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.     

Risk assessment for intimate partner violence: how can the police assess risk?

ABSTRACT

The use of risk assessment tools by frontline police for intimate partner violence has the potential to make a difference to policing. In this paper, the key aspects of intimate partner violence risk assessment are outlined critically with a particular emphasis on how they can be used in practice. Two, evidence-based, exemplars are reviewed. These are the Ontario Domestic Abuse Risk Assessment (ODARA), an example of the actuarial approach, and the Brief Spousal Assault Form for the Evaluation of Risk (B-SAFER), an example of the structured professional judgement approach. In addition, the victim giving his or her own appraisal of risk is discussed. All three approaches have some validity when administered properly but practical factors reduce this validity. The content of the risk assessment tools are outlined and practical concerns such as training, time to administer, reliability, validity, and the overlap of intimate partner violence with other forms of offending are discussed. A balanced overview of the strengths, weaknesses and future potential of intimate partner violence risk assessment is provided.     

Static screening instruments for risk of minor and major violence

Background: Screens for violent convictions that are simple, accessible and parsimonious are needed, as a first stage in identifying those at high risk for further assessment. Aims: To construct and validate screening tools for minor and major violence convictions for released prisoners. Methods: Internal validation sample of 1647 serious offenders and an external validation of 46,704 general prisoners. The outcomes were binary indicators for having at least one conviction for minor and major violence. Risk factors were convictions for violence and age. Results: In the external validation sample, the instrument for risk of minor violence (PMIV) identified correctly 60.8% of male and 66.2% of female general prisoners. For risk of major violence, the instrument (PMAV) identified correctly 68.0% of male and 79.3% of female prisoners. Conclusions: The PMIV and PMAV will efficiently assist practitioners in a first stage of screening before in-depth clinical assessment of risk for future violent convictions.     

The Effect of Framing Actuarial Risk Probabilities on Involuntary Civil Commitment Decisions

Despite a proliferation of actuarial risk assessment instruments, empirical research on the communication of violence risk is scant and there is virtually no research on the consumption of actuarial risk assessment. Using a 2 × 3 Latin Square factorial design, this experiment tested whether decision-makers are sensitive to varying levels of risk expressed probabilistically and whether the framing of actuarial risk probabilities is consequential for commitment decisions. Consistent with research on attribute framing, in which describing an attribute in terms of its complement leads to different conclusions, this experiment found that the way actuarial risk estimates are framed leads to disparate commitment decisions. For example, risk framed as 26% probability of violence generally led decision-makers to authorize commitment, whereas the same risk framed in the complement, a 74% probability of no violence, generally led decision-makers to release. This result was most pronounced for moderate risk levels. Implications for the risk communication format debate, forensic practice and research are discussed.     

HCR-20 violence risk assessments as a guide for treating and managing violence risk in a forensic psychiatric setting

Abstract

Over the past decades there has been a vast development in the research into risk factors for violence and the development of risk assessment instruments. One instrument that has been given special attention is the HCR-20 violence risk assessment scheme. However, little attention has been paid to the clinical applicability of this tool, i.e. how does this assessment scheme perform when utilized in clinical practice as a tool to guide intervention and management in order to alleviate risk of violent behaviour? The present study was a true prospective study into the utilization of the HCR-20 as a clinical routine. Data on forensic psychiatric patients (n = 81) from a forensic unit in Denmark are presented. As part of a clinical routine all patients were assessed for risk of future violence utilizing the structured professional judgement model, the HCR-20. Outcome measures were aggressive episodes during hospitalization and new convictions post discharge. The predictive validity of the HCR-20 was lower compared with previous findings. It is argued that this does not necessarily indicate poor predictive accuracy of the HCR-20. Rather, it may indicate that the HCR-20 is suitable for guiding risk management in order to prevent violent behaviour.     

Psychologists as ‘the quiet ones with the power’: understanding indeterminate sentenced prisoners’ experiences of psychological risk assessment in the United Kingdom

ABSTRACT

Prisoners serving indeterminate sentences in the United Kingdom do not know when or if they will be released from prison. Release and progression decisions are determined by the risk the ISP presents of reoffending. This makes the assessment of risk a high stakes business for ISPs. Whilst there is a large body of literature focused on prisoners’ general experiences of prison, there is an absence of specific empirical exploration of prisoners’ experiences of risk assessment. This paper aims to address this gap by reporting the results of a qualitative exploration of ISPs’ experiences of psychological risk assessment. Interviews with 10 ISPs were conducted and analysed using Grounded Theory methods. Analysis indicated that prisoners experienced the prison environment as characterised by violence, volatility and suffering. Psychological risk assessment is embedded within this emotionally and physically challenging context but also contributes to the experience of suffering. Within this context, prisoners felt stuck, powerless and out of control in relation to risk assessment, and experienced psychologists as untrustworthy yet powerful. Understanding prisoners’ experiences is the first step in resolving some of the long-reported difficulties in working relationships between psychologists and prisoners as well as making the process more procedurally just.     

CUSTODY DISPUTES INVOLVING ALLEGATIONS OF DOMESTIC VIOLENCE: TOWARD A DIFFERENTIATED APPROACH TO PARENTING PLANS

Premised on the understanding that domestic violence is a broad concept that encompasses a wide range of behaviors from isolated events to a pattern of emotional, physical, and sexual abuse that controls the victim, this article addresses the need for a differentiated approach to developing parenting plans after separation when domestic violence is alleged. A method of assessing risk by screening for the potency, pattern, and primary perpetrator of the violence is proposed as a foundation for generating hypotheses about the type of and potential for future violence as well as parental functioning. This kind of differential screening for risk in cases where domestic violence is alleged provides preliminary guidance in identifying parenting arrangements that are appropriate for the specific child and family and, if confirmed by a more in‐depth assessment, may be the basis for a long‐term plan. A series of parenting plans are proposed, with criteria and guidelines for usage depending upon this differential screening, ranging from highly restricted access arrangements (no contact with perpetrators of family violence and supervised access or monitored exchange) to relatively unrestricted ones (parallel parenting) and even co‐parenting. Implications for practice are considered within the context of available resources.     

The Competition–Violence Hypothesis: Sex,Marriage, and Male Aggression

Sexually active men, who are not in a monogamous relationship, may be at a greater risk for violence than men who are sexually active within monogamous relationships and men who are not sexually active. The current study examines changes in sexual behavior and violence in adolescence to early adulthood. Data on male (n = 4,597) and female (n = 5,523) respondents were drawn from four waves of the National Longitudinal Study of Adolescent and Adult Health (Add Health). HLM regression models indicate that men who transition to a monogamous, or less competitive, mode of sexual behavior (fewer partners since last wave), reduce their risk for violence. The same results were not replicated for females. Further, results were not accounted for by marital status or other more readily accepted explanations of violence. Findings suggest that competition for sex be further examined as a potential cause of male violence.     

Intimate Partner Homicide: Risk Assessment and Prospects for Prediction

Little is known about assessing the risk of intimate partner homicide (IPH). Research has shown that women killed by an intimate partner scored higher than abuse survivors in retrospectively measured risk for IPH. In this study, we examined the characteristics of 146 men who committed an actual or attempted act of IPH. Of these, 42% had prior criminal charges, 15% had a psychiatric history, and 18% had both; events which could feasibly have permitted a prior formal assessment of risk. We also identified a subsample of 30 who could be scored on the Ontario Domestic Assault Risk Assessment (ODARA; Hilton et al., Psychological Assessment, 16, 267–275, 2004). The mean ODARA score was at the 80th percentile of risk for domestic violence, although only 13 had a previously documented partner assault. We conclude that co-operation among sectors responding to domestic violence and the shared use of validated risk assessment will increase the prediction and potential prevention of IPH.     

IMPROVING THE ENFORCEMENT OF RESTRAINING ORDERS AFTER CASTLE ROCK V. GONZALES*

After the U.S. Supreme Court's decision in Castle Rock, reliance on domestic violence restraining orders does not offer the solution in and of itself. Our legal system needs to provide greater protection for victims of domestic violence. This note explores ways to use risk assessment tools to augment restraining orders, in addition to examining integrated domestic violence courts that take a proactive approach to aiding victims of abuse.     

Early Exposure to Violence in the Family of Origin and Positive Attitudes towards Marital Violence: Chinese Immigrant Male Batterers vs. Controls

This study examined self-reported early exposure to violence in the family of origin and positive attitudes towards marital violence as risk factors in court-referred Chinese immigrant male batterers (N = 64) versus controls (N = 62). Early exposure to violence was positively correlated with marital violence, but it alone did not differentiate the batterers from the controls, as both groups were widely exposed to it. While it was significantly correlated with marital violence in the batterer group, it was significantly correlated with depression in the control group. Positive attitudes towards marital violence were not only correlated with marital violence but also sufficient to differentiate the batterers from the controls. It also partially mediated the effect of early exposure to violence on marital violence. These two risk factors together accounted for 21.9% of the variance in marital violence over and above sociodemographic variables and marital dissatisfaction. Research and treatment implications based on these findings were outlined.

Popping the cultural bubble of violence risk assessment tools

Violence risk instruments are administered in medico-legal contexts to estimate an individual’s likelihood of future violence. However, their ostensible limitations; in particular their mono-cultural and risk-centric composition, has drawn academic attention. These concerns may facilitate erroneous risk evaluations for certain non-white populations. Yet it remains unaddressed how cultural differences will be appraised in a risk assessment framework and which specific cultural factors should be considered. Provisions under the Canadian Criminal Code allow for Gladue Reports, to be sought by judicial officers prior to sentencing Indigenous people. Gladue Reports provide insights into an Indigenous person’s unique circumstances that may have led to their offending as well as community-based options for rehabilitation. We proffer that there may be value in augmenting the risk evaluation with culturally relevant Gladue style considerations identified by relevant Indigenous people to provide a more holistic account of an Indigenous individual’s circumstances.     

Barriers to safety* for victims of domestic homicide

ABSTRACT

Research on domestic homicide has focused on risk factors presented by perpetrators such as prior violence, threats to kill, stalking, access to weapons, mental health concerns, controlling behaviour and separation. However, there has been less focus on the barriers that victims face regarding finding support, increasing personal safety and decreasing violence and risk of homicide. The present study explored 20 potential barriers that female domestic homicide victims faced using 183 cases occurring between 2002 and 2012 from the Ontario (Canada) Domestic Violence Death Review Committee to examine the presence and frequency of these barriers within the sample. Using two-step cluster analysis, different profiles of barriers were identified that centred on victims’ fear, social isolation and mental health. The study is limited in being a post hoc analysis of homicides and no causal links can be made. The implications of this finding are discussed in the context of risk assessment, risk management and safety planning.     

Personality disorder and violence in the national household population of Britain

Background: Antisocial personality disorder (ASPD) is strongly associated with violence but the effects of other personality disorder (PD) categories are uncertain. Purpose: To investigate associations between 10 DSM-IV PD categories and effects of co-occurring disorders on self-reported violence. Method: Cross-sectional survey of 8397 adults aged 16–74 years in households in Great Britain. Results: ASPD contributed strongly to the burden of violence in the British population. Paranoid and obsessive–compulsive PD made additional independent contributions, and narcissistic PD contributed to intimate partner violence. The prevalence of violence correlated with the number of PD categories. Comorbid alcohol dependence further increased the risk. Conclusions: Risk of violence increases with increasing severity of PD, measured by the number of PD categories, and with co-occurring alcohol dependence. Not all PD categories are associated with violence, and avoidant PD was protective. Identification of targets for future interventions may be obscured using a classification based solely on severity.     

Intimate partner violence victimization and household financial strain

Most scholars agree that low socio-economic status is associated with an elevated risk for violent victimization as well as offending. Nevertheless, it has been suggested that certain forms of violence—particularly intimate partner violence (IPV)—are more equally distributed in the population, not concentrating on the lower social strata as strongly as other forms of violence. In this paper, we examine the association between financial strain, measured on the household level, and two different types of victimization: IPV and violence committed by a person unknown to the victim. The analysis is based on the 2013 sweep of Finnish National Crime Victim Survey (n = 6,999), a nationally representative survey incorporating a mix of postal and web-based survey methodology. Multivariate analyses indicate that the risk for both kinds of victimization is highest among those who report financial difficulties. Moreover, the association between IPV and financial strain appears stronger when less serious violent incidences are excluded from the analysis.     

Implementing violence and incident reporting measures on a forensic mental health unit

The assessment of risk and prediction of violence in mental health units can play a large role in creating a safer environment for both the staff and the patients. Nurses in forensic units are in a unique position in regards to assessment of violence as they spend a great deal of time with the patients. Nurses on a forensic mental health unit scored the Brøset Violence Checklist (BVC) twice daily for 12 weeks for all patients either resident on or admitted to the unit (N?=?46). The Staff Observation Aggression Scale-Revised (SOAS-R) was used to report any adverse incidents (N?=?51). Data were examined at the both the item and scale level. Main results showed the area under the curve values of the BVC score, slide rule, and the sum of BVC and slide rule score in turn demonstrated strong predictive accuracy for inpatient aggression (0.68–0.73). Through logistic regression analyses the BVC uniquely predicted inpatient aggression but adding the slide rule did not improve prediction. Predictive accuracy was found across three diagnostic groups – dementia, psychosis and substance use disorders. These results provide further support on the predictive accuracy of the BVC for short-term violence in forensic mental health settings.     

Understanding dynamic risk factors for violence

ABSTRACT

Recent years have seen a consensus emerge regarding the dynamic risk factors that are associated with future violence. These risk factors are now routinely assessed in structured violence risk assessment instruments. They provide a focus for treatment in structured group programmes. However, relatively little attention has been paid to risk-related theoretical issues, whether these dynamic risk factors are causally related or simply correlates of violent offending, or the extent to which they change as a consequence of treatment. More challenging is the lack of evidence to suggest that changes in these dynamic risk factors actually result in reductions in violent offending. In this paper we consider the meaning of the term dynamic risk, arguing that only those factors that, when changed, reduce the likelihood of violent recidivism, can be considered to be truly dynamic. We conclude that few of the violence risk factors commonly regarded as dynamic fulfil this requirement. There is a need to think more critically about assessment findings and treatment recommendations relating to dynamic risk, and conduct research that establishes, rather than assumes, that certain dynamic risk factors are directly related to violence. Some suggestions for advancing knowledge and practice are provided.     

The Homicide–Suicide Phenomenon: Findings of Psychological Autopsies

Homicide–suicide represents a single episode of violence which may decimate an entire family. This study aimed to further describe motives and context of these tragedies. Psychological autopsies were completed for 18 homicide–suicide cases in Dallas, Texas. This included postevent interviews with surviving family members and review of police and coroner records. Two‐thirds of perpetrators had made either verbal or written threats prior to the homicide–suicide. A simplified typology describing victim–perpetrator relationship and motive type is suggested for future studies and clinical ease. Two‐thirds of perpetrators fell into the category of Intimate‐Possessive, most of whom were depressed men who were abusing substances and undergoing separation. Additional categories included Intimate‐Ailing, Filial‐Revenge, Familial‐Psychotic, and Friend‐Psychotic. Further, implications from this psychological autopsy study regarding risk assessment include use of collateral interviews regarding threats and past violence.     

Psychopathy and predatory violence in homicide,violent, and sexual offences: Factor and facet relations

Purpose. Evidence has been found pointing to a relationship between psychopathy and predatory violence. The present study investigated the violence mode and its relationship with psychopathy on factor as well as on facet levels. It was hypothesized that predatory violence would be related to the affective and/or interpersonal facets of psychopathy. A subsidiary hypothesis was that sexual offences could also be differentiated by means of violence mode. Methods. Participants were 82 male inmates convicted of a violent crime, a sexual crime, or a homicide. Psychopathy was assessed with the Hare PCL‐R2 and the violence mode was assessed by means of Cornell's Aggressive Incident Coding Sheet, based on interviews with the offenders and a review of the official record. Results. On the psychopathy subcomponent level, only the interpersonal facet was positively related with predatory violence. This association makes sense considering that psychopaths' interactions with others are defined by gradients of power and control and narcissistic gratification, rather than by attachment patterns. By contrast, the antisocial facet was associated negatively with predatory violence. Our subsidiary hypothesis concerning the possibility of differentiating sexual violence on the basis of the two violence modes was not confirmed. Conclusions. The present results add to the growing evidence that predatory violence is related to the personality traits of psychopathy rather than to its life‐style and antisocial characteristics. Therefore, a risk analysis of future predatory violent behaviour might benefit from the inclusion of the assessment of the personality facets of psychopathy instead of focusing solely on the antisocial behaviour.     

Trait Anger,Physical Aggression,and Violent Offending in Antisocial and Borderline Personality Disorders

Antisocial personality disorder (ASPD) and borderline personality disorder (BPD) are common conditions in forensic settings that present high rates of violence. Personality traits related to the five‐factor model personality domains of neuroticism and agreeableness have shown a relationship with physical aggression in nonclinical and general psychiatric samples. The aim of the present investigation was to examine the association of these personality traits with violence and aggression in ASPD and BPD. Results revealed that trait anger/hostility predicted self‐reported physical aggression in 47 ASPD and BPD subjects (β = 0.5, p = 0.03) and number of violent convictions in a subsample of the ASPD participants (β = 0.2, p = 0.009). These preliminary results suggest that high anger and hostility are associated with physical aggression in BPD and ASPD. Application of validated, self‐report personality measures could provide useful and easily accessible information to supplement clinical risk assessment of violence in these conditions.