Dynamic Risk Factors Underlying Violence

1. Dynamic Risk Factors Underlying Violence Responses to Treatment and Managing Violence

2. Risk

3. Risk is Uncertain A risk is a hazard or threat that is incompletely understood and therefore that can be forecast only with uncertainty

4. Risk is Complex Risk incorporates notions of the nature, severity, frequency, imminence, and likelihood of harm � not just probability

5. Risk is Inferential Risk does not exist physically, but rather reflects the perception of a potential or possible future

6. Risk is Contextual Risk exists in and is dependent on a specific situation or social-physical environment

7. Risk is Dynamic Risk changes over time Hazards change Situations change Information changes Inferences change

8. Assessing Risk for Violence

9. Assessment Gathering information to assist in decision making Not simply providing a diagnosis or prognosis Not simply considering a set of test items or risk factors determined before the evaluation Individualized inquiry

10. Actual, attempted, or threatened physical harm of another person that is deliberate and nonconsenting Includes fear-inducing behavior Includes intentional and reckless acts Includes violence against victims who cannot give full, informed consent Violence

11. Violence Risk Assessment Evaluations of people to Characterize the risk that they will commit sexual violence in the future Develop interventions to manage or reduce their violence risk

12. Goals Prevent violenceMore specifically... Understand risks posed Identify relevant risk factors Guide threat management Improve consistency of decisions Improve transparency of decisions

13. Defining Risk Factors

14. Different Definitions Consequence Correlate Predictor (marker) Static Dynamic Cause

15. Dynamic Risk Factors Two aspects of causal risk factors are dynamic Presence Relevance

16. The proximal cause of violence is a decision to act violently People decide to commit violence of specific types, at specific times, against specific victims People can � and usually do � decidenot to commit violence Causes of Violence

17. Nature of Decisions Decisions involve at least some degree of cognitive processing Violence is an option in the situation Rewards of violence may outweigh its costs Means of overcoming internal inhibitions Means of overcoming external inhibitions Means of overcoming victim resistance

18. Influences on Decisions The decision is influenced by a host of biological, psychological, and social factors Neurological insult, hormonal abnormality Psychosis, personality disorder Violent models, attitudes that condone violence Three types of influence Motivate Disinhibit Destabilize

19. Implications Risk factors for violence are things that influence decisions about violence Violence risk assessment is Understanding how and why people decided to commit violence in the past Determining the conditions under which they might make similar decisions again Violence risk management is Encouraging decisions to act non-violently

20. Identifying Risk Factors

21. Determining Relevance Three primary criteria Scientific � predictive accuracy Professional � theoretical importance and practical utility Legal � reasonableness

22. Problems With Scientific Criterion Prediction ? cause, explanation, or intervention Can lead to inclusion of �bad� but common or easy-to-assess factors Not everything that is important has been proven or validated scientifically Can lead to exclusion of �good� but rare or difficult-to-assess risk factors

23. Age Young is bad Sex Male is bad Facial hair Dense is bad Foot size Big is bad Example: The SIEVE

24. Focus on highly dynamic factors may bias risk assessments Can lead to exclusion of �good� but more stable and easy-to-ignore factors Conventional wisdom based on theory or practice may be plain wrong Can lead to inclusion of �bad� but vivid or dramatic factors Problems With Professional Criterion

25. Depression Present is good Anxiety Present is good Intelligence High is good Rorschach Seeing viscera is bad Example: Clinical Intuition

26. Problems With Legal Criterion Reasonableness is not a simple concept Requires careful balancing of probative and prejudicial impact of information in a given context

27. Combining Risk Factors

28. Two Approaches Discretionary versus Non-discretionary

29. Discretionary Approach Based on prevention paradigm Goal is to plan strategies to prevent a person from committing violence Information is gathered, weighted, and combined using the evaluator�s judgement Imposes no or limited structure on the evaluation or decision-making processes AKA judgemental, informal, intuitive, impressionistic

30. Discretionary: Limitations Foundation of judgement may be unclear Relies on charismatic authority Judgement may be imprecise May over-focus on dynamic aspects of risk Limited empirical support Agreement (reliability) Accuracy (validity)

31. Non-Discretionary Approach Based on prediction paradigm Goal is to estimate the probability that a person will commit violence Information is gathered, weighted, and combined using fixed and explicit rules Imposes rigid structure on the evaluation and decision-making processes AKA actuarial, algorithmic, mechanical, formalistic, statistical

32. Static-99 Hanson & Thornton (2000) Constructed in adult male correctional offenders and forensic patients from 4 sites in Canada and the UK 10 items weighted according to ability to �postdict� violence over 5-15 years Combination of the RRASOR (Hanson, 1997) and the SAC-J (Grubin, 1998) Total scores divided into 4 categories

33. Static-99 Items Prior sex offences Prior sentencing dates Non-contact sex offences Index non-sexual violence Prior non-sexual violence Any unrelated victims Any stranger victims Any male victims Young Single

34. Score Risk Category 0, 1 low risk category 2, 3 medium-low risk category 4, 5 medium-high risk category 6+ high risk category Risk Categories

35. Quinsey et al. (1998) Constructed in adult male patients assessed or treated at a maximum security hospital 12 items selected and weighted according to ability to �postdict� violence over 7-10 years Total scores divided into 9 bins, with estimated p(violence) from 0% to 100% VRAG

36. PCL-R score Elem. school problems Personality disorder Age (�) Separated from parents under age 16 Failure on prior conditional release Nonviolent offense history Never married Schizophrenia (�) Victim injury (�) Alcohol abuse Female victim (�) VRAG Items

37. Non-Discretionary: Limitations Not comprehensive Ignores individual circumstances Doesn�t obviate need for a �real� assessment Focuses on static factors Optimization reduces generalizability May not work well with different target groups, settings, or outcomes Use still requires professional judgment Which scales to use, how to interpret scores

38. Limitations (cont.) Empirical support is over-stated �Superiority� with respect to violence threat assessment has yet to be demonstrated Doesn�t address key legal issues Doesn�t assist users in determining the presence of and causal role played by mental abnormality Liability issues

39. Paul Bernardo is a Canadian serial murderer (3 sexual homicides) and serial rapist (75 known rapes) Currently serving life imprisonment for murder and an indeterminate sentence for the rapes Static-99 and VRAG completed on the basis of case history data Limitations: An Illustration

40. Bernardo�s Static-99 Prior sex offences 0 Prior sentencing dates 0 Non-contact sex offences 0 Index non-sexual violence 1 Prior non-sexual violence 0 Any unrelated victims 1 Any stranger victims 1 Any male victims 0 Young 0 Single 0

41. PCL-R score +4 ES problems -1 Personality disorder +3 Age 0 Separated from parents -2 Failure on prior CR 0 Nonviolent offenses -2 Marital status -2 Schizophrenia +1 Victim injury -2 Alcohol abuse +1 Female victim -1 Bernardo�s VRAG Results

42. Combining Risk Factors:The SPJ Approach

43. Challenge for Risk Assessment How do we combine the strengths of the discretionary and non-discretionary approaches? We need procedures that are: Guided by science, but also reflect professional and legal considerations Structured, but also flexible and responsive to the uniqueness of each case

44. Structured Professional Judgement Based on prevention paradigm Information is gathered, weighted, and combined using the evaluator�s judgement assisted by guidelines Aides m�moires, practice parameters Imposes no or limited structure on the evaluation or decision-making processes AKA empirically guided, empirically supported, evidence based judgement

45. SPJ: Uses Structure � not replace � professional evaluations of violence risk across a broad range of populations and settings Monitor or re-evaluate risk factors Guide case management strategies

46. SPJ: General Procedures Use manuals and worksheets to assist evaluation and documentation 5 steps: Gather information Identify risk factors Develop scenarios Plan management strategies Document judgements

47. 1. Gather Information Based on reason for assessment, gather all information that is reasonably necessary Focus on violence history and risk factors Corroborate across methods, sources Consider multiple domains Consider dynamic nature Evaluate adequacy of information Qualify opinions in light of critical missing information

48. 2. Identify Risk Factors Focus on standard factors as �areas of inquiry� Plus case-specific factors Synopsize relevant information Consider presence Including changes over time Consider relevance Including causal roles Think, �Why?�

49. Identify Risk Factors (cont.) Causal roles Motivators increase the perceived benefits or rewards of violence Disinhibitors decrease the perceived costs or punishments of violence Destabilizers generally impair the person�s decision making abilities or psychosocial adjustment

50. 3. Develop Scenarios Speculate about the kinds of violence the person might commit Primary hazards or concerns Describe plausible scenarios Consider severity, imminence, frequency/duration, likelihood, and factors likely to increase or decrease risk

51. 4. Plan Management Strategies Speculate about case management strategies for each scenario Monitoring Supervision Treatment or rehabilitation Victim safety planning

52. 5. Documentation Document judgments Case prioritization Risk for serious physical harm Need for immediate action Other risks indicated Case review Date for regularly scheduled review Triggers for immediate review

53. Documentation (cont.) Degree of effort and intervention required to prevent violence Low: Routine or usual; manage with low priority and intensity Moderate: Elevated or a concern; manage with some urgency and intensity High: Urgent or an emergency; manage with high priority and intensity

54. Advantages of SPJ Risk Assessment Comprehensive evaluation Reflects science, professional knowledge, and law Structured yet flexible Individualized Good fit for legal decision making Reasoned and reasonable Transparent Good fit for case management Potentially sensitive to change

55. Advantages (cont.) Good fit for quality assurance Possible to automate parts of the assessment Good fit for liability management

56. Limitations Judgements require expertise and training Better suited for experienced evaluators Use requires resources No such thing as �quick� risk assessment

57. SPJ Guidelines General violence HCR-20, SAVRY Sexual violence SVR-20, RSVP, ERASOR Spousal violence SARA, B-SAFER Child abuse CARE Stalking SAM

58. Risk Management:Preventing Violence

59. Paradox Expanding our theories of violence complicates assessment but introduces opportunities for management

60. A Conceptual Model Threat management comprises four distinct activities Monitoring Treatment Supervision Victim safety planning

61. Monitoring Monitoring is surveillance or repeated assessment Goal is to evaluate changes in risk over time so that management strategies can be revised as appropriate May be delivered by a range of mental health, social service, law enforcement, corrections, and security professionals

62. Procedures Contacts (face-to-face or telephonic) Client, victims, and other relevant people Field visits (home or work) Inspection of mail or telecommunications Electronic surveillance Physiological evaluation Polygraphic interviews; urine, blood, or hair analysis

63. Strategies Plans should specify the kind and frequency of contacts required Weekly face-to-face visits, daily phone contacts, monthly assessments� Plans should specify any �triggers� or �red flags� that might warn the individual�s risk of violence is imminent or escalating

64. Treatment Provision of (re-) habilitative services Goal is to improve deficits in the individual�s psychosocial adjustment Typically delivered by health care and social service professionals Inpatient or outpatient clinics, agencies

65. Procedures Treatments for mental disorder Individual, group, or family psychotherapy Psychoactive medications (e.g., anti-androgens) Attitude change Psychoeducational programs Social skills training programs Interpersonal, anger, vocational programs Stress reduction Legal, crisis, employment, relationship counseling

66. Strategies Should be multi-modal, where possible Should target deficits that are causally related to the individual�s violence behavior �Criminogenic needs� Treatment may be made a legal requirement

67. Supervision Restriction of rights or freedoms Goal is to make it (more) difficult for the individual to engage in further violence Typically delivered by law enforcement, corrections, legal, and security professionals In institutions or the community

68. Procedures Incapacitation Community supervision with restrictions Activity Movement Association Communication

69. Strategies Should target risk factors that are causally related to the individual�s violent behavior Risks or needs Should be implemented at a level of intensity commensurate with the degree of risk posed by the individual Least restrictive alternative

70. Victim Safety Planning Improving the victim�s dynamic and static security resources �Target hardening� Goal is to minimize the impact of any future violence on the victims� psychological and physical well being May be delivered by a range of social service, human resource, law enforcement, and private security professionals

71. Procedures Dynamic security Provide useful information concerning risk to victim and social supports Counseling with victims to increase awareness and vigilance Treatment to address psychosocial deficits in adjustment that interfere with self-protection Training in self-protection Protocols for handling unwanted communications, classes in physical self-defense

72. Procedures (cont.) Static security Improve visibility by adding lights, altering gardens or landscapes, and installing video cameras Restrict access by adding or improving door locks and security checkpoints Install alarms, or provide victims with personal alarms Relocate victim�s residence or workplace

73. Strategies Good victim liaison is paramount Focus on victim vulnerabilities causally related to violent behavior This is not victim-blaming Most relevant for �targeted violence� Identity of likely victims of future violence is known

74. Principles for Effective Management 1. Develop an assessment-based plan for managing risk Each element should be tied to one or more important risk factors Each important risk factor should be tied to one or more management strategies Plan should be explicit and distributed widely Plan should have target dates for review and revision

75. Effective Management (cont.) 2. Establish a multi-disciplinary team for managing risk Composition of the team should depend on the perpetrator and the risks he poses Responsibilities of team members should be made explicit Team should include victim or liaison

76. Effective Management (cont.) 3. Deliver comprehensive and integrated services All agencies should have clearly defined roles and responsibilities Including guidelines for proper documentation, communication, and coordination Policy and procedure manuals should be developed For each agency, or inter-agency

77. Conclusions

78. Conclusions Risk and risk factors are inherently dynamic Don�t try to predict violent behavior; instead try to understand (and influence!) causes of violence, including motivations and intentions Good risk assessment is essential for good risk management To identify priority problems, appropriate interventions, and optimal mode of delivery

79. Conclusions (cont.) Don�t use simple tools on their own to make complex judgments; instead, use them as decision aids in case formulation Use scenario planning to make case management plans more prescriptive Failing to plan is planning to fail

80. Contact Information Proactive ReSolutions Inc. #142-1020 Mainland Street Vancouver, BC Canada V6B 2T4 +1 (877) 595-9933 shart@proactive-resolutions.com www.proactive-resolutions.com