What I Learned Part III

• More on social media and medicine today. One survey of a surgery department showed half of residents and faculty had public Facebook accounts and a third posted professional information.
• People are using "mindfulness" therapy to treat sex offenders. No studies on efficacy.
• Offenders with bipolar and psychotic disorders are twice as likely to have more than two additional arrests than non- SMI offenders.
• Some criminal defendants try to claim that the government is a corporation, and that they should be tried under contract law rather than criminal law. This is sometimes called a "straw man defense" and may prompt judges to request a competency assessment.
• Defendants who graduate from mental health courts demonstrate improved life circumstnaces with regard to housing, quality of life, symptoms and compliance. Some studies have shown mental health courts to result in improvement for as many as 78% of defendants.
• Court ordered custody evaluators are more likely to recommend paternal custody if the mother is poor or has a history of psychiatric admissions. They are more likely to recommend maternal custody if the father has a history of arrests.
• No suicide prediction tool has a predictive validity greater than 3%.
• Forty percent of patients given opioids for non-cancer pain misuse their meds, 5% become addicted.
• In the UK people with ASPD may be subject to multiagency public protection agreements, sharing information between government agencies.

Coming up tomorrow:
      Correctional risk management and the forensic sciences sampler. Good luck to everyone without power in the snow!

In Treatment: Season2, Episode 3: The Turtle in Therapy

Oliver is back for therapy because of his parents' separation. All three family members are in the waiting room plugged into their iPods (Oliver has a shuffle). A smiling couple walks out of the office, "That wasn't so bad." Beacons of hope: Paul cured them, perhaps he can cure the Oliver family.

Oliver's having a rough time. He's reading Lord of the Flies, people think he's fat, and oh, he has the class turtle with him, one he's sure he can't keep alive. To every question, Oliver says, "Because my mom would call my dad and they would fight." Paul does a good job in addressing Oliver's questions about the happy couple who left-- "I don't talk to my other patients about you and I can't talk to you about them."

Bess (Oliver's mom) distorts Paul's words: "You don't think we should get divorced....parents should stay together no matter how unhappy they are and ultimately it would be better for the children?" Ah, this has to be pushing newly-divorced Paul's buttons. And it's suddenly clear that one of the issues here is that Mom is still hung up on Dad. It's a kind of ugly session when dad announces he has a new girlfriend... kind of amazing it isn't bloodier. Little Oliver gives Paul's next patient a rather hopeless look and the forgotten turtle remains in the office with Paul. He (?) retracts his turtly little head into his shell.
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How This Psychiatrist Thinks About Psychological Tests

First a big thank you to Gerbil for giving me the idea for this post. In a comment on my post "What Good Are Psychologists?" she mentioned psychiatrists who refer patients for diagnostic psychological testing. It got me thinking---this is a good thing---about why I do (or don't do) what I do.

I have to say I hardly ever request psychological tests. Even before I started working in prison, it just wasn't something I routinely did with my patients. When I was in residency we had lectures from psychologists about the different types of tests and what they're indicated for and a few things about interpretation, and later psychologists I've worked with have told me that I have a better understanding of testing than the average psychiatrist, but I'm not sure what that means.

For the lay readers among us, there are some general categories of psychological tests. There are personality tests that measures different character traits. There are intelligence tests that measure IQ. There are projective tests that are used to get an understanding of the person's interpersonal dynamics and style of thinking. There are neuropsychological tests that measure a person's cognitive capacity---ability to learn and remember, use language, coordinate eye-hand movements and so forth.

In general, when thinking about tests you have to consider what it is you're trying to figure out. If you have a patient who is failing in school you might want to order IQ or other achievement tests to see if the personal has a developmental disability or learning disability. If the patient has had a head injury or you think he or she might be getting demented you'd order neuropsychological testing. If you have a patient in therapy and you want material that might be useful to help the patient understand his own inner workings, you'd request projective testing and/or personality testing. Some tests are used as tools to predict certain things: whether or not someone would perform well on a certain job or whether or not they will re-offend as criminals.

It's important for tests to be used as part of an overall patient assessment. Test results fit into a whole database of information that a psychiatrist considers when making a diagnosis or putting together a treatment plan, in addition to a good patient history and a review of available treatment records.

It's also important to know whether or not the given test has been validated for your particular patient because 'normal' test results can be different for different groups of people. A test is only as good as the patients it's been based upon. For example, normal results for the original Minnesota Multiphasic Personality Inventory (MMPI, a test used to diagnose psychiatric disorders) was originally based upon only 500 people living in Minnesota. Much as I would like to think that Minnesota should be the gold standard for normalcy, this just isn't realistic. I mean really---Baltimoreans would end up looking pretty depressed compared to them. This is where a big limitation comes into play for me working in prison---many psychological tests have not been validated for use in prisoners.

Similarly, predictive tests only give group predictions and aren't necessarily reliable for the individual. A certain score on the Hare Psychopathy Checklist might give you a result that the patient has a 15% chance of re-offending, but that just means that out of 100 people with an identical score 85 will not re-offend and 15 will. The score doesn't tell you which of the two groups your patient will actually be in. The other trick with using tests to predict things is that many tests used for prediction have never been proven to have predictive value---there is no test to predict 'good parenthood', for example, yet psychological tests are used constantly in custody evaluations. It's important to know the limits of the test.

So...which tests do I actually use?

In prison the most common test I use is the Mini-Mental State Examination (MMSE). It was invented by two psychiatrists as a quick bedside test of cognitive functioning. You can give it in about ten minutes and it's a great way of measuring how brain impairment changes over time. You use it to check to see if someone's delirium is resolving, or as a screening tool for problems that should be investigated further.

In free society the most common tests I used, besides the MMSE, were general symptom inventories. For example, the Beck Depression Inventory (BDI) is a nice tool for measuring the severity of depressive symptoms. It's used to screen people for depression and also to monitor reponse to treatment.

I never use projective testing, mainly because I've never found it particularly useful for anything---maybe I would if I had a psychotherapy practice but even then I don't know too many psychiatrists who use them. I'd probably use neuropsychological tests if I could, but these are very specialized tests that have to be administered by a neuropsychologist (a subspecialty of psychology) and I don't know of any prisons who have one of those.

So that's my take on psychological tests. Thanks, Gerbil.

Ladies' Night Out

Or why I don't do custody cases anymore

A friend of mine desparately needed a night out on the town recently so last night we did it, a group of us each in our own various stages of life. I heard about past marriages (or more than one) current boyfriends, behaviors that make up the "why" in the Y chromosome, children, teenagers, laundry and discipline (or lack of it). By the end of the evening I came home feeling somewhat guilty that my life was so peaceful and relieved that I just didn't have to deal with any of that.

It brought back memories of doing court-ordered child custody evaluations. Keep in mind that over the years I've interviewed and worked with psychotic killers, rapists, drug kingpins, death row inmates, mafia figures and various other low-level criminal types.

I'll take them any day over a disgruntled non-custodial parent. Now, most divorces don't end up in court-ordered custody evaluations. The majority of people with kids split up, talk (or shout) amongst themselves and generally figure out what they need to do and when to do it without any court involvement other than a rubber stamp. Those weren't the cases I got. By definition, by the time a case came to me the couple had already been through one hearing, or three, as well as emergency motions for visitation and/or custody, domestic violence petitions, protective orders, social services investigations and/or criminal charges. These were not easy cases.

Over time I learned that all the allegations back and forth could generally be boiled down to four or five categories: allegations of abuse or neglect (physical or sexual), drug use, domestic violence, mental illness or something I call generic "lifestye differences". Non-custodial Mother alleges that Father dresses Daughter in age-inappropriate clothing so she looks like a "biker-chick" while Custodial Father complains that Mother wants Daughter in black patent leather shoes with white anklets. Or Mother alleges that Father is a lying psychopath with sexual interests in their teenage babysitter. Or Father really has been convicted of multiple felonies and the interview alone is enough to get you thinking about the distance between yourself and the nearest security alarm.

In memory of Kurt Vonnegut: So it goes. One must fight the temptation to toss the child to the nearest passing stranger.

The fathers I interview assume that because I'm a woman I will naturally side with the mother. The mothers assume that because I'm a woman I will naturally agree with their childrearing tactics and the fact that all men are rats. And they all want to know whether or not I have kids. (I don't.) Being childless is an advantage in these situations. I am not saddled with my own personal shtick of past marriages (or three), domestic violence and childrearing issues. And if being a biological parent had anything to do with good parenting skills we wouldn't need these evaluations to begin with.

The children are the most honest ones of everybody involved in the litigation. My ears would always perk up at any sentence out of their mouths that began "My mother wanted me to tell you..." They were honest even about their coaching. I was also surprised by some of the things the parents admitted: quizzing a child in detail about the other parents' sex life, plans to take the child and run, attempts to undermine the child's medical or mental health care. Sometimes the main goal of the evaluation was just to make sure the child didn't disappear or die in the process of growing up.

The fact of the matter is that there is no litmus test for being a good parent. In spite of the thousands of dollars being paid (to private forensic evaluators, not the court-employed folks) for interviews and psychological testing, no psychological test can tell you which parent is best for which kid. And the answer may be different for each individual child even when the same parents are involved. A child who is unpredicatable, emotionally labile and impulsive may do best with the parent who is patient, stable and consistent while the shy, slow-to-warm-up child needs an extroverted parent. Regardless, most kids are pretty resilient and they grow up to be normal responsible folks in spite of the craziness between their parents. I just hope they manage their own custody issues as well when they're adults.