The Handbook of Forensic Psychopathology and Treatment

Maaike Cima, Maaike Cima

• Editorial: Routledge
• Año: 2016
• ISBN:
  9781317267027
• Edición: 1
• Categoría: Psychology
• Categoría: Forensic Psychology

The Handbook of Forensic Psychopathology and Treatment explores the relationship between psychopathology and criminal behaviour in juveniles and adults. It provides a detailed explanation of the developmental pathway from the process of increasing criminal behaviour and becoming a forensic patient, to assessment, treatment and rehabilitation.

Incorporating theoretical and scientific research reviews, as well as reviews regarding forensic rehabilitation, the book covers the theory, maintenance and treatment of psychopathology in offenders who have committed a crime.

The Handbook of Forensic Psychopathology and Treatment will be of interest to masters and postgraduate students studying the relationship between psychopathology and crime, as well as researchers and clinicians working in forensic psychiatry institutions or departments.

Part I

Theoretical introduction

1 Defining forensic psycho(patho)logy

Eric Rassin

Introduction

Forensic psychology is a popular discipline. For example, of the approximately 13,000 members of the Dutch Psychological Association, 1,400 (i.e. 10%) call themselves forensic psychologists. Typical topics of reports produced by forensic psychologists are criminal responsibility, risk assessment, and competence to stand trial, but also the credibility of eyewitness testimony, confession evidence, and line-up outcomes, as well as child care and custody. The psychopathological consequences of crime, for example the development of post-traumatic stress disorder (PTSD) in victims, also fall within the domain of forensic psychology (see Gudjonsson & Haward, 1998; Sigurdsson & Gudjonsson, 2004). Forensic psychopathology is closely linked to forensic psychiatry, although the latter discipline is medical and hence quite practical, patient-centred, and less focused on psychological theories of mental disorders and crime.

In this chapter, the focus of forensic psychopathology will be discussed. Foremost, problems and challenges will be pinpointed. First, the legal context of forensic psychopathology will be briefly discussed. Next, assumptions underlying forensic psychopathology will be targeted, followed by scientific, legal, and ethical issues.

Crime and punishment

The criminal justice system seeks to sustain societal coherence. Within this main frame, several discrete punishment goals can be distinguished. For example, de Keijser, van der Leeden, and Jackson (2002) discuss no fewer than six effects of punishment. To start with, there is specific (the perpetrator will not engage in criminal activity again) and general (other members will not engage in criminal activities) prevention. Third, there is the immediate protection of society (incapacitation). Fourth, retribution is sought. That is, the perpetrator has to pay for and thus undo his crime. Fifth, and also crucial, is rehabilitation: once the perpetrator has completed his punishment, he can return to society with a clean sheet. Finally, there is the restoration of moral balance as a more abstract goal of punishment. That is, the balance in society is disturbed by the crime, and this disturbance can be resolved by punishing the perpetrator.

It remains to be seen to what extent the specific punishment goals can be achieved. For one thing, incapacitation will be complete by definition if the perpetrator is sentenced to imprisonment and thus removed from society. By contrast, the success of rehabilitation is less clear. Meanwhile, it must be feared that incarceration has some very negative side effects on mental functioning. For example, Pratt, Webb, and Shaw (2006) found that ex-criminals are at increased risk of committing suicide after release from prison. The scientific data on specific prevention (i.e. the reduction of recidivism) are not promising. Particularly, recidivism after incarceration is quite robust, with observed rates as high as 60% (see Wartna, El Harbachi, & van der Knaap, 2005).

The failure to prevent future crime by means of punishment is at odds with the classic behaviouristic notion that humans are sensitive to learning through reward and punishment. However, it must be acknowledged that the way in which offenders are punished in western societies is quite different from what behaviourists do in their animal laboratories. For the reduction of the forbidden behaviour to take place, punishment must be harsh, applied consistently, and applied with high contiguity. In practice, criminal punishment tends to be relatively lenient, applied infrequently (in approximately only 4% of the registered crimes; Rassin, 2009), and applied with considerable delay (see Dickinson, Watt, & Griffiths, 1992). Hence, it is not surprising that the specific preventive effect of criminal punishment is not as strong as would be expected based on scientific research on reward and punishment.

In the Netherlands, like in many other western countries, the criminal code has a clause that enables the judge to sentence mentally disordered offenders, not to regular imprisonment, but to incarceration in a forensic clinic. Forensic treatment can be ordered if the perpetrator has some ‘retarded development or disturbance of his mental capacities’. In theory, there can be several reasons to exclude mentally disordered offenders from the standard set of punishments. First, it can be considered immoral to seek retribution if the perpetrator is mentally disordered. Second, it can be argued that disordered offenders are incapable of learning from punishment, because there is something wrong with their behavioural inhibition system (Gray, 1982). Thus, the criminal irresponsibility clause simply assumes that disordered offenders are at increased risk of recidivism, even though the recidivism rates for non-disordered offenders are already considerably high, and with theoretical reason so.

Assumptions underlying the Dutch system of criminal irresponsibility

The mere existence of criminal irresponsibility clauses has several implications. First, as borne out by the considerations above, the legislator seemingly adheres to the punishment goals of retributions (or rather exceptions thereof) and specific prevention. By contrast, if incapacitation were the legislator’s primary goal of punishment, all offenders could simply be incarcerated without distinguishing between sane and disordered ones.

A second assumption underlying criminal irresponsibility clauses is that there is, or should be, a clear understanding of what constitutes irresponsibility (in the Dutch system: a retarded development or disturbance of mental capacities). Strikingly, there is little consensus on this matter. Presently, the bulk of forensic patients suffer from antisocial personality disorder, psychotic disorder, and/or paraphilia (Blansjaar, Beukers, & van Kordelaar, 2008). In the past, the distribution of disorders among forensic patients was, however, quite different (e.g. for a period of time there was more emphasis on addiction as a reason for irresponsibility; van der Wolf, 2012). While the psychiatric diagnosis is a major part of the forensic evaluation of offenders, traditionally, scientific forensic psychology has focused primarily on psychological theories of crime. Interestingly, the different psychological schools have produced their own insights (Robins, Gosling, & Craik, 1999). Evidently, behaviourism has produced some classical studies on the development of crime, such as Bandura, Ross, and Ross’ (1961) findings of the modelling of aggressive behaviour. However, behaviourism does not elaborate on the link between psychopathology and crime. Notably, the old psychodynamic theories did find their way into forensic psychopathology. For example, many people think that being victimised in childhood results in criminal behaviours in adulthood. Although this causal hypothesis may well be construed as a behaviouristic notion (i.e. seeing crime leads to acting criminally), some forensic psychologists seem to prefer a psychodynamic interpretation of this relationship (but see Rind, Bauserman, & Tromovitch, 1998). For example, Lehnecke (2004) postulates the theory that mentally disordered sex criminals have come to their illness and crime because of a triad of a childhood symbiotic relation with their mother, an absent father, and a psychotraumatic experience (e.g. being the victim of a sex crime). Cognitive psychologists have concentrated on mental deficits in disordered offenders such as a reduced recognition of emotions in others (Montagne et al., 2005), or lack of empathy (Ali, Amorim, & Chamorro-Premuzic, 2009), or even theory of mind (i.e. the attribution of mind to oneself and others; see Baron-Cohen, Leslie, & Frith, 1985). Such general deficits may lead the tenacious offender to behave egocentrically and antisocially. In the last decade, biologically oriented theories have become popular. Such theories can involve neurobiological processes (e.g. changes in hormonal activity as a cause of disinhibition and aggression, see Flinn, Ponzi, & Muehlenbein, 2012). Much attention has also been given to anatomic or functional abnormalities in the offender’s brain (Perez, 2012).

Forensic psychological practice has recently begun to focus on offenders’ personality traits deemed relevant. As such, the focus has shifted away from classic notions (e.g. the understanding of right and wrong) towards offenders’ characteristics that predict recidivism. Psychopathy, as measured with the Psychopathy Checklist Revised (PCL-R; Hare et al., 1990), is currently considered the best predictor of risk of future offending (Hildebrand, de Ruiter, & de Vogel, 2003; van der Wolf, 2012).

Besides the underlying moral theory of justice, and the need for consensus on the nature of criminal irresponsibility, a third assumption is that the relevant concepts can be measured reliably and validly. Mentally disordered offenders cannot be expected to always be frank in discussions with their therapists. It would be naive to lean on self-reports when diagnosing individuals in this population. It is evidently futile to ask an offender: ‘are you a psychopath?’ Therefore, the use of self-reports can be problematic in forensic psychology (see Cima, van Bergen, & Kremer, 2008). Test subjects may simply not be able to report on variables of interest, or may not wish to do so (see Schwarz, 1999, for self-report issues in general). Instead of self-reports, the primary source of information in forensic psychology is observation ratings. Although in the case of psychopathy, it is understandable that experts prefer to rely on observation scales rather than self-reports, it must be acknowledged that from a psychometric point of view, observation instruments are no less fragile than self-reports. Like the latter, the former ideally have to possess proven internal consistency, factor structure, test-retest reliability, and convergent, divergent, and predictive validity. And whereas self-reports do not need to be interrater-reliable, observation scales do. The list of desired psychometric properties is quite long, and it remains to be seen whether all observation scales relied on in forensic practice adhere to all criteria. As for the PCL-R, the forensic expert has to resist automatic inferences when scoring the test. Imagine a test subject who smiles in a friendly way at the psychologist. Would the psychologist think of this friendliness as superficial charm (one of the criteria for psychopathy) more readily if he knows that the subject is suspected of violent rape? Can it be excluded that the PCL-R score is somewhat artificially elevated because the test subject is generally a suspect of a severe crime, and is thus likely to meet various PCL-R criteria? Interestingly, there is a self-report measure of psychopathy that evades the well-known respondent bias by relying on items that hide their measurement pretence. Even though this Psychopathic Personality Inventory (PPI; Lilienfeld & Andrews, 1996) may be a considerable alternative to the PCL-R, to the best of the author’s knowledge, this measure is hardly or not employed in forensic clinics. A more classic example is that in clinical and forensic practice, the Rorschach ink blot test is still used (Koenraadt, Mooij, & van Mulbregt, 2007), even though its psychometric qualities are by and large unproven (Garb et al., 2005; Lilienfeld et al., 2006).

Recently, forensic practice has started to employ brain scans as diagnostic tools. Intuitively, it is appealing to scan the offender’s brain, because that yields the opportunity to study ‘the source’ of the problem. However, there are some flipsides to this development. For one thing, it is unclear to what extent brain abnormalities cause or even correspond with psychopathology or criminal behaviour. Further, the nature of for example fMRI (i.e. a compilation of thousands of statistical tests comparing changes in activity in numerous voxels) invites false positive conclusions (Vul, Harris, Winkielman, & Pashler, 2009). Nonetheless, brain scans are very popular at the moment (Weisberg, Keil, Goodstein, Rawson, & Gray, 2008). Meanwhile, there is some evidence that the inclusion of neuroscientific information in forensic reports influences judges in unexpected ways. For example, judges tend to be more lenient to psychopaths if the psychopathy is explained in terms of brain abnormalities and processes (Aspinwall, Brown, & Tabery, 2012).

Recently, Fazel, Singh, Doll, and Grann (2012) conducted a meta-analysis on the accuracy of well-known risk assessment instruments, such as the HCR-20, SVR-20, and PCL-R. The authors concluded that ‘Although risk assessment tools are widely used in clinical and criminal justice settings, their predictive accuracy varies’ and ‘their use as sole determinants of detention, sentencing, and release is not supported by the current evidence’ (p. 2). Of course, forensic psychologists can be expected to rely on more than one measure to reach their conclusions. However, it is not always so that accumulation of more imperfect diagnostic information increases the accuracy of the ultimate conclusion. By analogy, the soup does not get any better after throwing in more bad ingredients. Lilienfeld, Wood, and Garb (2006) refer to the mistaken idea that the soup should get better as the ‘alchemist’s fantasy’.

A fourth and final assumption underlying the criminal irresponsibility clause is that forensic treatment must be effective. If not, there would be no reason to treat offenders at all. It is important to note that, currently, forensic therapy does not aim at reducing psychiatric symptoms, but merely at making the patient fit for return to society. Hence, the adage in forensic psychiatry is ‘no cure but control’. Although it may be hard to believe, to date, the effects of much of the psychotherapeutic interventions currently practised in the forensic setting are unknown. Only recently has the field begun to develop ‘evidence-based’ therapies, thereby implicitly and somewhat reluctantly admitting that therapies so far may not have been evidence-based (van der Wolf, 2012). Not only are much of the forensic psychotherapies currently practised of unknown quality, some may even be counterproductive. For example, group therapy and insight-increasing therapies may make psychopaths better able to recruit future victims, and thus make them more dangerous than when they first were admitted to forensic care (Hildebrand, de Ruiter, & de Vogel, 2003). Notwithstanding this critique, looking at recidivism rates, it must be concluded that forensic treatment generally does work. By and large, forensic ex-patients re-offend only half as often as do ex-prisoners (Wartna et al., 2005).

Scientific, legal, and ethical issues

So far, several assumptions and cornerstones of forensic psychopathology have been discussed. In this section, a few more abstract problems concerning criminal irresponsibility will be highlighted. First, it is important to note that the institute of forensic psychopathology is in essence a paradox. It taps into a fundamental difference in legal and psychological reasoning. For the forensic psycho...