violence and risk assessment in clinical practice...–suicide attempts: holds for violence against...
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ViolenceandRiskAssessmentinClinicalPractice
RonaldSchouten,MD,JDLt.FredCabral
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Disclosures
• NeitherInormyspouse/partnerhasarelevantfinancialrelationshipwithacommercialinteresttodisclose
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Mywork
• MGHLaw&PsychiatryService• ForensicFellowshipPrograms
– MGH-HMS– St.ElizabethsHospital,Washington,DC
• Forensicpsychiatry:– Civil/Criminal– Violenceriskassessment– Threatassessment
• Campus• Workplace
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Clinicians,mentalillness,andviolence
• Violenceandthe24-hournewscycle.• Massshootingsgrabthepublic’sattention,butare– Asmall,butincreasing,partoftheoverallproblemofgunviolence(<6%)
– Commonly(andnotinfrequently,accurately)attributedto“mentalhealthproblems”
• Asmentalhealthprofessionals,weare– Expectedtobeabletodosomethingaboutit.– Sometimesheldresponsiblefornotpreventingit.– Faceethicalandlegaldilemmasreobtaining/sharinginformation.
– Oftenatalossregardingif,when,andhowwecanengagelawenforcement.
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Overview
• Violenceriskassessmentvs.Threatassessment• Mentalillnessandviolence• HIPAAandotherconfidentialityconcerns• Acaseexampleofhowadifficultcasecanbe/washandled
• Discussion
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What is the risk that my patient will harm himself or others?
What is the risk that a specific person/entity will be harmed, and what can be done?
Clinical examination
Psychological testing
Medical records
Mental health records
Legal documents
Police reports
Criminal histories
Violence Risks Assessment vs. Threat Assessment
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ChallengesinViolenceRiskAssessment
• Smallsamplesizes• Infrequentevents:
– Evensensitivemeasuresyieldahighrateoffalsepositives– Butthesearehighimpactinfrequenteventsthat
• Demandourattention• Arecoreelementsofyourjobs
• Hindsightis20/20– Riskchangesovertime– Earlymarkersmaybemissedentirely(orweretheymarkersatall?)
– Whenthingsgowell,noonenotices– Whenthingsgowrong,everyoneissmarterthanweare
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ChallengesoftheRiskAssessmentProcess
• Whatisthispersonlikelytodointhefuture?NielsBohr(andYogiBerra)onprediction.
• Whoisthisperson?– Whathavetheybeenlikeinthepast?– Whataretheylikenow?– Whataretheydoingcurrently?
• Howdowedistinguishwhichindividualswillmovefromthinkingtoacting?
Things are difficult to predict. Especially the future.
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Howdoweaddressthishardproblem?
• Understandingandrespectingthechallenges• Byusingassessmentmethodsthatrecognizethecomplexityofhumanbehavior
• Violenceriskastheproductoftheinteractionofmultiplevariables:– Individualrisk/protectivefactors– Environmentalrisk/protectivefactors– Situationalfactors(triggers)
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Riskassessment:abriefhistory• Unstructuredriskassessment– Clinicalimpressionbackedbyanecdotes,notdata– Profilingasanexample:
• ThelegacyofJamesBrussel,M.D.andtheMadBomber• Investigative,notpredictive,tools
• Actuarialassessment– “Numbersdon’tlie.”
• Smallsamplesizes;falsepositivesandfalsenegatives• Basedontherightsample?• Anumberwithoutadenominatortellsusnothing
• Currentstandard:Structuredprofessionaljudgment(SPJ)
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RecentattemptsatSPJforviolencerisk
• Generalviolence– HCR-20– VRAG– WAVR-21– CTAP-25– COVR– ColumbiaSuicideSeverityScale– SAVRY
• Psychopathytools:PCL-R,PPI-R,etc.• Appliedtoextremistviolence
– VERA-2:ViolentExtremismRiskAssessment– ERG-22:ExtremismRiskGuidelines– TRAP-18:TerrorismRiskAssessmentProtocol(loneactors)– MLG:Multi-LevelGuidelines(forgroupviolence)
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Howsignificantarespecificthreats?
• Poseathreatvs.Makeathreat- Somewhomakethreatsultimatelyposethreats- Manywhomakethreatsdonotposethreats(exceptinintimatepartnerviolence)
- Somewhoposethreatsnevermakethem- Huntersvs.Howlers
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Threateninglanguage
• Types:– Direct:mustbetakenseriously– Implied:manipulative?– Conditional:tobetakenseriously,becauseifthecontingencyarises…
• Thewayourstatutesusethelanguageofthreat:theexampleofCh.123§ 12– “…manifestedbyevidenceofthreatsof,orattemptsatsuicideorseriousbodilyharm…”
– “…manifestedbyevidenceofhomicidalorotherviolentbehaviororevidencethatothersareplacedinreasonablefear…”
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Threatstokill:averyspecificproblem
• Contradictoryfindingsrethreatsandactualviolence
• Highrateofmentalillnessamongthreateners:– Barnesetal2001
• 102threatenerssentforcourt-orderedevaluations• 57.8%assessedassufferingfrommentalillness;highprevalenceofpersonalitydisorderandsubstanceabuse
– Häkkänen(2006):69bombthreateners;21%mentallydisordered
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Threatstokill(cont’d)
• Warren,etal(2008)– AlladultsinVictoria,Australiaconvictedofmakingthreatstokillin1993-1994• Offense:utteringtokill,producingfearinthevictim• Studyincludedthosewhoalsocommittedadditionaloffenses,aswellasutterancealone
• Researchedoffenders’contactswithpublicmentalhealthservices
• Recordedsubsequentconvictions
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Threatstokill:Warren(cont’d)
• 565maleand48femaleoffenders• Meanage31.3years(range=17-72)• Targetofthreat– 38.2%:Intimates– 36.4%:Acquaintances/coworkers– 5.9%:Strangers– 0.2%Publicfigures
• Mentaldisorder:41.3%hadcontactwithpublicMHservicespriortoindexoffense– Substanceabusemostcommonprimarydx– Followedbyschizophreniaandpersonalitydisorder,APDmostcommonofthese
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Threatstokill:Warren(cont’d)
• Recidivism– Subsequentconvictionsfor53.9%– 44.4%forviolentoffenses– 3%(19)wentontocommithomicide– Originalthreatvictimthesubsequentvictimin85cases(13.9%)
– 5oforiginalvictimssubsequentlykilledbythethreatener;3otherswerevictimsofattemptedmurder
– Alsoreoffendedagainstindexvictim:assaults(50),rapes(3),stalking(11),furtherdeaththreats(10)
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Threatstokill:Warren(cont’d)
• Riskfactorsforsubsequentviolence– Diagnosisofsubstanceabuse– Youngerageatfirstconviction– Mentaldisorder– Absence ofpriorcriminalconviction– Threatenersatincreasedriskofdeath(suicide>homicide)
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AModelforViolenceRiskAssessment
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ViolenceSubtypes
• Impulsiveviolence- Reactive- Maybeculminationofextendedconflict- Victimmaybeunintended/unplanned- Ex:barfight,roadrage
• Targetedviolence- Predatory,planned- Aimedataspecificindividualorinstitution- Requiresabilitytoorganize- Ex:domesticstalker,workplaceorschoolviolence,ambushassault
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IndividualFactors:Static
• Personalhistoryof:– Violence– Suicideattempts:holdsforviolenceagainstselfandothers– Failedconditionalrelease/parole– Multiplecivilcommitments– Noncompliancewithtreatment– Neurological/cognitiveimpairment– Traitanger– Impulsivity– Arrests– Weaponsuseforemotionalrelease/PseudoCommando
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IndividualFactors:Static
• Personalhistoryof– Childabuse– Exposuretoviolenceinchildhood:Traumacounts– Bullying/beingbullied
• Familyhistoryof– Violence– Antisocialpersonalitydisorder/psychopathy
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IndividualFactors:Dynamic
• Perceptionofinjustice• Hopelessness• Motivationalfactors,e.g.grandiosity,revenge,delusions,searchforidentity/belonging/purpose
• Adverseresponsetoauthority
• Identificationwithviolence-themedgroups
• Unemployment• Lackofsocialsupport• Obsession/fanaticism• Suicidalorhomicidalideation
• Mentalillness,includingsubstanceabuse– Drinking+thinking– TheMaudsleyViolenceQuestionnaire
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IndividualFactors:MentalIllness
• Thestigmaproblem– Presumptionofastrongassociationbetweenseriousmentalillnessandviolence
– Folkpsychology:thereisclearlysomethingwrongwithsomeonewhoengagesinactsofviolence
• Beyondthestatutorydefinition:Whatdowemeanbymentalillness?– 365diagnosesinDSM-IVTR– Commonusage:majormentalillness(majordepression,bipolardisorder,psychoticdisorders)
– Butalso:substanceabuse,personalitydisorders,NOSdiagnoses
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MentalIllnessandViolence
• Fact:Absentactivepsychoticsymptoms,theriskofviolenceformentallyillindividuals(excludingsubstanceabuse)isnohigherthanfordemographicallysimilarmembersofthesamecommunitywhohaveneverbeentreated
• Fact:Individualswithseriousmentalillnessareatanincreasedriskofviolencethatisstatisticallysignificant,butnotbymuch
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MentalIllnessandViolence(cont’d)
• Individualswithmentaldisordersmostatrisk– Individualswithsubstanceabuse/dependence– Psychoticdisorderswithactivesymptoms• Paranoia,control,overridesymptoms• HistoryofOppositionalDefiantDisorderaschildrenand/or• HistoryofClusterBtraits/disorders:AntisocialPersonalityDisorderasadults(Psychopathy/SubclinicalPsychopathy)
– Historyofviolence(perpetratororvictim)
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Substanceabuseasariskfactor
Selfreportofviolenceinpreviousyear:DX %None 2OCD 11Bipolar/mania 11Panicdisorder 12Majordepression 12Schizophrenia 13Cannabisuse/dependence 19Alcoholuse/dependence 25Otheruse/dependence 35
Swanson, et al (1998)
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Butwhatdoesthattellusaboutindividualrisk?
• Therearemultipleriskfactorsinevershiftingcombinations
• Wecanidentifygroupsatincreasedriskofviolence
• Membershipinthatgroupmeansthatthepersonisatincreasedrisk,butthatdoesn’ttellusthatthepersonwillbeviolent
• Contextanddynamicfactorsarekey.
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Environmentalfactors
• Availablevictims?• Lackofsocialsupports,e.g.family,community• Cultureofviolence• Accesstoweapons• Highconflictsituation• Absenceofconstraints
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Situationalfactors
• Acuteandchronicstressors• FINAL– Financial– Intoxication– Narcissisticinjury– Acuteorchronicillness– Losses
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Thepathwaytoviolencemodel:Calhoun&Weston2003
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Constraintsonclinicians
• HIPAA?– Whenaproviderbelievesingoodfaiththatawarningtolawenforcement,familymembersofthepatient,orothersisnecessarytopreventorlessenaseriousandimminentthreattothehealthorsafetyofthepatientorothers,theprivacyruleallowstheprovider,consistentwithapplicablelawandstandardsofethicalconduct,toalertthosepersonswhomtheproviderbelievesarereasonablyabletorepentorlessenthethreat.45CFRSec.164.512(j)
– Maynotifyfamilytowatchforsymptoms,evenifharmnotimminent45CFR164.510(b)(2)
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Constraintsonclinicians
• Federalrestrictionsondisclosureofinformationrelatedtoalcoholanddrugabusetreatmentrecords:42USC290dd-2;42CFRPart2
• Statelaws:knowyourjurisdictionre– Tarasoffduties:permittedvs.required?– Confidentiality:
• Reasonablenessiskey• Alwaysdisclosetheleastamountofinformationnecessarytoavoidtheharminquestion
• Receivingisnotthesameasdisclosing
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Somedifficultquestions
• Whatcanwedotodivertpeopleatriskofinvolvementwiththecriminaljusticesystem?
• Shouldwe/canwecalllawenforcement?• Legalconcerns?• Ethicalconcerns?• Practicalconcerns:– Local?State?FBI?SecretService?– WhathappenstomypatientifIdo?
• Amodelforhowitcanhappen.
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Conclusion
• Whetheranindividualtipstowardsviolentactionorinactioninagivensituationdependsuponthebalancebetween– Contextvariables(personalandenvironmentalfactors)+capabilityand
– Theindividual’smindset/predisposition/vulnerability+protectivefactors
– Andtheinfluenceofsituationalriskandprotectivefactors• Themoredatawehave,thebetterwecanassessthelevelofrisk
• Butaccuratepredictionremainselusive
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Interactionswithlawenforcement
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Questions/Discussion