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Dead Right,


Sally C. Johnson MD Professor UNC Department of Psychiatry Forensic Psychiatry Program and Clinic Dead Right, Dead Wrong, or the Jury is Still Out: – PowerPoint PPT presentation

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Title: Dead Right,

Sally C. Johnson MDProfessorUNC Department of
PsychiatryForensic Psychiatry Program and Clinic
  • Dead Right,
  • Dead Wrong,
  • or the Jury is Still Out
  • The Complex Worlds of Violence and Mental Illness

Learning Objectives
  • Appreciate the complexity of the relationship
    between violence and mental illness
  • Understand the current state of risk assessment
  • Translate this understanding into a practical
    approach to risk management

  • 75 of people believe that people with mental
    illness are dangerous.

LiteratureMental illness and Violence
  • From Nursery Rhymes.

Lizzie Borden took an axe and gave her mother
forty whacks. When she saw what she had done
she gave her father forty-one.
  • To recent best-sellers

These were the lovely bones that had grown
around my absence
  • Susie Salmon cutting through a cornfield after
    school is persuaded by George Harvey, a man in
    his mid-40s who lives alone and builds dollhouses
    for a living, to have a look at his underground
    den. He rapes and kills her, dismembers her
    body, puts the parts in a safe and dumps it into
    a sinkhole.

  • We are led to believe that crazy people do
    crazy and frightening things.

Film Portrayal Mental Illness and Violence
  • The idea of the insane killer.

Takes a real life story like that of Ed Gein
and makes him into Norman Bates in Alfred
Hitchcocks Psycho
In the NewsMental Illness and Violence
  • Whether it is the poor handyman in need of a job

Bryan David Mitchell Elizabeth Smart Kidnapping
  • Or workplace violence that hits close to home

  • The murder of an NIMH administrator while trying
    to help a psychotic patient sent shockwaves
    through the mental health community, forcing
    clinicians to remember the rarebut ever
    presentrisk of violence. It is a rare scenario,
    the potential nightmare in the life of a
    psychiatrist a patient becomes violentwhile the
    psychiatrist and the patient are alone in the
    psychiatrist's office.
  • Wayne Fenton, M.D.
  • October 3, 2006

  • or a psychiatrist (possible terrorist) turned
    mass murderer

Nidal Malik Hasan Ft. Hood Killing Rampage
  • We are surrounded by possible links between
    violence and mental illness, and its frightening.

  • We are looking for a way to give names and faces
    to our fears

  • we want to know who is going to be violent and
    be able to stop them from being violent.

Cesare Lombrosos Atavism violent criminals
were throwbacks to primitive humans /
identifiable by physical characteristics / so
could just permanently detain or execute them
Whats the message?
Physical Signs of Imminent Violence (Berg, Bell,
and Tupin, 2000)
  • Chanting
  • Clenched Jaw
  • Flared Nostrils
  • Flushed face
  • Clenched or Gripping hands
  • Darting Eye Movements
  • Increased proximity of patient to Clinician
  • Inability of Patient to Comply with reasonable
    Limit setting

Core Issues to Consider
  • Definitions
  • Violence / Mental Illness
  • Assessment
  • Whats adequate? How often?
  • Prediction
  • Of what? For how long?
  • Prevention
  • Responsibility / Cost
  • Liability / Blame

Violence what does it mean?
  • Actual physical violence?
  • Potential for violent behavior?
  • Threat of violent behavior?
  • Breaking the law?
  • Psychological or emotional harm?
  • Risk to property?
  • Does it have to be a specific act or just a
    general propensity towards violence?

  • Does it have to be imminent?
  • Does frequency matter?
  • Does severity matter?
  • What about the setting?
  • Does it matter toward whom or what it is

What about defining Mental Illness or Mental
  • Clinically
  • ICD-10 the existence of a clinically
    recognizable set of symptoms or behavior
    associated with interference with personal
  • DSM-IV-TR a clinically significant behavioral
    or psychological syndrome or pattern that occurs
    in an individual associated with present
    distress disability or a significantly
    increased risk of suffering death, pain,
    disability, or an important loss of freedom

  • Within the legal/judicial system, mental illness
    or disorder is viewed as a legal, moral or policy
    judgment or definition-
  • not a clinical one.

  • Our legal system has long connected mental
    illness and violence and looked to clinicians to
    predict likelihood of future violence

Legal Areas of Violence Risk Prediction
  • Civil Commitment
  • OConnor v. Donaldson (1975) / Addington v. Texas
  • Civil Liability
  • Tarasoff v. Regents of the University of CA
  • Death Penalty Cases
  • Jurek v.Texas (1976) / Barefoot v. Estelle (1983)
  • Juveniles
  • Shall v Martin (1984)
  • Preventive Detention
  • U.S. v. Salerno (1987)
  • Sex Offender Commitment Statutes
  • Kansas v. Hendricks (1997) / US v Comstock (2010)

  • This legal dependence on clinical prediction of
    risk has persisted despite data suggesting that
    clinicians are often wrong in their predictions.

Natural experiments suggested clinicians were
wrong more often than not
  • Baxstrom v. Herald, (1966)-release or transfer of
    dangerous patients. In 4 yr. follow-up only 20
  • Dixon v. Attorney General of Commonwealth of PA
    (1971/1979-review)-86 false positive rate among
    those originally predicted to be dangerous
  • 1976-Cocozza/ Steadman-257 incompetent felons
    released 14 of those predicted as dangerous
    were rearrested 16 of those not viewed as
    dangerous were rearrested!
  • 1977-Patients released from Patuxent Institute/
    MD -58 false-positive rate in predictions of

  • In the wake of early legal decisions, research
    efforts increased with the aim to improve
    violence risk assessment in clinical practice and
    the criminal justice context by
  • identifying empirically-validated risk factors
  • developing risk assessment instruments based on
    empirically-validated risk factors

Methodological problems in earlier studies were
  • Large s of patients were lost to follow-up
  • Many had been treated for years
  • Reviews relied on official criminal records which
    grossly under-estimated violence
  • Definition of violence was inconsistent
  • Original predictions had not all been clinical
    many were administrative or legal
  • Turns out that Clinicians were actually right
    more often than not - but just barely

Review of History of Study of Relationship
between Violence and Mental Illness
  • Pre-deinstitutionalization studies showed no
    increased risk of violence
  • Post-deinstitutionalization studies began to show
    increased risk
  • It appeared that increased risk might be more
    connected to active symptoms rather than to
  • There was more and more evidence that the
    relationship between mental illness and violence
    was actually quite complex

MacArthur Violence Risk Assessment Study (1994)
  • Civil Admissions from inpatient psychiatric
    hospitals Western Psychiatric/ Pittsburgh, PA
    Western Missouri Mental Health Center/ Kansas
    City, MO Worcester State hospital and University
    of Massachusetts Medical Center / Worcester, MA
  • Ages 18-40
  • English Speaking / White or African-American
    (Hispanic at Worcester)
  • Chart Dx of Schizophrenia, schizophreniform,
    schizoaffective, depression, dysthymia, mania,
    brief reactive psychoses, delusional disorder,
    alcohol or drug abuse or dependence, or
    personality disorder. Research and clinician
    interviews in hospital two research interviews
    of patient and collateral informant with next 20
    weeks. Review of hospital, arrest and
    rehospitalization records

MacArthur Study-18.7 of patients were involved
in violent altercations Significant Findings
  • Men no more likely to be violent than women
    drinking , SA and medication non-compliance gt in
    men / women directed violence against family and
    at home
  • All measures (self report, hospital and arrest
    records)- previous violence and criminality
    strongly related to future violence
  • Prior physical abuse, but not sexual abuse as
    child was associated with post-DC violence
  • Parents history of substance abuse or criminal
    behavior strong relationship
  • All races in same disadvantaged neighborhood had
    same risk crime rate of neighborhoods pts. are
    discharged into may be important factor
  • Personality disorder/ adjustment disorder had
    greater risk than all other Dx
    schizophrenialtdepression or bipolar but gt than
    non-disordered population

MacArthur Study Findings continued.
  • Co-occurring Dx of Substance Abuse or Dependence
    strongly predictive
  • Psychopathy (the antisocial component) as
    measured by PCL predicted violence
  • Delusions were not predictive (even
    threat-control-over-ride) but suspiciousness was
  • Hallucinations/ command hallucinations were not
    predictive unless voices specifically commanding
    violent acts
  • Persistent violent thoughts during
    hospitalization and afterwards were predictive
  • Anger high scores on Novaco Anger Scale at
    hospitalization were twice as likely to engage
    in violent acts post DC

  • So where are we now,
  • more than 25 years later?

National Epidemiologic Survey on Alcohol and
Related Conditions (NESARC)
  • We employed a nationally representative,
    longitudinal dataset from this two wave,
    face-to-face survey conducted by the National
    Institute on Alcohol Abuse and Alcoholism. N
    34,653 subjects
  • Wave 1 (2001-2002) Wave 2 (2004-2005).
  • Our questions were
  • 1) Does severe mental illness (SMI) predict
    future violent behavior?
  • 2) What risk factors prospectively predict
    violent behavior?

Multivariate Predictors of Violent Behavior
Perpetrated Between Waves 1 and2
  • Dispositional Factors age, education, sex, race,
  • Historical Factors parental criminal history,
    witnessing parental fighting, history of any
    violence, history of juvenile detention
  • Clinical Factors Schizophrenia, Bipolar
    Disorder, Major Depression, Substance
    abuse/Dependence, SchizophreniaSA/D, Bipolar
    DisorderSA/D, DepressionSA/D, Perceives hidden
    threats in others
  • Contextual Factors Victimized in past year,
    family or friend died in past year, fired from
    job in past year, divorced or separated in past
    year, Unemployed for past year

Top Ten Predictors of Any Violent Behavior
Between Waves 1 and2
  • Age (younger)
  • History of any violent act
  • Male
  • Divorce or separation in the past year
  • History of physical abuse
  • Parental criminal history
  • Unemployment for the past year
  • Co-occurring severe mental illness and substance
  • Victimization in the past year

  • SMI did not predict severe/serious violence, even
    when combined with substance use disorders.
  • SMI was significantly associated with physical
    abuse by parents, parental arrests, substance
    disorders, recent victimization, and
  • 46 of those with SMI had co-morbid substance
    abuse/dependence. Violence risk was higher in
    this group than substance use without SMI.
  • People with SMI were more vulnerable to past
    histories that elevate violence risk and more
    prone to experience environmental stressors that
    also elevate violence risk.

  • Severe mental illness did NOT rank among the
    strongest predictors of violent behavior.
  • Severe mental illness alone was NOT statistically
    related to future violence, in bivariate or
    multivariate analyses.
  • People with any type of severe mental illness
    were NOT at increased risk of committing
    serious/severe violent acts.

Evolution from Violence Prediction to Risk (or
threat) Assessment
  • Violence Prediction
  • -focuses on the individual
  • -portrays dangerousness as a state
  • Risk Assessment
  • -focuses on person-situation interactions
  • -portrays dangerousness as
  • dynamic, contextual and continuous

We continue to be asked to assess risk of
  • Need for admission/ suitability for discharge
  • ER evaluations
  • Civil Commitment/ Release
  • Workplace/ school threats
  • Juvenile justice management
  • Sentencing/ Parole/ Probation/ Early Release
  • Sex Offender Commitments
  • Specialty Court Treatment Plans

Approaches to Risk Assessment
  • Unstructured Clinical Judgment
  • Actuarial
  • Structured Professional Judgment
  • Anamestic

Clinical Judgment
  • More accurate than chance (Mossman 1994) AUC .67
  • Does facilitate aspects of data gathering and
    data interpretation

  • Formal / equation-formula-graph- table used to
    arrive at a probability of some outcome
  • Objective, mechanistic, reproducible combination
    of predictive factors, selected and validated
    through empirical research against known outcomes
  • BUT clinicians have not embraced this
  • Hard to go from the abstract to the individual

Structured Professional Judgment
  • Presentation of specific risk factors derived
    from broad review of literature not specific data
    set- factors are well operationalized so their
    applicability can be coded yes-possibly-no-/
    multiple data sources/ evaluator draws conclusion
    weighing risk factors and intensity of management

  • Process of gathering detailed information about
    individuals history of violence. Question in
    detail about each particular violent event
    (preceding, subsequent, during)- thoughts,
    feelings and behaviors - to identify risk and
    protective factors that recur across violent
    events- identify target interventions

A Practical Guide to Risk Assessment
  • Build structure into your approach
  • Remember that violence is not a common event, so
    prediction is not easy
  • Start by thinking about the base rate for your
    clinical situation

  • Knowledge of the appropriate base rate is the
    most important single piece of information
    necessary to make an accurate violence risk
  • (Monahan 1981)

Base Rate
  • The proportion of a particular population who
    commit violence in a particular period of time
  • Starting point for subsequent evaluation of
  • Varies by type of violence, by method of
    detection, over time, and usually underestimates
    the true extent of violence

Practical Assessment of potential for violence
toward others involves considering
  • Risk and Protective Factors variables associated
    with the probability that violence will or will
    not occur
  • Harm the nature and severity of the probable
    results of the violent behavior
  • Risk Level the probability that violence will
  • Potential Victims who are the likely objects of
    the violence

Standardized Risk Assessment Tools
  • Assist the Clinician in gathering appropriate
  • Anchor assessment to established research
  • Access factors that are known to be associated
    with particular types of violence in specific
  • Should be used in conjunction with clinical risk
  • May not be as objective in application as we
    would hope.

When you think about using Risk Assessment Tools
  • Context
  • Purpose
  • Population
  • Parameters
  • Approach
  • Applicability
  • Heilbrun, et al. Violence Risk Assessment Tools
    Overview and Analysis/ Otto and Douglas Handbook
    of Violence Risk Assessment

Structured Risk Assessment Tools
  • Hare Psychopathy Checklists
  • Historical-Clinical Mangement-20 (HCR-20)
    Violence Risk Assessment Scheme
  • COVR-Classification of Violence Risk

Hare Psychopathy Checklists (PCL, PCL-R, PCLSV,
  • PCL-R 20 item construct rating scale
  • Used in research and clinical settings
  • Assesses psychopathy in adults
  • Involves semi-structured interview and review of
    file/collateral data
  • PCL-SV 12 item
  • PCLYV 20 items

Psychopathic Personality Construct
  • Personality traits and socially deviant
  • Glib and superficial charm
  • Egocentricity
  • Selfishness
  • Lack of empathy, guilt and remorse
  • Lack of enduring attachment to people,
    principles, or goals
  • Impulsive and irresponsible behavior
  • Tendency to violate explicit social norms

  • Ability to predict violent behavior depends on
    type of behavior being predicted( general v
    violent v sexual), context in which offender is
    or will be located ( corrections or community)
    and time frame of prediction ( 1 or 10 years)-
    and demographic variables age/ gender/ race and
    ethnicity need specific referral question to
    determine if should be used
  • Has modest to moderate relationship with future
    community violence and weak to modest with future
    institutional violence

Historical-Clinical Mangement-20 (HCR-20)
Violence Risk Assessment Scheme
  • Structured Professional Judgment model /
    translated into 16 languages
  • Intended to facilitate assessments of risk for
    interpersonal violence (actual, attempted or
    threatened), clear unambiguous threats of harm,
    including psychological harm, to person or
  • Intended to provide a structured assessment of
    the risk factors that are present in a given
    case, the relevance of the risk factors for a
    given individuals violence risk, and what risk
    management strategies might be put into place in
    order to mitigate that risk.
  • Historical / Clinical and Risk Management Scales

Checklist from HCR-20
  • Historical previous violence, young age at first
    violent incident, relationship instability,
    employment problems, substance use problems,
    major mental illness, psychopathy, early
    maladjustment, personality disorder, prior
    supervision failure

Checklist from HCR-20
  • Clinical lack of insight, negative attitudes,
    active symptoms of major mental illness,
    impulsivity, unresponsiveness to treatment
  • Risk Management Items plans lack feasibility,
    exposure to destabilizers, lack of personal
    support, noncompliance with medication, stress

COVR-Classification of Violence Risk
  • Computer-based program to determine category of
  • Iterative Classification Tree (ICT)
  • Designed to mirror clinical decision making
  • Differentiates between low and high risk

Violence Risk Assessment Decision-Making Models
  • Flipping a Coin -gt AUC.50
  • Clinical Decision-Making -gt AUC.66
  • History of Violence -gt AUC.71
  • Psychopathy Checklist -gt AUC.75
  • Violence Risk Appraisal Guide -gt AUC.76
  • HCR-20 -gt AUC.80
  • MacArthur Risk Assessment Study -gt AUC.82
  • Perfect Accuracy -gt AUC1.0

  • No risk assessment should rely solely on the
    results of any one instrument information
    gleaned from use of these structured instruments
    should be used to inform risk assessment and
    assist in risk communication.

Given all we now know
  • What is a practical approach to risk management?

LEAD A Four-Step Approach to Assessing Violence
  • LOOK at static, individual-level factors known to
    empirically relate to violent behavior in your
    population (dispositional and historical factors)
  • EXAMINE for presence of protective factors or
    unique individualized factors from both the micro
    and macro environments (contextual factors)
  • ADJUST your risk assessment by considering
    dynamic individual variables (clinical factors)
  • DOCUMENT your assessment and risk management plan
    and communicate it to those who need to know

Specific Tasks
  • Identifying/quantifying the risk
  • Modifying the acute risk
  • Managing the chronic risk
  • Balancing the seriousness of potential outcome
    with the probability of its occurrence

Keep in Mind
  • Time frame of prediction
  • Structure of setting
  • Institution v. Community
  • Impact of aging / group involvement

Think about identifying
  • Behaviors that are not a product of illness but
    likely to be patient choice
  • Lifestyle choices and issues that are going to be
    difficult to modify and about which you have no
    direct ability to modify
  • Patients competence to be making decisions that
    might influence ability to carry out violent act

Share the Risk
  • Collect collateral information
  • Consult with your peers
  • Tackle limiting confidentiality head-on
  • Engage your patient and their support system in
    establishing a risk management plan and in
    ongoing management of risk

Develop a Violence Prevention Plan
  • Distinguish Static ( Demographic and Past
    History) and Dynamic Factors (Subject to change
    with intervention such as access to weapons,
    psychotic symptoms, active substance abuse,
    living setting and situation)
  • Focus on current status of each dynamic factor
  • Develop a plan to address the combination of
    factors unique to the individual
  • Determine the setting and parameters necessary to
    safely implement the plan
  • Document this process

Communicate the risk and the management plan to
those who need to know
  • Guided By
  • Research Data / Instrument Construction
  • Ethical Standards
  • Laws
  • Admissibility Standards / Decisions
  • Professional Guidelines
  • Clinical experience

  • Manage Your Liability by the quality of your risk
    assessment, the thoughtfulness of your risk
    management and the excellence of your

Improving Your Understanding of Violence and
Mental Illness Just Might
  • Help to eliminate destructive and common myths
    about mental illness and violence
  • Reduce the overall incidence of violence in our
  • Enhance the safety in clinical settings
  • Improve how the criminal justice system responds
    to people with mental illness
  • Keep you out of the courtroom, where the question
    could be

  • Was your risk assessment
  • and your risk management
  • Dead Right or Dead Wrong?

  • The Jury is still out!