Risk assessment chpt 10
Forensic psychiatrist in Dallas -Used unstructured clinical judgment -Expelled from professional association in 1995 for claims of 100% accuracy in predicting violence
Dr. James Grigson Nicknamed "Dr. Death" (A.K.A. Dr. Doom or "the hanging shrink")
Experts on Risk Assessment
Hart, 2001: "We never know an individual's risk for violence; we merely estimate it assuming various conditions." Kraemer et al. (1997, p. 340): ''The process of using risk factors to estimate the likelihood (i.e., probability) of an outcome occurring in a population.'' Reid Meloy: "You will always know less than you think you do about the patients or clients you examine; and, there are abnormal human behaviors that mental health treatment cannot fix."
Andrews & Bonta, 1995 This is a 54-item rating scale used to assess the likelihood of general recidivism among adult offenders. It is designed to measure attributes of offenders and their situations in relation to level of supervision and treatment decisions. It has been validated for use with adult male and female correctional offenders.
LEVEL OF SERVICE INVENTORY - Revised (LSI-R)
Contextual Risk Factors
Lack of social support to help individual in his or her day-to-day life Easy access to weapons Easy access to victims
Civil Commitment Laws
Legal declaration of mental illness When can a person be placed in a hospital for treatment? Such laws and definitions of mental illness vary by state
STATIC-99 Issues
Like most actuarial risk assessment instruments, it is only +/- 70% accurate. -False positives - over-predicting risk -False negatives - under-predicting risk Over-reliance on unchanging static risk factors to the exclusion of changing dynamic risk factors is a significant problem in Vermont (and elsewhere).
________ consists of the development of strategies to manage or reduce this level of risk.
Management
Female Offenders and Risk
More similarities in risk factors for men and women than differences -Gender-specific risk factors History of self-injury Poor self-esteem -How well do risk assessment instruments developed with male offenders work with female offenders? LSI-R has predictive validity
Person-Situation Paradigm.. what does it look like
Not just WHO is likely to ____, but When Where How and...............Under what circumstances?
Historical Risk Factors
Past antisocial behavior Age of onset of antisocial behavior Childhood history of maltreatment Past supervision failure, escape, or institution maladjustment
The ________ is a brief actuarial instrument designed to estimate the probability of sexual and violent recidivism among adult males who have already been convicted of at least one sexual offense against a child or non-consenting adult. It is not recommended for adolescents less than 18 years of age, female offenders or offenders who have only been convicted of prostitution, pimping, public toileting, or possession of indecent materials.
STATIC-99
Decisions guided by predetermined list of risk factors derived from research literature Judgment of risk level is based on professional judgement Diverse group of professionals
Structured Professional Judgment
Clinical Risk Factors
Substance use Mental disorder Diagnosis of schizophrenia or affective disorders "Threat/control override" (TCO) symptoms
details about. STATIC-99 (Sex Offense Specific Measure)
Ten item scale Total score 0-12 0,1 Low 2,3 Moderate-Low 4,5 Moderate-High 6+ High
Structured Professional Judgment
The HCR-20 (Now in V3) is widely considered the best Structured Professional Judgment Risk Assessment Instrument HCR stands for Historical, Clinical, Risk Mgmt Violence Risk Assessment - Vers. 3
Developed on a sample of over 600 men from a maximum security hospital in Canada (Penetanguishene). An actuarial instrument to assess risk of violence among violent offenders who were released from prison. Violent recidivism was defined as "any new charge for a violent offense or returned to the correctional setting." The VRAG is composed of 12 variables.
Violence Risk Appraisal Guide (VRAG)
Actuarial Instruments
Violence Risk Appraisal Guide (VRAG; Harris et al., 1993) Static-99 (Hanson & Thornton, 1999)
STATIC-99
Widely used in criminal, forensic and correctional settings. Instrumental in most sexually violent predator (SVP) determinations. Not as easy to score as it seems. Many scoring rules to understand.
Gender differences in criminality
Women engage in less crime Women reoffend at lower rates Childhood victimization more prevalent Mental disorders more prevalent
HCR-20 (AKA HCR V3)
a Structured Professional Judgment Instruments The HCR-20 (now HCR V3) was developed by Chris Webster and others at Simon Fraser University in British Columbia. The format is similar to the PCL-R. It is a 20-item checklist, with each item scored 0, 1 or 2. Violence in the instrument is defined as "actual, attempted or threatened harm to a person or persons
a base rate is a technical terms with three basic components:
a behavior, a group of people, and a time frame.
______ : process of ceasing to engage in criminal behavior
desistance
______ risk factors: Subject to change by intervention, treatment, or environmental control
dynamic
example of outcomes in making predictions: Mr. Smith is in your hospital and the treatment team believes that he is going to be violent and does not recommend discharge. Mr. Smith stays 5 years at the hospital and never had violent behaviors.
fale positive
example of outcomes in making predictions: Mr. Jones is in your hospital and the treatment team recommends discharge because he is not a danger. Mr. Jones goes home, retrieves his AK-47 and proceeds to kill 10 people at McDonalds restaurant.
false negative
Structured Clinical Guides
invite clinicians to consider a number of variables which will have some application to the assessment of risk in the case under consideration. This type of assessment is based on the idea that a great deal has been learned over the past two decades about the factors which should be taken in account when conducting risk assessments on various types of mental health, forensic, and correctional populations. The various structured guides (see below) define terms, provide items which seem merited on the basic of scientific and professional grounds, and suggest methods of scoring.
______________ consists of the development of strategies to manage or reduce this level of risk.
management
_______ involves an analysis of the likelihood of future criminal or violent act
prediction
An assessment of risk includes two components:
prediction and management.
Level of Service Inventory - Revised
-Criminal History -Education/Employment -Financial -Family/Marital -Accommodation (the influence of address) -Leisure/Recreation (spare time use) -Companions (friends and associates) -Alcohol/Drugs (mostly looking at past year) -Emotional/Personal (psychological status) -Attitudes/Orientation (antisocial/prosocial views)
HCR 20 Risk management (future)
-Exposure to destabilizers -Lack of personal support -Noncompliance with remediation attempts -Plans lack feasibility -Stress
Risk Categories:
-General violence -Workplace violence -Spousal violence -Sexual risk -Terrorism -School violence
HCR 20 clinical present
-Lack of insight -Negative attitudes -Active symptoms of major mental illness -Impulsivity -Unresponsive to treatment
HCR- 20 historical past
-Young age at first violence -Relationship instability -Employment problems -Previous violence -Substance abuse problems -Major mental disorder -Psychopathy -Early maladjustment (home and school) -Personality disorder -Prior supervision failure
Factors relating to desistance:
-age -employment -marital relationships
static risk factors contributions
-age -gender -criminal history -childhood abuse -history of substance abuse
Baxstrom and Dixon studies highlighted:
-base rate for violence low -false positive rate high
dynamic risk factors contributions
-persons living conditions -current substance use -active symptoms -access to weapons -impulsivity
VRAG
.1.Did not live with both biological parents until age 16. 2.Elementary school maladjustment. 3.History of alcohol problems. 4.Never married. 5.Criminal history for nonviolent offenses. 6.Failure on prior conditional release. 7.Age at index offense <26. 8. Victim injury none or slight. 9. No female victim. 10. Any personality disorder (DSM III). 11. No schizophrenia diagnosis (DSM III). 12. PCL-R score >25.
Risk Principle
1. Reserve intensive levels of corrections supervision and treatment for higher risk cases. 2. Do not use these levels of supervision and treatment for lower risk cases. 3. Use of valid and reliable risk assessment tools gives the criminal justice system a triage capability.
Need Principle
1. There are many needs and potential treatment targets identified in corrections populations. 2.Some are related to criminal risk; some are not. 3.Focus on those needs which are "criminogenic" (ie. causally related to crime) such as social affiliations, drugs and criminal attitudes. 4.When criminogenic needs are addressed, the risk of recidivism declines.
3 Major Types of Risk Assessment*
1. Unstructured Clinical Judgement -Subjective -Poor reliability and accuracy 2. Actuarial -Mathematically derived estimates of probability excellent reliability and accuracy but Static not dynamic -Prediction, not management 3. Structured Professional Judgment -Clinical judgment structured by review of scientifically derived risk factors -Good reliability, and as good or better than actuarial
Responsivity Principle
1.When providing treatment services for forensic or corrections populations, use methods which are matched to the learning style of the population. 2.Cognitive-behavioral, skill-building, and relapse preventing interventions fit this model. 3.Non-directive, non-specific "talk therapy" methods do not. 4.The use of appropriate intervention models lowers risk; other models have either no effect on recidivism or they may actually raise it
Four types of outcomes in making predictions:
A true positive is a correct prediction of a person predicted to be violent and who does engage in violence. A true negative is a correct prediction of a person predicted not to be violent and who does not act violently. A false positive is an incorrect prediction of a person predicted to be violent but is not. A false negative is an incorrect prediction of a person predicted to be non-violent but acts violently.
Dispositional Risk Factors
Demographics -Age -Gender Personality characteristics -Impulsivity -Psychopathy
Violence Risk Appraisal Guide (VRAG)
scoring for the VRAG items in the book by Marne Rice and colleagues, Violent Offender: Appraising and Managing Risk.** the tool uses the clinical record, particularly the psycho-social history component, as a basis for scoring as opposed to interview or questionnaires. The Hare PCL-R (Psychopathy Checklist -Revised) score is incorporated into the VRAG calculations of risk. The score places the individual in one of nine equal sized categories where the probability of violent recidivism is then determined for a 7 or 10 year period. Probabilities range from 0-100%.
_____ risk factors: historical and unchangeable (or change very slowly)
static
Most actuarial risk instruments include only _________
static risk factors
Decisions characterized by professional discretion and lack of guidelines Subjective No specific risk factors No rules about how risk decisions should be made
unstructured clinical judgement
History of Risk Assessment in the 1960's
Baxstrom v. Herald (1966) Dixon v. Attorney General of the Commonwealth of Pennsylvania (1971)
Dangerousness to Self or Others
Central to commitment proceedings Assessing dangerousness The role of mental health professionals Grave disability - Inability to care for self
ex of base rate
Example—My prediction is that everyone listening to this presentation at this moment will sleep within the next 24 hours: a base rate of 100%. (Actually some will sleep within the next few minutes.)
-Analysis first used by insurance companies to calculate financial risk -Measures developed through analysis of outcomes that are associated with "predictor variables" Variables weighted according to their ability to differentiate between groups Weighted variables combined to form a scale Scale cross-validated on different populations to derive estimates of probability that specific outcome will occur in a particular time Production of "life tables"
actuarial prediction
