Saturday, October 29, 2011

What I Learned Part II

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

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

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

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

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

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

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

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

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


jesse said...

Thank you, Clink. What is fascinating to me is the overlap between different systems of reference. Psychiatry and Law are two such systems. Both look at the relationship of the individual to others and assess questions of volition and ability to follow the rules.

One point about the facts of the likelihood of violence from people with mental illness: The relevant issue is not that, as in example 3 "People with mental illnesses are more likely to be violent against themselves than against others" but how likely they are to be violent to others compared to the general population.

If, for instance (totally fictitious statistic follows) the chance of any random individual being violent to others is 0.3% but the chance of a person diagnosed with bipolar disorder being violent is 2% then there would be reason to regard bipolar disorder as increasing the chance of violence.

So it could be (supposition only!) that news media are focussed on the increase in likelihood compared to the general population and so glide over the statistics relating to violence of those with mental illness compared to others with mental illness.

It could well be that those with mental illness are less likely than the those in the general population to be violent, and that would be a very important fact.

rob lindeman said...

Another similarity between law and psychiatry with respect to questions of volition: Individuals rarely if ever make voluntary contact with representatives of state-law enforcement. So too with Psychiatry. Especially (I should say 'primarily') in the world of forensic Psychiatry, individuals rarely if ever make voluntary contact with a Psychiatrist. To the contrary, virtually all the 'treatment' at the hands of a forensic Psychiatrist is practiced on an involuntary, unwilling client. This is a 'pediatric' model of care. I know whereof I speak.

Regarding civil commitment of sex offenders: Here is yet another group of Americans, who, like Sovereign Citizens, we shun and despise. And yet Sovereign Citizens we tend to leave alone. Sex offenders are punished for their crimes, not their mental states, for the rest of their lives... or is it that we do punish their mental states for the rest of their lives?

wv = irersit; an urge, any urge, that stays with an individual forever and justifies their ostracism from society, see leper

Anonymous said...

I will be sure to apologize to my children for the involuntary pediatric treatment they received as they were growing up. When it comes to one of them though, I will first have to beg his forgiveness that he is alive, following the involuntarily treatments and hospitalizations he endured ,and, no doubt, recalls on a cellular level. I will be sure to do this when he returns from whatever fun he is out having with his friend.
As to sex offenders Rob, quite frankly, I do not give a damn if we punish sex offenders for the rest of their lives. We do not punish mental states, we punish actions. If my neighbor dreams of having sex with my child and never acts on that fantasy, I will never know, my child will be okay and I will still collect his mail during his vacations. If he does act on that fantasy he becomes an OFFENDER. In case they did not cover that in your extensive and expensive schooling, that means he or she has committed what most people consider a criminal act.
If you have never fallen into the hands of a sexual predator, count yourself lucky. Please do keep advertising your views, as I am sure they will help parents in your area determine whether they wish to entrust you with the care of their children.

Samantha said...

thought you would appreciate this young artists (David Foox) work in raising awareness for organ donation. His creepy cute toys stand 3.25" tall and are one of 24 different body parts.

CatLover said...

I keep it a secret that I have bipolar, because I learned early that people assume you are an axe murderer. I even heard this crap a couple years ago from the wife of one of my husband's friends, when I was intensely depressed, that he should "be afraid of me, that I might attack him." There was no basis for this belief at ALL. It really hurt my feelings, and I have not spoken to her since.
She even tried to talk my husband into fearing me, and she was only an acquaintance & therefore has no idea how I behave. She has a sister with bipolar whom she despises, and all that anger was vomited up onto me, when I was in a crisis.

Jane said...

"To the contrary, virtually all the 'treatment' at the hands of a forensic Psychiatrist is practiced on an involuntary, unwilling client. This is a 'pediatric' model of care. I know whereof I speak."

Just out of curiosity, does that ever break your heart having to treat little ones? I can remember holding down my nephew when he was a baby cuz he needed eye drops I think. He cried so hard. Is it ever difficult for you when you have to force treatment and make babies cry?

@CatLover: Wow. You weren't even manic and she thought you might get violent. I hope your husband told her off! Hope he said, "Don't you be talkin' 'bout my wife like that, guuuurl!

rob lindeman said...

Jane, it happens every day and it never gets easier. I console myself (most of the time) by telling myself that the child is not an autonomous adult, endowed with the right to be left alone if he so chooses (sort of like psyche patients). Nevertheless, unless I have a very good, solid reason for doing so, I don't do anything to a child he doesn't want me to do. Adults are luckier: even if I have a good reason, they get to say 'no'