ASSESSING RISK OF HARM: ETHICAL AND PRACTICE ISSUES UPDATE

1. ASSESSING RISK OF HARM:ETHICAL AND PRACTICE ISSUESUPDATE PPA CE AND ETHICS CONFERENCE Harrisburg, PA March 31, 2011

2. Bruce E. Mapes, Ph.D.PO Box 1028Exton, PA 19341 610-696-8740 maroje@hotmail.com

3. The frustrated judge asked … • “How can two competent and respected PhD psychologists review the same data and reach two diametrically opposed opinions?” • “For every PhD there is an equal and opposite PhD”

4. PREDICTION V. ASSESSMENT • Person will or will not do something • Probability statements • Nomethetic data • Individually based

5. WHAT IS RISK? • Hazard forecasted with uncertainty. • Ideas of nature, severity, frequency, imminence, and likelihood • Context specific • Only estimated

6. RISK ASSESSMENT? • Process of gathering information to assist decision-making. • It is not simply a diagnosis or prognosis. • It is not predetermined test items or risk factors. • It is an individualized process to assist in decision-making.

7. GOALS? • To contain and reduce risk. • To guide interventions. • To improve consistency of decisions. • To improve the transparency of decisions. • To protect the rights of the individual, the community, and potential victims.

8. POPULATIONS STUDIED • Outpatient settings • Inpatient settings • Minimum security prisons • Moderate security settings • Maximum security settings • Supermax Settings • Forensicsettings

9. CRITERION VARIABLE • Re-hospitalization (violence v. nonviolence) • Re-arrest (violence v. non-violence) • Re-conviction (violence v. nonviolence)

10. RESEARCH ISSUES • Low base rates • Correlations • Retrospective v. Prospective studies • Changing base rates (decrease in violent crime) • What do low and high risk mean? • Imminent v. longer-term risk • Sample sizes • First offense v. recidivism • Self - Report

11. VIOLENCE HETEROGENEITY • Risk level varies as a function of instrument used • Sexual Deviancy v. Chronic Antisociality • Wingspread Conference • Situational Couples Violence • Separation Instigated Violence • Coercive – Controlling Violence

12. MHP - HISTORY • Prior violence and criminality more strongly associated with post-discharge violent behavior among all psychiatric patients, regardless of the diagnosis (Monahan, et.al., 1996, 2001, 2003)

13. MHP – CHILDHOOD ABUSE • Physical abuse as a child and as an adolescent presented higher risk of post-discharge violence than did childhood limited abuse. • No significant relationship between sexual abuse as child and violence.

14. MHP - DIAGNOSIS • Patients with co-occurring personality disorders and adjustment disorders were higher risk than those with just major mental illness. • The presence of significant character pathology with antisociality was the most critical factor

15. MHP – CHARACTER PATHOLOGY • Limited traits of psychopathy and / or antisocial behavior more predictive of future violence for all patients. • On Hare PCL-R, antisocial factor was more predictive of violence than was the emotional detachment factor. • Presence of Childhood Conduct Disorder and Schizophrenia 2X more likely to commit a violent offense than Schizophrenics without history of Conduct Disorder

16. HORMONES • Testosterone levels may not be related to violence, but may influence whether violence is directly or indirectly expressed. (Streuber, 2007). • Competitive attitudes

17. NEUROLOGICAL FACTORS • Is frontal lobe related to violence or getting caught? (Adrian Raine, et al, 2004) • Role of technology (Small and Vorgan, 2008) • Complex interaction between brain functioning and environment.

18. NEUROCRIMINOLOGY • Amygdala - 18% volume reduction • Middle Frontal Gyrus – 18% volume reduction • Orbital Frontal Gyrus – 9% volume reduction • Lack of fear conditioning in 3 year olds

19. PSYCHOLOGICAL FACTORS - HANSON • General family problems • Degree of physical contact • Presence or absence of empathy / remorse • Social Skill level • Sexual or physical abuse as child • General psychological problems • Substance abuse

20. Psych factors - continued • Denial • Cognitive Distortions • Low self-esteem • Psychological test results (Hanson et. al.)

21. ATTACHMENT • “It may become an empirically grounded truism years from now that attachment pathology is a centrally necessary but insufficient component to explain violence.” (Meloy, 2003)

22. D&A – SEX OFFENDERS • “Substance abuse does not often, if ever – at least by itself – predispose a person to commit sexually violent acts.” • “Although alcohol for example may increase one’s desire for sex, there is no known ‘pathological intoxication’ that causes sexual fantasies or urges of an illegal nature.” (Doren, 2002, pp. 101-102)

23. D&A – NONSEXUAL VIOLENCE • Substance abuse in and of itself does not have a strong relation to violence. Chronic substance use exposes the individual to antisocial peers, attitudes, and environments. It is this complex interaction which is important. (Andrews and Bonta, 2010, pp. 293 – 294)

24. PROFILES? • There was no accurate or useful profile. • Rarely sudden, impulsive act. • Others often knew of plans / idea • Rarely was plan directly communicated to victim • Most displayed some type of behavior of concern prior to the attack • Most had difficulty coping with significant losses or personal failures.

25. Profiles • Many attackers had previously considered or attempted suicide. • Many attackers felt bullied, persecuted, or injured by others prior to the attack. • Most had access to and had used weapons prior to the attack. (Safe School Initiative, 2002)

26. COMPUTERS • Chatrooms • Education on any type of violence • Many “sick people” willing to help • May normalize violent behavior • Increasing role in violent behavior

27. INTERNET PORNOGRAPHY • Loss of satisfaction with current partner • Normalize very deviant acts • Chatrooms normalizing Pedophilia • File sharing • Accidently downloading is rare

28. CHILD PORNOGRAPHY • If the interest in child pornography meets the DSM-IV TR criteria for the diagnosis of Pedo-philia, it is appropriate to give this diagnosis. (Seto, et. al., 2010) • 59% + who are Pedophiles based on child pornography have had a contact offense.

29. A COMPLEX ALGEBRA • Sexual and nonsexual violent behavior involve the complex, cumulative interaction of bio-chemical, genetic, structural brain, psychological, and environmental factors across the lifespan.

30. ANTISOCIAL DECISION-MAKING • Rarely a random act – one decides to engage in antisocial behavior. • Considers the potential for success. • Considers potential to overcome internal inhibitions. • Considers potential to overcome external obstacles.

31. DECISION-MAKING EVOLVES • Our own experiences and those of others. • Decision-making process reflects adaptations to changing circumstances as different behavioral options are considered.

32. THREE COMPONENTS • To formulate and use equations. • The ability to learn from experience. • The ability to see different options.

33. DECISION-MAKING PATTERNS • Normal • Avoider • Limit Testers • Opportunist • Antisocial Generalist

34. RISK FACTORS • Static – historical factors (don’t change) • Dynamic – can be modified but are stable for weeks, months, years (e.g., association with violent individuals). • Acute – immediate situations (e.g., associates) or immediate emotional state such as anger, resentment, revenge.

35. CENTRAL EIGHT RISK-NEED FACTORS • Chronic history of antisocial behavior • Conduct Disorder / Antisocial Personality Pattern • Antisocial Cognitions (attitudes, justification) • Antisocial Associates

36. Central Eight • Family / Marital Relationship quality • School / Work: quality of relationships and performance • Leisure / Recreation: level of involvement and satisfaction in prosocial activities • Substance Abuse (especially environmental factors such as associates) (Andrews and Bonta, 2010)

37. ASSESSING RISK • What precipitated referral? • What is the intent or goal? • Does the person have a plan? • Does the person have the means? • Does the person have the opportunity?

38. DESIRED INFORMATION BASE • History of violent and nonviolent antisocial behavior • Internal factors • External Factors

39. WHAT PRECIPITATED REFRRAL? • Verbal or written comment? • Some type of action by the subject? • What was the situation?

40. INTENT? • What does person gain? • Let off steam? • Attention? • Harass? • Expression of anger? • Hostility or Instrumental Aggression? • Revenge?

41. PLAN? • Does the person have a plan? • How detailed is the plan? • How long has it been developing? • What resources have aided the development? • How realistic is the plan? • What is the pool of potential victims?

42. MEANS • Does the person have the means to carry out the plan? • How quickly can the person access the means? • How serious might the violence be (level of lethality?) • Has the person practiced?

43. OPPORTUNITY? • Availability of victim(s)? • Likelihood of situation presenting itself? • Ability to make situation occur? • Likelihood of detection?