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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. Overview. How we perceive risk and make decisions What do we know about violence?

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Assessing dangerousness myths and research l.jpg

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

    • We’re 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


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Substance Abuse as a Risk Factor

Self report of violence in previous year:DX%None2OCD11Bipolar/mania11Panic disorder12Major depression12Schizophrenia13Cannabis use/dependence19Alcohol use/dependence25Other use/dependence35


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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)

  • Interview—if 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 subject’s life might increase or decrease risk?


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Pathway to Violence6.Attack5.Breach4.Preparation3.Research & Planning2.Ideation1.GrievanceCalhoun 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(cont’d)

  • 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 ain’t so much the things we don’t know that get us into trouble. It’s the things we know that ain’t so.”

Artemus Ward

(Charles Farrar Browne)


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