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Forensic Practice: Pride and PrejudicesName: Jay Adams, Ph.D. Address: 26 Hillcrest Drive, Paso Robles, CA. 93446 Phone: (805) 238-4454 E-Mail: jayklaus@msn.com Affiliation: California Department of Corrections, California Men’s Colony Staff Psychologist, retired Key Concepts: forensic practice, psychopathy, self-injury, criminal thinking, child abuse/trauma literature Abstract:The field of forensic psychology and psychiatry has evolved rapidly and our research instruments and experts command growing respect among both the scientific community and lay audiences. We have, however, focused almost exclusively on assessment rather than treatment and, in doing this, have fostered the perception that most forensic clients are not amenable to treatment. The author discusses the role of child abuse in the backgrounds of many forensic clients and suggests how the literature on adult survivors of abuse could be applied to the treatment of forensic populations. Forensic Practice: Pride and Prejudiceby Jay Adams, Ph.D. The practice of forensic psychology and psychiatry has made tremendous advances
in the past 20 years. We have moved from a field based on vague, subjective
opinion, devoid of any support in objective research, to a plethora of well-established
research instruments and a rapidly growing body of well-founded research studies.
High-profile experts such as Park Deitz and Lenore Walker have given many forensic
issues widespread public exposure. Television shows on real crime and forensic
investigation continue to proliferate, reflecting seemingly endless public interest.
Forensic psychiatrists, psychologists and social workers can take pride in the
recognition and acceptance our field has achieved in a relatively short period
of time. Our field has become almost exclusively devoted to assessment ("Slap 'em with a number and forget it," as one of my forensic colleagues bluntly put it), unfortunately fostering the belief that most forensic clients are not treatable and that our job is complete when we have succeeded in assigning our clients a label, almost always a pejorative one. This orientation provides little help to those of us who are charged with the treatment of forensic clients in settings such as prisons, forensic state hospitals, parole outpatient clinics, and conditional release programs. In my own facility, far more training is provided on identifying malingerers and psychopaths than on effective treatment approaches for the much greater numbers of clients who do not fall into either one of these groups. Obviously those working in forensic settings need to know how to identify malingerers and psychopaths, who drain resources and may pose a danger to staff and other inmates. They should NOT, however, be encouraged to believe that most of their clients cannot benefit from treatment. The Hare Psychopathy Checklist has become one of the most widely used instruments in forensic settings and has proven extremely valuable, yet little attention has been paid to the following caveat by Hare (1993): "The neglect and abuse of children can cause horrendous psychological damage. Children damaged in this way often have lower I.Q.'s and an increased risk of depression, suicide, acting out and drug problems. They are more likely than others to be violent and to be arrested as juveniles. Among preschool children, the abused and neglected are more likely than other children to get angry, refuse to follow directions, and to show a lack of enthusiasm. By the time they enter school, they tend to be hyperactive, easily distracted, lacking in self-control, and not well liked by their peers, but these factors do not make them psychopaths” (p. 170). This is an accurate description of many of our clients, but Hare unfortunately does not address the problem of how to distinguish true psychopaths from those who are “abuse reactive.” It is not unusual to hear forensic clinicians assume someone is a psychopath because he has done something violent. Prisoners with histories of child abuse would be likely to score high on Factor 2 of the Hare Scale (anti-social behavior/acting out) because it is a reflection of anger toward authority (“early behavioral problems,” “juvenile delinquency,” “revocation of conditional release”) plus difficulty with emotional and impulse control (“poor behavior controls,” “promiscuous sexual behavior,” “impulsivity,” “irresponsibility,” “lack of realistic long-term goals“). They might score lower on Factor 1 (aggressive narcissism) because items such as “glibness/ superficial charm,” and “conning/manipulative” are not consistent with the dynamics and long-term consequences of child abuse. There are, however, some items on Factor 1 that could also reflect abuse dynamics rather than psychopathy. For example, the appearance of "shallow affect," "lack of remorse," and "lack of empathy" may in fact be due to the presence of dissociation. "Promiscuous sexual behavior," a component of both Factors 1 and 2, is well-known to be a symptom of sexual abuse. Briere (1992), describing the various aspects of altered/dysfunctional sexuality that are common to adult survivors of sexual abuse, includes “a history of multiple, superficial, often quite brief sexual relationships that quickly end as intimacy develops” (p.52). Jehu (1988) states: “Several writers have noted the associated problems of promiscuity and over-sexualized relationships among victims...In this context the term ‘promiscuity’ is used to refer to a series of transient, casual, and superficial relationships that the victim seems to pursue compulsively and from a sense of obligation rather than desire... oversexualization implies that a relationship must include a sexual component however inappropriate it may be, or that it is perceived to have such a component when none exists” (p.133). Another item included in both Factors 1 and 2, "many short-term marital relationships," could reflect serial exploitation, but it could just as easily indicate problems with intimacy. Difficulty with intimate relationships is one of the most commonly cited long-term effects of sexual abuse. Courtois (1988) describes this in some detail: “...many survivors experience serious difficulty with interpersonal and intimate relationships...The survivor’s self-denigration often makes positive regard from anyone impossible to accept. This pattern may have developed from a very young age, resulting in a lack of friends and social skills and later in nonexistent or failed intimate relationships...Many survivors find themselves constantly fearful of rejection and disappointment” (p.218). Most sexual abuse of children occurs within a close relationship. Therefore, as intimacy and demands for closeness increase in adult relationships, many survivors become more anxious and may sabotage the relationship in a variety of ways. Briere (1996), speaking of male sexual abuse survivors, states, “The survivor may (a) seek out sexual contact as a way to gain nurturance, support, and validation; (b) find such superficial contact unsatisfying after the initial excitement has faded and the person involved appears to make excessive demands (e.g., for intimacy or relationship); leading to (c) a search for new, ‘better’ partners” ( p. 26). These are musings based on the clinical observations of someone familiar with the child abuse literature. They are offered as a caution to other forensic professionals to be aware that Hare Scale scores may be inflated by a history of child abuse. There has been no research on this aspect of the Hare Scale. Similarly, there are a number of ways in which abuse survivors may mistakenly be given a diagnosis of malingering and denied treatment. I have encountered inmates who had been labeled as malingerers because they lied about psychotic symptoms in order to obtain psychotropic medication. Upon further inquiry, it was not unusual to find that the individual was experiencing nightmares and other trauma-related sleeping difficulties, and had lied in order get meds that would help him sleep. Another misdiagnosis occurs when trauma survivors report that they are hearing voices “inside” their heads and clinicians unfamiliar with trauma symptoms assume that they are malingering auditory hallucinations. Briere (1997) has pointed out that most standard psychological tests currently in use were developed before the long-term effects of psychological trauma were well recognized, and therefore may misinterpret or distort trauma effects. “Examiners using older instruments may confuse intrusive posttraumatic symptomatology with hallucinations, obsessions, primary process, or ‘fake bad’ responses; misinterpret dissociative avoidance as fragmented thinking, chaotic internal states, or the negative signs of schizophrenia; and misidentify trauma-based cognitive phenomena (e.g., hypervigilance or generalized distrust) as evidence of paranoia or other delusional processes” (Briere, p. 71). In addition to learning the Hare Scale, tests for malingering, and older instruments such as the Rorschach and MMPI, forensic psychologists and psychiatrists should also be familiar with more recently developed instruments designed to identify clients who suffer from trauma-related problems. Resistance to acknowledging the pervasiveness of child abuse has been around at least since the time of Freud. Perhaps we have a need to see people who engage in violent or anti-social acts as evil, somehow inherently different from the rest of us. Perhaps it is difficult, without a familiarity with the dynamics and long-term effects of child abuse, to understand why data based on self-report of child abuse history is likely to greatly under-estimate its actual prevalence. Courtois (1988) reports that approximately half of all incest survivors who seek treatment do not disclose their incest during intake and assessment. A variety of complicated reasons why survivors of abuse do not disclose have been discussed in detail by Courtois (1988), Sgroi (1989), and others. These reasons include lack of memory or awareness of having been abused, feelings of stigmatization, previous negative experiences with disclosure, mistrust, the need to protect the perpetrator and/or other family members, fear of the perpetrator, emotional disconnection from the abusive experience (“It didn’t bother me”), failure to recognize that what occurred was abusive (“I deserved it”) and shame. Many of these reasons for non-disclosure are greatly compounded when dealing with incarcerated populations, especially males and especially when the issue is sexual abuse. The vast research and clinical literature on the long-term effects of trauma and child abuse is one of the richest potential resources for helping forensic treatment staff understand and deal therapeutically with the behavior of their clients , but is rarely applied in forensic settings. For example, Miller (1993), writing about trauma re-enactment syndrome among female abuse survivors, offers a variety of ways of understanding the meaning of self-injurious behavior and how to treat it. Much of what she writes is applicable to the male prison population. Just as a history of abuse is often under-reported, so too is one of its most serious long-term sequelae, self-mutilation. Miller notes: “Women who self-mutilate ...are reluctant to disclose their behavior, generally because they are ashamed and because such disclosures are frequently met with revulsion and condemnation” (p.78). Moreover, in forensic settings, self-injury is frequently met with punitive measures, such as being stripped and placed in a Locked Observation Unit. Conversations with inmates in confidential group settings have led me to the conclusion that self-injury is greatly under-reported among prisoners and often goes un-noticed, even among the diagnosed mentally ill. When it is noticed, it is almost always interpreted by staff as motivated by a desire to die or as a way of achieving any one of a variety of secondary gains. The reality of this behavior is much more complex in many instances. “Various researchers have hypothesized that self-mutilating behavior serves temporarily to reduce the psychic tension associated with extremely negative affect, self-loathing and guilt, intense depersonalization, feelings of helplessness, and/or painfully fragmented thought processes” (Briere, 1992, p.66). Miller (1994) writes that self-injury “can feel like relief because it anesthetizes against the pain of despair, rage, fear of shame. It can serve as a distraction from unbearable feelings and thoughts. It can be a form of self-punishment, appropriate to feelings of being bad, undeserving, disgusting, and selfish. [It] can serve as a communication about ...childhood experiences, or about the longing for protection...not received in childhood” (p.45). Unless staff understands this type of behavior, they run the risk of making the situation worse, causing even greater self-injury and losing the opportunity for really beneficial therapeutic work. One of the most widely used forms of therapy in forensic settings is confrontation of “thinking errors” or “cognitive distortions” that are thought to be characteristic of those who break the law. Most manuals used in conducting Criminal Thinking Groups derive from the work of Yochelson and Samenow (1977) and the therapy approach is largely cognitive. Most of these manuals appear to assume (incorrectly) that everyone who engages in criminal thinking is a psychopath. The assertion that criminals have a “criminal personality” or engage in “criminal thinking” explains nothing; it is a tautology. However, many criminally-oriented "cognitive distortions" take on deeper meaning when viewed through the prism of child abuse. For example, the concept of “zero state” is described in criminal thinking manuals as “the periodic experience of oneself as being nothing; a feeling of absolute worthlessness, hopelessness, and futility.” This description could have come verbatim out of virtually any one of hundreds of books and articles on the long-term effects of child abuse. “Chronic exposure to situations wherein one is unable to terminate powerful aversive stimuli (e.g., beatings, forced sexual contact, continuous criticism) is thought to lead to subsequent ‘learned helplessness’ and impaired self-efficacy”( Briere, 1992, p. 26). “In addition to the fear of violence, survivors consistently report an overwhelming sense of helplessness” Herman, 1992, p.98). The concept of “power thrust” relates to the criminal’s need for power, control, and dominance, a need which grows out of early experiences of powerlessness and helplessness while being abused. Briere continues: “In contrast to passivity and impaired self-efficacy..., other survivors of child abuse appear to deal with the experiences of powerlessness through extreme investment in control” (1992, p.27). Lisak (1997) has contended that the interaction of childhood abuse with masculine socialization, with its gender rigidity and emotional constriction, greatly increases the chances that male survivors of abuse will go on to become perpetrators, exerting power over others in a destructive and often violent manner. Another aspect of criminal thinking is an absence of trust which causes many
forensic clients to describe themselves as “loners.” It is sometimes
articulated by inmates as the credo of “Do unto others before they do
unto you,” and is cited as a “thinking error” by Yochelson
and Samenow (1977). Difficulty with trust is one of the long-term effects of
child abuse most frequently reported in the literature. According to Briere
(1992), “Perhaps one of the most disruptive and painful aspects of child
abuse is its impact on the survivor’s ability to trust. Requiring as it
does a suspension of defensive activities and an assumption of safety at the
hands of another, trust is especially difficult for most people who were severely
maltreated as children...” (p.51). Despite impressive advances in forensic assessment techniques, there has been relatively little attempt to apply knowledge from other fields to the treatment of forensic clients. No body of research is more deserving of attention from forensic practitioners than that deriving from attachment theory (Bowlby, 1969). Four decades of detailed observation of caretaker-infant interaction (Ainsworth et al., 1978; Main, 1995, 2000), coupled with new technology (PET scans), have greatly advanced our knowledge of how the brain develops, how it is influenced by early relationships, and how it is impacted by stress. Main and her colleagues (Main & Solomon, 1990; Hesse & Main, 2000) have established that virtually all those who grow up to commit violent acts have childhoods that are characterized by a particular type of attachment relationship with their primary caretaker, called “insecure/disorganized type.” This type of insecure attachment occurs when the primary caretaker, who is usually the refuge and source of comfort that an infant turns to when frightened, is simultaneously the source of fear. This leaves the infant confused and without a “safe base” to which to return when threatened. A detailed exploration of attachment theory is beyond the scope of this paper. The reader is referred to Siegal (1996) and Perry (1997) for comprehensive discussions of the relationship between attachment theory and recent developments in neuroscience. See Friedrich (1995) for an excellent account of the application of attachment theory to psychotherapy. Perry (1997) asserts that “Early life experience determines core neurobiology” (p. 126). Moreover, “both lack of critical nurturing experience and excess exposure to traumatic violence will alter the developing central nervous system, predisposing to a more impulsive, reactive, and violent individual... Lack of appropriate affective experience early in life and the resulting malorganization of attachment capabilities plays a major role in the current epidemic of senseless violence...” (Perry, 1997, p. 131-132). Individuals who have suffered early maltreatment (before age 2) have problems with impulse control (Perry, 1997), deficits in empathy (Main & George, 1985), and difficulties modulating anger, sexual involvement and self-destructive behavior (van der Kolk et al., 1996). The relevance of trauma theory and attachment research to forensic populations could not be more clear. Often a great deal of money is spent on forensic assessments which result in recommendations for services that do not exist. No doubt there are some individuals whom Lykken (1995) calls “constitutional psychopaths” who have no history of abuse and are simply born with different wiring from the rest of us. These people, however, are relatively rare and are far out-numbered in forensic populations by by individuals with histories of multiple, severe child abuse. There is pervasive resistance to the repeated finding that the vast majority of forensic clients have been abused as children, which often finds voice in phrases like “the abuse excuse.” In 25 years of working with forensic clients, it has been my consistent experience that inmates’ denial of child abuse and its impact is far more of a problem than inmates using it as an excuse for their behavior. This clinical impression has been confirmed by research. Studies of abused delinquents “suggest, if anything, a tendency to minimize, forgive, and forget previously documented abuse” (Swica, Lewis and Lewis, 1996, p. 431). All too often clinicians in forensic settings take the attitude that they can‘t really be expected to provide meaningful or effective therapy to such a “hopeless” and “unmotivated” population. By dismissing their clients with labels such as “manipulative,” “attention-seeking,” “personality disorder,” and “psychopath,” they absolve themselves from responsibility for doing their jobs. Dvoskin (2000) exhorts us to do better: “If we see their problems as current moral weakness rather than the scabs of old wounds, we rob them of their history.” A few clinicians (e.g., Gilligan, 1996; Lisak, 1997; Lewis, 1998) who work with forensic clients have grasped the importance of the link between childhood abuse and adult violence/criminality, but thus far their voices have been largely ignored by forensic practitioners. The refrain is repeated over and over that “most people who are abused do not become criminals”. While this is thankfully true, it is not helpful. The fact remains that most people who do become criminals have been abused. We can continue to deny the serious impact of child abuse and its clear relationship to adult violence by turning a blind eye. Or we can turn our attention to the growing field of research on the long-term effects of child abuse and actually do something to help our clients and prevent future violence. Dr. Jay Adams has been practicing forensic psychology for more than 25 years. She may be reached by e-mail at jayklaus@msn.com.
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