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Assessing Risk for Violence

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1Assessing Risk for Violence. Stephen 40assessed as part of comprehensive violence
D. Hart Simon Fraser University. risk assessments The presence of
2Violence. Actual, attempted, or psychopathy compels a conclusion of high
threatened physical harm that is risk The absence of psychopathy does not
deliberate and nonconsenting Includes compel a conclusion of low risk
violence against victims who cannot give Psychopathy must be assessed by trained
full, informed consent Includes professionals using adequate procedures.
fear-inducing behavior, where threats may 41Decision Tree. Homicidal/suicidal?
be implicit or directed at third parties. YES. High Risk. NO. Sexual sadism? YES.
3Violence as a Choice. The proximal High Risk. NO. Psychopathic? (e.g., PCL-R
cause of violence is a decision to act > 30). YES. High Risk. NO. Assess other
violently The decision is influenced by a factors (e.g., HCR-20).
host of biological, psychological, and 42Risk Scales: Features. Designed solely
social factors Neurological insult, to predict an outcome High-fidelity
hormonal abnormality Psychosis, Optimized for specific outcome, time
personality disorder Exposure to violent period, population, and context Impose
models, attitudes that condone violence. rigid structure On all of the evaluation
4We Can’t Predict Violence… Violence is process On all of the decision-making
too rare to predict with any accuracy, by process.
any means “Professional” decisions are 43Risk Scales: Limitations. Still
particularly bad Predictions of violence require professional judgment Which scales
necessitate a deterministic view of to use How to interpret scores
behavior. Justification of use still requires
5Or, Can We? The issue of prediction is induction Our population is like theirs
moot Don’t predict, evaluate risk (e.g., Our use of the test is like theirs Results
suicide) Regardless, predictions made by may be easily misinterpreted
professionals are reliably better than Pseudo-objective, pseudo-scientific.
chance The scientific literature on 44VRAG. Violence Risk Appraisal Guide
violence is large and growing Any choice Quinsey et al. (1998) Constructed in adult
can be predicted. male patients assessed or treated at a
6What is Risk Assessment? Process of maximum security hospital 12 items
understanding a hazard to limit its weighted according to ability to postdict
potential negative impact Hazard violence over 7 year follow-up Total
identification (which events occur?) scores divided into 9 bins, with estimated
Hazard accounting (how frequently?) p(violence) from 0% to 100%.
Scenarios of exposure (under which 45VRAG Items. PCL-R score Elem. school
conditions?) Risk characterization problems Personality disorder Age (—)
(conditions present?) Risk management Separated from parents under age 16
(which interventions?). Failure on prior conditional release.
7Nature of Violence Risk. Violence risk Nonviolent offense history Never married
is a multi-faceted construct Nature: what Schizophrenia (—) Victim injury (—)
kinds of violence might occur? Severity: Alcohol abuse Female victim (—).
how serious might the violence be? 46VRAG: Potential Problems. The VRAG is,
Frequency: how often might violence occur? in essence, a history lesson: What if
Imminence: how soon might violence occur? patient profile changes? What if p
Likelihood: what is the probability that (violence) changes? What if the assessment
violence might occur? context changes?
8Risk is Context-Specific. We never 47VRAG: Actual Problems? Paul Bernardo
know a person’s risk for violence; we is a convicted serial murderer (3 sexual
merely estimate it assuming certain homicides) and serial rapist (75 known
conditions Assuming institutionalization, rapes) Currently serving life imprisonment
assuming release with supervision, for murder, and an indeterminate sentence
assuming release without treatment for for the rapes VRAG completed on the basis
substance use… Consequently, relative or of case history data.
conditional risk judgments are more useful 48Bernardo’s VRAG Results. Total: -1 Bin
than absolute or probabilistic risk #: 4 p(viol): 17% - 31%. PCL-R score +4
judgments. Elem. school… -1 Personality disorder +3
9Goals of Risk Assessment. To make Age 0 Separated from… -2 Failure on prior…
better decisions Improve consistency 0 Nonviolent offense… -2 Marital status -2
Protect public safety Guide intervention Schizophrenia +1 Victim injury -2 Alcohol
Protect clients’ rights Liability abuse +1 Female victim -1.
management. 49Problems With All. Focus on negative
10Risk Characterization Content Issues. characteristics “Sticky” labels What about
11What to Include? Three primary strengths (resources, “buffer” factors)?
criteria Empirical (predictive accuracy) Risk assessment ? risk management What to
Professional (practical utility) Legal do with high-risk individuals? Quality
(fairness and reasonableness). control Who will assess risk, and how?
12Problems With Empirical Criterion. Not 50Risk References. Boer, D. P., Hart, S.
everything that is important has been D., Kropp, P. R., & Webster, C. D.
proven or validated scientifically Can (1997). Manual for the Sexual Violence
lead to exclusion of “good” but rare or Risk-20: Professional guidelines for
difficult-to-assess risk factors assessing risk of sexual violence.
Prediction ? cause, explanation, or Burnaby, British Columbia: Simon Fraser
intervention Can lead to inclusion of University. Grove, W. M., & Meehl, P.
“bad” but common or easy-to-assess E. (1996). Comparative efficiency of
factors. informal (subjective, impressionistic) and
13Example: The SIEVE. Age Young is bad formal (mechanical, algorithmic)
Sex Male is bad Facial hair Dense is bad prediction procedures: The
Foot size Big is bad. clinical-statistical controversy.
14Problems With Professional Criterion. Psychology, Public Policy, and Law, 2,
Focus on dynamic factors may bias risk 293-323. Kropp, P. R., Hart, S. D.,
assessments Can lead to exclusion of Webster, C.W., & Eaves, D. (1995).
“good” but static or easy-to-ignore Manual for the Spousal Assault Risk
factors Conventional wisdom of Assessment Guide, 2nd ed. Vancouver, BC:
professionals may be plain wrong Can lead British Columbia Institute on Family
to inclusion of “bad” but vivid or Violence. Meehl, P. E. (1996). Clinical
dramatic factors. versus statistical prediction: A
15Example: Clinical Intuition. theoretical analysis and a review of the
Depression Present is good Anxiety Present literature. Northvale, NJ: Jason Aronson.
is good Intelligence High is good (Original work published in 1954.).
Rorschach Seeing viscera is bad. 51Risk References (cont.). Melton, G.
16Problems With Legal Criterion. Useful B., Petrila, J., Poythress, N. G., &
for excluding risk factors, but not for Slobogin, C. (1997). Psychological
including them It can be argued that evaluations for the courts: A handbook for
almost any risk factor is unfair or mental health professionals and lawyers
unreasonable in some respect. (2nd ed.). New York: Guilford. Quinsey, V.
17Risk Characterization Procedural L., Rice, M. E., Harris, G. T., &
Issues. Cormier, C. (1998). Violent offenders:
18Conventional Approaches. Professional Appraising and managing risk. Washington,
judgment Unstructured or “clinical” DC: American Psychological Association.
Anamnestic (see Melton et al., 1997) Webster, C. D., Douglas, K. S., Eaves, D.,
Structured (e.g., HCR-20, SVR-20) & Hart, S. D. (1997). HCR-20:
Actuarial decision-making Psychological Assessing risk for violence, version 2.
tests (e.g., MMPI-2, PCL-R) Risk scales Burnaby, British Columbia: Simon Fraser
(e.g., VRAG, RRASOR). University.
19Professional Judgment. Most 52But How Accurate Are Characterizations
commonly-used method for violence risk of Risk?
assessment Familiar to professionals 53A Complex Phenomenon. Studying the
Familiar to courts and tribunals General accuracy of risk characterizations is
strengths of method Flexible (easy difficult due to the complexity of… The
administration) Requires limited training characterizations The violence The
and technology Person-centered follow-up Indexes of accuracy.
(“idiographic”). 54The Characterizations. Evaluator:
20Unstructured: Features. No constraints Professional vs. researcher; novice versus
on evaluation Any information can be expert Process: Clinical vs. actuarial,
considered Information can be gathered in contextual vs. context-free Timing:
any manner No constraints on decisions Admission vs. discharge, static vs.
Information can be weighted and combined dynamic Metric: Uni- vs.
in any manner Results can be communicated multi-dimensional, categorical vs.
in any manner. continuous.
21Unstructured: Limitations. No 55The Violence. Direction: Self vs.
systematic empirical support Low agreement others, acquaintances vs. strangers
(unreliable) Low accuracy (unvalidated) Nature: Instrumental vs. reactive
Foundation is unclear (unimpeachable) Severity: Threats vs. battery vs. homicide
Relies on charismatic authority Decisions Frequency: Single vs. multiple events
are broad bandwidth Focus is on Context: Situational precipitants or
culpability, not action. co-factors.
22Anamnestic: Features. Imposes minor 56The Follow-Up. Data source: Patient
structure on evaluation Must consider, at vs. collaterals vs. records Time at risk:
a minimum, nature and context of past Weeks vs. months vs. years Interventions:
violence Action-oriented Logically related Dynamic factors, life events Monitoring:
to development of risk management Continuous vs. endpoint.
strategies Consistent with “relapse 57Indexes of Accuracy. Comparison group:
prevention” or “harm reduction” Other patients vs. normals Statistic: Uni-
approaches. vs. multi-variate, time Weighting of
23Anamnestic: Limitations. Unknown errors: Equal vs. differential
reliability Unknown validity Assumes that Interpretation: Chance vs. status quo vs.
history will repeat itself Violent careers perfection.
are static Violent people are specialists. 58Science Responds to Complexity.
24Structured: Features. Imposes major 59Example: Psychopathy. Harris, Rice,
structure on evaluation Must consider, at & Cormier (1991).
a minimum, a fixed and explicit set of 60Example (cont.). In this study...
risk factors Specifies process for Accuracy of positive predictions is 77%
information-gathering Imposes minor Accuracy of negative predictions is 79%
structure on decision Specifies language Overall accuracy is 78% Chance-corrected
for communicating findings agreement is 53% Correlation is .53 Odds
Action-oriented. ratio is 12.5.
25Structured: Limitations. Requires 61Example (cont.). So, how did we do?
“retooling” of evaluation process Relative to chance: Great! Relative to
Systematized information-gathering New perfection: Awful! Relative to the status
training and technology Justification for quo: ???
imposing structure requires inductive 62What is the status quo? Predictions of
logic (faith) What works elsewhere will violence using the PCL-R typically have an
work here Professional discretion is effect size (r) of about .35; the average
appropriate. effect size for psychosis is about .30 An
26HCR-20. HCR-20, version 2 Webster, effect size of .40 may be the “forensic
Douglas, Eaves, & Hart (1997) Designed sound barrier” But what is the status quo
to assess risk for violence in those with in other human endeavors?
mental or personality disorders 10 63Meta-Meta-Analysis. Lipsey &
Historical, 5 Clinical, and 5 Risk Wilson (1993) reviewed 302 meta-analyses
Management factors. Determined typical effect sizes for
27Applications. Assess clinical psychological, educational, and medical
evaluations of violence risk across a interventions.
broad range of populations and settings 64Psychological Interventions. CBT — ?
Civil and forensic psychiatric, depression .44 Psychotherapy — any ? .39
correctional Institution, community Correctional programs (youths) .23 — any ?
Monitor clinical and situational factors Diversion (youths) — ? recidivism .20
that may be relevant to violence Guide Correctional treatment (adults) .12 — any
risk management strategies. ?
28Conceptual Basis. Intended to bridge 65Educational Interventions. Small
clinical and empirical domains and classes — ? class climate .26 Tutoring — ?
knowledge bases Evidence-based risk grades .20 Small classes — ? grades .10
assessment Content determined rationally Media campaigns — ? seatbelt use .06.
Based on reviews of scientific and 66Medical Interventions. Speech therapy
professional literatures Not optimized on — ? stuttering .54 Bypass surgery — ?
a particular sample. angina pain .37 Cyclosporine — ? organ
29Temporal Organization. rejection .15 Bypass surgery — ? mortality
30Historical Factors. Previous violence .07 ASA — ? heart attack .04.
Young age at first violence Relationship 67Violence Predictions in Context.
instability Employment problems Substance Speech therapy — ? stuttering .54 CBT — ?
use problems. Major mental illness depression .44 Bypass surgery — ? angina
Psychopathy Early maladjustment pain .37 Psychopathy — ? violence .35
Personality disorder Prior supervision Psychosis — ? violence .30 Small classes —
failure. ? class climate .26.
31Clinical & Risk Management 68Conclusions. Violence predictions, on
Factors. Lack of insight Negative the whole, are just as good as most other
attitudes Active symptoms of major mental human prognostications Consider other
illness Impulsivity Unresponsive to fields... Stock analysts Meteorologists
treatment. Plans lack feasibility Exposure Fire inspectors Structural engineers.
to destabilizers Lack of personal support 69Risk Assessment: Reports and
Noncompliance with remediation attempts Testimony.
Stress. 70General Issues. Acknowledge
32Actuarial Decision-Making. professional qualifications But, less
Commonly-used adjunctive method for important than approach used Acknowledge
violence risk assessment Familiar to some limits of information base But,
professionals (psychologists) Somewhat comprehensiveness depends on context
familiar to courts and tribunals General Explain risk factors considered Empirical,
strengths of method Highly professional, legal justification
structured/systematic (“objective”) Acknowledge uncertainty of “predictions”.
Empirically-based (“scientific”). 71Do Don’t. Use multiple approaches Make
33Psychological Tests: Features. Measure relative or conditional risk judgments
some disposition that predicts violence, Make detailed risk management
according to past research Reliability and recommendations. Rely on a single approach
validity of test-based decisions has been Make absolute or probabilistic risk
evaluated Imposes major structure On some judgments Ignore the issue of what can or
part of the evaluation process On some should be done.
part of the decision-making process. 72Special Issues: Professional. Report
34Psychological Tests: Limitations. should tell a story Summarize the
Require professional judgment Which tests circumstances of past violence and any
to use How to interpret scores recent changes in them Describe the likely
Justification of use requires inductive nature and context (scenarios) of future
logic Our population is like theirs Our violence Identify factors that may
use of the test is like theirs. increase risk and therefore serve as flags
35PCL:SV. Symptom construct rating scale for re-assessment Recommend, evaluate, and
requires clinical / expert judgment based prioritize risk management strategies.
on “all data” Data obtained from two 73Cross-Exam: Professional. What, if
primary sources: review of case history any, is the basis of your expertise in the
(required) interview / observation assessment of violence risk? What is the
(recommended). scientific basis for your decision (not)
36PCL:SV: Items. Part 1 Superficial to follow these procedures? What is the
Grandiose Deceitful Lacks remorse Lacks scientific basis for your decision (not)
empathy Doesn’t accept responsibility. to consider these factors? Can you state
Part 2 Impulsive Poor behavioral controls with any reasonable degree of scientific
Lacks goals Irresponsible Adolescent certainty the likelihood that X will be
antisocial behavior Adult antisocial violent?
behavior. 74Special Issues: Actuarial. Report
37PCL: Summary #1. The correlation should provide full interpretation of test
between the PCL and violent recidivism scores Be familiar with research
averages about .35 Regardless of length of supporting the test’s reliability and
follow-up Even in sex offenders, forensic validity Discuss general limitations of
patients, women, delinquents — even in the test Discuss limitations of the test
nonviolent, nonpsychopathic offenders in this case.
Association is quasi-linear (positive and 75Cross-Exam: Actuarial. Isn’t it
monotonic). arbitrary to consider risk factors such as
38PCL: Summary #2. Among psychopaths A, B, and C, but to ignore D, E, and F? Is
(e.g., PCL-R > 30) released from there any scientific evidence that scale Z
prison, the 5-year violent reoffense rate predicts outcome Y in patients at this
is about 70% Versus about 30% in low group clinic? How do you know that predictions
(< 20) and 50% in medium group (21-29) using scale Z are accurate for Mr. X? By
Versus low group, psychopaths are at very using scale Z, aren’t you simply relying
high risk for reoffense (rate ratio = 2x on statistical profile evidence?
to 3x; odds ratio = 5x to 10x). 76Contact Information. Stephen D. Hart,
39PCL: Summary #3. Psychopaths not only Ph.D. Department of Psychology Simon
commit more violence, they commit Fraser University Burnaby, British
different kinds of violence The violence Columbia Canada V5A 1S6 Tel: 604.291.5485
of psychopaths often has unusual or / Fax: 604.291.3427 E-mail:
atypical motivations Instrumentality/gain shart@arts.sfu.ca URL:
Impulsivity/opportunism Sadism. www.sfu.ca/psychology/groups/faculty/hart.
40PCL: Conclusions. Psychopathy must be
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