Dead Right, Dead Right,

Dead Wrong,Dead Wrong,

or the Jury is Still Out: or the Jury is Still Out:

The Complex Worlds of Violence and Mental IllnessThe Complex Worlds of Violence and Mental Illness

Sally C. Johnson MDSally C. Johnson MDProfessorProfessorUNC Department of PsychiatryUNC Department of PsychiatryForensic Psychiatry Program and ClinicForensic Psychiatry Program and Clinic

Learning ObjectivesLearning Objectives

Appreciate the complexity of the Appreciate the complexity of the relationship between violence and relationship between violence and mental illnessmental illness

Understand the current state of Understand the current state of risk assessmentrisk assessment

Translate this understanding into Translate this understanding into a practical approach to risk a practical approach to risk managementmanagement

75% of people believe that 75% of people believe that people with mental illness people with mental illness are dangerous. are dangerous.

Literature:Literature:Mental illness and Mental illness and ViolenceViolence

From Nursery Rhymes….From Nursery Rhymes….

Lizzie Borden took an axe and gave her mother forty

whacks. When she saw what she had

done she gave her father forty-one.

To recent best-sellers…To recent best-sellers…

““These were the lovely bones that had These were the lovely bones that had grown around my absence…” grown around my absence…”

Susie Salmon cutting through Susie Salmon cutting through a cornfield after school is a cornfield after school is persuaded by George Harvey, persuaded by George Harvey, a man in his mid-40s who a man in his mid-40s who lives alone and builds lives alone and builds dollhouses for a living, to dollhouses for a living, to have a look at his have a look at his underground den. He rapes underground den. He rapes and kills her, dismembers her and kills her, dismembers her body, puts the parts in a safe body, puts the parts in a safe and dumps it into a sinkhole. and dumps it into a sinkhole.

We are led to believe that “crazy” We are led to believe that “crazy” people do crazy and frightening people do crazy and frightening things.things.

Film Portrayal: Film Portrayal: Mental Illness and Mental Illness and ViolenceViolence

The idea of the insane killer….The idea of the insane killer….

Takes a real life story like that of Ed Gein

… and makes him into Norman Bates in

Alfred Hitchcock’s “Psycho”

In the News:In the News:Mental Illness and ViolenceMental Illness and Violence

Whether it is the poor handyman in Whether it is the poor handyman in need of a job…need of a job…

Bryan David Mitchell Elizabeth Smart Kidnapping

Or workplace violence that hits Or workplace violence that hits close to home…close to home…

The murder of an NIMH administrator while trying to help The murder of an NIMH administrator while trying to help a psychotic patient sent shockwaves through the mental a psychotic patient sent shockwaves through the mental health community, forcing clinicians to remember the health community, forcing clinicians to remember the rare—but ever present—risk of violence. It is a rare rare—but ever present—risk of violence. It is a rare scenario, the potential nightmare in the life of a scenario, the potential nightmare in the life of a psychiatrist: a patient becomes violent…while the psychiatrist: a patient becomes violent…while the psychiatrist and the patient are alone in the psychiatrist and the patient are alone in the psychiatrist's office. psychiatrist's office.

Wayne Fenton, M.D.October 3, 2006

……or a psychiatrist (possible or a psychiatrist (possible terrorist) turned mass murderer…terrorist) turned mass murderer…

Nidal Malik Hasan Ft. Hood Killing Rampage

We are surrounded by possible We are surrounded by possible links between violence and mental links between violence and mental illness, and it’s frightening.illness, and it’s frightening.

We are looking for a way to give We are looking for a way to give names and faces to our fears…names and faces to our fears…

……we want to know who is going to we want to know who is going to be violent and be able to stop them be violent and be able to stop them from being violent. from being violent.

Cesare Lombroso’s “Atavism”: violent criminals were throwbacks to

primitive humans / identifiable by physical characteristics / so could

just permanently detain or execute them

What’s the message?What’s the message?

Physical Signs of Imminent Physical Signs of Imminent Violence Violence (Berg, Bell, and Tupin, 2000)(Berg, Bell, and Tupin, 2000)

ChantingChanting Clenched JawClenched Jaw Flared NostrilsFlared Nostrils Flushed faceFlushed face Clenched or Gripping handsClenched or Gripping hands Darting Eye MovementsDarting Eye Movements Increased proximity of patient to Increased proximity of patient to

ClinicianClinician Inability of Patient to Comply with Inability of Patient to Comply with

reasonable Limit settingreasonable Limit setting

Core Issues to ConsiderCore Issues to Consider

DefinitionsDefinitions Violence / Mental IllnessViolence / Mental IllnessAssessmentAssessment What’s adequate? How often? What’s adequate? How often? PredictionPrediction Of what? For how long?Of what? For how long?PreventionPrevention Responsibility / CostResponsibility / CostLiability / BlameLiability / Blame

Violence: what does it Violence: what does it mean?mean?

Actual physical violence? Actual physical violence? Potential for violent behavior?Potential for violent behavior? Threat of violent behavior?Threat of violent behavior? Breaking the law?Breaking the law? Psychological or emotional harm?Psychological or emotional harm? Risk to property?Risk to property? Does it have to be a specific act or just a Does it have to be a specific act or just a

general propensity towards violence?general propensity towards violence?

Does it have to be imminent?Does it have to be imminent? Does frequency matter?Does frequency matter? Does severity matter?Does severity matter? What about the setting? What about the setting? Does it matter toward whom or Does it matter toward whom or

what it is directed?what it is directed?

What about defining Mental What about defining Mental Illness or Mental Disorder?Illness or Mental Disorder?

Clinically…Clinically…

ICD-10 : “the existence of a clinically ICD-10 : “the existence of a clinically recognizable set of symptoms or behavior recognizable set of symptoms or behavior associated … with … interference with personal associated … with … interference with personal functions”.functions”.DSM-IV-TR : “DSM-IV-TR : “a clinically significant behavioral a clinically significant behavioral or psychological syndrome or pattern that occurs or psychological syndrome or pattern that occurs in an individual …associated with present in an individual …associated with present distress … disability … or a significantly distress … disability … or a significantly increased risk of suffering death, pain, disability, increased risk of suffering death, pain, disability, or an important loss of freedom …or an important loss of freedom …

BUT…BUT…

Within the legal/judicial Within the legal/judicial system, mental illness or system, mental illness or disorder is viewed as a disorder is viewed as a legal, moral or policy legal, moral or policy judgment or definition-judgment or definition-

not a clinical one.not a clinical one.

Our legal system has long connected mental illness and violence and looked to clinicians to predict likelihood of future violence:

Civil CommitmentCivil Commitment O’Connor v. Donaldson O’Connor v. Donaldson (1975) / (1975) / Addington v. Texas Addington v. Texas

(1979)(1979) Civil LiabilityCivil LiabilityTarasoff v. Regents of the University of CATarasoff v. Regents of the University of CA (1976) (1976) Death Penalty CasesDeath Penalty CasesJurek v.Texas Jurek v.Texas (1976) / (1976) / Barefoot v. EstelleBarefoot v. Estelle (1983) (1983) JuvenilesJuvenilesShall v Martin Shall v Martin (1984)(1984) Preventive DetentionPreventive Detention U.S. v. SalernoU.S. v. Salerno (1987) (1987) Sex Offender Commitment StatutesSex Offender Commitment StatutesKansas v. Hendricks Kansas v. Hendricks (1997) / (1997) / US v Comstock (2010)US v Comstock (2010)

““

Legal Areas of Violence Risk Prediction

This legal dependence on clinical This legal dependence on clinical prediction of risk has persisted prediction of risk has persisted despite data suggesting that despite data suggesting that clinicians are often wrong in their clinicians are often wrong in their predictions.predictions.

Natural experiments Natural experiments suggested clinicians were suggested clinicians were wrong more often than not:wrong more often than not: Baxstrom v. Herald, (1966)-Baxstrom v. Herald, (1966)-release or transfer of release or transfer of

“dangerous” patients. In 4 yr. follow-up only 20% assaultive“dangerous” patients. In 4 yr. follow-up only 20% assaultive

Dixon v. Attorney General of Commonwealth Dixon v. Attorney General of Commonwealth of PA (1971/1979-review)-of PA (1971/1979-review)-86% false positive rate among those 86% false positive rate among those originally predicted to be dangerousoriginally predicted to be dangerous

1976-Cocozza/ Steadman-257 incompetent 1976-Cocozza/ Steadman-257 incompetent felons released: 14% of those predicted as felons released: 14% of those predicted as dangerous were rearrested; 16% of those not dangerous were rearrested; 16% of those not viewed as dangerous were rearrested!viewed as dangerous were rearrested!

1977-Patients released from 1977-Patients released from Patuxent Patuxent Institute/ MD Institute/ MD -58% false-positive rate in -58% false-positive rate in predictions of violencepredictions of violence

In the wake of early legal decisions, In the wake of early legal decisions, research efforts increased with the aim to research efforts increased with the aim to improve violence risk assessment in clinical improve violence risk assessment in clinical practice and the criminal justice context by:practice and the criminal justice context by:

– identifying empirically-validated risk identifying empirically-validated risk factorsfactors

– developing risk assessment instruments developing risk assessment instruments based on empirically-validated risk based on empirically-validated risk factorsfactors

Methodological problems in earlier Methodological problems in earlier studies were identified …studies were identified …

Large #s of patients were lost to follow-up Large #s of patients were lost to follow-up Many had been treated for yearsMany had been treated for years Reviews relied on official criminal records Reviews relied on official criminal records

which grossly under-estimated violencewhich grossly under-estimated violence Definition of violence was inconsistentDefinition of violence was inconsistent Original predictions had not all been Original predictions had not all been

clinical: many were administrative or legalclinical: many were administrative or legal Turns out that Clinicians were actually Turns out that Clinicians were actually

right more often than not - but just barelyright more often than not - but just barely

Review of History of Study of Review of History of Study of Relationship between Violence Relationship between Violence and Mental Illnessand Mental Illness

Pre-deinstitutionalization studies showed no Pre-deinstitutionalization studies showed no increased risk of violenceincreased risk of violence

Post-deinstitutionalization studies began to show Post-deinstitutionalization studies began to show increased riskincreased risk

It appeared that increased risk might be more It appeared that increased risk might be more connected to active symptoms rather than to connected to active symptoms rather than to diagnosesdiagnoses

There was more and more evidence that the There was more and more evidence that the relationship between mental illness and violence relationship between mental illness and violence was actually quite complexwas actually quite complex

MacArthur Violence MacArthur Violence Risk Assessment Study Risk Assessment Study (1994)(1994) Civil Admissions from inpatient psychiatric hospitals: Western Civil Admissions from inpatient psychiatric hospitals: Western

Psychiatric/ Pittsburgh, PA; Western Missouri Mental Health Psychiatric/ Pittsburgh, PA; Western Missouri Mental Health Center/ Kansas City, MO; Worcester State hospital and Center/ Kansas City, MO; Worcester State hospital and University of Massachusetts Medical Center / Worcester, MAUniversity of Massachusetts Medical Center / Worcester, MA

Ages 18-40Ages 18-40 English Speaking / White or African-American (Hispanic at English Speaking / White or African-American (Hispanic at

Worcester)Worcester) Chart Dx of Schizophrenia, schizophreniform, schizoaffective, Chart Dx of Schizophrenia, schizophreniform, schizoaffective,

depression, dysthymia, mania, brief reactive psychoses, depression, dysthymia, mania, brief reactive psychoses, delusional disorder, alcohol or drug abuse or dependence, or delusional disorder, alcohol or drug abuse or dependence, or personality disorder. Research and clinician interviews in personality disorder. Research and clinician interviews in hospital; two research interviews of patient and collateral hospital; two research interviews of patient and collateral informant with next 20 weeks. Review of hospital, arrest and informant with next 20 weeks. Review of hospital, arrest and rehospitalization recordsrehospitalization records

MacArthur Study-18.7 % of patients were MacArthur Study-18.7 % of patients were involved in violent altercations: involved in violent altercations: Significant Findings Significant Findings

Men no more likely to be violent than womenMen no more likely to be violent than women; drinking ; drinking , SA and medication non-compliance > in men / women , SA and medication non-compliance > in men / women directed violence against family and at homedirected violence against family and at home

All measures (self report, hospital and arrest records)- All measures (self report, hospital and arrest records)- previous violence and criminalityprevious violence and criminality strongly related to strongly related to future violencefuture violence

Prior physical abusePrior physical abuse, but not sexual abuse as child was , but not sexual abuse as child was associated with post-DC violenceassociated with post-DC violence

Parents history of substance abuse or criminal Parents history of substance abuse or criminal behaviorbehavior: strong relationship: strong relationship

All races All races in same disadvantaged neighborhood in same disadvantaged neighborhood had same had same riskrisk: crime rate of neighborhoods pts. are discharged into : crime rate of neighborhoods pts. are discharged into may be important factormay be important factor

Personality disorder/ adjustment disorderPersonality disorder/ adjustment disorder had greater had greater risk than all other Dx; schizophrenia<depression or bipolar risk than all other Dx; schizophrenia<depression or bipolar but > than non-disordered populationbut > than non-disordered population

MacArthur Study Findings MacArthur Study Findings continued….continued….

Co-occurring Dx of Substance Abuse or Dependence Co-occurring Dx of Substance Abuse or Dependence strongly predictivestrongly predictive

PsychopathyPsychopathy (the antisocial component) as measured by (the antisocial component) as measured by PCL predicted violencePCL predicted violence

Delusions were not predictive (even threat-control-over-Delusions were not predictive (even threat-control-over-ride) but ride) but suspiciousnesssuspiciousness was was

Hallucinations/ command hallucinations were not predictive Hallucinations/ command hallucinations were not predictive unless unless voices specifically commanding violent actsvoices specifically commanding violent acts

Persistent violent thoughtsPersistent violent thoughts during hospitalization and during hospitalization and afterwards were predictive afterwards were predictive

AngerAnger: high scores on Novaco Anger Scale at : high scores on Novaco Anger Scale at hospitalization were twice as likely to engage in violent hospitalization were twice as likely to engage in violent acts post DCacts post DC

::

So where are we now,So where are we now,

more than 25 years more than 25 years later?later?

National Epidemiologic Survey on National Epidemiologic Survey on Alcohol and Related Conditions Alcohol and Related Conditions (NESARC)(NESARC)

We employed a nationally representative, We employed a nationally representative, longitudinal dataset from this two wave, longitudinal dataset from this two wave, face-to-face survey conducted by the face-to-face survey conducted by the National Institute on Alcohol Abuse and National Institute on Alcohol Abuse and Alcoholism. N= 34,653 subjects Alcoholism. N= 34,653 subjects

Wave 1 (2001-2002) Wave 2 (2004-2005).Wave 1 (2001-2002) Wave 2 (2004-2005).

Our questions were:Our questions were:1) 1) Does severe mental illness (SMI) predict Does severe mental illness (SMI) predict future future violent behavior?violent behavior?2) 2) What risk factors prospectively predict What risk factors prospectively predict violent violent behavior?behavior?

Multivariate Predictors of Multivariate Predictors of Violent Behavior Perpetrated Violent Behavior Perpetrated Between Waves 1 and2Between Waves 1 and2

Dispositional FactorsDispositional Factors: age, education, sex, race, : age, education, sex, race, incomeincome

Historical FactorsHistorical Factors: parental criminal history, : parental criminal history, witnessing parental fighting, history of any violence, witnessing parental fighting, history of any violence, history of juvenile detentionhistory of juvenile detention

Clinical FactorsClinical Factors: Schizophrenia, Bipolar Disorder, : Schizophrenia, Bipolar Disorder, Major Depression, Substance abuse/Dependence, Major Depression, Substance abuse/Dependence, Schizophrenia+SA/D, Bipolar Disorder+SA/D, Schizophrenia+SA/D, Bipolar Disorder+SA/D, Depression+SA/D, Perceives hidden threats in othersDepression+SA/D, Perceives hidden threats in others

Contextual FactorsContextual Factors: Victimized in past year, family : Victimized in past year, family or friend died in past year, fired from job in past year, or friend died in past year, fired from job in past year, divorced or separated in past year, Unemployed for divorced or separated in past year, Unemployed for past yearpast year

Top Ten Predictors of Any Top Ten Predictors of Any Violent Behavior Between Violent Behavior Between Waves 1 and2Waves 1 and2 Age (younger)Age (younger) History of any violent actHistory of any violent act MaleMale Divorce or separation in the past yearDivorce or separation in the past year History of physical abuseHistory of physical abuse Parental criminal historyParental criminal history Unemployment for the past yearUnemployment for the past year Co-occurring severe mental illness and Co-occurring severe mental illness and

substance abusesubstance abuse Victimization in the past yearVictimization in the past year

SMI did not predict severe/serious violence, even SMI did not predict severe/serious violence, even when combined with substance use disorders. when combined with substance use disorders.

SMI was significantly associated with physical SMI was significantly associated with physical abuse by parents, parental arrests, substance abuse by parents, parental arrests, substance disorders, recent victimization, and disorders, recent victimization, and unemployment.unemployment.

46% of those with SMI had co-morbid substance 46% of those with SMI had co-morbid substance abuse/dependence. Violence risk was higher in abuse/dependence. Violence risk was higher in this group than substance use without SMI.this group than substance use without SMI.

People with SMI were more vulnerable to past People with SMI were more vulnerable to past histories that elevate violence risk and more histories that elevate violence risk and more prone to experience environmental stressors that prone to experience environmental stressors that also elevate violence risk. also elevate violence risk.

Severe mental illness did Severe mental illness did NOTNOT rank among rank among the strongest predictors of violent behavior.the strongest predictors of violent behavior.

Severe mental illness alone was Severe mental illness alone was NOTNOT statistically related to future violence, in statistically related to future violence, in bivariate or multivariate analyses. bivariate or multivariate analyses.

People with any type of severe mental illness People with any type of severe mental illness were were NOTNOT at increased risk of committing at increased risk of committing serious/severe violent acts.serious/severe violent acts.

Evolution from Violence Evolution from Violence Prediction to Risk (or threat) Prediction to Risk (or threat) AssessmentAssessment

Violence PredictionViolence Prediction

-focuses on the individual-focuses on the individual

-portrays dangerousness as a state-portrays dangerousness as a state

Risk AssessmentRisk Assessment

-focuses on person-situation interactions-focuses on person-situation interactions

-portrays dangerousness as -portrays dangerousness as

dynamic, contextual and continuousdynamic, contextual and continuous

We continue to be asked to We continue to be asked to assess risk of violence:assess risk of violence:

Need for admission/ suitability for dischargeNeed for admission/ suitability for discharge ER evaluationsER evaluations Civil Commitment/ ReleaseCivil Commitment/ Release Workplace/ school threatsWorkplace/ school threats Juvenile justice managementJuvenile justice management Sentencing/ Parole/ Probation/ Early ReleaseSentencing/ Parole/ Probation/ Early Release Sex Offender CommitmentsSex Offender Commitments Specialty Court Treatment PlansSpecialty Court Treatment Plans

Approaches to Risk Approaches to Risk AssessmentAssessment

Unstructured Clinical JudgmentUnstructured Clinical Judgment

ActuarialActuarial

Structured Professional JudgmentStructured Professional Judgment

AnamesticAnamestic

Clinical JudgmentClinical Judgment

More accurate than chance More accurate than chance (Mossman 1994) AUC= .67(Mossman 1994) AUC= .67

Does facilitate aspects of data Does facilitate aspects of data gathering and data interpretationgathering and data interpretation

ActuarialActuarial

Formal / equation-formula-graph- table used Formal / equation-formula-graph- table used to arrive at a probability of some outcometo arrive at a probability of some outcome

Objective, mechanistic, reproducible Objective, mechanistic, reproducible combination of predictive factors, selected combination of predictive factors, selected and validated through empirical research and validated through empirical research against known outcomesagainst known outcomes

BUT clinicians have not embraced thisBUT clinicians have not embraced this Hard to go from the abstract to the Hard to go from the abstract to the

individualindividual

Structured Professional Structured Professional JudgmentJudgment

Presentation of specific risk factors Presentation of specific risk factors derived from broad review of derived from broad review of literature not specific data set- literature not specific data set- factors are well operationalized so factors are well operationalized so their applicability can be coded: yes-their applicability can be coded: yes-possibly-no-/ multiple data sources/ possibly-no-/ multiple data sources/ evaluator draws conclusion weighing evaluator draws conclusion weighing risk factors and intensity of risk factors and intensity of managementmanagement

AnamesticAnamestic

Process of gathering detailed Process of gathering detailed information about individual’s history information about individual’s history of violence. Question in detail about of violence. Question in detail about each particular violent event each particular violent event (preceding, subsequent, during)- (preceding, subsequent, during)- thoughts, feelings and behaviors - to thoughts, feelings and behaviors - to identify risk and protective factors identify risk and protective factors that recur across violent events- that recur across violent events- identify target interventionsidentify target interventions

A Practical Guide to A Practical Guide to Risk Assessment…Risk Assessment…

Build structure into your approach Build structure into your approach Remember that violence is not a Remember that violence is not a

common event, so prediction is common event, so prediction is not easynot easy

Start by thinking about the base Start by thinking about the base rate for your clinical situationrate for your clinical situation

““Knowledge of the appropriate Knowledge of the appropriate base rate is the most important base rate is the most important single piece of information single piece of information necessary to make an accurate necessary to make an accurate [violence] risk prediction.”[violence] risk prediction.”

(Monahan 1981)(Monahan 1981)

Base RateBase Rate

The proportion of a particular The proportion of a particular population who commit violence in a population who commit violence in a particular period of timeparticular period of time

Starting point for subsequent Starting point for subsequent evaluation of probabilityevaluation of probability

Varies by type of violence, by method Varies by type of violence, by method of detection, over time, and usually of detection, over time, and usually underestimates the true extent of underestimates the true extent of violenceviolence

Practical Assessment of Practical Assessment of potential for violence toward potential for violence toward others involves considering…others involves considering…

Risk and Protective FactorsRisk and Protective Factors: variables : variables associated with the probability that associated with the probability that violence will or will not occurviolence will or will not occur

HarmHarm:: the nature and severity of the the nature and severity of the probable results of the violent behaviorprobable results of the violent behavior

Risk LevelRisk Level: the probability that violence : the probability that violence will occurwill occur

Potential VictimsPotential Victims: who are the likely : who are the likely objects of the violence objects of the violence

Standardized Risk Standardized Risk Assessment ToolsAssessment Tools

Assist the Clinician in gathering appropriate Assist the Clinician in gathering appropriate datadata

Anchor assessment to established researchAnchor assessment to established research Access factors that are known to be Access factors that are known to be

associated with particular types of violence associated with particular types of violence in specific populations.in specific populations.

Should be used in conjunction with clinical Should be used in conjunction with clinical risk assessmentrisk assessment

May not be as objective in application as we May not be as objective in application as we would hope.would hope.

When you think about using When you think about using Risk Assessment Tools:Risk Assessment Tools:

ContextContext PurposePurpose PopulationPopulation ParametersParameters ApproachApproach ApplicabilityApplicability

Heilbrun, et al. Violence Risk Assessment Tools: Overview and Heilbrun, et al. Violence Risk Assessment Tools: Overview and Analysis/ Otto and Douglas Analysis/ Otto and Douglas Handbook of Violence Risk Handbook of Violence Risk AssessmentAssessment

Structured Risk Structured Risk Assessment ToolsAssessment Tools

Hare Psychopathy ChecklistsHare Psychopathy Checklists

(PCL, PCL-R, PCL:SV, PCL:YV)(PCL, PCL-R, PCL:SV, PCL:YV) Historical-Clinical Mangement-20 Historical-Clinical Mangement-20

(HCR-20) Violence Risk (HCR-20) Violence Risk Assessment SchemeAssessment Scheme

COVR-Classification of Violence COVR-Classification of Violence RiskRisk

Hare Psychopathy Hare Psychopathy Checklists (PCL, Checklists (PCL, PCL-RPCL-R, , PCL:SV, PCL:YV)PCL:SV, PCL:YV) PCL-R: 20 item construct rating scalePCL-R: 20 item construct rating scale Used in research and clinical settingsUsed in research and clinical settings Assesses psychopathy in adultsAssesses psychopathy in adults Involves semi-structured interview and Involves semi-structured interview and

review of file/collateral datareview of file/collateral data PCL-SV: 12 itemPCL-SV: 12 item PCL:YV: 20 itemsPCL:YV: 20 items

Psychopathic Psychopathic Personality ConstructPersonality Construct

Personality traits and socially deviant Personality traits and socially deviant behaviors:behaviors:Glib and superficial charmGlib and superficial charmEgocentricityEgocentricitySelfishnessSelfishnessLack of empathy, guilt and remorseLack of empathy, guilt and remorseLack of enduring attachment to people, Lack of enduring attachment to people, principles, or goalsprinciples, or goalsImpulsive and irresponsible behaviorImpulsive and irresponsible behaviorTendency to violate explicit social normsTendency to violate explicit social norms

PCLPCL

Ability to predict violent behavior depends on Ability to predict violent behavior depends on type of behavior being predicted( general v type of behavior being predicted( general v violent v sexual), context in which offender is violent v sexual), context in which offender is or will be located ( corrections or community) or will be located ( corrections or community) and time frame of prediction ( 1 or 10 years)- and time frame of prediction ( 1 or 10 years)- and demographic variables – age/ gender/ and demographic variables – age/ gender/ race and ethnicity; need specific referral race and ethnicity; need specific referral question to determine if should be usedquestion to determine if should be used

Has modest to moderate relationship with Has modest to moderate relationship with future community violence and weak to future community violence and weak to modest with future institutional violencemodest with future institutional violence

Historical-Clinical Mangement-20 (Historical-Clinical Mangement-20 (HCR-20HCR-20) ) Violence Risk Assessment SchemeViolence Risk Assessment Scheme

Structured Professional Judgment model / translated into Structured Professional Judgment model / translated into 16 languages16 languages

Intended to facilitate assessments of risk for interpersonal Intended to facilitate assessments of risk for interpersonal violence (actual, attempted or threatened), clear violence (actual, attempted or threatened), clear unambiguous threats of harm, including psychological unambiguous threats of harm, including psychological harm, to person or persons.harm, to person or persons.

Intended to provide a structured assessment of the risk Intended to provide a structured assessment of the risk factors that are present in a given case, the relevance of factors that are present in a given case, the relevance of the risk factors for a given individual’s violence risk, and the risk factors for a given individual’s violence risk, and what risk management strategies might be put into place what risk management strategies might be put into place in order to mitigate that risk.in order to mitigate that risk.

Historical / Clinical and Risk Management Scales Historical / Clinical and Risk Management Scales

Checklist from HCR-20Checklist from HCR-20

HistoricalHistorical: previous violence, : previous violence, young age at first violent incident, young age at first violent incident, relationship instability, relationship instability, employment problems, substance employment problems, substance use problems, major mental use problems, major mental illness, psychopathy, early illness, psychopathy, early maladjustment, personality maladjustment, personality disorder, prior supervision failuredisorder, prior supervision failure

Checklist from HCR-20Checklist from HCR-20

ClinicalClinical: lack of insight, negative : lack of insight, negative attitudes, active symptoms of attitudes, active symptoms of major mental illness, impulsivity, major mental illness, impulsivity, unresponsiveness to treatmentunresponsiveness to treatment

Risk Management ItemsRisk Management Items: plans : plans lack feasibility, exposure to lack feasibility, exposure to destabilizers, lack of personal destabilizers, lack of personal support, noncompliance with support, noncompliance with medication, stressmedication, stress

COVRCOVR--Classification of Violence RiskClassification of Violence Risk

Computer-based program to Computer-based program to determine category of riskdetermine category of risk

Iterative Classification Tree (ICT)Iterative Classification Tree (ICT) Designed to mirror clinical decision Designed to mirror clinical decision

making processmaking process Differentiates between low and Differentiates between low and

high risk populationshigh risk populations

Violence Risk Assessment Decision-Making Models

Flipping a CoinFlipping a Coin -> AUC=.50-> AUC=.50

Clinical Decision-Making Clinical Decision-Making -> AUC=.66-> AUC=.66

History of Violence History of Violence -> AUC=.71-> AUC=.71

Psychopathy ChecklistPsychopathy Checklist -> AUC=.75-> AUC=.75

Violence Risk Appraisal Guide Violence Risk Appraisal Guide -> AUC=.76-> AUC=.76

HCR-20 HCR-20 -> AUC=.80-> AUC=.80

MacArthur Risk Assessment StudyMacArthur Risk Assessment Study -> -> AUC=.82AUC=.82

Perfect AccuracyPerfect Accuracy -> AUC=1.0-> AUC=1.0

No risk assessment should rely No risk assessment should rely solely on the results of any one solely on the results of any one instrument: information gleaned instrument: information gleaned from use of these structured from use of these structured instruments should be used to instruments should be used to inform risk assessment and assist inform risk assessment and assist in risk communication.in risk communication.

Given all we now Given all we now know…know…

What is a practical What is a practical approach to risk approach to risk management?management?

LEADLEAD: A Four-Step Approach : A Four-Step Approach to Assessing Violence Risk to Assessing Violence Risk

LOOKLOOK at static, individual-level factors known at static, individual-level factors known to empirically relate to violent behavior in your to empirically relate to violent behavior in your population (dispositional and historical factors)population (dispositional and historical factors)

EXAMINEEXAMINE for presence of protective factors or for presence of protective factors or unique individualized factors from both the unique individualized factors from both the micro and macro environments (contextual micro and macro environments (contextual factors)factors)

ADJUSTADJUST your risk assessment by considering your risk assessment by considering dynamic individual variables (clinical factors)dynamic individual variables (clinical factors)

DOCUMENTDOCUMENT your assessment and risk your assessment and risk management plan and communicate it to those management plan and communicate it to those who need to knowwho need to know

Specific Tasks:Specific Tasks:

Identifying/quantifying the riskIdentifying/quantifying the risk Modifying the acute risk Modifying the acute risk Managing the chronic riskManaging the chronic risk Balancing the seriousness of Balancing the seriousness of

potential outcome with the potential outcome with the probability of it’s occurrenceprobability of it’s occurrence

Keep in Mind:Keep in Mind:

Time frame of predictionTime frame of prediction Structure of setting Structure of setting

– Institution v. CommunityInstitution v. Community Impact of aging / group Impact of aging / group

involvementinvolvement

Think about identifying:Think about identifying:

Behaviors that are not a product of Behaviors that are not a product of illness but likely to be patient choiceillness but likely to be patient choice

Lifestyle choices and issues that are Lifestyle choices and issues that are going to be difficult to modify and going to be difficult to modify and about which you have no direct ability about which you have no direct ability to modifyto modify

Patient’s competence to be making Patient’s competence to be making decisions that might influence ability decisions that might influence ability to carry out violent actto carry out violent act

Share the RiskShare the Risk

Collect collateral informationCollect collateral information Consult with your peersConsult with your peers Tackle limiting confidentiality head-onTackle limiting confidentiality head-on Engage your patient and their support Engage your patient and their support

system in establishing a risk system in establishing a risk management plan and in ongoing management plan and in ongoing management of riskmanagement of risk

Develop a Violence Develop a Violence Prevention PlanPrevention Plan Distinguish Static ( Demographic and Past Distinguish Static ( Demographic and Past

History) and Dynamic Factors (Subject to History) and Dynamic Factors (Subject to change with intervention such as access to change with intervention such as access to weapons, psychotic symptoms, active weapons, psychotic symptoms, active substance abuse, living setting and situation)substance abuse, living setting and situation)

Focus on current status of each dynamic factorFocus on current status of each dynamic factor Develop a plan to address the combination of Develop a plan to address the combination of

factors unique to the individualfactors unique to the individual Determine the setting and parameters Determine the setting and parameters

necessary to safely implement the plannecessary to safely implement the plan Document this processDocument this process

Communicate the risk and the Communicate the risk and the management plan to those management plan to those who need to knowwho need to know

Guided By:Guided By:Research Data / Instrument Research Data / Instrument ConstructionConstructionEthical StandardsEthical StandardsLawsLawsAdmissibility Standards / DecisionsAdmissibility Standards / DecisionsProfessional GuidelinesProfessional GuidelinesClinical experienceClinical experience

Manage Your Liability by the Manage Your Liability by the quality of your risk quality of your risk assessment, the assessment, the thoughtfulness of your risk thoughtfulness of your risk management and the management and the excellence of your excellence of your documentationdocumentation..

Improving Your Understanding of Improving Your Understanding of Violence and Mental Illness Just Violence and Mental Illness Just Might…Might…

Help to eliminate destructive and Help to eliminate destructive and common myths about mental illness and common myths about mental illness and violenceviolence

Reduce the overall incidence of violence Reduce the overall incidence of violence in our communitiesin our communities

Enhance the safety in clinical settingsEnhance the safety in clinical settings Improve how the criminal justice system Improve how the criminal justice system

responds to people with mental illnessresponds to people with mental illness Keep you out of the courtroom, where Keep you out of the courtroom, where

the question could be…the question could be…

Was your risk assessment Was your risk assessment

and your risk management… and your risk management…

Dead Right or Dead Dead Right or Dead Wrong?Wrong?

The Jury is still The Jury is still out!out!