www.mghcme.org

ViolenceandRiskAssessmentinClinicalPractice

RonaldSchouten,MD,JDLt.FredCabral

1

www.mghcme.org

Disclosures

• NeitherInormyspouse/partnerhasarelevantfinancialrelationshipwithacommercialinteresttodisclose

www.mghcme.org

Mywork

• MGHLaw&PsychiatryService• ForensicFellowshipPrograms

– MGH-HMS– St.ElizabethsHospital,Washington,DC

• Forensicpsychiatry:– Civil/Criminal– Violenceriskassessment– Threatassessment

• Campus• Workplace

www.mghcme.org

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.

www.mghcme.org

Overview

• Violenceriskassessmentvs.Threatassessment• Mentalillnessandviolence• HIPAAandotherconfidentialityconcerns• Acaseexampleofhowadifficultcasecanbe/washandled

• Discussion

www.mghcme.org

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

www.mghcme.org

ChallengesinViolenceRiskAssessment

• Smallsamplesizes• Infrequentevents:

– Evensensitivemeasuresyieldahighrateoffalsepositives– Butthesearehighimpactinfrequenteventsthat

• Demandourattention• Arecoreelementsofyourjobs

• Hindsightis20/20– Riskchangesovertime– Earlymarkersmaybemissedentirely(orweretheymarkersatall?)

– Whenthingsgowell,noonenotices– Whenthingsgowrong,everyoneissmarterthanweare

www.mghcme.org

ChallengesoftheRiskAssessmentProcess

• Whatisthispersonlikelytodointhefuture?NielsBohr(andYogiBerra)onprediction.

• Whoisthisperson?– Whathavetheybeenlikeinthepast?– Whataretheylikenow?– Whataretheydoingcurrently?

• Howdowedistinguishwhichindividualswillmovefromthinkingtoacting?

Things are difficult to predict. Especially the future.

www.mghcme.org

Howdoweaddressthishardproblem?

• Understandingandrespectingthechallenges• Byusingassessmentmethodsthatrecognizethecomplexityofhumanbehavior

• Violenceriskastheproductoftheinteractionofmultiplevariables:– Individualrisk/protectivefactors– Environmentalrisk/protectivefactors– Situationalfactors(triggers)

www.mghcme.org

Riskassessment:abriefhistory• Unstructuredriskassessment– Clinicalimpressionbackedbyanecdotes,notdata– Profilingasanexample:

• ThelegacyofJamesBrussel,M.D.andtheMadBomber• Investigative,notpredictive,tools

• Actuarialassessment– “Numbersdon’tlie.”

• Smallsamplesizes;falsepositivesandfalsenegatives• Basedontherightsample?• Anumberwithoutadenominatortellsusnothing

• Currentstandard:Structuredprofessionaljudgment(SPJ)

www.mghcme.org

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)

www.mghcme.org

Howsignificantarespecificthreats?

• Poseathreatvs.Makeathreat- Somewhomakethreatsultimatelyposethreats- Manywhomakethreatsdonotposethreats(exceptinintimatepartnerviolence)

- Somewhoposethreatsnevermakethem- Huntersvs.Howlers

www.mghcme.org

Threateninglanguage

• Types:– Direct:mustbetakenseriously– Implied:manipulative?– Conditional:tobetakenseriously,becauseifthecontingencyarises…

• Thewayourstatutesusethelanguageofthreat:theexampleofCh.123§ 12– “…manifestedbyevidenceofthreatsof,orattemptsatsuicideorseriousbodilyharm…”

– “…manifestedbyevidenceofhomicidalorotherviolentbehaviororevidencethatothersareplacedinreasonablefear…”

www.mghcme.org

Threatstokill:averyspecificproblem

• Contradictoryfindingsrethreatsandactualviolence

• Highrateofmentalillnessamongthreateners:– Barnesetal2001

• 102threatenerssentforcourt-orderedevaluations• 57.8%assessedassufferingfrommentalillness;highprevalenceofpersonalitydisorderandsubstanceabuse

– Häkkänen(2006):69bombthreateners;21%mentallydisordered

www.mghcme.org

Threatstokill(cont’d)

• Warren,etal(2008)– AlladultsinVictoria,Australiaconvictedofmakingthreatstokillin1993-1994• Offense:utteringtokill,producingfearinthevictim• Studyincludedthosewhoalsocommittedadditionaloffenses,aswellasutterancealone

• Researchedoffenders’contactswithpublicmentalhealthservices

• Recordedsubsequentconvictions

www.mghcme.org

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

www.mghcme.org

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)

www.mghcme.org

Threatstokill:Warren(cont’d)

• Riskfactorsforsubsequentviolence– Diagnosisofsubstanceabuse– Youngerageatfirstconviction– Mentaldisorder– Absence ofpriorcriminalconviction– Threatenersatincreasedriskofdeath(suicide>homicide)

www.mghcme.org

AModelforViolenceRiskAssessment

19

www.mghcme.org20

ViolenceSubtypes

• Impulsiveviolence- Reactive- Maybeculminationofextendedconflict- Victimmaybeunintended/unplanned- Ex:barfight,roadrage

• Targetedviolence- Predatory,planned- Aimedataspecificindividualorinstitution- Requiresabilitytoorganize- Ex:domesticstalker,workplaceorschoolviolence,ambushassault

www.mghcme.org

IndividualFactors:Static

• Personalhistoryof:– Violence– Suicideattempts:holdsforviolenceagainstselfandothers– Failedconditionalrelease/parole– Multiplecivilcommitments– Noncompliancewithtreatment– Neurological/cognitiveimpairment– Traitanger– Impulsivity– Arrests– Weaponsuseforemotionalrelease/PseudoCommando

www.mghcme.org

IndividualFactors:Static

• Personalhistoryof– Childabuse– Exposuretoviolenceinchildhood:Traumacounts– Bullying/beingbullied

• Familyhistoryof– Violence– Antisocialpersonalitydisorder/psychopathy

www.mghcme.org

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

www.mghcme.org

24

IndividualFactors:MentalIllness

• Thestigmaproblem– Presumptionofastrongassociationbetweenseriousmentalillnessandviolence

– Folkpsychology:thereisclearlysomethingwrongwithsomeonewhoengagesinactsofviolence

• Beyondthestatutorydefinition:Whatdowemeanbymentalillness?– 365diagnosesinDSM-IVTR– Commonusage:majormentalillness(majordepression,bipolardisorder,psychoticdisorders)

– Butalso:substanceabuse,personalitydisorders,NOSdiagnoses

www.mghcme.org

MentalIllnessandViolence

• Fact:Absentactivepsychoticsymptoms,theriskofviolenceformentallyillindividuals(excludingsubstanceabuse)isnohigherthanfordemographicallysimilarmembersofthesamecommunitywhohaveneverbeentreated

• Fact:Individualswithseriousmentalillnessareatanincreasedriskofviolencethatisstatisticallysignificant,butnotbymuch

www.mghcme.org

26

MentalIllnessandViolence(cont’d)

• Individualswithmentaldisordersmostatrisk– Individualswithsubstanceabuse/dependence– Psychoticdisorderswithactivesymptoms• Paranoia,control,overridesymptoms• HistoryofOppositionalDefiantDisorderaschildrenand/or• HistoryofClusterBtraits/disorders:AntisocialPersonalityDisorderasadults(Psychopathy/SubclinicalPsychopathy)

– Historyofviolence(perpetratororvictim)

www.mghcme.org27

Substanceabuseasariskfactor

Selfreportofviolenceinpreviousyear:DX %None 2OCD 11Bipolar/mania 11Panicdisorder 12Majordepression 12Schizophrenia 13Cannabisuse/dependence 19Alcoholuse/dependence 25Otheruse/dependence 35

Swanson, et al (1998)

www.mghcme.org

Butwhatdoesthattellusaboutindividualrisk?

• Therearemultipleriskfactorsinevershiftingcombinations

• Wecanidentifygroupsatincreasedriskofviolence

• Membershipinthatgroupmeansthatthepersonisatincreasedrisk,butthatdoesn’ttellusthatthepersonwillbeviolent

• Contextanddynamicfactorsarekey.

www.mghcme.org

Environmentalfactors

• Availablevictims?• Lackofsocialsupports,e.g.family,community• Cultureofviolence• Accesstoweapons• Highconflictsituation• Absenceofconstraints

www.mghcme.org

Situationalfactors

• Acuteandchronicstressors• FINAL– Financial– Intoxication– Narcissisticinjury– Acuteorchronicillness– Losses

www.mghcme.org

31

Thepathwaytoviolencemodel:Calhoun&Weston2003

www.mghcme.org

Constraintsonclinicians

• HIPAA?– Whenaproviderbelievesingoodfaiththatawarningtolawenforcement,familymembersofthepatient,orothersisnecessarytopreventorlessenaseriousandimminentthreattothehealthorsafetyofthepatientorothers,theprivacyruleallowstheprovider,consistentwithapplicablelawandstandardsofethicalconduct,toalertthosepersonswhomtheproviderbelievesarereasonablyabletorepentorlessenthethreat.45CFRSec.164.512(j)

– Maynotifyfamilytowatchforsymptoms,evenifharmnotimminent45CFR164.510(b)(2)

www.mghcme.org

Constraintsonclinicians

• Federalrestrictionsondisclosureofinformationrelatedtoalcoholanddrugabusetreatmentrecords:42USC290dd-2;42CFRPart2

• Statelaws:knowyourjurisdictionre– Tarasoffduties:permittedvs.required?– Confidentiality:

• Reasonablenessiskey• Alwaysdisclosetheleastamountofinformationnecessarytoavoidtheharminquestion

• Receivingisnotthesameasdisclosing

www.mghcme.org

Somedifficultquestions

• Whatcanwedotodivertpeopleatriskofinvolvementwiththecriminaljusticesystem?

• Shouldwe/canwecalllawenforcement?• Legalconcerns?• Ethicalconcerns?• Practicalconcerns:– Local?State?FBI?SecretService?– WhathappenstomypatientifIdo?

• Amodelforhowitcanhappen.

www.mghcme.org

Conclusion

• Whetheranindividualtipstowardsviolentactionorinactioninagivensituationdependsuponthebalancebetween– Contextvariables(personalandenvironmentalfactors)+capabilityand

– Theindividual’smindset/predisposition/vulnerability+protectivefactors

– Andtheinfluenceofsituationalriskandprotectivefactors• Themoredatawehave,thebetterwecanassessthelevelofrisk

• Butaccuratepredictionremainselusive

www.mghcme.org

Interactionswithlawenforcement

www.mghcme.org

Questions/Discussion