A Response to Dr Allen Frances on SVP/Paraphilias

[Editor's note: On January 20, 2011, the following commentary was posted on the Sexual Abuse: A Journal of  Research and Treatment (SAJRT) Web site at http://sajrt.blogspot.com/2012/01/guest-blog-from-dr-deirdre-dorazio-on.html. Our thanks to SAJRT.]

In a recent article written in the Psychiatric Times¹ entitled California DMH Instructs SVP Evaluators on Proper DSM-IV-TR Diagnosis,¹ DSM-IV editor Dr Allen Frances reviewed a training session offered to California state evaluators conducting evaluations of potential sexually violent predators (SVPs). Readers interested in learning more about the California SVP statute are referred to the California Coalition On Sexual Offending information paper referenced at the end of this article.² Dr Frances’ article commences:

By far the most important event in the sad history of the Sexually Violent Predator (SVP) statutes occurred in Sacramento between September 9 and September 11, 2011. The California Department of Mental Health (DMH) conducted a 3-day workshop to educate its evaluators on proper procedures in diagnosing DSM-IV mental disorders. This could be a turning point in solving what has been the most vexing problem at the delicate interface between psychiatry and the law.¹

Dr Frances is a frequent commentator on issues related to Paraphilia diagnosis, DSM-5, and sexual offender civil commitment (SOCC). In reading Dr Frances’ posts about Paraphilia diagnosis, DSM-5, and SOCC laws, I get the notion that he is a man deeply possessed-possessed by the idea of doing whatever it takes to undermine all three. His published works on the topics swarm with passion, allure by acrimony and, in my opinion, are built on a rational foundation of sand. The sharp realization of this latter point brings me to the uncomfortable position of writing this post.

On the one hand, I ask myself, “Why ever would you want to get involved in this mess?” Surely, rationality is not a key player in this arena, why attempt to bring some to the forefront? Anything I might have to offer will likely be twisted and misused as fuel for the cauldron. On the other hand, having read Dr Frances’ most recent piece involving his interpretation of the recent training for California evaluators-which I attended-I cannot dismiss my experience. My experience of the meeting is vastly discrepant from that which Dr Frances portrays.

So, why am I getting involved in this “mess”? There is a vocation in the work that we do as professionals that necessitates a response. It is out of this internal imperative that I seek to clarify Dr Frances’ distorted interpretations.

It is one thing to have an opinion and state it. But, it is another thing entirely to embark on a veritable witchhunt against people and ideas. After all, my colleagues and I who work conducting SVP evaluations are professionals, just like those that treat the less than one percent of these men eventually committed as SVPs in California, as well as the researchers and academics that join us in a shared goal of helping alleviate the societal problem of sexual abuse. We put ourselves on the front line of a psychic battlefield every day to help men convicted of sexual crimes. We, sexual offenders included, all share the most fundamental of human qualities. However, there is a feature of humans possessed that contributes to a splitting-off that leads to thinking that some other group of persons-“them”-has no resemblance to the rest of “us.” Unfortunately, in this case, I am in Dr Frances’ ousted “them” group.

At this point, I hope readers will infer the point that our endeavors to diagnose illness in this particular domain engender an “us versus them” attitude, which ultimately fuels diagnostic and Sex Offender Civil Commitment debates, but does not serve our collective goal, our vocation, of healing.

How disturbing then that some SVP evaluators remain ignorant of DSM-IV, leading them to provide supposedly “expert” testimony that is simply incompetent. They blithely write reports filled with idiosyncratic and incorrect diagnostic opinions that can result in the unjustified psychiatric hospitalization of simple criminals who have already served their apportioned prison terms.¹

The “idiosyncratic evaluators” here in California, to whom Dr Frances refers, are extensively trained professionals who have many of experience in the area of severe sexual abuse. For myself, I worked for several years for the California DMH program that treats men committed as SVPs. This is the same DMH Dr Frances lauds as “rescuing proper diagnostic practice” and “redeeming forensic psychology.” Paradoxically, he also notes it as an agency providing “unjustified psychiatric hospitalization of simple criminals.”

So, I seem to get discredited twice by Dr Frances, once for treating people within the civil commitment context, and another for being an “idiosyncratic evaluator”-a resistant member of a “hard corps of stubborn dead-enders” that is “mistaken and incompetent” by exercising “independent clinical judgment of any given case.” It seems the real grievance Dr Frances has is not that evaluators are “ignorant” or “incompetent,” but that we are not sufficiently deferential to him. In truth, many of us have heard Dr Frances’ arguments many times and simply do not find him convincing.

The great news is that the California (DMH) has taken upon itself the responsibility to improve diagnostic practice in SVP cases. It sponsored a landmark workshop for its evaluators . . .¹

Having attended the training to which Dr Frances refers, my opinion-and I believe the opinion of the others in attendance-is that the training was not “landmark” as Dr Frances described. Further, it did not occur as Dr Frances purports. It was not implemented to correct aberrant diagnostic practices. Rather, its intent was to train a new group of California SVP evaluators with veritably no prior experience conducting SVP evaluations, and only few having significant experience working with high risk sexual offenders. In an interesting corollary, the trainer-although a long-time doctor working for DMH administration in the Mentally Disordered Offender unit-had been recently asked to assume additional responsibilities by leading the Sex Offender Commitment Program SVP evaluation services. By his own admission, this trainer has little experience working with SVPs specifically, but he does have a lot of experience in the forensic assessment of other types of mentally ill offenders.

Rather than a landmark event, the training was a laudable endeavor of the newly established leader to train a group of new evaluators within the unique context of both parties being relatively new to the subject. A secondary purpose was to provide a refresher to those of us already experienced evaluators currently doing the work. The training did not focus exclusively on “proper procedures in diagnosing DSM-IV mental disorder,” as Dr Frances states. It was a beginner training and overview seeking to ensure that certain minimum standards are routinely applied in conducting SVP evaluations for DMH in California

I have specific concerns about several interpretations made about this training session in the article by Dr Frances. The first point that Dr Frances interprets from the training is that the trainer instructed evaluators to:

1. NOT carelessly confuse the relatively common crime of rape with the very infrequent mental disorder of paraphilia.¹

It is my opinion that the trainer did, indeed, underscore this point. He instructed the new evaluators not to equate the act of rape with Paraphilia Not Otherwise Specified (NOS). In doing so, the trainer restated the obvious to the experienced evaluators regarding the utilization of Paraphilia NOS as a predisposing mental disorder in SVP evaluations. The message was, “All rapists do not suffer from a Paraphilia.” The message was NOT that there is no such thing as a paraphilia involving sexual arousal to coercion. It was NOT that evaluators should not diagnose that paraphilic proclivity via use of Paraphilia NOS when they determine it is present. The trainer noted a general rule that if a diagnosis is outside the contemporary DSM, it is out of bounds for DMH SVP reports, but he also reminded those in attendance that Paraphilia NOS is a DSM-listed disorder.

The most egregious error is the creative misuse of the designation “Paraphilia NOS.” Many SVP evaluators incorrectly assume that rape by itself is grounds for diagnosing paraphilia-ignoring the fact that this notion has been explicitly rejected by DSM-III, DSM-IIIR, DSM-IV, and DSM-5.¹

This is not the first time Dr Frances has written about California DMH and Paraphilia NOS. After his first article³ about the same California DMH SVP evaluator training, I was asked while testifying whether the DMH had instructed evaluators, as Dr Frances alleged, not to employ Paraphilia NOS as a potential qualifying disorder in SVP evaluations. Afterwards, in personal correspondence with the trainer, I double-checked DMH’s intention in this regard. The trainer confirmed that my understanding was correct-that CA DMH is not advising its evaluators against the use of Paraphilia NOS as a potentially qualifying mental disorder.

It is also worthy to note that in a more recent training attended by many of the California SVP evaluators that occurred in December 2011 (at which the trainer of the September event was present), Dr David Thornton⁴ provided compelling scientific evidence to support the notion that such a disorder (ie, Paraphilic Coercive Disorder) actually does exist. During that training, there was general consensus among California evaluators that a disorder of sexual deviancy involving sexual arousal to non-consent themes exists. Participants expressed an appreciation for Dr Thornton’s empirical analysis and lack of bombastic rhetoric. Most agreed that the current DSM lacks a proper place for paraphilic coercion; however, this does not apparently dissuade them from utilizing the NOS category to compensate for DSM-IV’s failings.

In contrast to his stated opinion, in the current article Dr Frances seems to come very close to acknowledging that there may be some offenders for whom the “act of rape” may be a “precondition” for attaining sexual arousal. He seems to allow that this may be a bona fide expression of Paraphilia NOS-one that others have sought to define as Paraphilic Coercive Disorder.

Any diagnosis of “Paraphilia NOS, nonconsent” should contain both affirmative evidence that the act of rape was a precondition for attaining sexual arousal and a complete differential diagnosis that rules out the much more common contexts of rape.¹

It is also valuable to note that in addressing the process of assessing for an SVP qualifying mental disorder, the DMH trainer cautioned against a practice of automatically disqualifying Antisocial Personality Disorder as a potential predisposing mental disorder. The trainer noted that California statutes do not exclude such and stated that a personality disorder may very well predispose a given sexual offender to perpetrate sexual offenses. This opinion is consistent with data presented by Dr Thornton at the December 2011 training-illustrating that a high density of non-sexual criminality, along with a low density of sexual deviance among sex offenders, is generally as predictive of sexual re-offense as a high density of sexual deviance paired with a low density of non-sexual criminality among sex offenders.

The second point Dr Frances perceived as having been underscored at the September 2011 CA DMH training is:

2. (evaluators should) NOT use “hebephilia” as an excuse for making a “Paraphilia NOS” diagnosis because having sex with pubescent youngsters is not a DSM-IV mental disorder.¹

With respect to this issue, I cannot comment regarding its veracity as a point made in the training. This is because I can find no mention of the word “hebephilia” or any related topic in the workshop’s PowerPoint handouts, nor did I make any personal notes to the effect.

Last, Dr Frances opined that the training instructed evaluators to:

3. NOT confuse the violence inherent in all rapes with the sexually arousing use of violence that specifically defines the extremely rare DSM disorder of Sexual Sadism…Sexual Sadism requires that the violence be inflicted specifically because causing pain and humiliation is necessary for sexual arousal.¹

In my recollection and opinion, the trainer did, indeed, underscore the importance of not automatically inferring that a person suffers from Sexual Sadism simply because of the presence of violent behavior. My experience is that evaluators do not automatically infer such but rather they strive to disinter factors that illustrate an underlying sexual arousal pattern. A problem with Sexual Sadism as a diagnostic option absent a diagnostic option for a paraphilia of sexual coercion sets up a serious challenge to accurate diagnosis. Conceptualizing Sexual Sadism as an “all or none” diagnosis, without appreciation of the oft-observed presence of arousal to coercion, leaves many evaluators without a route to diagnostic precision. In his quest to denigrate PCD, Dr. Frances continues to leave us with no direction whatsoever in regard to those offenders who demonstrate what others in the literature have referred to as the paraphilic rape pattern, biastophilia, or paraphilic coercion.

Dr. Frances concluded his article with a unique packaging and sales attempt of his agenda, using as wrapping his twists on the California DMH training combined with DSM-5 developments. He exalted California DMH by declaring that the training “was brilliantly conducted and under the powerful auspices of California DMH” while prophesying that the training will not “solve the SVP problem for California.” This statement would surely lead any nave reader to speculate there must be a serious problem in the way SVP evaluations are conducted in California or, at least, that there were serious problems with those evaluations conducted prior to the training. He noted that we, as independent contractors, are free to exercise independent clinical judgment in any given case. He graciously gave us permission to choose to continue our diagnostic practices in a mistaken, incompetent, and careless manner.

But the tide has definitively turned against careless SVP diagnosis. The combination of the DSM-5 rejection of “coercive paraphilia” and the California DMH’s reigning in of idiosyncratic evaluators should together presage the beginning of the end for the misuse of DSM in SVP cases.¹ 

In this final note, Dr. Frances combines his misrepresentation of California’s recent DMH training points with the rejection of the DSM-5 proposal for Paraphilic Coercive Disorder in an effort to propagandize that no such disorder involving sexual arousal to coercion exists. Here, he seems to allow personal umbrage to predominate his arguments against the DSM-5 Paraphilias Subworkgroup-a committee he has not been asked to be a part of this time around. Dr. Frances reiterates his opinion that to persist to acknowledge the presence of paraphilias involving coercion or pubescent victims means that evaluators are misusing the DSM, implying that the book itself dictates the reality of mental disorder. However, this is not consistent with the experience of professionals that actually work with severe sexual abusers who do not doubt these conditions exist among the sub-group of severe sex offenders. The combination of harsh language and misrepresentation of facts that has come to characterize Dr. Frances’ work is of little assistance to those tasked with accurately characterizing the mental disorders of severe sexual abusers. We deserve better from leaders in the field.

References1. Frances A. California DMH Instructs SVP Evaluators on Proper DSM-IV-TR Diagnosis. Psychiatr Times. January 4, 2012. http://www.psychiatrictimes.com/forensic-psych/content/article/10168/2012928.
2. D’Orazio D, Arkowitz S, Adams J, Maram W. The California sexually violent predator statute: History, description, and areas of improvement. San Jose, California: CCOSO. 2009.
3. Frances A. Another step toward ending the Paraphilia NOS fad: The California DMH takes a stand. Psychiatr Times. October 10, 2011. http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1968141.
4. Thornton D. Advanced training in sexual offender assessment. Paper presented at workshop hosted by Central Coast Clinical and Forensic Psychology Services, Atascadero, California. December 12 and 13, 2011.