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.

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.

Deinstitutionalization and other factors in the criminalization of persons with serious mental illness and how it is being addressed.

One of the major concerns in present-day psychiatry is the criminalization of persons with serious mental illness (SMI). This trend began in the late 1960s when deinstitutionalization was implemented throughout the United States. The intent was to release patients in state hospitals and place them into the community where they and other persons with SMI would be treated. Although community treatment was effective for many, there was a large minority who did not adapt successfully and who presented challenges in treatment. Consequently, some of these individuals' mental condition and behavior brought them to the attention of law enforcement personnel, whereupon they would be subsequently arrested and incarcerated. The failure of the mental health system to provide a sufficient range of treatment interventions, including an adequate number of psychiatric inpatient beds, has contributed greatly to persons with SMI entering the criminal justice system. A discussion of the many issues and factors related to the criminalization of persons with SMI as well as how the mental health and criminal justice systems are developing strategies and programs to address them is presented.

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.

Understanding and Treating Offenders with Serious Mental Illness in Public Sector Mental Health.

This article begins with the history of the rise and fall of the state hospitals and subsequent criminalization of persons with serious mental illness (SMI). Currently, there is a belief among many that incarceration has not been as successful as hoped in reducing crime and drug use, both for those with and those without SMI. Moreover, overcrowding in correctional facilities has become a serious problem necessitating a solution. Consequently, persons with SMI in the criminal justice system are now being released in large numbers to the community and hopefully treated by public sector mental health. The issues to consider when releasing incarcerated persons with SMI into the community are as follows: diversion and mental health courts; the expectation that the mental health system will assume responsibility; providing asylum and sanctuary; the capabilities, limitations, and realistic treatment goals of community outpatient psychiatric treatment for offenders with SMI; the need for structure; the use of involuntary commitments, including assisted outpatient treatment, conservatorship and guardianship; liaison between treatment and criminal justice personnel; appropriately structured, monitored, and supportive housing; management of violence; and 24-hour structured in-patient care. Copyright © 2017 John Wiley & Sons, Ltd.

Rediscovering the Concept of Asylum for Persons with Serious Mental Illness.

Treating persons with serious mental illness is a complex and challenging endeavor. One intervention that has received little attention in recent years is the need for asylum. Asylum means a sanctuary, a place that lowers levels of stress and provides protection, safety, security, and social support, as well as an array of treatment services. The concept of "asylum" may have lost favor because it was equated with the abysmal conditions found in the state psychiatric hospitals of the past. Among the reasons persons with serious mental illness have been arrested and incarcerated is society's failure to provide adequate levels of asylum. With the release of tens of thousands of mentally ill inmates from state and federal jails and prisons, it is time to revisit this concept, not only for these persons but for those who have not been criminalized. Asylum can be found in various settings, including with family in the patient's home, in a board-and-care facility, or in a psychiatric hospital if necessary. Not all persons with a major mental illness are capable of achieving high levels of social and vocational functioning; however, living in a place that provides asylum can promote a higher quality of life. The value of asylum for many persons with serious mental illness should not be underestimated.

Decarceration of U.S. jails and prisons: where will persons with serious mental illness go?

Decarceration (decreasing the number of persons incarcerated in U.S. jails and prisons) has begun. It is estimated that more than 350,000 persons with serious mental illness (SMI) are among those incarcerated in the United States and that many thousands of them will probably be among those released. Currently, the prison population in general is being reduced as a consequence of concerns about overcrowding and of policies and programs such as reclassification of drug possession, which would affect many persons with mental illness. Court-ordered diversion and changes in sentencing guidelines are also serving to reduce prison populations. In recent years, the mental health system did not have to manage as large a number of persons with SMI, especially those who were among the most difficult and expensive to treat, because many of them were incarcerated in jails and prisons. Now, with decarceration and the release of many such persons, the mental health system may be expected to assume more responsibility for them and should be prepared and funded to meet their needs. This population of persons with SMI needs structure and treatment that, depending upon their individual needs, may include 24-hour supportive housing, ACT and FACT teams, assisted outpatient treatment, psychiatric medication, and psychiatric hospitalization.

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.

Some perspectives on criminalization.

In recently published articles, there has been an underemphasis on the role serious mental illness (SMI) plays in causing persons to be in the criminal justice system. Increasing attention has been paid to other factors, including criminogenic needs. While these needs may be present and contribute to criminal behavior, persons with SMI who are at greatest risk of criminalization are those who are not receiving adequate treatment, structure, social control, and, when necessary, 24-hour care in the mental health system. Cognitive behavioral therapy (CBT) has been used to reduce recidivism for prisoners, including those with SMI, but persons impaired by their untreated psychotic symptoms may not be able to profit from it. The importance of psychiatric treatment must not be underestimated. Moreover, given their current constraints, correctional systems may not be able to continue accepting large numbers of persons with SMI. Many offenders with serious mental illness pose difficult and expensive problems in treatment and management, such as nonadherence to medication, potential for violence, and substance abuse. The mental health system needs to be given more funding and to take more responsibility for these challenging individuals.

Evolution of the psychological autopsy: fifty years of experience at the Los Angeles County Chief Medical Examiner-Coroner's Office.

The origin of the psychological autopsy was in the late 1950s and the result of a collaboration between the Los Angeles County Chief Medical Examiner-Coroner's Office and the Los Angeles Suicide Prevention Center. It was conceptualized as a thorough retrospective analysis of the decedent's state of mind and intention at the time of death. It was used initially in "equivocal" deaths where the manner of death was possibly either suicide or accident. Later, it was used in cases where a party (primarily family members) protested the Medical Examiner-Coroner's suicide determination. Over the past 25 years, the University of Southern California Institute of Psychiatry, Law, and Behavioral Science has served as the psychiatric/psychological consultants to the Coroner's Department. Research findings, the use of this approach in high-profile cases, and the most recent manner in which the psychological autopsy is conducted are discussed.

Meeting the needs of those persons with serious mental illness who are most likely to become criminalized.

Persons with serious mental illness are a heterogeneous group. A large majority recognize that they are mentally ill, and they are treatment adherent, often able to work, and do not have major problems with substance abuse and violence. However, a substantial minority exists who receive little attention in the literature. They may not believe that they are mentally ill (the possible result of anosognosia), are nonadherent to psychiatric treatment, may have acute psychotic symptoms and serious substance abuse problems, may become violent when stressed, and may show less potential for recovery. This minority is at most risk for criminalization. High degrees of structure may help reduce this risk. They need a range of outpatient and inpatient treatment, including assertive community treatment, intensive case management, assisted outpatient treatment, structured housing, co-occurring substance abuse treatment, pre- and postbooking diversion, and available hospital beds. The mental health system can reduce criminalization by taking greater responsibility for these challenging persons.

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.

Defining mental disorder when it really counts: DSM-IV-TR and SVP/SDP statutes.

Civil commitment under the sexually violent predator (SVP) statutes requires the presence of a statutorily defined diagnosed mental disorder linked to sexual offending. As a consequence of broad statutory definitions and ambiguously written court decisions, a bright line separating an SVP mental disorder from ordinary criminal behavior is difficult to draw. Some forensic evaluators reject whole categories of DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders: Text Revision) diagnoses as qualifying disorders (e.g., personality and substance abuse disorders), while others debate whether recurrent rape constitutes a paraphilic disorder. We argue that the ramifications of the SVP process, in representing both the balancing of public safety and the protection of an individual's right to liberty, demand that decisions about what is a legally defined mental disorder not be made in an arbitrary and idiosyncratic manner. Greater clarity and standardization must come from both sides: the legalists who interpret the law and the clinicians who apply and work under it.

Four-facet PCL-R structure and cognitive functioning among high violent criminal offenders.

High violent inmates (N = 126) were administered the Psychopathy Checklist-Revised (PCL-R; Hare, Clark, Grann, & Thornton, 2000; Hare et al., 1990) and neuropsychological measures. No significant correlations were present between the overall PCL-R score and 14 cognitive measures. A violence score, computed as the total number of violent acts across all situations and types, was significantly correlated with the PCL-R total score and Facet 2 but not with the other three facets. Our data suggest that Facet 2 elevations may prove relevant to violence risk assessment; this link, however, needs further exploration with larger samples.

Predicting the likelihood of future sexual recidivism: pilot study findings from a California sex offender risk project and cross-validation of the Static-99.

Pilot findings on 137 California sex offenders followed up over 10 years after release from custody (excluding cases in which legal jurisdiction expired) are presented. The sexual recidivism rate, very likely inflated by sample selection, was 31 percent at five years and 40 percent at 10 years. Cumulatively, markers of sexual deviance (multiple victim types) and criminality (prior parole violations and prison terms) led to improved prediction of sexual recidivism (receiver operating characteristic [ROC] = .71, r = .46) than singly (multiple victim types: ROC = .60, r = .31; prior parole violations and prison terms: ROC = .66, r = .37). Long-term Static-99 statistical predictive accuracy for sexual recidivism was lower in our sample (ROC = .62, r =.24) than the values presented in the developmental norms. Sexual recidivism rates were higher in our study for Static-99 scores of 2 and 3 than in the developmental sample, and lower for scores of 4 and 6. Given failures to replicate developmental norms, the Static-99 method of ranking sexual recidivism risk warrants caution when applied to individual offenders.

Treatment prospects for persons with severe mental illness in an urban county jail.

OBJECTIVE: A retrospective study of inmates with severe mental illness in a large, urban county jail aimed to obtain information about their psychiatric and criminal histories and status, the psychiatric services they used while incarcerated, and the challenges they might present in psychiatric treatment after release. METHODS: The authors ascertained demographic characteristics, diagnoses, psychiatric and legal histories, and current psychiatric condition and treatment from jail psychiatric records of a random sample of 104 male inmates with mental illness and from electronic county mental health records and state records of criminal histories. RESULTS: Seventy-eight inmates (75%) were diagnosed as having a severe mental illness. Of these, 59 (76%) required inpatient care or its equivalent for part of their time in jail for the current offense. Of the inmates with severe mental illness, 92% had a history of nonadherence to medications before this arrest, 95% had prior arrests, 72% had prior arrests for violent crimes against persons, and 76% were known to have a history of substance abuse. CONCLUSIONS: A large percentage of persons with severe mental illness received their acute psychiatric inpatient treatment in the criminal justice system rather than in the mental health system. The persons with severe mental illness in this study would present a major challenge in treatment in any setting given their psychiatric and criminal histories. The resources of the mental health system need to be greatly expanded, with priority given to treating persons who are criminalized or who are in danger of becoming criminalized.

The impact of surgical castration on sexual recidivism risk among sexually violent predatory offenders.

The relationship of surgical castration to sexual recidivism in a sexually violent predator/sexually dangerous person (SVP/SDP) population is reviewed. A review of the literature on castrated sex offenders reveals a very low incidence of sexual recidivism. The low sexual recidivism rates reported are critiqued in light of the methodologic limitations of the studies. Better designed testicular/prostate cancer studies have demonstrated that, while sexual desire is reduced by orchiectomy, the capacity to develop an erection in response to sexually stimulating material is not eliminated. The relevance of this literature to SVP/SDP commitment decisions and ethics is discussed. Two vignettes of castrated, high-risk sex offenders illustrate how to address risk reduction. Two tables are presented: the first outlines individual case data from a difficult-to-obtain report, and the second summarizes the most frequently cited castration studies on sexual recidivism. Orchiectomy may have a role in risk assessments; however, other variables should be considered, particularly as the effects can be reversed by replacement testosterone.