brian van brunt, ed.d. brian.vanbruntwku director of counseling and testing western kentucky university

1. 1 Brian Van Brunt, Ed.D. Brian.vanbrunt@wku.edu Director of Counseling and Testing Western Kentucky University

2. 2 Threat Assessment There is an increase in discussions surround threat assessment following the Virginia Tech and NIU shootings. This presentation is designed to assist counselors and psychologists and student affairs personal to improve their communication and expectations surrounding threat assessment and treatment.

3. 3 Common Language Though we are being asked to do more with threat assessment---let’s remember: With the exception of sexual assault, College and Universities remain safer then the general community and provide more support, supervision and monitoring (for 18-24 year olds compared to non-college sample). Violent Victimization of College Students report (Baum & Klaus, 2005),Violent Victimization of College Students report (Baum & Klaus, 2005),

4. 4 Common Language We are concerned with addressing behavior, not targeting those with mental illness. We are concerned with aggression, threats intimidation, hoarding of weapons and the frustration, anger and isolation that leads to an act of violence. Those with mental illness are more likely to be the victims of violence, not perpetrators (Choe, Tepin, Abrams; 2008). persons who are seriously mentally ill are far more likely to be the victims of violence than its initiatorspersons who are seriously mentally ill are far more likely to be the victims of violence than its initiators

5. 5 Mandated Assessment The process where a third party involved with a student refers a student for some number of individual sessions with a counselor, psychologist or therapist. This often is a result of the student breaking a campus policy i.e., suicide threat, cutting behavior, angry outburst, stalking behavior, alcohol or drug use, sexual harassment.

6. 6 Mandated Programming Third-party requires a student to attend a group or classroom presentation. These often are psycho-educational and are commonly offered in the areas of drug or alcohol policy violation, although models exist for interpersonal violence as well. These programs may focus on reducing anger, improving social interactions with others or addressing sexual harassment issues.

7. 7 Mandated Treatment/Counseling Mandated treatment often follows the initial assessment and occurs in either a group or individual setting. Students are referred by a third party to counseling in order to meet sanctioning requirements or to stay involved in a club, organization, class, team or enrolled in the university.

8. 8 A bit about Mandated Referrals… There is no assessment that will predict violence – most assessments are not designed to try. The most useful assessment looks at situations rather than individuals and offers insight as to levels of concern. There is no treatment that will guarantee prevention of further acts of violence for any particular individual. There are group data that treatment reduces the likelihood of future violence.

9. 9 The best we can hope for with individuals is an “educated guess” at the level of risk and likelihood of threat and danger. We base this on past behavior, current symptoms, the student’s general attitude & compliance, and the situation surrounding the individual of concern. A bit about Mandated Referrals…

10. 10 Treatment provides skills and tools. The student is responsible for making use of these tools. (horse to water) A bit about Mandated Referrals…

11. 11 Referrals work better when there is an on-going positive relationship with the referral source. Everyone is stressed with the heightened “hot potato” issues raised with threat teams and judicial referrals. Take the time to form relationships during the down times of the year so that the relationship is solid when the difficult situations arise. A crisis is not a fruitful moment for creating a positive relationship. A bit about Mandated Referrals…

12. 12 What information would you need to perform an accurate assessment? (golden rule) Incident report, witness statements Past judicial history, staff reports Academic transcript, GPA, class list Situational (life) information Housing records Follow up contact numbers Pre-Assessment Information

13. 13 It is always easier to have a student sign a release of information during the initial meeting than attempting to track them down afterwards for a signature Contact referral source to see if they have preferred forms (HIPAA, ROI) Explain why you are requesting information, what you need and when you need it. (build rapport) Pre-Assessment Information JeffJeff

14. 14 Be clear about what they are looking for as a result of the assessment, treatment or programming. When the referral is done, do they need a letter? Does that letter need to include specific statements or come from a particular provider? Ask for these things prior to the referral. Be clear at the start what you need. Pre-Assessment Information

15. 15 Conduct periodic follow-up calls with referral agent, particularly if this is an off-campus referral (summer example). Pre-Assessment Information BrianBrian

16. 16 HIPAA HIPAA applies if: Does the person, business, or agency furnish bill, or receive payment for, health care in the normal course of business? If the answer is yes, does the person, business, or agency conduct covered transactions? If yes, are any of the covered transactions transmitted in electronic form? If the answer to this question is yes, the person, business, or agency is a covered health care provider and must comply with all HIPAA regulations

17. 17 HIPAA HIPAA does not apply to most centers since most centers don’t bill clients or transmit electronic billing. If HIPAA does apply, it just requires the signature of a release of information to get permission from the student to share information. We suggest judicial offices obtain these HIPAA ROI forms prior to mandating a student to counseling.

18. 18 HIPAA Gene Deisinger (2008) of Iowa State makes a good point in his recent book Handbook for Campus Threat Assessment and Management Teams: “…The Threat Assessment Team can provide the information it knows to an individual’s therapist or counselor…this may enhance the treatment that the mental health professional is able to provide.” p.91 “…access to mental health information may be helpful …but it is more important to consider incorporating any treating mental health professionals into the case management plan.” p. 92

19. 19 FERPA FERPA offers departments working together for a student’s best interests a wide latitude to share information. These individual’s must be “educational officials with a legitimate need to know.” Deisinger (2008) suggest threat assessment team members are given this classification. FERPA does not apply to medical or counseling records. A signed release of information addresses information sharing in a way that removes any guesswork.

20. 20 HIPAA and FERPA

21. 21 Mandated? There are some counselors and psychologists who aren’t comfortable with “mandated” anything when it comes to their clients. They make arguments against this based on the idea of autonomy---that all clients must choose to enter treatment or assessment willingly. Mental Health professionals on a college campus are not like private practitioners; the greater good of the community needs to be taken into account.

22. Mandated? Nearly every community utilizes court mandated involuntary treatment. Like many states, VA, often mandates treatment for those assessed for mental health concerns and released into the community. In the VA Tech case, mandated treatment was ordered, but never provided due a complex set of circumstances. That omission has been identified as one of the places where the tragedy might have been avoided. I suggest this resource is needed in the university community as well. JeffJeff

23. 23 Mandated? Mandated treatment is used commonly in other areas: DUI and substance related offenses Domestic violence and restraining orders Sexual assault Anger management treatment programs Employee Assistance Programs (EAP) related to work performance Sexual harassment and sensitivity

24. 24 Mandated? In a survey of 603 counseling center directors, Oetting, Ivey, and Weigel (1970) reported that 20% of centers provided disciplinary counseling and 33% of counseling center directors evaluated disciplinary cases referred to their centers.

25. 25 Mandated? In national survey data, Dannells (1990) documented "a huge increase in disciplinary counseling in counseling services, from 38% in 1978 to 60% in 1988" (p. 412).

26. 26 Mandated? More recently, Gallagher (2006) surveyed college counselors in the American College Counseling Association (ACCA). Results included data showing 88% of counseling centers offering some sort of mandated assessment service.

27. 27 Mandated?

28. 28 Mandated? The ACA ethics code states “Clients have the freedom to choose whether to enter into or remain in a counseling relationship...” A.2.a “Centers may provide mandatory assessment and other consultations to campus units, but must not make admissions, disciplinary, curricular or other administrative decisions involving students.” -IACS 2005

29. 29 Mandated? “While AUCCCD is opposed to ongoing mandated treatment, we recognize the value of mandated assessment when it is precipitated by clear problematic behavior and violation of college and university conduct codes.” -2007 position paper

30. 30 We will now explore the ethical codes related to counselors providing mandated assessment and counseling along with a review of commonly used testing measures.

31. 31 There are several ethical obligations that first must be met. The authority counselors and psychologists typically follow…

32. 32 The clinician must be primarily concerned with the dignity and welfare of the client. While there may be pressure from another source, the counselor cannot force or compel the student. (ACA: A.1.a; A.2.a; IACS:4) The clinician must define their role for the client. Dual relationships (evaluation vs. counseling, being a director of counseling at a college) must be disclosed before the assessment. (ACA:E.13.b) Ethics 1) Dignity and welfare; 2) agree to assessments; 3) define roles, avoid dual relationships,1) Dignity and welfare; 2) agree to assessments; 3) define roles, avoid dual relationships,

33. 33 The clinician must perform within their scope of practice. They must have training and knowledge of the assessment or treatment. This applies to any tests they will administer. (ACA: C.2.a, D.2.a) The clinician cannot have a prior counseling relationship with the student. (ACA E.13.c) The clinician should not be in the position of making decisions in a disciplinary or judicial case. They should consult, always providing services which respect the dignity and welfare of their client. (IACS: A) Ethics 1) Within scope of practice; 2) no prior relationship; 3) don’t be in decision making roles1) Within scope of practice; 2) no prior relationship; 3) don’t be in decision making roles

34. 34 Clinicians cannot release information without client’s permission. They cannot release information that will harm the client (ACA:B.2.c, B:1:c) When using tests (ACA: E.2, E4,E.6.a, E.9.a, IACS: 1.b, APA: 9.01.a) Must be appropriate, Reliable and Valid Clinician must have training Must take diversity issues into account Only release raw data to qualified source Findings based "on information and techniques sufficient to substantiate” APA: 9.01.a Ethics 1) No release with permission, Test---a) right test for the situation, b) clinical trained, c) diversity issues, d) raw data release, e) findings based on techniques sufficient to substantiate1) No release with permission, Test---a) right test for the situation, b) clinical trained, c) diversity issues, d) raw data release, e) findings based on techniques sufficient to substantiate

35. 35 Develop a clearly worded informed consent spelling out for the student what will happen and how the results will be shared. This must be done prior to the assessment Informed Consent

36. 36 Outline the scope of your assessment The tests, costs and time involved in completing Limit access to raw test data to qualified individuals with client written consent Outline who will receive the assessment List kind of information will be collected (past therapy, past inpatient, past court involvement, arrests, felonies) Clearly spell out what happens if the student no-shows appointments (who is notified) Informed Consent

37. 37 If a judicial office requires off-campus assessment, the counselor/psychologist can help advocate for the student to ensure a smooth process. Ask: The specifics of what they require, If the clinician/center has acceptable credentials for the assessment being asked for Help the student understand the time and cost issues as they related to insurance, self-pay and scheduling their assessment Advocacy

38. 38

39. 39 When thinking about assessment, remember the Saxe poem about the blind men and the elephant…

40. 40 When reviewing tests and measures to better assess symptoms and risk be aware… There is no measure that predicts future violence There is no substitute to a solid clinical interview You must have the training needed to choose, administer, score, interpret and report the results for a given test Choosing your Assessments

41. 41 When performing assessments, there is no test or measure that substitutes for common sense and clinical judgment. An effective assessment can measure risk on a comparative basis When writing reports and letters, base your observations and conclusions on the information at hand. Choosing your Assessments

42. 42 Avoid “going out on a limb” and making statements that cannot be reasonably backed up by the facts at hand. As a professor of mine once said, “While it makes for a more interesting report, be careful when using speculation and opinion that can’t be substantiated.” Choosing your Assessments

43. 43 Structured Clinical Interviews MOSAIC, HCR-20, HARE-PCL-R Deception Detection TOMM, PDS Baseline Measures MMPI-2, MSE Symptom Based STATIC-99: Sexual, STAXI-2: Anger, FAVT: Violence EDIT: Eating Disorder, Beck Scales, FAST/FASI: self-harm Anti-social JI-R Types of Assessments

44. 44 Treatment Suggestions

45. 45 Treatment Suggestions

46. 46 Treatment Suggestions

47. 47 Treatment Suggestions

48. 48

49. 49 Treatment Suggestions

50. 50 Treatment Suggestions

51. 51 National Behavioral Intervention Team Association (NaBITA) Model

52. 52

53. 53

54. 54 Case Study

55. 55 River was hospitalized for a Tylenol and medication overdose during September, she had not been to counseling on campus prior. 1a Housing contacted counseling and the Dean, River was asked to complete an assessment as she returned to campus (parents contacted, ROI signed). 1b;1c;1d;1e She works with counseling 1f and completes the counseling assessment. 1g Case Study One

56. 56 During a counseling appointment, River admits to cutting self and has the wounds dressed at health services. St. Lucy’s Medical Center report arrives. 1h She has another overdoes attempt and is called in for a hearing after being released from the hospital. Student suspended for a semester following a return from the second hospitalization. 1i Case Study One

57. 57 Case Study One Timeline

58. 58 Case Study Key Points

59. 59 Case Study Key Points

60. 60 Case Study Key Points

61. 61 Case Study Key Points

62. 62 Malcolm reported for harassing another student who lived in his hall. 3a Other reports come in of odd behavior. 3b, 3c He is suspended from campus by judicial affairs pending an off-campus counseling assessment. 3d Malcolm signs releases for information 3e and a consent to treatment with counseling. 3f Malcolm has a brief assessment at an off-campus hospital emergency room. 3g Case Study Three

63. 63 Malcolm releases information to judicial affairs and is allowed to return to school. 3h Malcolm attends counseling on-campus and completes some additional assessments. 3i Several more reports of threatening (demanding his therapist’s cell phone) and odd behavior (asking roommate’s mother for $20,000) came from around campus. Malcolm met with judicial affairs and opted for a voluntary withdrawal. (extra suspension letter) 3j Case Study Three

64. 64 Case Study Three Timeline

65. 65 Case Study Key Points

66. 66 Case Study Key Points

67. 67 Case Study Key Points

68. 68 Case Study Key Points

69. 69 Test Overview

70. 70 HCR-20 This guided structured interview has the clinician rate Historical, Clinical and Risk Management items to create a risk profile which includes past, present and future areas of exploration. It’s 10 historical factors focus on the past, the 5 Clinical items are meant to reflect current, dynamic (changeable) correlates of violence. The future contains 5 Risk Management items, which focus attention on situational post-assessment factors that may aggravate or mitigate risk.

71. 71 HCR-20

72. 72 MOSAIC MOSAIC is an expert system computer- assisted program created by the deBecker Company in the 1980’s. It uses a number of separate databases – recommended for university use are the University Student and employee data bases The program is designed to guide the clinician through a series of questions (with interactive suggestions of additional focus areas and questions based on responses). Questions are directed to clinician, not client.

73. 73 MOSAIC MOSAIC creates a dangerous threat scale (1-10) and a confidence factor scale (1-200). The clinician can click on questions to see supporting citations and read a brief overview of the research being cited for each question.

74. 74 MOSAIC

75. 75 HARE Psychopathy Checklist The PCL-R is a clinical rating scale (rated by a psychologist or other professional) of 20 items. Each of the items in the PCL-R is scored on a three-point (0, 1, 2) scale based on answers given following a semi-structured interview. The measures assesses two major factors Factor 1: "selfish, callous and remorseless use of others” Factor 2: "chronically unstable, antisocial and socially deviant lifestyle”

76. 76 Hare PCL-R 2nd

77. 77 Test of Memory Malingering Is designed to provide a reliable, economical first step as part of a full psychological battery to help assess whether an individual is falsifying symptoms of memory impairment. Subjects are given 50 pictures which have high face validity as a test of learning and memory. They then recall a number of these pictures---expected recall is 50% by chance (or a score of 25). Scores less than 18 indicate a lower score than would be achieved by chance.

78. 78 TOMM

79. 79 Paulhus Deception Scale (PDS) The Paulhus Deception Scales (PDS) is a 40 item self-report questionnaire designed to measure the tendency to give socially acceptable or desirable responses. It measures self deception and impression management. The PDS is useful in identifying individuals who distort their responses and in evaluating the honesty of their responses, as it is administered concurrently with other instruments. BrianBrian

80. 80 PDS

81. 81 Minnesota Multipahsic Personality Inventory (MMPI-2) The Minnesota Multiphasic Personality Inventory (MMPI-2) was developed in 1989 and is the most frequently used personality test in the mental health fields. This assessment was designed to help identify personal, social, and behavioral problems in psychiatric patients. The test helps provide relevant information to aid in problem identification, diagnosis, and treatment planning for the patient. Jeff?Jeff?

82. 82 MMPI-2 Jeff?Jeff?

83. 83 Mental Status Exams Mental Status Examinations provide a clinical snapshot of the behaviors, affect, emotions and psychological state. They are helpful in establishing baseline behavior and create a common language between treatment teams. One form of the Mental Status Exam is the SMSME, a standardized set of questions often given in medical settings. JeffJeff

85. 85 MSE

86. 86 STATIC-99 The Static-99 is a brief actuarial instrument designed to estimate the probability of sexual and violent recidivism among adult males. Can only be used with those who have already been convicted of at least one sexual offense against a child or non-consenting adult. Helps assess long-term risk potential, not useful for measuring change, treatment effects or readiness for release

87. 87 STATIC-99

88. 88 State Trait Anger Expression Inventory (STAXI-2) The STAXI-2 was developed in 1999 and provides easily administered (57 questions) and objectively scored measures of the experience, expression, and control of anger for adults and adolescents, ages 16 years and older. State AngerFeeling AngryFeel Like Expressing Anger VerballyFeel Like Expressing Anger Physically Trait AngerAngry Temperament Angry Reaction

89. 89 STAXI-2

90. 90 Firestone Assessment of Violent Thoughts (FAVT) This new measure is designed to assess the underlying thoughts that predispose violent behavior. Screening device useful for threat assessment, indentify violent thoughts and tracking over time with on-going treatment clients 5 levels: Paranoid/Suspicious, Persecuted Misfit, Self-Depreciating/Pseudo-Independent, Self-Aggrandizing, Overtly Aggressive 2 theory scales: Instrumental/Proactive Violence/Reactive violence

91. 91 FAVT

92. 92 Firestone Assessment of Self-Destructive Thoughts (FAST) and Suicidal Intent (FASI) The FAST is a self-report survey with 84 items which are used to rate self-destructive thoughts on 11 scales. The first five scales look at low self-esteem, inwardness and self-defeating thoughts. Scale six looks at thoughts that support the cycle of addiction. Scales seven through eleven look at self-annihilating thoughts leading to suicide. These scales make up the FASI. BrianBrian

93. 93 FAST/FASI BrianBrian

94. 94 Beck Series (BDI-2, BAI, BSS, BHS) This series of four symptom measures includes Beck Depression Scale-2 (BDI-2) created in 1996 Beck Anxiety Inventory (BAI) created in 1990 Beck Suicide Scale (BSS) created in 1991 Beck Hopelessness Scale (BHS) created in 1988 Useful computer program included in set to track trends over time. Each test only takes 5-10 minutes to administer and under 5 minutes to score. BrianBrian

95. 95 Beck Series BrianBrian

96. 96 Jesness Inventory Revised (JI-R) The Jesness Inventory (JI) is a brief (155-item) true-false questionnaire with 11 personality subtype scales that measure key traits and attitudes, including Social Maladjustment, Manifest Aggression, Value Orientation, Withdrawal-Depression, Immaturity, Social Anxiety, Autism, Repression, Alienation, Denial, and Asocial Index The nine subtypes are Undersocialized/Active, Undersocialized/Passive, Conformist, Group-Oriented, Pragmatist, Autonomy-Oriented, Introspective, Inhibited, and Adaptive.

97. 97 JI-R BrianBrian

98. 98 Resources Carr, J. L. (2005). American College Health Association campus violence white paper. Deisinger, G., Randazzo, M., O’Neill, D. & Savage, J. (2008). Handbook for campus threat assessment & management teams. Applied Risk Management, LLC. Baltimore, MD: American College Health Association.Choe, JY., Teplin, LA & Abram, KM. (2008). Perpetration of violence, violent victimization, and severe mental illness: balancing public health concerns. Psychiatric Services, 59(2), 153-164. Baum, K., & Klaus, P. (2005, January). Violent victimization of college students, 1995-2002. (NCJ Publication No. 206836). Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics).

99. 99 Resources Choe, JY., Teplin, LA & Abram, KM. (2008). Perpetration of violence, violent victimization, and severe mental illness: balancing public health concerns. Psychiatric Services, 59(2), 153-164. Dannells (1990). Changes in Disciplinary Policies and Practices over 10 Years. Journal of College Student Development, 31(5), 408-14. Gallagher, R. (2006, 2007). National Survey of counseling Center Directors. International Association Counseling Services. Oetting, E., Ivey, A. and Weigel, R. (1970). The College and University counseling Center. Journal of Consulting and Clinical Psychology, 34, 124-127. Pollard, J.W., (1994). Treatment for perpetrators of rape and other violence. In Berkowitz, A. (Ed.), New Directions in Student Affairs, Men and Rape: Theory, Research, and Prevention programs in higher education, No. 65, New York: Jossey Bass.

100. 100 Resources HIPAA website http://www.hipaacomply.com/ FERPA website www.ed.gov/policy/gen/guid/fpco/ferpa/students.html