we suggest embedding psychopathy within a broad model of general personality functioning, namely the five factor model (McCrae & Costa, 1990). Drawing on our previous work in the area using expert ratings, correlational approaches, and a "translation" of the PCL-R, we provide a consensus description of the core elements of psychopathy: extremely high interpersonal antagonism, pan-impulsivity, the absence of negative self-directed affect, the presence of angry hostility, and interpersonal assertiveness. We end with a discussion of the implications of this analysis for understanding, researching, and measuring psychopathy.

A classification tree approach to the development of actuarial violence risk assessment tools

Since the 1970s, a wide body of research has suggested that the accuracy of clinical risk assessments of violence might be increased if clinicians used actuarial tools. Despite considerable progress in recent years in the development of such tools for violence risk assessment, they remain primarily research instruments, largely ignored in daily clinical practice. We argue that because most existing actuarial tools are based on a main effects regression approach, they do not adequately reflect the contingent nature of the clinical assessment processes. To enhance the use of actuarial violence risk assessment tools, we propose a classification tree rather than a main effects regression approach. In addition, we suggest that by employing two decision thresholds for identifying high- and low-risk cases--instead of the standard single threshold--the use of actuarial tools to make dichotomous risk classification decisions may be further enhanced. These claims are supported with empirical data from the MacArthur Violence Risk Assessment Study.

Factors that predispose, prime and precipitate NREM parasomnias in adults: clinical and forensic implications

Sleepwalking and related disorders are the result of factors that predispose, prime and precipitate episodes. In the absence of one or more of these factors sleepwalking is unlikely to occur. Predisposition to sleepwalking is based on genetic susceptibility and has a familial pattern. Priming factors include conditions and substances that increase slow wave sleep (SWS) or make arousal from sleep more difficult. These factors include sleep deprivation, alcohol, medications, situational stress and fever among others. The patient with a genetic predisposition to sleepwalking and with priming factors still requires a precipitating factor or trigger to set the sleepwalking episode in motion. Classical theories of sleepwalking were based primarily on case reports. Recently some of these theories have been tested in the sleep laboratory. Experimental sleep deprivation studies of sleepwalkers generally report an increase in complex behaviors during SWS, although one prominent study reported the opposite effect. However, the generally accepted theory that alcohol and medications can induce sleepwalking episodes remains entirely based on clinical and forensic case reports. Alleged cases of alcohol related sleepwalking often involve individuals lacking the generally accepted characteristics of sleepwalkers but with very high blood alcohol levels that could in and of itself account for complex behaviors noted without the presence of sleepwalking. Further, the effects of high levels of alcohol dramatically decrease SWS, a finding inconsistent with sleepwalking. Case reports of medication-related induction of apparent sleepwalking most often present a complex medical and psychiatric history associated with multiple medications. These patients often lack the clinical history and other criteria currently required for the diagnosis of sleepwalking. The medication-related behaviors may instead represent some other condition in an awake, but impaired patient. Sleep laboratory research has identified sleep disordered breathing, periodic leg movements, noise and touch among others as proximal triggers of sleepwalking episodes. Treatment of these triggers may result in resolution of sleepwalking without medication. Further sleep laboratory research is needed before experimental findings can be used for routine diagnostic and forensic purposes.

Ethyl glucuronide--the direct ethanol metabolite on the threshold from science to routine use

AIMS

Current biological state markers remain suboptimal with regard to sensitivity and specificity for monitoring recent alcohol consumption in various settings. Furthermore, these biomarkers can be influenced by age, gender and a variety of substances and non-alcohol-associated diseases and do not cover fully the time axis for alcohol intake. Ethyl glucuronide (EtG) is a non-volatile, water-soluble, stable, direct metabolite of ethanol that can be detected in various body fluids, tissues and hair. Shortly after the consumption even of small amounts of ethanol, EtG becomes positive. It can detect ethanol intake up to 80 hours after the complete elimination of alcohol from the body, covering a unique and important time spectrum for recent alcohol use. EtG seems to meet the need for a sensitive and specific marker to elucidate alcohol use not detected by standard testing.

DESIGN, SETTING, PARTICIPANTS, METHODS AND FINDINGS

The literature was reviewed with a focus on possible diagnostic and therapeutic applications, currently available methods and future perspectives. To date, more than 4000 samples of body fluids, tissues and hair from approximately 1500 individuals have been assessed.

CONCLUSIONS

The data suggest that EtG is a useful tool in numerous settings, including alcohol and drug treatment (to detect lapse/relapse and for motivational feedback), in safety sensitive work settings where use is dangerous or in other settings where alcohol use may be risky (e.g. such as driving, work-place, pregnancy or monitoring physicians or other professionals who are in recovery and working) or for resolving forensic questions. If the question of recent alcohol consumption has to be answered in a binary way (yes/no), such as for determining lapses. the use of EtG in urine is among the preferred tests. The use of this marker alone and complementary with other biological state markers and self-reports is expected to lead to significant improvement in treatment outcome, therapy efficacy and cost reduction.

Linking commercial burglaries by modus operandi: tests using regression and ROC analysis

This paper uses statistical models to test directly the police practice of utilising modus operandi to link crimes to a common offender. Data from 86 solved commercial burglaries committed by 43 offenders are analysed using logistic regression analysis to identify behavioural features that reliably distinguish between linked and unlinked crime pairs. Receiver operating characteristic analysis is then used to assign each behavioural feature an overall level of predictive accuracy. The results indicate that certain features, in particular the distances between burglary locations, lead to high levels of predictive accuracy. This study therefore reveals some of the important consistencies in commercial burglary behaviour. These have theoretical value in helping to explain criminal activity. They also have practical value by providing the basis for a diagnostic tool that could be used in comparative case analysis.

The super-ordinate nature of the psychopathy checklist-revised

Psychopathy, while perhaps the earliest and most recognized personality disorder, is the subject of intense debate about its nature and measurement. The most recent proposal on its structural nature suggests that it is a multifaceted construct, made up of at least four dimensions reflecting Interpersonal, Affective, Lifestyle, and Antisocial anomalies (Hare & Neumann, 2005, 2006). These dimensions are significantly interrelated, suggesting that they are indicators for a super-ordinate factor. The nature of this higher-order factor may reflect the unifying feature which comprehensively defines the disorder. To examine this super-factor, the current study used several very large data sets of male (N = 4865) and female (N = 1099) offenders, and forensic psychiatric patients (N = 965), who were assessed with the Psychopathy Checklist-Revised (PCL-R; Hare, 2003). Structural equation modeling results indicated that the four first-order factor dimensions could be explained by a single second-order cohesive super-factor.

Age differences in young children's responses to open-ended invitations in the course of forensic interviews

To elucidate age differences in responses to free-recall prompts (i.e., invitations and cued invitations) and focused recognition prompts (i.e., option-posing and suggestive utterances), the authors examined 130 forensic interviews of 4- to 8-year-old alleged victims of sexual abuse. There were age differences in the total number of details elicited as well as in the number of details elicited using each of the different types of prompts, especially invitations. More details were elicited from older than from younger children in response to all types of prompts, but there were no age differences in the proportion of details (about 50%) elicited using invitations. Cued invitations elicited 18% of the total details, and the number of details elicited using cued invitations increased with age. Action-based cues consistently elicited more details than other types of cues.

Critical issues in psychological autopsy studies

This paper reviews research based on the psychological autopsy (PA) method applied to the study of suicide. It evidences the presence of a number of methodological problems. Shortcomings concern sampling biases in the selection of control subjects, confounding influences of extraneous variables, and reliability of the assessment instruments. The absence of homogeneity among studies in the procedure employed, as well as the lack of defined guidelines for performing this type of inquiry are emphasized. Questions needing empirical investigation in the future are pointed out. It is concluded that the validity and reliability of findings emerging from the use of this method of investigation would benefit from a standardization of its application.

Effects of a relapse prevention program on sexual recidivism: final results from California's sex offender treatment and evaluation project (SOTEP)

Final results from a longitudinal investigation of the effectiveness of cognitive-behavioral treatment with sexual offenders are presented. The study was a randomized clinical trial that compared the reoffense rates of offenders treated in an inpatient relapse prevention (RP) program with the rates of offenders in two (untreated) prison control groups. No significant differences were found among the three groups in their rates of sexual or violent reoffending over an 8-year follow-up period. This null result was found for both rapists and child molesters, and was confirmed in analyses using time to reoffense as the outcome and those controlling for static risk differences across the groups. Closer examination of the RP group's performance revealed that individuals who met the program's treatment goals had lower reoffense rates than those who did not. Although our results do not generally support the efficacy of the RP model, they do suggest a number of ways in which this kind of treatment program can be improved. This study also emphasizes the importance of including appropriate control groups in treatment outcome research. Additional controlled investigations are needed to address the many questions that remain about when and how treatment works for sexual offenders.

Facilitated psychiatric advance directives: a randomized trial of an intervention to foster advance treatment planning among persons with severe mental illness

OBJECTIVE

Studies show a high potential demand for psychiatric advance directives but low completion rates. The authors conducted a randomized study of a structured, manualized intervention to facilitate completion of psychiatric advance directives.

METHOD

A total of 469 patients with severe mental illness were randomly assigned to a facilitated psychiatric advance directive session or a control group that received written information about psychiatric advance directives and referral to resources in the public mental health system. Completion of an advance directive, its structure and content, and its short-term effects on working alliance and treatment satisfaction were recorded.

RESULTS

Sixty-one percent of participants in the facilitated session completed an advance directive or authorized a proxy decision maker, compared with only 3% of control group participants. Psychiatrists rated the advance directives as highly consistent with standards of community practice. Most participants used the advance directive to refuse some medications and to express preferences for admission to specific hospitals and not others, although none used an advance directive to refuse all treatment. At 1-month follow-up, participants in the facilitated session had a greater working alliance with their clinicians and were more likely than those in the control group to report receiving the mental health services they believed they needed.

CONCLUSIONS

The facilitation session is an effective method of helping patients complete psychiatric advance directives and ensuring that the documents contain useful information about patients' treatment preferences. Achieving the promise of psychiatric advance directives may require system-level policies to embed facilitation of these instruments in usual-care care settings.

A bifactor approach to modeling the structure of the psychopathy checklist-revised

To date, models of the structure of psychopathy as assessed by the Psychopathy Checklist-Revised (PCL-R) have taken a higher-order approach in which the factors of the PCL-R are modeled as correlated elements of a higher-order psychopathy construct. Here, we propose an alternative structural model of the PCL-R, the bifactor model, which accounts for the covariance among PCL-R items in terms of a general factor reflecting the overlap across all items, and independent subfactors reflecting the unique coherency among particular groups of items. We present examples of how this alternative structural model can account for diverging associations between different subsets of PCL-R items and external criteria in the domains of personality and psychopathology, and we discuss implications of the bifactor model for future research on the conceptualization and assessment of psychopathy.

Facial emotion processing in criminal psychopathy. Preliminary functional magnetic resonance imaging study

BACKGROUND

It has been suggested that people with psychopathic disorders lack empathy because they have deficits in processing distress cues (e.g. fearful facial expressions).

AIMS

To investigate brain function when individuals with psychopathy and a control group process facial emotion.

METHOD

Using event-related functional magnetic resonance imaging we compared six people scoring > or =25 on the Hare Psychopathy Checklist-Revised and nine non-psychopathic healthy volunteers during an implicit emotion processing task using fearful, happy and neutral faces.

RESULTS

The psychopathy group showed significantly less activation than the control group in fusiform and extrastriate cortices when processing both facial emotions. However, emotion type affected response pattern. Both groups increased fusiform and extrastriate cortex activation when processing happy faces compared with neutral faces, but this increase was significantly smaller in the psychopathy group. In contrast, when processing fearful faces compared with neutral faces, the control group showed increased activation but the psychopathy group decreased activation in the fusiform gyrus.

CONCLUSIONS

People with psychopathy have biological differences from controls when processing facial emotion, and the pattern of response differs according to emotion type.

Detecting malingered neurocognitive dysfunction using the reliable digit span in traumatic brain injury

This study assessed the effectiveness of Greiffenstein's Reliable Digit Span (RDS) score for the detection of malingered neurocognitive dysfunction. Participants were 54 traumatic brain injury patients referred for neuropsychological evaluation. Twenty-four met the Slick, Sherman, and Iverson criteria for at least probable malingered neurocognitive dysfunction. The control group was composed of 30 patients without external incentive and who thus did not meet the Slick criteria. All patients completed the digit span test as part of either the WAIS-R or WAIS-III. The RDS scores were calculated, and sensitivity, specificity, and predictive power were examined for several cutoffs. Classification accuracy for the RDS was excellent. Issues related to the clinical application of this technique are discussed.

Marlowe-Crowne Social Desirability Scale and short Form C: forensic norms

Marlowe-Crowne Social Desirability Scale (MC) (Crowne & Marlowe, 1960) scores were collected on 1096 individuals involved in forensic evaluations. No prior publication of forensic norms was found for this instrument, which provides a measure of biased self-presentation (dissimulation). MC mean score was 19.42 for the sample. Also calculated was the score on Form C (MC-C) (Reynolds, 1982), and the mean for this 13-item scale was 7.61. The scores for the current sample generally are higher than those published for non-forensic groups, and statistical analysis indicated the difference was significant for both the MC and MC-C (d =.75 and.70, respectively, p <.001). Neither gender nor educational level proved to be significant factors in accounting for variance, and age did not appear to be correlated with scores. Group membership of subjects based on referral reason (family violence, abuse, neglect, competency, disability) was significant for both the MC and MC-C scores. Results suggest the MC or MC-C can be useful as part of a forensic-assessment battery to measure biased self-presentation.

EssenCES, a short questionnaire for assessing the social climate of forensic psychiatric wards

BACKGROUND

A supportive ward atmosphere is considered by many to be a precondition for successful treatment in forensic psychiatry, but there is a clear need for a valid and economic climate evaluation instrument.

AIMS

To validate a short questionnaire, designed for assessing forensic psychiatric wards. Climate dimensions measured with the 'Essen Climate Evaluation Schema' (EssenCES) are 'Therapeutic Hold', 'Patients' Cohesion and Mutual Support' and 'Safety' (versus threat of aggression and violence).

METHOD

In 17 forensic mental hospitals in Germany, patients and staff completed the EssenCES and other questionnaires. Problematic events were recorded over a period of 3 weeks on each ward.

RESULTS

The anticipated three factor structure of the instrument was confirmed. The pattern of correlations also provided support for the validity of the subscales.

CONCLUSIONS

The climate questionnaire is an economic and valid instrument for assessing the ward atmosphere in forensic psychiatry. Findings from a pilot study in England give confidence to the structural validity of the English version too.

The language of suicidology

This 2005 Louis I. Dublin Award Address explores some of the basic difficulties and controversies inherent in the development and universal acceptance of a nomenclature for suicidology. Highlighted are some of the unresolved challenges with agreeing upon a mutually exclusive set of terms to describe suicidal thoughts, intentions, motivations, and self-destructive behaviors.

Classification Accuracy of the Test of Memory Malingering in Traumatic Brain Injury: Results of a Known-Groups Analysis

This study used a known-groups design to determine the classification accuracy of the Test of Memory Malingering (Tombaugh, 1996, 1997) in detecting cognitive malingering in traumatic brain injury (TBI). Forty-one of 161 TBI patients met Slick, Sherman, and Iverson (1999) criteria for Malingered Neurocognitive Dysfunction. Twenty-two no-incentive memory disorder patients were also included. The original cutoffs (<45) for Trial 2 and Retention demonstrated excellent specificity (less than a 5% false positive error rate) and impressive sensitivity (greater than 45%). However, these cutoffs are actually conservative in the context of mild TBI. Over 90% of the non-MND mild TBI sample scored 48 or higher on the Retention Trial and none scored less than 46 while 60% of the MND patients claiming mild TBI were detected at those levels. Trial 1 also demonstrated excellent classification accuracy. Application of these data to clinical practice is discussed.

A framework for integrating dimensional and categorical classifications of personality disorder

Although empirical evidence strongly supports a dimensional representation of personality disorder, there is strong resistance to dimensional classification due in part to concerns about clinical utility. Acceptance of an evidence-based dimensional classification would be facilitated by information on how such a system would map onto existing diagnoses. With this objective in mind, an integrated framework is proposed that combines categorical and dimensional diagnoses. A two-component classification is adopted that distinguishes between the diagnosis of general personality disorder and the assessment of individual differences in the form the disorder takes. Then, the DSM definition of personality disorders is extended by defining individual disorders as categories of trait dimensions. This makes it possible to develop an integrated classification organized around a set of empirically derived primary traits. Assessments of these traits may then be combined to generate categorical and dimensional diagnoses. It is argued that this approach would introduce an etiological perspective into the classification of personality disorder and improve categorical classification by providing an explicit definition of each diagnosis. The clinical utility of incorporating a dimensional classification is discussed in terms of convenience and acceptability, value in predicting outcomes and treatment planning, and usefulness in organizing and selecting interventions.