Assessing%20Dangerousness:%20Myths%20and%20Research

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Assessing Dangerousness Myths and Research

• Ronald Schouten, MD, JD
• Associate Professor of Psychiatry
• Harvard Medical School
• Director, Law Psychiatry Service
• Massachusetts General Hospital

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Overview

• How we perceive risk and make decisions
• What do we know about violence?
• Some specific issues in risk assessment
• Domestic violence
• Stalking
• Public figures
• Assessing the evidence
• Clinician/expert testimony
• Screening instruments
• Methodology

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Risk

• Risk Likelihood x Severity of consequences

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How We Make Decisions About Risk (and everything
else)

• Experiential system Knowing it
• Reflexive Hair on the back of the neck test.
• Rapid
• Effortless
• Often not conscious
• I just know it.
• But can you explain it?
• Affect driven

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How We Make Decisions About Risk

• Analytic system Knowing about it
• Slow
• Algorithmic
• Based on normative rules
• Probability calculus
• Data-based risk assessment
• Formal logic

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How We Make Decisions Heuristics

• Emotions make a difference The Affective
  Heuristic
• Fear/dread of event correlates with level of risk
  and perceived probability, e.g. sex offenders
• Risk/benefit analysis Perceived benefit is
  inversely related to perceived risk, and vice
  versa
• Familiarity
• People overestimate the risk of events that are
  unfamiliar and that they cannot control
• Ex Health care workers and SARS

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How We Make Decisions Heuristics

• Availability heuristic similar events that have
  occurred within recent memory are seen as more
  likely to occur
• Geographic proximity/identification with victims
• Probability neglect
• When strong emotions are involved, we tend to
  focus on the severity of the outcome, rather than
  the probability that the outcome will occur
• We tend to overestimate the likelihood of low
  probability events, and underestimate the
  likelihood of higher probability events

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How We Make Decisions Biases

• Extremeness aversion
• Presentation bias
• Proportions and absolute numbers convey more risk
  than percentages
• Narrative accounts convey the most risk
• Confirmatory bias we interpret information in a
  manner that is consistent with our world view
• Hindsight bias

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How We Make Decisions Biases

• Negative information, e.g. of a bad outcome,
• Is rated as more valuable than positive
  information
• Those delivering negative news are seen as more
  skilled

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How We Make Decisions About Risk

• These are all natural and, in most cases,
  adaptive elements of judgment and decision
  making, except
• When biases unduly shape the outcome
• When dealing with novel situations and the usual
  mental rules of thumb lead us astray

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What Do We Know About Violence?
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Subtypes of Violence

• Increased arousal subtype (Impulsive)
• Reactive, high affect, irritable, impulsive
• More co-morbidity with psychiatric diagnoses
• More responsive to clinical interventions
• May require containment to begin interventions
• Ex Domestic violence, bar fight, road rage, most
  mental-illness associated violence

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Subtypes of Violence

• Proactive Subtype (Predatory), aka Targeted
  violence
• Planned
• Controlled, goal-directed, ego-syntonic
• May be affective display
• More socialization to violence
• Requires more external containment and sanction
• Ex Domestic stalker, school or workplace
  violence

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Some Examples
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The Violence Formula

• Violence is the product of the interaction of
• Individual variables (personality traits,
  illness)
• Environmental variables (whether the environment
  promotes or dissuades violence)
• Situational variables (acute and chronic stress)
  FINAL
• Financial
• Intoxication
• Narcissistic injury
• Acute or chronic illness
• Losses

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Mental Illness and Violence
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Traditional Views

• Public
• Individuals with mental illness are at high risk
  of violent behavior
• Mental health professionals assessments of risk
  are no better than chance
• Clinicians
• The mentally ill are no more likely to be violent
  than others
• Were able to assess risk with sufficient
  certainty to justify civil commitment

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Current Research

• Mental disorder is a modest risk factor when the
  mentally ill are considered as a group
• There is a subgroup of individuals with serious
  mental illness who are at significantly increased
  risk
• Psychosis, substance abuse, and antisocial
  behavior are significant risk factors

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• Severe mental illness alone does not
  significantly predict future violence rather,
  historical, dispositional, and contextual factors
  are associated with future violence.
• Elbogen, E. B., Johnson, S. C. (2009). The
  intricate link between
• violence and mental disorder. Archives of
  General Psychiatry, 66 (2),
• 152-161.

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Mental Illness and Violence

• Individuals most at risk
• Individuals with substance abuse/dependence
• Psychotic disorders with active symptoms
• Paranoia or control override
• History of Oppositional Defiant Disorder as
  children and/or
• History of Antisocial Personality Disorder as
  adults

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Violent Diagnoses by Group(From Steadman et al
1998)Courtesy Judith G. Edersheim, MD, JD
Diagnosis Percent Violent
Major Mental Illness Without Substance Abuse 17.9
Major Mental Illness With Substance Abuse 31.1
Other Mental Illness with Substance Abuse 43.0
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Substance Abuse as a Risk Factor

• Self report of violence in previous
  yearDX None 2OCD 11Bipolar/mani
  a 11Panic disorder 12Major
  depression 12Schizophrenia 13Cannabis
  use/dependence 19Alcohol use/dependence 25Othe
  r use/dependence 35

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Limitations on the Utility of Studies of the
Violent Mentally Ill

• Applicability to non-clinical populations
• Not diagnosed
• No diagnosis
• Applicability of static and dynamic risk factors
• Are they the same for patients and nonpatients?
• Cultural issues?

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The Risk Assessment Process

• Nature of the perceived threat/risk
• Targeted vs. impulsive
• Relationship between actor and victim(s)
• Manipulation vs.revenge
• Sources of information
• Current circumstances
• Risk factors
• Records review (including criminal)
• Interviewif possible
• Applying the formula

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Models of Assessing/Understanding Risk

• Critical to distinguish between
• Historical (static) risk and protective factors
• Static risk factors cannot be changed
• Historical risk factors describe risk trajectory
• May provide actuarial risk against a base rate
• Dynamic risk and protective factors
• Dynamic factors are points for intervention
• Social, family, community, clinical factors

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Assessing Risk of Violence

• Focus Pose a threat vs. Make a threat
• Some who make threats ultimately pose threats
• Many who make threats do not pose threats
• Some who pose threats never make them
• Hunters vs. Howlers

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Targeted Violence Domestic and Otherwise

• Identifying information
• Background information
• Current life information
• Attack-related behaviors
• Motive?
• Target selection
• Communication with target or others?
• Interest in targeted violence, perpetrators,
  extremists?

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Targeted Violence Domestic and Otherwise

• History of mental illness?
• Organized enough to act?
• Recent loss or loss of status leading to
  desperation and despair?
• Actions consistent with statements?
• Are those who know the subject concerned?
• What factors in subjects life might increase or
  decrease risk?

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Pathway to Violence
6. Attack 5. Breach
4. Preparation 3. Research
Planning 2. Ideation 1. Grievance
Calhoun and Weston, Contemporary Threat
Management (2003)
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Specific Situations Domestic Violence/Stalking
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Ontario Domestic Assault Risk Assessment

• Prior domestic assault (against a partner or
  child) in police .26
• Prior nondomestic assault (against anyone other
  than a partner or child) .15
• Prior sentence to a term of 30 days or more .28
• Prior failure on conditional release (bail,
  parole, probation, no-contact ord.) .25
• Threatened to harm or kill anyone during index
  offense .12
• Unlawful confinement of victim during index
  offense .12

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Ontario Domestic Assault Risk Assessment(contd)

• Victim fears repetition of violence .14
• Victim and/or offender have more than one child
  altogether .24
• Offender is in stepfather role in this
  relationship .22
• Offender is violent outside the home (to people
  other than a partner or child) .20
• Offender has more than one indicator of substance
  abuse problem .27
• Offender has ever assaulted victim when she was
  pregnant .13
• Victim faces at least one barrier to support .11

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Risk Factors for Violence in Stalking

• Risk of physical violence in stalking 25-35
  risk of psychosocial harm much higher
• Prior intimate relationship
• Threats (different from celebrity cases) 45 of
  those threatened are assaulted
• Mental illness no evidence of clear relationship
• Substance abuse, especially with other mental
  disorder
• Past criminal history(/-), if ex-intimate
• Recidivism associated with youth, prior intimate
  relationship, Cluster B personality disorder,
  absence of psychotic or delusional disorder

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Assessing the Evidence
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The Jargon Problem
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Red Flags in Expert/Clinician Testimony

• Overstatement of certainty
• Full remission
• Guarantee
• Cured
• Experiential vs. analytic thinking
• Finger in the wind?
• Is there data available on the issue?
• Was it considered?

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Screening Instruments?

• PCL-R (Hare Psychopathy Checklist
• Proven reliability and validity
• High scores of failed conditional release and
  recidivism
• Possible Daubert problems re study population
• Projective tests, e.g. Rorschach Inkblot Test?

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Screening Instruments?

• HRT-20
• Item categories Historical, Clinical,Risk
  management
• Max score is 40, but no cutoffs
• Clinical and research tool
• VRAG (Violence Risk Appraisal Guide)
• Offers prediction of recidivism by violent
  offenders
• Accepted in some jurisdictions
• MacArthur Violence Risk Assessment Study
• Diverse population of civilly committed patients
• Identifies risk of violence within one year of
  discharge
• A work in progress

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The Great Debate Actuarial vs. Clinical

• Given the multiples influences on risk
  perception, will we put our trust in a pure
  analytic system?
• Current standard risk assessment based upon
  actuarial risk factors informed by solid clinical
  judgment that is relatively free of affective
  heuristics and bias

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The Misinformation Challenge

• It aint so much the things we dont know that
  get us into trouble. Its the things we know that
  aint so.
• Artemus Ward
• (Charles Farrar Browne)