Forensic Evaluation of Refugees from Myanmar.

Forensic evaluators may have little experience and knowledge of the political context of Myanmar, the Burmese people, and the refugee crisis. Oppression of several ethnic minority groups has marked Burmese military rule of Myanmar for several decades. Protracted trauma exposure, both pre- and post-migration, among refugee populations increases the risk for mental health disorders, particularly depression, anxiety, alcohol abuse, and posttraumatic stress disorder. These experiences may result in anger and psychiatric manifestations that bring Burmese refugees in conflict with the law in their host country. Culture influences how mental distress is experienced and reported, and it can influence a forensic evaluator's assessment of psychological-legal matters, such as competency to stand trial and asylum evaluations. The salience of cultural competence becomes particularly pressing given the small number of those of Burmese background in the United States. Most evaluations will be performed by forensic mental health professionals who are not Burmese in ethnicity, nor familiar with Burmese culture. In this article, we provide a backdrop of the military suppression of ethnic minorities prior to discussing the integration of cultural matters in forensic assessments of competency to stand trial, competency for extradition, and asylum seekers in Burmese refugees.

Pathways for VA and community stakeholder management of military veterans with sexual offenses: Sexual and nonsexual recidivism rates and risk factors in military veterans released from California sexually violent predator (SVP) commitment.

Military veterans with sexual offenses committed after discharge are often eligible for Veterans Affairs (VA) services including health care. There are few, if any, studies of sexual recidivism among military veterans with sexual offense histories to guide clinical management. This study examined diagnostic and postrelease sexual and nonsexual recidivism among military sexual offenders released from California sexually violent predator (SVP) commitment. The sample consisted of 363 males; 131 were identified as military veterans and 232 as civilians. The rates of recidivism were assessed for two follow-up periods: a fixed 5-year and a total 21-year follow-up. Recidivism was operationalized as any new sexual, violent, or general criminal arrest or conviction occurring after discharge to the community in California. We found a low risk for sexual reoffense for both groups. Specific to veterans, the rates for sexual and nonsexual violent recidivism were under 7% for both follow-up periods. Diagnostically, veterans had a significantly higher rate of pedophilic disorder and lower rate of antisocial personality disorder than civilians; neither were predictive of sexual recidivism or any other recidivism. On average, veterans were 61 years old at discharge; and older age at discharge was associated with a significantly lower likelihood of recidivism of any type. A relatively high proportion of veterans had a history of childhood sexual abuse and head trauma. Trauma-informed care may be a particularly valuable treatment approach for veterans with sexual offenses. These data may aid the VA and other providers in forming evidence-based decisions regarding the management of veterans with sexual offenses. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Illuminating Sociocultural and Ethnocultural Consciousness in Forensic Practice.

In recent decades, there has been an evolution in forensic psychiatry and psychology toward closer examination of the professionals' attitudes and intentions in their practice. We theorize that the progressive change reflects increased attention to the experiences of evaluators and evaluees in their social worlds. This cultural focus complements the traditional emphasis on biomedical elements, such as neuropsychiatric disorders. We suggest that sociocultural factors (such as poverty, trauma, and sexual orientation) and ethnocultural factors (such as those related to ethnic status, discrimination, and racialized application of risk assessment) have contributed substantially to these developments in forensic practice. We utilize past and current literature to illustrate the change and to frame it as a way of improving practice. This is a call for forensic practitioners to enhance their awareness of the impact of social and ethnocultural factors. We recommend further examination of these ideas by training programs and broader scholarly discussion in educational forums.

Reset for systematic action: Removing VA barriers to housing and treatment for military veterans with sexual offenses.

Though the U.S. Department of Veterans Affairs (VA) provides housing, residential treatment, and mental health care to justice involved veterans, those with sexual offenses face daunting obstacles to securing such services, including exclusion from housing programs, and lack of mental health services to treat sexual deviancy disorders. The VA's strategy to date may reflect a large system's caution in systematically addressing a problem that involves a population with an even higher degree of stigma than homelessness. Failure to develop strategies to address this problem reflects the need for a VA system-wide, consistent, and effective approach across relevant domains that incorporate the current state of knowledge and practice. Since 2006, the VA's program serving justice system veterans has been highly effective in serving the reentry veteran population. The challenge of serving veterans with sex offenses can and must be met with a similar level of effectiveness. In this commentary, we propose that the VA, beginning with the Secretary, adopt a "reset" policy and programmatic action agenda to enhance access to housing and treatment for sexual deviancy disorders. We offer specific pathways for implementation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Addressing Systemic Bias in Violence Risk Assessment.

Criminal history plays a prominent role in violence risk assessments. For people in nondominant groups, disproportionate criminal justice involvement may unfairly and inaccurately elevate violence risk in evaluations. Criminal justice reports continue to document higher rates of arrest and convictions for those in minoritized racial groups. Bureau of Justice surveys have found that ethnic minorities are more likely to serve time when crime is violent than are Whites. Black males ages 18 and 19 were 12.7 times more likely to be imprisoned than White males of the same ages. In fact, across all age bands, from 18 to 65 and older, Blacks had higher rates of imprisonments than Whites. Racial inequities in incarceration rates can translate into a Black offender receiving higher risk scores on actuarial instruments than a White offender and thus a biased misclassification as high risk. Awareness of the impact of structural biases that may be embedded in violence risk assessments is critical to fair assessments. We highlight sources of potential systemic racial bias embedded within existing violence risk assessment methods and conclude with potential methods to enhance structural competency and reduce the risk of biased assessments.

Factors associated with repeat sexual offending among U.S. military veterans compared to civilians.

Although veterans have lower incarceration rates than civilians, large national surveys find higher rates of incarceration for sexual offenses among veterans compared to non-veterans. However, little is known about the factors associated with repeat sexual offending among veterans. This study examines characteristics of veterans who committed sexual offenses and how they differ from civilians with those offenses. It also examined if the factors that differ between veterans and civilians who have a history of repeat sexual offenses and those who do not. Based on previous research related to risk in veterans, we expected there may be veteran-specific risk factors. This study used the Survey of Inmates in State and Federal Correctional Facilities. Predictors were identified through a review of the literature regarding sexual offense risk assessment and justice-involved veterans. Risk factors were examined using logistic regression analysis. In a multivariate logistic regression, there were significant interactions between veteran status and age, race, and education in the prediction of repeat offense status. Prior incarceration for a non-sexual offense was also associated with repeat offense status. Findings suggests that civilian risk factors are relevant to veteran risk assessment, an important finding that can help inform intervention and risk management with veterans.

A Comparison of Risk Factors Among Discharged Military Veterans and Civilians Involuntarily Hospitalized Under California's Sexually Violent Predator Act.

While military veterans have a lower overall rate of incarceration for criminal offenses than civilians, they have a higher rate of incarceration for violent sexual offenses. Despite military veteran overrepresentation among individuals adjudicated for violent sexual offenses, little is known about their risk factors for sexual offending. This study compared military veterans and civilians who had been involuntarily hospitalized and discharged pursuant to California's Sexually Violent Predator Act. Pedophilic disorder appeared nearly twice as often among veterans than civilians (62.7% vs. 38.7%), whereas antisocial personality disorder was twice as common among civilians compared to veterans (48.1% vs. 23.9%). Consistent with the result for pedophilic disorder, veterans were more likely to target male victims age 13 and below, while civilians tended to target female victims over the age of 13. The results suggest different risk profiles for veterans compared to civilians who have been convicted of sexually violent offenses.

Applying Collaborative Justice to Sexually Violent Predator Civil Commitment.

Sexually violent predator (SVP) statutes are unique in that these laws allow for the indefinite civil psychiatric commitment of sex offenders after their criminal sentences have been served. In addition to the high cost of psychiatric hospitalization, recently observed low base rates of sexual recidivism of sex offenders released from custody suggest that, in select SVP cases, a collaborative justice model of outpatient placement may be feasible in lieu of lengthy and costly placement in state hospitals. Given its position as one of the states with a large number of SVP commitments, California offers an opportunity to implement a collaborative justice model for adult sex offenders found to meet SVP criteria. In this article, a template for such a model is suggested. Admittedly, this model faces multiple obstacles, both within the judicial system and in the public arena. Nonetheless, public concerns may be mitigated through high-control parole plus additional treatment and controls, interim halfway house placement, and community prosocial support systems.

Case Law Considerations in the Use of ASPD in SVP/SDP Evaluations.

The use of antisocial personality disorder (ASPD) as a qualifying mental disorder for a sexually violent predator (SVP) or a sexually dangerous person (SDP) commitment continues to arouse controversy. Two common questions arise. Is ASPD considered a qualifying mental disorder in statutory or case law definitions? Can ASPD be the sole qualifying mental disorder? We review case law for guidance as to when ASPD may serve as a sole qualifying diagnosis in SVP/SDP evaluations. Other than the federal government and New York, all other jurisdictions with SVP/SDP commitments permit the use of ASPD as a stand-alone diagnosis when it can be linked to sexually violent behavior. ASPD is a viable qualifying disorder when the pattern of offending is atypical, severe, and can be linked to the risk for further sexual offending. ASPD is less viable as a qualifying diagnosis when it is manifested primarily by criminal behavior, the sex crimes are situational in context (e.g., substance abuse, negative peer affiliation), or the disorder cannot be linked to future sexual offending. Case law can provide guidelines, but the forensic clinician as the diagnostic expert bears the responsibility of providing a cogent and sound rationale as to why ASPD drives the risk for sexual reoffense.

Veterans in Prison for Sexual Offenses: Characteristics and Reentry Service Needs.

Among prison-incarcerated men in the United States, more veterans (35%) have a sexual offense conviction than nonveterans (23%). Limited research has investigated factors explaining the link between military service and sexual offending. Nationally representative data from prison-incarcerated men (n = 14,080) were used to examine the association between veteran status and sexual offenses, adjusting for demographic, childhood, and clinical characteristics. Veterans had 1.35 higher odds (95% confidence interval = [1.12, 1.62], p < .01) of a sexual offense than nonveterans. Among veterans, those who were homeless or taking mental health medications at arrest had lower odds and veterans with a sexual trauma history had higher odds of a sexual offense compared with other offense types. Offering mental health services in correctional and health care settings to address trauma experiences and providing long-term housing options can help veterans with sexual offenses as they transition from prison to their communities.

Coming home from prison: Adapting military resilience training to enhance successful community reintegration for justice-involved Iraq-Afghanistan veterans.

We propose a veteran-centric justice model of resilience training developed by the military for assisting service members coming home from war and modify it to assist Iraq/Afghanistan veterans coming home from prison. Incarceration has been identified as a stress aftereffect of the prolonged Iraq and Afghanistan combat deployments. Notably, the rate of Iraq and Afghanistan-era incarcerated veterans increased from 4% to 13% between 2004 and 2012 for all incarcerated veterans. Successful reentry to the community from prison incarceration is difficult, with rearrest and reincarceration a frequent occurrence. Moreover, combat stress conditions may weaken the justice-involved Iraq/Afghanistan's veteran's ability to face challenges posed by the return home from prison. As in the war zone, the return home from prison may be idealized with unrealistic expectations and/or goals, thus setting up the returning veteran for disappointment, anger, deepening of alienation and disconnection from larger civilian society, and the risk of return to maladaptive mechanisms for coping. Resilience training can be provided in psychoeducational venues prior to prison release and with follow-up postrelease. Resilience building offers promise as an intervention to enhance the justice-involved veteran's successful community reentry. (PsycINFO Database Record

Linking Mental Disorder and Risk in Sexually Violent Person Assessments.

A common criticism of sexually violent person (SVP) laws is that psychiatric commitment has been co-opted to continue the incarceration of dangerous criminals, not dangerous individuals with mental illness. This opinion may have credence because some forensic clinicians use a "silo" approach (i.e., diagnosing based on historical criminal behavior rather than current symptomatology, and formulating risk for future sexual violence based on actuarial scores rather than characteristics and features of the mental condition). A silo process fosters a missing link; namely, the absence of a nexus between the mental condition and risk. This approach violates the necessary predicate for involuntary civil commitment, that the symptoms of an individual's current mental disorder be linked to and support a present sexual danger to others. In this article, we provide a brief overview of SVP statutes; describe how the silo approach compromises accurate diagnosis and identification of relevant risk factors; and present actual and fictitious cases illustrating the presence and absence of the missing link.

Cognitional Impairment: Is There a Role for Cognitive Assessment in the Treatment of Individuals Civilly Committed Pursuant to the Sexually Violent Predator Act?

Sexually Violent Predator statutes allow the involuntary treatment of individuals who are found to pose a threat to public safety. Most sex offender treatment programs rely on cognitive interventions to reduce the risk of recidivism. The purpose of this study was to examine (a) whether individuals with paraphilia diagnoses have cognitive deficits compared with the general population; (b) whether individuals diagnosed with pedophilia differed on cognitive performance when compared with individuals diagnosed with paraphilia not otherwise specified (NOS), nonconsent; and (c) whether individuals with paraphilia plus antisocial personality disorder (ASPD) differed in cognitive performance when compared with individuals with a paraphilia diagnosis only. The sample consisted of 170 males (M age = 50.21; SD = 10.22) diagnosed with pedophilia or paraphilia NOS, nonconsent, who were detained or civilly committed to a forensic psychiatric hospital. Assessments included Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Wechsler Abbreviated Scale of Intelligence (WASI), and Wide Range Achievement Test 4 (WRAT4). Individuals diagnosed with pedophilia and paraphilia NOS, nonconsent, obtained lower scores than matched controls based on the RBANS Immediate Memory, Visuospatial/Constructional, Delayed Memory indices and Total Score. In comparison with individuals with paraphilia NOS, nonconsent, those with pedophilia diagnosis had lower scores on the RBANS Delayed Memory. Individuals diagnosed with a paraphilia disorder combined with ASPD demonstrated trends toward lower IQ scores than those with a paraphilia diagnosis only. Treatment programs can improve their chance of success by assessment of cognitive processes, and offer therapy in a style that is consistent with the cognitive abilities of their clients.

End-of-life mental health assessments for older aged, medically ill persons with expressed desire to die.

In recent years, assisted suicide has been legalized in four states for those who are terminally ill and wish to end their lives with the assistance of lethal doses of medications prescribed by a physician. The ethics-related and legal questions raised by end-of-life suicide and decisional capacity to refuse treatment assessments are complex. In treating patients with end-stage medical conditions or disorders that severely affect the future quality of their lives, clinicians tend to engage in suicide prevention at all costs. Overriding the patient's expressed desire to die conflicts with another value, however, that of the individual's right to autonomy. We provide a framework for understanding these difficult decisions, by providing a review of the epidemiology of suicide in later life; reviewing findings from a unique dataset of suicides among the elderly obtained from the Los Angeles County Coroner's Office, as well as data from states with legalized assisted suicide; presenting a discussion of the two frameworks of suicidal ideation as a pathological versus an existential reaction; and giving a case example that highlights the dilemmas faced by clinicians addressing decisional capacity to refuse treatment in an elderly, medically ill patient who has expressed the wish to die.

Moving upstream: why rehabilitative justice in military discharge proceedings serves a public health interest.

The cultural divide between US military and civilian institutions amplifies the consequences of military discharge status on public health and criminal justice systems in a manner that is invisible to a larger society. Prompt removal of problematic wounded warriors through retributive justice is more expedient than lengthy mental health treatment. Administrative and punitive discharges usually preclude Department of Veterans Affairs eligibility, posing a heavy public health burden. Moving upstream--through military rehabilitative justice addressing military offenders' mental health needs before discharge--will reduce the downstream consequences of civilian maladjustment and intergenerational transmission of mental illness. The public health community can play an illuminating role by gathering data about community effect and by advocating for policy change at Department of Veterans Affairs and community levels.

Screening for violence risk in military veterans: predictive validity of a brief clinical tool.

OBJECTIVE: Violence toward others is a serious problem among a subset of military veterans. The authors evaluated the predictive validity of a brief decision support tool to screen veterans for problems with violence and identify potential candidates for a comprehensive risk assessment. METHOD: Data on risk factors at an initial wave and on violent behavior at 1-year follow-up were collected in two independent sampling frames: a national random-sample survey of 1,090 Iraq and Afghanistan veterans and in-depth assessments of 197 dyads of veterans and collateral informants. Risk factors (lacking money for basic needs, combat experience, alcohol misuse, history of violence and arrests, and anger associated with posttraumatic stress disorder) were chosen based on empirical support in published research. Scales measuring these risk factors were examined, and items with the most robust statistical association with outcomes were selected for the screening tool. Regression analyses were used to derive receiver operating characteristic curves of sensitivities and specificities, with area under the curve providing an index of predictive validity. RESULTS: The resultant 5-item screening tool, called the Violence Screening and Assessment of Needs (VIO-SCAN), yielded area-under-the-curve statistics ranging from 0.74 to 0.78 for the national survey and from 0.74 to 0.80 for the in-depth assessments, depending on level of violence analyzed. CONCLUSIONS: Although the VIO-SCAN does not constitute a comprehensive violence risk assessment and cannot replace fully informed clinical decision making, it is hoped that the screen will provide clinicians with a rapid, systematic method for identifying veterans at higher risk of violence, prioritizing those in need a full clinical workup, structuring review of empirically supported risk factors, and developing plans collaboratively with veterans to reduce risk and increase successful reintegration in the community.

Critical concerns in Iraq/Afghanistan war veteran-forensic interface: veterans treatment court as diversion in rural communities.

The veteran-forensic interface is an emerging area of relevance to forensic clinicians assessing or treating returning Iraq and Afghanistan war veterans facing criminal sanctions. Veterans' Treatment Court (VTC) represents a recent diversion mechanism for low-level offenses that is based on a collaborative justice model. Thirty-nine percent of veterans who served in Iraq or Afghanistan and receiving VA services reside in rural areas. Rural veterans facing criminal justice charges may be at a disadvantage due to limited access to forensic psychiatrists with relevant expertise in providing veterans services for diversion. Therefore, widening the pool of forensic clinicians who have such expertise, as well as knowledge of the signature wounds of the wars as related to aggression and reckless behavior is necessary. This article presents an overview of VTCs and discusses the role of forensic clinicians as stakeholders in this process.

Critical concerns in Iraq/Afghanistan war veteran-forensic interface: combat-related postdeployment criminal violence.

Identifying whether there is a nexus between Iraq and Afghanistan combat injuries and civilian violence on return from deployment is complicated by differences in reactions of individuals to combat exposure, the overlapping effects of traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), and the low base rate of civilian violence after combat exposure. Moreover, the overall prevalence of violence among returning Iraq and Afghanistan combat war veterans has not been well documented. Malingered symptoms and either exaggeration or outright fabrication of war zone exposure are challenges to rendering forensic opinions, with the risk reduced by accessing military documents that corroborate war zone duties and exposure. This article serves as a first step toward understanding what may potentiate violence among returning Iraq and Afghanistan veterans. We offer a systematic approach toward the purpose of forensic case formulation that addresses whether combat duty/war zone exposure and associated clinical conditions are linked to criminal violence on return to civilian life.

Normative versus consequential ethics in sexually violent predator laws: an ethics conundrum for psychiatry.

Nineteen states and the federal government have statutes for the civil commitment of sexually violent predators (SVP). The American Psychiatric Association has vigorously opposed SVP laws, citing the abuse of both individual civil rights and of psychiatry in forwarding preventive detention. Those who support the laws underscore that the statutes target highly dangerous sex offenders. There are two different approaches to understanding ethics-based problems and their solutions. The normative approach assumes that there is a universal, intuitive, abstract, correct answer to a given question. However, there is no universal right way to balance the important normative ethic of protecting individual rights with the equally important normative ethic of protecting public safety. A less universal approach, consequential ethics, becomes necessary when abstract normative values conflict and lead to opposing conclusions. In this commentary, we examine and attempt to resolve the conflicting positions raised by the SVP statutes by using consequential versus normative ethics.

Alice in actuarial-land: through the looking glass of changing Static-99 norms.

The Static-99, an actuarial rating method, is employed to conduct sexual violence risk assessment in legal contexts. The proponents of the Static-99 dismiss clinical judgment as not empirical. Two elements must be present to apply an actuarial risk model to a specific individual: sample representativeness and uniform measurement of outcome. This review demonstrates that both of these elements are lacking in the normative studies of the Static-99 and its revised version, the Static-99R. Studies conducted since the publication of the Static-99 have not replicated the original norms. Sexual recidivism rates for the same Static-99 score vary widely, from low to high, depending on the sample used. A hypothetical case example is presented to illustrate how the solitary application of the Static-99 or Static-99R recidivism rates to the exclusion of salient clinical factors for identifying sexual dangerousness can have serious consequences for public safety.