Dynamic Risk Factors Underlying Violence

1
Dynamic Risk Factors Underlying Violence

• Responses to Treatment and Managing Violence

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Risk
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Risk is Uncertain

• A risk is a hazard or threat that is incompletely
  understood and therefore that can be forecast
  only with uncertainty

4
Risk is Complex

• Risk incorporates notions of the nature,
  severity, frequency, imminence, and likelihood of
  harm not just probability

5
Risk is Inferential

• Risk does not exist physically, but rather
  reflects the perception of a potential or
  possible future

6
Risk is Contextual

• Risk exists in and is dependent on a specific
  situation or social-physical environment

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Risk is Dynamic

• Risk changes over time
• Hazards change
• Situations change
• Information changes
• Inferences change

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Assessing Risk for Violence
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Assessment

• Gathering information to assist in decision
  making
• Not simply providing a diagnosis or prognosis
• Not simply considering a set of test items or
  risk factors determined before the evaluation
• Individualized inquiry

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Violence

• Actual, attempted, or threatened physical harm of
  another person that is deliberate and
  nonconsenting
• Includes fear-inducing behavior
• Includes intentional and reckless acts
• Includes violence against victims who cannot give
  full, informed consent

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Violence Risk Assessment

• Evaluations of people to
• Characterize the risk that they will commit
  sexual violence in the future
• Develop interventions to manage or reduce their
  violence risk

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Goals

• Prevent violenceMore specifically...
• Understand risks posed
• Identify relevant risk factors
• Guide threat management
• Improve consistency of decisions
• Improve transparency of decisions

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Defining Risk Factors
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Different Definitions

• Consequence
• Correlate
• Predictor (marker)
• Static
• Dynamic
• Cause

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Dynamic Risk Factors

• Two aspects of causal risk factors are dynamic
• Presence
• Relevance

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Causes of Violence

• The proximal cause of violence is a decision to
  act violently
• People decide to commit violence of specific
  types, at specific times, against specific
  victims
• People can and usually do decidenot to
  commit violence

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Nature of Decisions

• Decisions involve at least some degree of
  cognitive processing
• Violence is an option in the situation
• Rewards of violence may outweigh its costs
• Means of overcoming internal inhibitions
• Means of overcoming external inhibitions
• Means of overcoming victim resistance

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Influences on Decisions

• The decision is influenced by a host of
  biological, psychological, and social factors
• Neurological insult, hormonal abnormality
• Psychosis, personality disorder
• Violent models, attitudes that condone violence
• Three types of influence
• Motivate
• Disinhibit
• Destabilize

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Implications

• Risk factors for violence are things that
  influence decisions about violence
• Violence risk assessment is
• Understanding how and why people decided to
  commit violence in the past
• Determining the conditions under which they might
  make similar decisions again
• Violence risk management is
• Encouraging decisions to act non-violently

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Identifying Risk Factors
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Determining Relevance

• Three primary criteria
• Scientific predictive accuracy
• Professional theoretical importance and
  practical utility
• Legal reasonableness

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Problems With Scientific Criterion

• Prediction ? cause, explanation, or intervention
• Can lead to inclusion of bad but common or
  easy-to-assess factors
• Not everything that is important has been proven
  or validated scientifically
• Can lead to exclusion of good but rare or
  difficult-to-assess risk factors

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Example The SIEVE

• Age Young is bad
• Sex Male is bad
• Facial hair Dense is bad
• Foot size Big is bad

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Problems With Professional Criterion

• Focus on highly dynamic factors may bias risk
  assessments
• Can lead to exclusion of good but more stable
  and easy-to-ignore factors
• Conventional wisdom based on theory or practice
  may be plain wrong
• Can lead to inclusion of bad but vivid or
  dramatic factors

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Example Clinical Intuition

• Depression Present is good
• Anxiety Present is good
• Intelligence High is good
• Rorschach Seeing viscera is bad

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Problems With Legal Criterion

• Reasonableness is not a simple concept
• Requires careful balancing of probative and
  prejudicial impact of information in a given
  context

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Combining Risk Factors
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Two Approaches

• Discretionary
• versus
• Non-discretionary

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Discretionary Approach

• Based on prevention paradigm
• Goal is to plan strategies to prevent a person
  from committing violence
• Information is gathered, weighted, and combined
  using the evaluators judgement
• Imposes no or limited structure on the evaluation
  or decision-making processes
• AKA judgemental, informal, intuitive,
  impressionistic

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Discretionary Limitations

• Foundation of judgement may be unclear
• Relies on charismatic authority
• Judgement may be imprecise
• May over-focus on dynamic aspects of risk
• Limited empirical support
• Agreement (reliability)
• Accuracy (validity)

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Non-Discretionary Approach

• Based on prediction paradigm
• Goal is to estimate the probability that a person
  will commit violence
• Information is gathered, weighted, and combined
  using fixed and explicit rules
• Imposes rigid structure on the evaluation and
  decision-making processes
• AKA actuarial, algorithmic, mechanical,
  formalistic, statistical

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Static-99

• Hanson Thornton (2000)
• Constructed in adult male correctional offenders
  and forensic patients from 4 sites in Canada and
  the UK
• 10 items weighted according to ability to
  postdict violence over 5-15 years
• Combination of the RRASOR (Hanson, 1997) and the
  SAC-J (Grubin, 1998)
• Total scores divided into 4 categories

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Static-99 Items

• Prior sex offences
• Prior sentencing dates
• Non-contact sex offences
• Index non-sexual violence
• Prior non-sexual violence

• Any unrelated victims
• Any stranger victims
• Any male victims
• Young
• Single

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Risk Categories

• Score Risk Category
• 0, 1 low risk category
• 2, 3 medium-low risk category
• 4, 5 medium-high risk category
• 6 high risk category

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VRAG

• Quinsey et al. (1998)
• Constructed in adult male patients assessed or
  treated at a maximum security hospital
• 12 items selected and weighted according to
  ability to postdict violence over 7-10 years
• Total scores divided into 9 bins, with estimated
  p(violence) from 0 to 100

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VRAG Items

• PCL-R score
• Elem. school problems
• Personality disorder
• Age ()
• Separated from parents under age 16
• Failure on prior conditional release

• Nonviolent offense history
• Never married
• Schizophrenia ()
• Victim injury ()
• Alcohol abuse
• Female victim ()

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Non-Discretionary Limitations

• Not comprehensive
• Ignores individual circumstances
• Doesnt obviate need for a real assessment
• Focuses on static factors
• Optimization reduces generalizability
• May not work well with different target groups,
  settings, or outcomes
• Use still requires professional judgment
• Which scales to use, how to interpret scores

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Limitations (cont.)

• Empirical support is over-stated
• Superiority with respect to violence threat
  assessment has yet to be demonstrated
• Doesnt address key legal issues
• Doesnt assist users in determining the presence
  of and causal role played by mental abnormality
• Liability issues

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Limitations An Illustration

• Paul Bernardo is a Canadian serial murderer (3
  sexual homicides) and serial rapist (75 known
  rapes)
• Currently serving life imprisonment for murder
  and an indeterminate sentence for the rapes
• Static-99 and VRAG completed on the basis of case
  history data

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Bernardos Static-99

• Prior sex offences 0
• Prior sentencing dates 0
• Non-contact sex offences 0
• Index non-sexual violence 1
• Prior non-sexual violence 0
• Any unrelated victims 1
• Any stranger victims 1
• Any male victims 0
• Young 0
• Single 0

Total 3 Medium-Low Risk
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Bernardos VRAG Results

• PCL-R score 4
• ES problems -1
• Personality disorder 3
• Age 0
• Separated from parents -2
• Failure on prior CR 0
• Nonviolent offenses -2
• Marital status -2
• Schizophrenia 1
• Victim injury -2
• Alcohol abuse 1
• Female victim -1

Total -1 (Bin 4) p(viol) 17 - 31
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Combining Risk FactorsThe SPJ Approach
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Challenge for Risk Assessment

• How do we combine the strengths of the
  discretionary and non-discretionary approaches?
• We need procedures that are
• Guided by science, but also reflect professional
  and legal considerations
• Structured, but also flexible and responsive to
  the uniqueness of each case

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Structured Professional Judgement

• Based on prevention paradigm
• Information is gathered, weighted, and combined
  using the evaluators judgement assisted by
  guidelines
• Aides mémoires, practice parameters
• Imposes no or limited structure on the evaluation
  or decision-making processes
• AKA empirically guided, empirically supported,
  evidence based judgement

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SPJ Uses

• Structure not replace professional
  evaluations of violence risk across a broad range
  of populations and settings
• Monitor or re-evaluate risk factors
• Guide case management strategies

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SPJ General Procedures

• Use manuals and worksheets to assist evaluation
  and documentation
• 5 steps
• Gather information
• Identify risk factors
• Develop scenarios
• Plan management strategies
• Document judgements

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1. Gather Information

• Based on reason for assessment, gather all
  information that is reasonably necessary
• Focus on violence history and risk factors
• Corroborate across methods, sources
• Consider multiple domains
• Consider dynamic nature
• Evaluate adequacy of information
• Qualify opinions in light of critical missing
  information

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2. Identify Risk Factors

• Focus on standard factors as areas of inquiry
• Plus case-specific factors
• Synopsize relevant information
• Consider presence
• Including changes over time
• Consider relevance
• Including causal roles
• Think, Why?

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Identify Risk Factors (cont.)

• Causal roles
• Motivators increase the perceived benefits or
  rewards of violence
• Disinhibitors decrease the perceived costs or
  punishments of violence
• Destabilizers generally impair the persons
  decision making abilities or psychosocial
  adjustment

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3. Develop Scenarios

• Speculate about the kinds of violence the person
  might commit
• Primary hazards or concerns
• Describe plausible scenarios
• Consider severity, imminence, frequency/duration,
  likelihood, and factors likely to increase or
  decrease risk

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4. Plan Management Strategies

• Speculate about case management strategies for
  each scenario
• Monitoring
• Supervision
• Treatment or rehabilitation
• Victim safety planning

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5. Documentation

• Document judgments
• Case prioritization
• Risk for serious physical harm
• Need for immediate action
• Other risks indicated
• Case review
• Date for regularly scheduled review
• Triggers for immediate review

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Documentation (cont.)

• Degree of effort and intervention required to
  prevent violence
• Low Routine or usual manage with low priority
  and intensity
• Moderate Elevated or a concern manage with some
  urgency and intensity
• High Urgent or an emergency manage with high
  priority and intensity

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Advantages of SPJ Risk Assessment

• Comprehensive evaluation
• Reflects science, professional knowledge, and law
• Structured yet flexible
• Individualized
• Good fit for legal decision making
• Reasoned and reasonable
• Transparent
• Good fit for case management
• Potentially sensitive to change

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Advantages (cont.)

• Good fit for quality assurance
• Possible to automate parts of the assessment
• Good fit for liability management

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Limitations

• Judgements require expertise and training
• Better suited for experienced evaluators
• Use requires resources
• No such thing as quick risk assessment

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SPJ Guidelines

• General violence HCR-20, SAVRY
• Sexual violence SVR-20, RSVP, ERASOR
• Spousal violence SARA, B-SAFER
• Child abuse CARE
• Stalking SAM

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Risk ManagementPreventing Violence
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Paradox

• Expanding our theories of violence complicates
  assessment but introduces opportunities for
  management

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A Conceptual Model

• Threat management comprises four distinct
  activities
• Monitoring
• Treatment
• Supervision
• Victim safety planning

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Monitoring

• Monitoring is surveillance or repeated assessment
• Goal is to evaluate changes in risk over time so
  that management strategies can be revised as
  appropriate
• May be delivered by a range of mental health,
  social service, law enforcement, corrections, and
  security professionals

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Procedures

• Contacts (face-to-face or telephonic)
• Client, victims, and other relevant people
• Field visits (home or work)
• Inspection of mail or telecommunications
• Electronic surveillance
• Physiological evaluation
• Polygraphic interviews urine, blood, or hair
  analysis

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Strategies

• Plans should specify the kind and frequency of
  contacts required
• Weekly face-to-face visits, daily phone contacts,
  monthly assessments
• Plans should specify any triggers or red
  flags that might warn the individuals risk of
  violence is imminent or escalating

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Treatment

• Provision of (re-) habilitative services
• Goal is to improve deficits in the individuals
  psychosocial adjustment
• Typically delivered by health care and social
  service professionals
• Inpatient or outpatient clinics, agencies

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Procedures

• Treatments for mental disorder
• Individual, group, or family psychotherapy
• Psychoactive medications (e.g., anti-androgens)
• Attitude change
• Psychoeducational programs
• Social skills training programs
• Interpersonal, anger, vocational programs
• Stress reduction
• Legal, crisis, employment, relationship counseling

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Strategies

• Should be multi-modal, where possible
• Should target deficits that are causally related
  to the individuals violence behavior
• Criminogenic needs
• Treatment may be made a legal requirement

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Supervision

• Restriction of rights or freedoms
• Goal is to make it (more) difficult for the
  individual to engage in further violence
• Typically delivered by law enforcement,
  corrections, legal, and security professionals
• In institutions or the community

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Procedures

• Incapacitation
• Community supervision with restrictions
• Activity
• Movement
• Association
• Communication

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Strategies

• Should target risk factors that are causally
  related to the individuals violent behavior
• Risks or needs
• Should be implemented at a level of intensity
  commensurate with the degree of risk posed by the
  individual
• Least restrictive alternative

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Victim Safety Planning

• Improving the victims dynamic and static
  security resources
• Target hardening
• Goal is to minimize the impact of any future
  violence on the victims psychological and
  physical well being
• May be delivered by a range of social service,
  human resource, law enforcement, and private
  security professionals

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Procedures

• Dynamic security
• Provide useful information concerning risk to
  victim and social supports
• Counseling with victims to increase awareness and
  vigilance
• Treatment to address psychosocial deficits in
  adjustment that interfere with self-protection
• Training in self-protection
• Protocols for handling unwanted communications,
  classes in physical self-defense

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Procedures (cont.)

• Static security
• Improve visibility by adding lights, altering
  gardens or landscapes, and installing video
  cameras
• Restrict access by adding or improving door locks
  and security checkpoints
• Install alarms, or provide victims with personal
  alarms
• Relocate victims residence or workplace

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Strategies

• Good victim liaison is paramount
• Focus on victim vulnerabilities causally related
  to violent behavior
• This is not victim-blaming
• Most relevant for targeted violence
• Identity of likely victims of future violence is
  known

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Principles for Effective Management

• 1. Develop an assessment-based plan for managing
  risk
• Each element should be tied to one or more
  important risk factors
• Each important risk factor should be tied to one
  or more management strategies
• Plan should be explicit and distributed widely
• Plan should have target dates for review and
  revision

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Effective Management (cont.)

• 2. Establish a multi-disciplinary team for
  managing risk
• Composition of the team should depend on the
  perpetrator and the risks he poses
• Responsibilities of team members should be made
  explicit
• Team should include victim or liaison

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Effective Management (cont.)

• 3. Deliver comprehensive and integrated services
• All agencies should have clearly defined roles
  and responsibilities
• Including guidelines for proper documentation,
  communication, and coordination
• Policy and procedure manuals should be developed
• For each agency, or inter-agency

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Conclusions
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Conclusions

• Risk and risk factors are inherently dynamic
• Dont try to predict violent behavior instead
  try to understand (and influence!) causes of
  violence, including motivations and intentions
• Good risk assessment is essential for good risk
  management
• To identify priority problems, appropriate
  interventions, and optimal mode of delivery

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Conclusions (cont.)

• Dont use simple tools on their own to make
  complex judgments instead, use them as decision
  aids in case formulation
• Use scenario planning to make case management
  plans more prescriptive
• Failing to plan is planning to fail

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Contact Information

• Proactive ReSolutions Inc.
• 142-1020 Mainland Street
• Vancouver, BC
• Canada V6B 2T4
• 1 [phone]
• shart_at_proactive-resolutions.com
• www.proactive-resolutions.com