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Society is having a moment of reflection about the role of law enforcement and correctional facilities in addressing societal problems. During this moment, psychiatry is being asked by courts to arbitrate who qualifies and ultimately deserves certain judgments.
In particular, we are asked to assess how dangerous an individual may be using violent risk assessment tools and measures of antisocial disorders. As such, we are tasked with pointing out the negative factors of defendants. Alternatively, psychiatry is also asked to explain, using biopsychosocial determinants, what led an individual to act in a deviant manner. As such, we are tasked with pointing out mitigating factors of defendants. In this article, we attempt to look at limitations in both paradigms to encourage a more prudent forensic approach.
Negative factors
The criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM) are not composed of rigid rules with validity markers to measure their veracity but leave room for clinical judgment, variance across individuals, and future research and treatment needs.
There are some benefits to having room for clinical judgment, but it can also lead to overdiagnosis.1 This problem is particularly reflected in the diagnosis of antisocial personality disorder (ASPD), the criteria of which includes failure to conform to social norms, deceitfulness, impulsivity, irritability, recklessness, irresponsibility, and lack of remorse. Each of these criteria is ripe for subjectivity by an inexperienced or biased reviewer.
For example, it is common in our practice to see only two discrete events interpreted as a “pattern of behavior.” Such events could include two lapses in judgment to demonstrate a pattern of behavior meeting the criteria for ASPD. Using this logic, however, most Americans would meet those criteria. According to the National Survey of Drug Use and Health, the majority of Americans have tried illicit substances.2 We presume that many have tried illicit substances at least two times in their lives – in theory creating a pattern – and that subsequently they omitted that information on standard employment application forms. In doing so, they could easily be interpreted in court to have demonstrated failure to follow rules, deceitfulness in wrongfully filing an employment application, impulsivity in deciding to use drugs, recklessness in choosing to use drugs, irresponsibility for using drugs, and a lack of remorse by not acknowledging the use on an employment application, thereby meeting criteria for antisocial personality disorder.
The well-respected Hare Psychopathy Checklist contains similar opportunities for subjective interpretation by a biased evaluator. Conning, glibness, lack of guilt, lack of realistic goals, and irresponsibility are easily diverted to pathologize an individual into an exaggerated sense of menace. Journalist Jon Ronson famously challenged those concepts in his book, “The Psychopath Test: A Journey Through the Madness Industry,” a New York Times bestseller. It is common in our practice to see evaluators list dozens of scales allegedly proving someone’s dangerousness, without realizing the recurrent subjectivity involved in all those assessments.
Forensic evaluators arguing for conviction often rely on violence risk assessments to establish defendants’ propensity for future violence and to predict recidivism. There are numerous violence risk assessment tools, including: the Violence Risk Scale,3 the HCR-20 version 3 (HCR-20 v3),4 and Correctional Offender Management Profiling for Alternative Sanctions (COMPAS). Yet, despite their perceived rigor and reliability from being established assessments, their usefulness continues to be challenged.5Julia Dressel and Hany Farid, PhD, showed in 2018 how people with little to no criminal justice expertise and given only the sex, age, and previous criminal history of defendants were no less accurate than COMPAS.6 Those findings are concerning and should give us pause when we are tempted to rely on seemingly objective measures that can lead us astray. Not only can such reliance result in injudicious court decisions, but it can saddle defendants with a documented report of their perceived elevated risk for violence.
In the forensic setting, ASPD is often treated like a lifelong diagnosis. This is in part because of personality disorders being defined since the DSM-III as “enduring patterns ... [that] continue throughout most of adult life.” Even if a defendant who is diagnosed with ASPD no longer behaves antisocially, a historical ASPD diagnosis is difficult to escape. Historical behavior is part of the diagnosis, and there are no guidelines to determine at what point a person can be rid of it or what redeeming qualities or circumstances make a prior diagnosis inappropriate.
Yet, some evidence suggests that ASPD is one of the least reliable psychiatric diagnoses and that the agreement between providers of such a diagnosis was “questionable.”7Robert D. Hare, PhD, himself has been described as believing that “an awful lot of people misuse his checklist.”8 And a recent study found no “evidence for the claim that [Hare Psychopathy Checklist] psychopaths are untreatable ... on the contrary, there was replicated evidence of positive treatment outcomes.”9 Unfortunately, legal structures often help enshrine an erroneous ASPD diagnosis by imposing more punishing sentences to those diagnosed. Instead, we should recognize that ASPD can also be the culmination of biological as well as changing social and environmental circumstances.
Mitigating factors
On the other side, the defense expert also faces significant challenges, though the tools are different. Contrary to the prosecuting expert who loads an arsenal of subjective assessment tools, the defense expert will point to childhood trauma and mental illness as extenuating explanations for a crime. Having suffered abuse as a child is advanced to justify someone’s subsequent violence. This problem is reflected in the diagnosis of posttraumatic stress disorder (PTSD). An unscrupulous expert may simply allow an evaluee to endorse symptoms without clinical correlates or rigorous validation to advance this narrative.
For example, psychiatrists commonly ascribe the DSM criteria A for PTSD, “directly experiencing the traumatic event(s),” to a smaller slight in life. Some experts suggest that a medical diagnosis, even if not life-threatening but perceived as such, could warrant the diagnosis.10 This would expand our understanding of trauma and its consequences significantly. Yet already, a survey of Detroit area residents in 1998 found that 89.6% of the interviewees reported having experienced a significant trauma and that the average number of traumatic experiences was 4.8.11 The meaning of a diagnosis that can be applied to almost 90% of a population has unclear usefulness, especially if meant to diminish guilt and responsibility.
More recently, citing Adverse Childhood Experiences (ACEs) has been a common method of supporting mitigating evaluations. Using the ACEs questionnaires, researchers have supported the idea that social programs are a key player in an improved criminal justice system. The ACEs study identified 10 forms of childhood trauma in 17,000 patients, including abuse, neglect, abandonment, household dysfunction, and exposure to violence, that were strongly associated with negative psychological outcomes, engagement in high-risk behaviors, significant medical consequences, and even early death.12 However, similarly to past trauma, the prevalence of ACEs in the forensic population is the norm, not the exception.
Additional thoughts
Of particular concern is when diagnostic criteria intersect or seemingly contradict one another. For example, acts such as an outburst of anger may be interpreted by one evaluator as a sign of deviance, irritability, or recklessness – and meeting antisocial personality disorder criteria. Whereas another evaluator may interpret the same incident as hypervigilance, exaggerated startle response, or self-destructive behavior in PTSD.
An incident of not assisting someone in need may be interpreted as lack of remorse and glibness from antisocial characteristics or avoidance and detachment from others as a reaction to past trauma. Flashbacks from trauma can be interpreted by some as violent fantasies. Even the experience of trauma can be viewed as a risk factor for future violence. In some ways, our perspectives are influenced by our examination of someone’s history through the lens of sociopathy or empathy.
In summary
Psychiatry is entrusted by courts to comment on negative and mitigating factors. Negative factors hinge in part on our subjective impression of sociopathy, and mitigating factors hinge, in part, on our empathy for a defendant’s trauma. Psychiatry should recognize the limitations of both sides and humble itself in providing balanced evaluations to courts.
Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. Dr. Amendolara is a first-year psychiatry resident at University of California, San Diego. He spent years advocating for survivors of rape and domestic violence at the Crime Victims Treatment Center in New York and conducted public health research at Lourdes Center for Public Health in Camden, N.J. Dr. Amendolara has no disclosures. Dr. Ngo is a second-year child neurology resident at University of California, Los Angeles. She received a master’s degree in narrative medicine from Columbia University, New York. She has no disclosures.
References
1. Frances A. Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma and the Medicalization of Ordinary Life. Harper Collins, 2013.
2. Key Substance Use and Mental Health Indicators in the United States. National Survey on Drug Use and Health. 2018.
3. Wong SCP and Gordon A. Psychol Public Policy Law. 2006;12(3):279-309.
4. Douglas KS et al. Mental Health Law & Policy Institute. About the Historical Clinical Risk Management-20, Version 3.
5. Angwin J et al. ProPublica. 2016 May 23.
6. Dressel J and Farid H. Sci Adv. 2018;4(1). doi: 10.1126/sciady.aao5580.
7. Freedman R et al. Am J Psychiatry. 2013 Jan;170(1):1-5.
8. Lillie B. The complexities of the psychopath test: A Q&A with Ron Jonson. TEDBlog. 2012 Aug 15.
9. Larsen RR et al. Psychol Public Policy Law. 2020;26(3):297-311.
10. Cordova MJ. Psychiatric Times. 2020 Jul 31;37(7).
11. Breslau N et al. Arch Gen Psychiatry. 1998;55(7):626-32.
12. Reavis JA et al. Perm J. 2013 Spring;17(2):44-8.
Society is having a moment of reflection about the role of law enforcement and correctional facilities in addressing societal problems. During this moment, psychiatry is being asked by courts to arbitrate who qualifies and ultimately deserves certain judgments.
In particular, we are asked to assess how dangerous an individual may be using violent risk assessment tools and measures of antisocial disorders. As such, we are tasked with pointing out the negative factors of defendants. Alternatively, psychiatry is also asked to explain, using biopsychosocial determinants, what led an individual to act in a deviant manner. As such, we are tasked with pointing out mitigating factors of defendants. In this article, we attempt to look at limitations in both paradigms to encourage a more prudent forensic approach.
Negative factors
The criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM) are not composed of rigid rules with validity markers to measure their veracity but leave room for clinical judgment, variance across individuals, and future research and treatment needs.
There are some benefits to having room for clinical judgment, but it can also lead to overdiagnosis.1 This problem is particularly reflected in the diagnosis of antisocial personality disorder (ASPD), the criteria of which includes failure to conform to social norms, deceitfulness, impulsivity, irritability, recklessness, irresponsibility, and lack of remorse. Each of these criteria is ripe for subjectivity by an inexperienced or biased reviewer.
For example, it is common in our practice to see only two discrete events interpreted as a “pattern of behavior.” Such events could include two lapses in judgment to demonstrate a pattern of behavior meeting the criteria for ASPD. Using this logic, however, most Americans would meet those criteria. According to the National Survey of Drug Use and Health, the majority of Americans have tried illicit substances.2 We presume that many have tried illicit substances at least two times in their lives – in theory creating a pattern – and that subsequently they omitted that information on standard employment application forms. In doing so, they could easily be interpreted in court to have demonstrated failure to follow rules, deceitfulness in wrongfully filing an employment application, impulsivity in deciding to use drugs, recklessness in choosing to use drugs, irresponsibility for using drugs, and a lack of remorse by not acknowledging the use on an employment application, thereby meeting criteria for antisocial personality disorder.
The well-respected Hare Psychopathy Checklist contains similar opportunities for subjective interpretation by a biased evaluator. Conning, glibness, lack of guilt, lack of realistic goals, and irresponsibility are easily diverted to pathologize an individual into an exaggerated sense of menace. Journalist Jon Ronson famously challenged those concepts in his book, “The Psychopath Test: A Journey Through the Madness Industry,” a New York Times bestseller. It is common in our practice to see evaluators list dozens of scales allegedly proving someone’s dangerousness, without realizing the recurrent subjectivity involved in all those assessments.
Forensic evaluators arguing for conviction often rely on violence risk assessments to establish defendants’ propensity for future violence and to predict recidivism. There are numerous violence risk assessment tools, including: the Violence Risk Scale,3 the HCR-20 version 3 (HCR-20 v3),4 and Correctional Offender Management Profiling for Alternative Sanctions (COMPAS). Yet, despite their perceived rigor and reliability from being established assessments, their usefulness continues to be challenged.5Julia Dressel and Hany Farid, PhD, showed in 2018 how people with little to no criminal justice expertise and given only the sex, age, and previous criminal history of defendants were no less accurate than COMPAS.6 Those findings are concerning and should give us pause when we are tempted to rely on seemingly objective measures that can lead us astray. Not only can such reliance result in injudicious court decisions, but it can saddle defendants with a documented report of their perceived elevated risk for violence.
In the forensic setting, ASPD is often treated like a lifelong diagnosis. This is in part because of personality disorders being defined since the DSM-III as “enduring patterns ... [that] continue throughout most of adult life.” Even if a defendant who is diagnosed with ASPD no longer behaves antisocially, a historical ASPD diagnosis is difficult to escape. Historical behavior is part of the diagnosis, and there are no guidelines to determine at what point a person can be rid of it or what redeeming qualities or circumstances make a prior diagnosis inappropriate.
Yet, some evidence suggests that ASPD is one of the least reliable psychiatric diagnoses and that the agreement between providers of such a diagnosis was “questionable.”7Robert D. Hare, PhD, himself has been described as believing that “an awful lot of people misuse his checklist.”8 And a recent study found no “evidence for the claim that [Hare Psychopathy Checklist] psychopaths are untreatable ... on the contrary, there was replicated evidence of positive treatment outcomes.”9 Unfortunately, legal structures often help enshrine an erroneous ASPD diagnosis by imposing more punishing sentences to those diagnosed. Instead, we should recognize that ASPD can also be the culmination of biological as well as changing social and environmental circumstances.
Mitigating factors
On the other side, the defense expert also faces significant challenges, though the tools are different. Contrary to the prosecuting expert who loads an arsenal of subjective assessment tools, the defense expert will point to childhood trauma and mental illness as extenuating explanations for a crime. Having suffered abuse as a child is advanced to justify someone’s subsequent violence. This problem is reflected in the diagnosis of posttraumatic stress disorder (PTSD). An unscrupulous expert may simply allow an evaluee to endorse symptoms without clinical correlates or rigorous validation to advance this narrative.
For example, psychiatrists commonly ascribe the DSM criteria A for PTSD, “directly experiencing the traumatic event(s),” to a smaller slight in life. Some experts suggest that a medical diagnosis, even if not life-threatening but perceived as such, could warrant the diagnosis.10 This would expand our understanding of trauma and its consequences significantly. Yet already, a survey of Detroit area residents in 1998 found that 89.6% of the interviewees reported having experienced a significant trauma and that the average number of traumatic experiences was 4.8.11 The meaning of a diagnosis that can be applied to almost 90% of a population has unclear usefulness, especially if meant to diminish guilt and responsibility.
More recently, citing Adverse Childhood Experiences (ACEs) has been a common method of supporting mitigating evaluations. Using the ACEs questionnaires, researchers have supported the idea that social programs are a key player in an improved criminal justice system. The ACEs study identified 10 forms of childhood trauma in 17,000 patients, including abuse, neglect, abandonment, household dysfunction, and exposure to violence, that were strongly associated with negative psychological outcomes, engagement in high-risk behaviors, significant medical consequences, and even early death.12 However, similarly to past trauma, the prevalence of ACEs in the forensic population is the norm, not the exception.
Additional thoughts
Of particular concern is when diagnostic criteria intersect or seemingly contradict one another. For example, acts such as an outburst of anger may be interpreted by one evaluator as a sign of deviance, irritability, or recklessness – and meeting antisocial personality disorder criteria. Whereas another evaluator may interpret the same incident as hypervigilance, exaggerated startle response, or self-destructive behavior in PTSD.
An incident of not assisting someone in need may be interpreted as lack of remorse and glibness from antisocial characteristics or avoidance and detachment from others as a reaction to past trauma. Flashbacks from trauma can be interpreted by some as violent fantasies. Even the experience of trauma can be viewed as a risk factor for future violence. In some ways, our perspectives are influenced by our examination of someone’s history through the lens of sociopathy or empathy.
In summary
Psychiatry is entrusted by courts to comment on negative and mitigating factors. Negative factors hinge in part on our subjective impression of sociopathy, and mitigating factors hinge, in part, on our empathy for a defendant’s trauma. Psychiatry should recognize the limitations of both sides and humble itself in providing balanced evaluations to courts.
Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. Dr. Amendolara is a first-year psychiatry resident at University of California, San Diego. He spent years advocating for survivors of rape and domestic violence at the Crime Victims Treatment Center in New York and conducted public health research at Lourdes Center for Public Health in Camden, N.J. Dr. Amendolara has no disclosures. Dr. Ngo is a second-year child neurology resident at University of California, Los Angeles. She received a master’s degree in narrative medicine from Columbia University, New York. She has no disclosures.
References
1. Frances A. Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma and the Medicalization of Ordinary Life. Harper Collins, 2013.
2. Key Substance Use and Mental Health Indicators in the United States. National Survey on Drug Use and Health. 2018.
3. Wong SCP and Gordon A. Psychol Public Policy Law. 2006;12(3):279-309.
4. Douglas KS et al. Mental Health Law & Policy Institute. About the Historical Clinical Risk Management-20, Version 3.
5. Angwin J et al. ProPublica. 2016 May 23.
6. Dressel J and Farid H. Sci Adv. 2018;4(1). doi: 10.1126/sciady.aao5580.
7. Freedman R et al. Am J Psychiatry. 2013 Jan;170(1):1-5.
8. Lillie B. The complexities of the psychopath test: A Q&A with Ron Jonson. TEDBlog. 2012 Aug 15.
9. Larsen RR et al. Psychol Public Policy Law. 2020;26(3):297-311.
10. Cordova MJ. Psychiatric Times. 2020 Jul 31;37(7).
11. Breslau N et al. Arch Gen Psychiatry. 1998;55(7):626-32.
12. Reavis JA et al. Perm J. 2013 Spring;17(2):44-8.
Society is having a moment of reflection about the role of law enforcement and correctional facilities in addressing societal problems. During this moment, psychiatry is being asked by courts to arbitrate who qualifies and ultimately deserves certain judgments.
In particular, we are asked to assess how dangerous an individual may be using violent risk assessment tools and measures of antisocial disorders. As such, we are tasked with pointing out the negative factors of defendants. Alternatively, psychiatry is also asked to explain, using biopsychosocial determinants, what led an individual to act in a deviant manner. As such, we are tasked with pointing out mitigating factors of defendants. In this article, we attempt to look at limitations in both paradigms to encourage a more prudent forensic approach.
Negative factors
The criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM) are not composed of rigid rules with validity markers to measure their veracity but leave room for clinical judgment, variance across individuals, and future research and treatment needs.
There are some benefits to having room for clinical judgment, but it can also lead to overdiagnosis.1 This problem is particularly reflected in the diagnosis of antisocial personality disorder (ASPD), the criteria of which includes failure to conform to social norms, deceitfulness, impulsivity, irritability, recklessness, irresponsibility, and lack of remorse. Each of these criteria is ripe for subjectivity by an inexperienced or biased reviewer.
For example, it is common in our practice to see only two discrete events interpreted as a “pattern of behavior.” Such events could include two lapses in judgment to demonstrate a pattern of behavior meeting the criteria for ASPD. Using this logic, however, most Americans would meet those criteria. According to the National Survey of Drug Use and Health, the majority of Americans have tried illicit substances.2 We presume that many have tried illicit substances at least two times in their lives – in theory creating a pattern – and that subsequently they omitted that information on standard employment application forms. In doing so, they could easily be interpreted in court to have demonstrated failure to follow rules, deceitfulness in wrongfully filing an employment application, impulsivity in deciding to use drugs, recklessness in choosing to use drugs, irresponsibility for using drugs, and a lack of remorse by not acknowledging the use on an employment application, thereby meeting criteria for antisocial personality disorder.
The well-respected Hare Psychopathy Checklist contains similar opportunities for subjective interpretation by a biased evaluator. Conning, glibness, lack of guilt, lack of realistic goals, and irresponsibility are easily diverted to pathologize an individual into an exaggerated sense of menace. Journalist Jon Ronson famously challenged those concepts in his book, “The Psychopath Test: A Journey Through the Madness Industry,” a New York Times bestseller. It is common in our practice to see evaluators list dozens of scales allegedly proving someone’s dangerousness, without realizing the recurrent subjectivity involved in all those assessments.
Forensic evaluators arguing for conviction often rely on violence risk assessments to establish defendants’ propensity for future violence and to predict recidivism. There are numerous violence risk assessment tools, including: the Violence Risk Scale,3 the HCR-20 version 3 (HCR-20 v3),4 and Correctional Offender Management Profiling for Alternative Sanctions (COMPAS). Yet, despite their perceived rigor and reliability from being established assessments, their usefulness continues to be challenged.5Julia Dressel and Hany Farid, PhD, showed in 2018 how people with little to no criminal justice expertise and given only the sex, age, and previous criminal history of defendants were no less accurate than COMPAS.6 Those findings are concerning and should give us pause when we are tempted to rely on seemingly objective measures that can lead us astray. Not only can such reliance result in injudicious court decisions, but it can saddle defendants with a documented report of their perceived elevated risk for violence.
In the forensic setting, ASPD is often treated like a lifelong diagnosis. This is in part because of personality disorders being defined since the DSM-III as “enduring patterns ... [that] continue throughout most of adult life.” Even if a defendant who is diagnosed with ASPD no longer behaves antisocially, a historical ASPD diagnosis is difficult to escape. Historical behavior is part of the diagnosis, and there are no guidelines to determine at what point a person can be rid of it or what redeeming qualities or circumstances make a prior diagnosis inappropriate.
Yet, some evidence suggests that ASPD is one of the least reliable psychiatric diagnoses and that the agreement between providers of such a diagnosis was “questionable.”7Robert D. Hare, PhD, himself has been described as believing that “an awful lot of people misuse his checklist.”8 And a recent study found no “evidence for the claim that [Hare Psychopathy Checklist] psychopaths are untreatable ... on the contrary, there was replicated evidence of positive treatment outcomes.”9 Unfortunately, legal structures often help enshrine an erroneous ASPD diagnosis by imposing more punishing sentences to those diagnosed. Instead, we should recognize that ASPD can also be the culmination of biological as well as changing social and environmental circumstances.
Mitigating factors
On the other side, the defense expert also faces significant challenges, though the tools are different. Contrary to the prosecuting expert who loads an arsenal of subjective assessment tools, the defense expert will point to childhood trauma and mental illness as extenuating explanations for a crime. Having suffered abuse as a child is advanced to justify someone’s subsequent violence. This problem is reflected in the diagnosis of posttraumatic stress disorder (PTSD). An unscrupulous expert may simply allow an evaluee to endorse symptoms without clinical correlates or rigorous validation to advance this narrative.
For example, psychiatrists commonly ascribe the DSM criteria A for PTSD, “directly experiencing the traumatic event(s),” to a smaller slight in life. Some experts suggest that a medical diagnosis, even if not life-threatening but perceived as such, could warrant the diagnosis.10 This would expand our understanding of trauma and its consequences significantly. Yet already, a survey of Detroit area residents in 1998 found that 89.6% of the interviewees reported having experienced a significant trauma and that the average number of traumatic experiences was 4.8.11 The meaning of a diagnosis that can be applied to almost 90% of a population has unclear usefulness, especially if meant to diminish guilt and responsibility.
More recently, citing Adverse Childhood Experiences (ACEs) has been a common method of supporting mitigating evaluations. Using the ACEs questionnaires, researchers have supported the idea that social programs are a key player in an improved criminal justice system. The ACEs study identified 10 forms of childhood trauma in 17,000 patients, including abuse, neglect, abandonment, household dysfunction, and exposure to violence, that were strongly associated with negative psychological outcomes, engagement in high-risk behaviors, significant medical consequences, and even early death.12 However, similarly to past trauma, the prevalence of ACEs in the forensic population is the norm, not the exception.
Additional thoughts
Of particular concern is when diagnostic criteria intersect or seemingly contradict one another. For example, acts such as an outburst of anger may be interpreted by one evaluator as a sign of deviance, irritability, or recklessness – and meeting antisocial personality disorder criteria. Whereas another evaluator may interpret the same incident as hypervigilance, exaggerated startle response, or self-destructive behavior in PTSD.
An incident of not assisting someone in need may be interpreted as lack of remorse and glibness from antisocial characteristics or avoidance and detachment from others as a reaction to past trauma. Flashbacks from trauma can be interpreted by some as violent fantasies. Even the experience of trauma can be viewed as a risk factor for future violence. In some ways, our perspectives are influenced by our examination of someone’s history through the lens of sociopathy or empathy.
In summary
Psychiatry is entrusted by courts to comment on negative and mitigating factors. Negative factors hinge in part on our subjective impression of sociopathy, and mitigating factors hinge, in part, on our empathy for a defendant’s trauma. Psychiatry should recognize the limitations of both sides and humble itself in providing balanced evaluations to courts.
Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. Dr. Amendolara is a first-year psychiatry resident at University of California, San Diego. He spent years advocating for survivors of rape and domestic violence at the Crime Victims Treatment Center in New York and conducted public health research at Lourdes Center for Public Health in Camden, N.J. Dr. Amendolara has no disclosures. Dr. Ngo is a second-year child neurology resident at University of California, Los Angeles. She received a master’s degree in narrative medicine from Columbia University, New York. She has no disclosures.
References
1. Frances A. Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma and the Medicalization of Ordinary Life. Harper Collins, 2013.
2. Key Substance Use and Mental Health Indicators in the United States. National Survey on Drug Use and Health. 2018.
3. Wong SCP and Gordon A. Psychol Public Policy Law. 2006;12(3):279-309.
4. Douglas KS et al. Mental Health Law & Policy Institute. About the Historical Clinical Risk Management-20, Version 3.
5. Angwin J et al. ProPublica. 2016 May 23.
6. Dressel J and Farid H. Sci Adv. 2018;4(1). doi: 10.1126/sciady.aao5580.
7. Freedman R et al. Am J Psychiatry. 2013 Jan;170(1):1-5.
8. Lillie B. The complexities of the psychopath test: A Q&A with Ron Jonson. TEDBlog. 2012 Aug 15.
9. Larsen RR et al. Psychol Public Policy Law. 2020;26(3):297-311.
10. Cordova MJ. Psychiatric Times. 2020 Jul 31;37(7).
11. Breslau N et al. Arch Gen Psychiatry. 1998;55(7):626-32.
12. Reavis JA et al. Perm J. 2013 Spring;17(2):44-8.