A Classification Tree Approach to the Development of Actuarial Violence Risk Assessment Tools

Since the 1970s, a wide body of research has suggested that the accuracy of clinical risk assessments of violence might be increased if clinicians used actuarial tools. Despite considerable progress in recent years in the development of such tools for violence risk assessment, they remain primarily research instruments, largely ignored in daily clinical practice. We argue that because most existing actuarial tools are based on a main effects regression approach, they do not adequately reflect the contingent nature of the clinical assessment processes. To enhance the use of actuarial violence risk assessment tools, we propose a classification tree rather than a main effects regression approach. In addition, we suggest that by employing two decision thresholds for identifying high- and low-risk cases--instead of the standard single threshold--the use of actuarial tools to make dichotomous risk classification decisions may be further enhanced. These claims are supported with empirical data from the MacArthur Violence Risk Assessment Study.     

Mental Disorder, Violence, and Gender

Recent studies have reported comparable rates of violence among men and women with mental disorder, raising important issues for clinical risk assessment. This study examines the relationship between gender and violence using data from the MacArthur Violence Risk Assessment Study. Patients in acute psychiatric wards were interviewed 5 times over the year following their discharge to the community. Results showed some differences between men and women in the violence committed immediately following discharge, with rates for men being higher. But the prevalence of violence over the 1 year was similar for female and male discharged patients. However, there were substantial gender differences in the situational context of the violence committed. Men were more likely to have been drinking or using street drugs, and less likely to have been adhering to prescribed psychotropic medication, prior to committing violence. The violence committed by men was more likely to result in serious injury than the violence committed by women, and men were more likely than women to be arrested after committing a violent act. Women were more likely to target family members and to be violent in the home.     

Cultural Cognition and Public Policy: The Case of Outpatient Commitment Laws

What explains controversy over outpatient commitment laws (OCLs), which authorize courts to order persons with mental illness to accept outpatient treatment? We hypothesized that attitudes toward OCLs reflect “cultural cognition” (DiMaggio, P. Annl Rev Sociol 23:263–287, 1997), which motivates individuals to conform their beliefs about policy-relevant facts to their cultural values. In a study involving a diverse sample of Americans (N = 1,496), we found that individuals who are hierarchical and communitarian tend to support OCLs, while those who are egalitarian and individualistic tend to oppose them. These relationships, moreover, fit the cultural cognition hypothesis: that is, rather than directly influencing OCL support, cultural values, mediated by affect, shaped individuals’ perceptions of how effectively OCLs promote public health and safety. We discuss the implications for informed public deliberation over OCLs.     

‘I'm still a hustler’: entrepreneurial responses to precarity by participants in phase I clinical trials

Abstract

This paper questions the implications of entrepreneurial responses to conditions of employment precarity by ‘healthy volunteers’ in phase I clinical trials in the United States. Such individuals are typically serial participants who often identify as professional volunteers and seek out drug studies as their primary source of income. Drawing on extensive qualitative research, this paper illustrates how healthy volunteers selectively import the identity of ‘hustler’ from the street environment and reposition it as connoting a set of valuable creative skills that give them a competitive edge over other participants. An entrepreneurial ethos allows them to view personal sacrifice and exposure to potentially dangerous drugs as smart investments leading to financially stable futures. These discursive moves normalize extractive, and at times dehumanizing, labour relations that offload expenses and risks to workers.     

Endorsement of personal benefit of outpatient commitment among persons with severe mental illness.

This study examines whether individuals who experienced involuntary outpatient commitment (OPC) attribute benefit to this intervention. It was found that the majority of experimental subjects who underwent a period of OPC did not personally endorse OPC's benefits at the end of the study, either because they did not think it improved treatment adherence or because they rejected their own need for continued treatment. However, at the end of the study, a positive appraisal of benefit was roughly twice as likely among subjects who actually experienced positive treatment outcomes. These data provide little support for acceptance and "gratitude" as a rationale to support decision making about OPC continuation. Rather, clinicians need to rely on other clinical and empirical data for such decision making.     

Assessing Violence Risk Among Discharged Psychiatric Patients: Toward an Ecological Approach

This paper draws upon data from the Pittsburgh site of the MacArthur Foundation's Risk Assessment Study, a large-scale study of violence risk among persons discharged from psychiatric hospitals, to examine the effect of the neighborhood context on risk of violence. This paper has two purposes: (1) to assess the extent to which the inclusion of neighborhood characteristics enhances violence prediction models—models that traditionally only include individual-level characteristics; and (2) to assess the consistency of individual level risk factors across different neighborhood contexts. Results indicate that neighborhood poverty has an impact over and above the effects of individual characteristics in identifying cases with violence. These findings support efforts to include neighborhood context in the assessment and management of violence risk among discharged psychiatric patients.