Transcript Xtreme Color 4

Violence Risk:
How to think about high-risk behaviors
& what can be done to manage them
Charles Amrhein, PsyD
The Bronx TASC
Mental Health Court Program
ON THE FRONT LINES: BUILDING SKILLS FOR REENTRY
AND DIVERSION at The John Jay College of Criminal Justice
March 31, 2010
Conceptualizing Risk Issues
• As an analogy to weather forecasting
• The type of violence involved:
– Reactive/Affective vs. Predatory
• Risk assessment &/or management
– Dynamic & static risk factors
– Actuarial (statistical) vs. Clinical or
Professional Judgment approaches
– Differences between traditional mental
health view & forensic perspectives
• Use of the HCR-20
Workshop Objectives
• Convey several principles of risk
assessment & management
• Shift thinking about violence from a
personal trait to a behavior in context
– Context is important in understanding
violent & non-violent behaviors
• The past predicts the future
– How can we understand the past in order
to improve prediction?
Weather Forecasting
Climate is highly predictable…
…but today’s weather is not.
This is an issue of likelihood,
rather than exact prediction.
So how can we understand what affects
someone’s likelihood of being violent?
• Understand the person before he or she
poses a threat
• Learn any unique “warning signs” that can
help predict an increased risk
Defining Violence
• An intentional act of aggression toward
another human being that physically
injures, or is likely to physically injure,
that person.
Some examples:
The Menendez Brothers
California, 1989
Erik & Lyle; found guilty of murder in the first
degree in March 1996 for the deaths of their
parents; received life in prison without parole
Ted Kaczynski
Captured in Montana, 1996
The Unabomber; killed 3 & wounded 22 during
a series of mail-bombings from 1978 to 1995;
received life in prison without parole
Mike Tyson
Bit opponent, 1997
Pro boxer; bit off part of Evander Holyfield’s
ear during a fight; also convicted of sexual
assault in 1992 & served 3 years in prison
Types of Violence
• Reactive (Emotional or Affective)
• Predatory
What does a cat look like when it’s scared?
Reactive or affective violence is rooted in a
highly emotional state.
What does a cat look like when hunting?
Predatory violence involves less nervous
system activity, ability to “lie in wait” for a
desired target.
Affective Violence
Predatory Violence
Intense physiological arousal
Minimal physiological arousal
Subjective experience of emotion
No awareness of emotion
Reactive & immediate
Planned & purposeful
Internal or external perceived threat
No imminent or perceived threat
Time-limited sequence of behaviors
No time-limited sequence
Possible displacement of target
No displacement of target
Heightened but diffuse awareness
Heightened & focused awareness
Primarily emotional & defensive
Primarily cognitive
Goal is threat reduction
Violent behavior is planned
Affective/Reactive Violence
• Threat can be internal or external
• Perception of threat commonly leads to
anxiety
– Extreme anxiety can become paranoia, a
belief of being in danger that primarily
comes from one’s mind
Affective/Reactive Violence
• Reactive violence is driven by
overwhelming affect
• Can be due to anger, anxiety, shame, or
another intense emotion that leads to a
loss of control
• Root of this is sense of threat/danger
– Crimes of passion; protecting self or other
from harm to life or limb
Pathways to Violence
• Predatory: because this violence is
targeted, prelude to it may involve
threats, planning, gaining access to
target &/or weapons
– Useful when this type of information is
available to others
• Reactive: intense emotion leads to
autonomic nervous system activation
– Clenched fists, fast/loud speech,
psychomotor agitation, change in posture
Assessing Risk
Importance of History
• The quality of a risk assessment
depends on a good, thorough history
• Best predictor of future violence is past
violence
• Assessment requires understanding
the conditions under which previous
violence occurred
Static Risk Factors
• Often part of a person’s history &
cannot be changed with intervention
• Often demographic data or yes/no
variables
– Age
– Gender
– Childhood abuse
– Prior supervision failures
– Parental history of drug use or criminality
Dynamic Risk Factors
• Subject to change by intervention,
treatment, or environmental control
• Usually existing factors
– Person’s living conditions
– Current drug use or abstinence
– Active symptoms, including psychosis
– Access to weapons
Approaches to Violence Prediction
• Structured professional judgment
– HCR-20: clinical judgment with
consideration of several risk-related
variables
• Statistical or actuarial prediction
– VRAG: useful with large groups &
statistical prediction, rather than clinical or
other conditions specific to an individual
• Threat assessment
– Used for targeted or predatory violence to
assess the likelihood or danger of a threat;
used in school or workplace violence
Conducting the
Interview/Assessment
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Past violence = best predictor
What’s most violent past act?
Look for patterns in prior violence
Contributors: (violence occurs only…)
– When psychotic, manic, etc.
– Following recent loss
– Following interpersonal insult or argument
• Mental status & drug use prior to act
• What precipitated the violence?
• Degree of psychopathy
– How to assess this; not Antisocial PD
• Remorse or regret following violence?
– Any internal self-monitoring
• Degree of injury
• Collateral or corroborating information
• Person’s thoughts & feelings prior to
acting violently
• Be sure to assess each prior violent act
in detail
Suicide Assessment
• Very similar, also involves detailed
inquiry into prior attempts
– How the person survived
– How lethal were the means used
– What was the likelihood of discovery
– Feelings of regret/disappointment afterward
– Follow-up with treatment after discharge
The HCR-20
• 20-item checklist used to predict risk of
future violence in psychiatric or forensic
populations
• Items chosen based on literature review
& input of experienced clinicians
• Clinician rates each item for presence or
absence, generates scores on 3 scales
• Allows for clinical judgment based on
this set of risk factors
Historical Items
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Previous violence
Young age at 1st violent incident
Relationship instability
Employment problems
Substance use problems
Major mental illness
Psychopathy
Early maladjustment
Personality disorder
Prior supervision failure
Clinical Items
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Lack of insight
Negative attitudes
Active symptoms of major mental illness
Impulsivity
Unresponsiveness to treatment
Risk Management Items
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Plans lack feasibility
Exposure to destabilizers
Lack of personal support
Non-compliant with remediation attempts
Stress
Managing Risk
Managing Risk Factors
• Dynamic risk variables are more
open to intervention than are static
variables
• Reactive violence is often
precipitated by dynamic factors that
can be controlled
– Medication compliance, level of
supervision, adequate support
network
Changing Pathways to Violence
• Predatory: reduce hostility; reduce
access to weapons/target; warn/protect
• Reactive: address intense emotional
reaction by interpersonal containment
(including hospitalization), or by other
interventions (medication, therapy)
– Grievance
– Idea/Emotion
– Attack
Risk Management Options
• Adjust level of monitoring/supervision
• Medications
– Change medication or adjust dose
– Monitor administration; use injectables
• Psychotherapy interventions
• Therapeutic Alliance
– Psychopathy & violence vary with quality
of therapeutic alliance
• Detox, rehab, or MICA facility
Risk Management Options
• Activities
– Clubhouses
– Vocational programming
• ACT Team
• Inpatient hospitalization
• Have law enforcement transport person
to a psychiatric ER
– Regardless of whether person is admitted,
this is an intervention on its own
Risk Management Options
• Limit access to means of violence, or to
the potential target of violent behavior
• Outpatient civil commitment
– In NYS, this is AOT – a court-order that
mandates outpatient treatment
– Critics argue that enforcement tools are
lacking, but this still raises level of
compliance with treatment for many people
Duty to Protect
• Tarasoff v. Regents of the University of
California, 1976
• Guidelines: Reasonable threat of
imminent harm places obligation on the
clinician to protect the potential target
• Form of protection varies by jurisdiction
– Calling police, notifying the target, having
aggressor hospitalized or incapacitated, etc.
• High reporting standard
– Higher than that for suspected child abuse
End