Violence and Risk Assessment in Clinical Practice...–Suicide attempts: holds for violence against...

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www.mghcme.org Violence and Risk Assessment in Clinical Practice Ronald Schouten, MD, JD Lt. Fred Cabral 1

Transcript of Violence and Risk Assessment in Clinical Practice...–Suicide attempts: holds for violence against...

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ViolenceandRiskAssessmentinClinicalPractice

RonaldSchouten,MD,JDLt.FredCabral

1

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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


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