Mental Illness and Assessing the Risk of Violence

1. Mental Illness and Assessing the Risk of Violence Breaking New Barriers NJAMHA Conference, Princeton May 7, 2003 Dr. Grant Harris gharris@mhcp.on.ca www.mhcp-research.com

2. Mental Illness and Assessing the Risk of Violence History Clinical Assessment Empirical Research Actuarial Devices Dynamic and Static Characteristics System Performance Implications

3. Mental Illness and Assessing the Risk of Violence Mental illness and violence Serious mental illness and violence Poverty of clinicians� evaluations �Violence cannot be predicted�

4. Big (relatively) objective risk assessment, psychopathy, violent history, juvenile delinquency, separation from parents, childhood aggression, antisocial peers, conduct disorder, alcohol abuse Medium nonviolent criminal history, adult criminal history, substance abuse, marital status, antisocial personality, psychotic diagnosis* and some symptoms*, age* Small clinical opinion, self esteem, offense seriousness*, IQ*, some psychotic symptoms* Not: psychological distress, remorse, mood disorder Mental Illness and Assessing the Risk of Violence

5. Development of the VRAG: 618 MDOs, Variables, Predictor Selection, Definition of Violent Recidivism, Multivariate Methods, Subgroups, Weighting System� How Well Does it Work? Correlation w Speed, Severity of Violence Actuarial Risk Assessment:The Violence Risk Appraisal Guide

6. The Violence Risk Appraisal Guide (VRAG) Psychopathy Checklist Score Elementary school maladjustment Age at index offense* DSM III personality disorder Separation from parents before age 16 Failure on prior conditional release History of nonviolent offenses

7. The Violence Risk Appraisal Guide (VRAG) Never married DSM III schizophrenia* Victim injury in index offense* History of alcohol abuse Male victim in index offense

8. Performance of the VRAG

10. Replications of VRAG/SORAG (n=30)

11. Mental Illness and Assessing the Risk of Violence Violence Risk Appraisal Guide: Number of violent offenses, speed of violent recidivism, severity of violent recidivism Severe violence, Short term prediction Not improved by clinical opinion BUT... VRAG is designed for �who� not designed for �when�

12. Mental Illness and Assessing the Risk of Violence Prospects for dynamic predictors about �when� Difference/change scores inherent Complaints, hostility, unrealistic plans, takes no responsibility

13. Mental Illness and Assessing the Risk of Violence An objective measure of risk to the public An opportunity to inform assessment, treatment and service planning Evaluation of system performance

14. Social withdrawal Poor use of leisure time Inactivity Insolence Anger Noncompliance Poor self care Conversational skill deficit Nonparticipation in programs Impulsivity The Ontario Forensic SurveyOak Ridge 1998 -- Common Problems:

17. Risk-related Performance

18. Community Access and Supervision Forensic Clinicians Services and Risk: r = .17, p < .05 Precautions and Risk: r = .13, p < .05 Review Board Conditions and Risk: r = -.13, p < .05 What Happens Conditions and Risk: r = -.07, ns

19. Actuarial Risk Assessment and Forensic Clinical Practice Assessment -- risk related problems Treatment -- risk related problems Decision Making -- Formula for Forensic Disposition: Resources, Offense Severity, Time since Index, Recent Behavior, Long Term Behavior, VRAG Score -> Recommended Placement

20. Oak Ridge - Clinical Problems 1. Assessment Opportunities Criteria: Gaps are big and local; Risk Sexual knowledge, Community Resources, Reading, Work skills, General knowledge, Unrealistic discharge plans, No remorse, Same delusion as index... Criminal attitudes, Criminal associates, Sexual misbehaviors, Substance abuse, Threats of harm to specific person

21. Oak Ridge - Clinical Problems 2. Treatment Opportunities Criteria: Problems common & severe; Risk Social withdrawal, Poor use leisure, Unusual thoughts, Inactivity, Suspicion, Conceptual disorganization, Conversational skills, Poor self care, Hallucinations, Lacks friends, Psychotic actions Anger, Insolence, Denies all problems, Impulsivity, Noncompliance, Insulting & teasing, Refuses therapy, Threatening, Inconsiderate, Complains about staff, Assaults

22. Oak Ridge - Clinical Problems 3. Service Opportunities? Disciplines Participation a crucial clinical problem Unit Specialization Programs for Risk-related problems

23. What Influences Ontario Review Board Decisions?(Hilton & Simmons, 2001) Percentage of MDOs Recommended Since most of the variables in the model of clinician recommendations were unrelated or inversely related to risk, You won�t be surprised to see this graph It shows, clinician�s recommendations are unrelated to risk of violence. The chance of being recommended for transfer by the senior clinician is the same regardless of the patient�s level of risk. Any emphasis on dangerousness or public safety is absent from these recommendations. I�m not saying that clinicians don�t think about risk, or they don�t look at the VRAG, But after all the information they try to juggle, they come up with a recommendation that does not reflect the risk of violent recidivism So, if the board needs to hear evidence from clinicians to address some of its considerations, It should still look at evidence that is related to risk of violence if their decisions are to reflect dangerousness or public safety. The clinicians are not speaking to that issue. Since most of the variables in the model of clinician recommendations were unrelated or inversely related to risk, You won�t be surprised to see this graph It shows, clinician�s recommendations are unrelated to risk of violence. The chance of being recommended for transfer by the senior clinician is the same regardless of the patient�s level of risk. Any emphasis on dangerousness or public safety is absent from these recommendations. I�m not saying that clinicians don�t think about risk, or they don�t look at the VRAG, But after all the information they try to juggle, they come up with a recommendation that does not reflect the risk of violent recidivism So, if the board needs to hear evidence from clinicians to address some of its considerations, It should still look at evidence that is related to risk of violence if their decisions are to reflect dangerousness or public safety. The clinicians are not speaking to that issue.

24. Mental Illness and Assessing the Risk of Violence MacArthur Violence Risk Assessment Study 3 sites, emergency units, 58% voluntary, 59% male, diagnoses, ethnic groups CTS self report and other sources, 5 follow-up assessments

25. Mental Illness and Assessing the Risk of Violence Modified VRAG: 10 items 20 weeks: serious violence (ROC = .72), number of incidents (r = .34), injury (r = .25) 50 weeks: serious violence, number of violent incidents, arrests for violence, injury, severity Sex, symptoms, diagnoses, psychopathy, nonpatients

26. Implications: Patients are more at risk �Forensicization� of Mentally Ill

27. Conclusions: Mental disorders pose a public safety threat� � but schizophrenia and other serious mental illnesses are not risk factors in identified populations� compared to other conditions� Difficulty of small targets

28. Conclusions: Clinical practice has the opportunity to improve public safety Using new developments in risk assessment� And methods to seek system improvements�.