Chapter 1

Question 1

Why are Risk assessment & management fundamental in our lives?

Answer 1

Every day when making decisions, we think ahead to what may happen and reflect on problems that may arise
estimate how likely the problems are to occur
decide on any action we should take to deal with these potential difficulties

Question 2

How do we process situations usually?

Answer 2

We always go through same process: look ahead, form a view on main potential problems, we consider priorities, and we then take specific action to mitigate the risks

Question 3

What sequence of evaluation processes are used in violence risk assessment?

Answer 3

Assessing same as in everyday situation + assess and manage the future risk of violence presented by someone who has history of violent behaviour

Question 4

What is the ultimate task of mental health professionals and what are the consequences?

Answer 4

Decision of whether a given patient will be released from the hospital
Decisions are a careful assessment of factors that impact risk of harm to self or others
legal and clinical considerations related to working with potentially dangrous patients become a routine aspect of outpatient mental health practice –> could impact confidentiality

Question 5

What key shifts were observed in field of violence assessment and its consequences?

Answer 5

First violence predicition to violence risk assessment to now evolution towards violence risk management
–> informational silo that potentially impedes optimal risk management practice

Question 6

What is the main requirement of risk assessment and what are its categories?

Answer 6

Information from multiple sources (as many as possible)
Sources of info can be grouped into three categories: clinical interviews, documentation review and collateral information

Question 7

What link has long been established and what are the consequences?

Answer 7

–> link between mental disorder and risk to others has long been acknowledged

recent years have seen increasing public concern relating to violence committed by psychiatric patients

context of elevated awareness and anxiety about the potential risks posed to others by psychiatric patients

risk assessments should be documented and communicated accurately if the necessarily high standards of clinical practice are to be achieved

Question 8

what is the consequence that risk assessment is an inexact science?

Answer 8

Little consistency or convention on how risks are classified and reported in practice

Question 9

What is understood under formulation and what are its roots?

Answer 9

Formulation is understood as an approach to conceptualizing problems with a view to specifying interventions + has its roots in the “application of psychological science to clinical problems” and may be regarded as pivotal in the historical development of clinical psychology practice

Question 10

What is case formulation?

Answer 10

regarded as a “core clinical skill” and provides a framework that enables inferences to be made about the factors causing and maintaining problems, and to inform interventions

Question 11

What is a common theme across different approaches to formulation?

Answer 11

application of a systematic method to organize information and hypothesize about possible causal mechanisms underlying a problem

Question 12

What is Weersakera’s integrative scheme?

Answer 12

consideration of factors according to a framework of “Four P’s”

• -> predisposing factors (i.e., longer-term pre-existing vulnerabilities)
• -> precipitating factors (more recent triggering events or issues)
• -> perpetuating factors (that are maintaining the problem),
• -> protective factors (resources that may mitigate or reduce the impact of the problem)

a clinician is better placed to identify what may need to be targeted in therapeutic work or treatment to address the presenting issues

Question 13

What is usually done with risk assessment in therapeutic practice?

Answer 13

individual clinicians may draw on one or more theoretical models in their analysis of the presenting problem

particular model employed provides a theoretical framework

• -> within which to understand the problem
• -> which orients the therapist towards specific issues which, according to the model, are viewed as particularly salient and likely to be priorities for assessment and treatment

formulations of the same case using different models can, despite their differences, complement one another and contribute to a more complete understanding

Question 14

What happens with absence of reliance on one theoretical model in practice?

Answer 14

absence of a reliance on one particular theoretical model may be viewed as a strength, based on an appreciation that an individual’s difficulties are the product of an interaction between multiple factors—biological, psychological, and social

Question 15

What document is kown to have outlined a guidance framework to practicioners?

Answer 15

Royal College of Psychiatrists

Question 16

What did the key clincial practice document by RCoP recommend?

Answer 16

A formulation should be made based on these and all other items of history and mental state. . . the formulation should, so far as possible, specify factors likely to increase the risk of dangerous behaviour and those likely to decrease it

proposed some helpful structure
–> The formulation should aim to answer the following questions
• How serious is the risk?
• Is the risk specific or general?
• How immediate is the risk? How volatile is the risk?
• What specific treatment, and which management plan, can best reduce the risk?

Question 17

What new idea did Doyle and Dolan propose?

Answer 17

formulation should be a practical solution to the task at hand

drew attention to a context of “evidence-based practice,” which required the risk assessment endeavour to be approached in a “systematic fashion”

Question 18

What are the five steps in the five step model by Doyle and Dolan (2002)?

Answer 18

Step 1: Case Information (i.e., past history, mental state, personality assessments)
Step 2: Presence of Risk Factors (i.e., Past history of violence, dispositional factors, clinical factors, contestual factors)
Step 3: Presence of protective factors (i.e., responding to treatment, good insight)
Step 4: Risk formulation (i.e., historical, current, future)
Step 5: Management Plan (i.e., treatment, supervision, victim safety planning)

Question 19

What is the background infor of the five step plan?

Answer 19

formulation of the information obtained from review of history, information from clients, and observation from corroboratory sources is regarded as a key step in the process, which follows on to inform care planning, treatment and management decisions in a logical sequence that enables the reasons for clinical decision making to be transparently observed

idiosyncratic and individualized risk formulation promotes better understanding of the presenting problems and risks and provides a framework for subsequent interventions

Question 20

What are formulation-based approaches used for?

Answer 20

to understanding and address the problems encountered by forensic practitioners, including violence and offending behaviour

Question 21

What approach is described by Jones (2004)?

Answer 21

an approach in which attention is given to Offence Paralleling Behaviour (OPB)

any form of offence-related behavioural (or fantasized behavioural) pattern that is observed at any point before or after an offence

provide insight into the offense cycle and the repeating trajectory of offending behaviour

emphasized that offending behaviour is a process, and that systematic analysis of antecedent events is likely to increase understanding of what/how factors may interact and contribute to similar behaviour occurring in the future

highlights the link between a formulation and engagement in treatment
–> Case formulation is viewed as a means to enhance motivation to change in offenders

six-step practice algorithm to facilitate the case formulation
–>includes a thorough assessment of motivation, identifying obstacles to engagement, and ongoing assessment of OPB

Question 22

What is Ward’s (2002) integration of the risk-need and good lives model of offender rehabilitation?

Answer 22

central aim is to “identify clinical phenomena or problems associated with offending behaviour
–> includes a risk estimate and identification of criminogenic needs and their location in offender vulnerabilities and lifestyles

Question 23

What is the document entitled Best Practice in Managing Risk?

Answer 23

Department of Health recently published it as an outcome of work

framework addresses three main areas of clinical risk

• -> violence (including antisocial and offending behaviour)
• -> self-harm/suicide
• -> and self-neglect

risk formulation was included as a core component within the risk management planning cycle

Question 24

What is risk communication and what are its methods?

Answer 24

risk formulation should inform management interventions that are developed into a risk management plan, so formulation can also be an effective means of communicating risk

Descriptive Approach, Predictive Approach, Categorical Approach, and Explanatory approach

Question 25

What is the Descriptive Approach of risk communication?

Answer 25

risk is simply described in terms of the nature of the risk and, as an unstructured process, any information may be considered for inclusion

widely found in practice and frequently evident in routine clinical and legal reports where the aim is to generate a narrative formulation specific to the individual case

may under- or overemphasize information, as they are wholly dependent on the subjective discretion of the individual assessor and therefore the risk of bias is increased

Question 26

What is the predictive approach in risk communication?

Answer 26

Nondiscretionary

emphasis is on absolute statements of risk (e.g., 70% probability) wherein the prediction is based on objective data

usually derived from an actuarial scale or test that has demonstrable reliability and validity

defining feature of actuarial-predictive approaches is that, within the model, the development of instruments involves the aggregation of data from a large sample of individuals

When such tools are applied to individual cases, there are limitations to the extent to which they can consider contextual and dynamic factors that may be of relevance

subject of considerable debate

Question 27

What is the categorical approach in risk communication?

Answer 27

classifications such as low, medium, or high are typically used in communication of risk

suggested that these distinctions are easily understood and can inform decision making in a timely manner

shown that disagreement around interpretation of such term or confusion as to the clinical implications

in a clinical setting the individual or team communicating that a patient is assessed as ‘high risk’ will be duty bound to try to ensure that the risk outcome does not actually occur  incur such high levels of supervision or restriction that the likelihood of an adverse event actually becomes very low, sometimes referred to as the ‘risk paradox’ in terms of the relationship between prediction and outcome

Question 28

What is the explanatory approach in risk communication?

Answer 28

Risk formulation can be viewed as such

endeavour is focused more on understanding the risk, with a process of enquiry as to why the person is a risk, what that risk comprises, and in what circumstances it might be expressed

risk formulation may be regarded as a form of analysis that can assist practitioners to explain the origins, development, and maintenance of risk behaviour, while providing a crucial link between assessment and management in clinical practice

Question 29

What are the six general distinctions between the violence risk assessment in therapeutic versus forensic contexts?

Answer 29

Identifiable Victims
Imminent versus Time Unlimited Risk
The Role of Mental Illness
Nature of Professional Relationship
Origin of Violence Risk Question
Use of Standardized Instruments

Question 30

What are the three main approaches to risk assessment?

Answer 30

1. Actuarial tool
2. Unstructured clinical judgement
3. Structured clinical judgement

Question 31

How widely spread is assessment of violence risk?

Answer 31

• over 60% of general psychiatric patients are routinely assessed for violence risk, rising to above 80% in forensic psychiatric hospitals

Question 32

By what has the use of tools for risk assessment been driven by?

Answer 32

o public concern about safety of mentally ill patients
o research evidence that severe mental illness is associated with violence
o clinical practice guidelines in some countries e.g., recommend violence risk assessment for all patients with schizophrenia
o criminal justice systems in many countries have welcomed the use of risk assessment to assist sentencing and release decisions

Question 33

What does the current group of risk assessment tools provide?

Answer 33

They currently either provide a o probabilistic estimate of violence risk in a specified time period (actuarial instruments), or allow for a professional judgment to be made on risk level (for example, low, moderate, or high) after considering the presence or absence of a predetermined set of factors (structured clinical judgment instruments)

–> Over 150 of these structured measures currently exist,15 and are starting to be implemented in low- and middle-income countries

Question 34

What are the disadvantages of risk assessment tools?

Answer 34

time consuming and resource intensive
–>taking many hours to complete by a multidisciplinary group of professionals

can also be expensive
–> training is required for most tools, and payment is often needed for individual use

predictive accuracy remains a source of considerable uncertainty

• -> some reviews recommending their use in clinical and correctional settings
• -> others finding that they lead to an unacceptably high number of false positive decisions

Question 35

What are the nine most common risk assessment tools?

Answer 35

Structured clinical judgment tools included the Historical,
Clinical, Risk management-20 (HCR-20)
Structured Assessment of Violence Risk in Youth (SAVRY)
Spousal Assault Risk Assessment (SARA)
Violence Risk Appraisal Guide (VRAG)
Sex Offender Risk Appraisal Guide (SORAG)
Sexual Violence Risk-20 (SVR-20)
Static-99
Level of Service Inventory-Revised (LSI-R)
Psychopathy Checklist-Revised (PCL-R)

Question 36

What are the three categories of risk assessment tools in what they measure?

Answer 36

Designed to predict violent offending (HR-20; SAVRY, SARA, VRAG)
Predict Sexual offending (SORAG, SVR-20, Static-99)
Predict any criminal offending (LSI-R, PCL-R)

Question 37

What was the PCL-R originally developed for vs now?

Answer 37

 originally developed to diagnose PPD
 NOW: widely used for risk assessment purposes, as numerous studies have found the PCL-R score to be statistically significantly associated with criminal and antisocial outcomes

Question 38

What are actuarial tools?

Answer 38

concerned with prediction

the histories, and outcomes of samples of violent offenders are studied to find characteristics that predict recidivism

statistical equation is then derived, allowing other individuals to be compared with the sample, and producing a numerical probability of repeat violent behaviour

‘non-discretionary’  require the person using them to make forced choice responses based on facts, usually ‘yes’ or ‘no’ to whether each of a list of risk factors is present

Question 39

What are the most well-known actuarial instruments?

Answer 39

RM2000, Static-2002, VRAG

Question 40

What are the limitations of actuarial tools?

Answer 40

individual must be similar enough to the sample population
–> characteristics and recidivism rates of different offender groups may vary greatly

meaningful predictions about individuals cannot be made from group data

cannot be used to measure change in risk, as they are usually based on fixed or ‘static’ information
–> of no use in determining whether progress has been made in response to rehabilitation

Long-range predictions in the low to mid-range, such as a 20–30% chance of reoffending in 10 years, are particularly unhelpful

Question 41

What is one solution to a possible limitation of actuarial tools?

Answer 41

recently published actuarial tools, such as the Stable and Acute Dynamic Risk Assessment Tool (SA07; Hanson 2007) do include dynamic risk factors
–> of no help in describing what exactly might go wrong, when, and how to prevent it

Question 42

What are actuarial tools useful for?

Answer 42

useful for professionals who must deal with many individuals or who do not have the time or skills to undertake a comprehensive assessment

used for screening and to assist in identifying at an early stage, individuals within a group about whom there should be concern

apply an actuarial tool for guidance on the recidivism outcomes for particular types of offenders and offences

Question 43

What are structured clincial judgements?

Answer 43

involves the combination of clinical experience and research-based evidence

recommendations for best practice and comprise factors that have a demonstrated empirical association with increased risk for violence

approach is dynamic and can be repeated

• -> allowing progress in response to risk management strategies
• -> changes in circumstances to be considered

Question 44

What is the purpose of SPJs?

Answer 44

planning and prevention rather than prediction

identifying the presence and relevance of risk factors

detailed description of what could reasonably be expected to happen in certain situations

structure clinical decision making regarding the likelihood of violent behaviour and the conditions under which violence might be expected to occur

inform the identification of risk-reducing treatment and management strategies

Question 45

What are shared characteristics of tools developed according to SPJ approach?

Answer 45

Items are identified after a systematic review of the existing scientific research

Judgments about degree of risk are made without a numeric formular

• -> decision maker assesses the weight to be given to the specific items and typically communicates conclusions in a categorical manner (e.g., low, moderate, high)
• -> additive model of risk (only adding risk factors) is overly simplistic
• -> considering the individual manifestation and relevance of each item for the particular individual
• -> Specific clusters of risk factors, or even a single risk factor, may play a disproportionate role in increasing an individual’s level of risk

Question 46

What are Hart and Kropp’s pinciples for SPJ?

Answer 46

1. SPJ Schemes are preventitive
   - -> not only predicitve but also preventitive and guide evaluators
   - -> firstly, consider the individual and contextual factors that are believed to increase or decrease risk for violence, then identify specific interventions that may be useful for managing or reducing that risk
2. SPJ Schemes are structured
   - -> provide general guidance regarding how to carry out the assessment, present specific factors to consider
   - -> provide a description of and instructions for rating each item
   - -> describe how to make and communicate the final risk judgment
   - -> provide explicit recommendations
3. SPJ Schemes are flexible
   - -> assessments are individualized and contextualized
   - -> evaluator’s discretion is valued
   - -> SPJs contain factors that are expected to change over time in saliency and relevance in different ways for different individuals
   - -> may be considered as “works in progress.” > i.e., based on current discourse in the empirical, professional, and legal spheres

Question 47

What are the strenghts of structural clinical judgements?

Answer 47

reviewer is provided with information on the risk factors known to be linked to particular forms of violence recidivism

required to

• -> gather comprehensive information about the case
• -> to evaluate that information and
• -> to assess the individual within the framework of these risk factors

help in risk management planning and can provide evidence of progress (can be repeated over time)

superior to actuarial instruments

• -> actuarial instruments are rigid, and they are unable to capture key aspects of an individual case
• -> structured approach reduces rater-bias and provides greater transparency to decision-making

Question 48

What are the recommended streps for SPJ tools?

Answer 48

1. Gather information about client using multiple sources and different methods
2. Evaluate adequacy of information
3. Write down evidence for and against each questionnaire item + consider before making rating
4. Appraise presence of each factor and any changes over time
5. Consider manifestation and relevance of each risk factor + evaluate whether it is a critical item (= an item that, on its own, compels a conclusion of high risk)
6. Review item description and scoring guidelines in manual
7. Consider patterns among, clusters of and associations between risk factors
8. Weigh items according to salience and relevance
9. Assign overall risk level
10. Make context-specific considerations that could affect validity of overall risk estimate
11. Offer opinion about likelihood of future violence, imminence (how soon will violence occur?), severity (potential or anticipated degree of harm to victim?), density (how much violence will occur?), likely targets (family, friends, strangers?) and weapon use (none, type, etc.)
12. Identify + communicate specific treatment, supervision, monitoring, and management strategies
13. Discuss recommendations regarding when a re-evaluation is needed or what would trigger an immediate review
    - -> a final risk judgment of low, moderate, or high should never be presented in the absence of an explanation or justification, specified risk management plans, and time parameters regarding re-evaluation

Question 49

What is the predictive accuracy of risk assessments?

Answer 49

even with the best risk assessment approach, incidents may still occur that were not predicted or on the other hand there may be a problem of “over prediction” of risk

adverse events will still occur from time to time

Clinical risk assessment has aptly been compared with weather forecasting

• -> not 100 percent accurate all the time
• -> provide a reasonable estimate of the likelihood
• -> possibility to make an informed judgement of what to do (e.g., take an umbrella or risk getting wet)

most risk assessment tools have poor to moderate accuracy in most cases

more than half of individuals judged by tools as high risk are false positives

• -> may be detained unnecessarily
• -> False positives may be especially common in minority ethnic groups

Rates of false negatives are usually much lower

• -> in typical cases around 9% of those classed as low risk will go on to offend
• -> may be released or discharged too early, posing excessive risk to the public
• -> frequently associated with significant controversy and outrage

evidence suggests that some incidents may be preventable if risk assessments are conducted, and certain risk management plans are made
–> prevalence of prediction errors does not entirely undermine the rationale for conducting risk assessments and they should still be used by professionals to try to eliminate risk

Question 50

What is the predicitive validity of most used tools in risk assessment?

Answer 50

based on diagnostic odds ratios, violence risk assessment tools performed best, and had higher positive predictive values than tools aimed at predicting sexual offending

instruments for violence and sexual offending produced high sensitivities and negative predictive values

instruments for general offending had lower diagnostic odds ratios, areas under the curve, sensitivities, and negative predictive values and higher specificities and positive predictive values than the other two classes of instrument

instruments performed moderately well in identifying those individuals at higher risk of violence and other forms of offending –> good to inform treatment and management decisions

if used as sole determinants of sentencing, and release or discharge decisions, these instruments are limited by their positive predictive values

• -> In samples with lower base rates than those that contributed to the review, such as in general psychiatry, positive predictive values will probably be even lower
• -> negative predictive values were high, and suggest that these tools can effectively screen out individuals at low risk of future offending
• -> view that violence, sexual, or criminal risk can be predicted in most cases is not evidence based
• -> tools are not sufficient on their own for the purposes of risk assessment
• -> can only be used to roughly classify individuals at the group level, and not to safely determine criminal prognosis in an individual case
• -> actuarial instruments focusing on historical risk factors perform no better than tools based on clinical judgment
• -> however, what constitutes an appropriate balance between the ethical implications of detaining people based on the predictive ability of these tools and the need for public protection will primarily be a political consideration

Question 51

What is the heterogeneity of risk assessment tools?

Answer 51

moderate levels of heterogeneity for the instruments assessing violence risk and higher levels for instruments assessing sexual and general offending risk

no evidence that sex, ethnicity, age, type of instrument, temporal design, assessment setting, location of offending outcome, length of follow-up, sample size, or publication status was associated with differences in predictive validity

heterogeneity in the performance of these measures depended on the purpose of the risk assessment

Question 52

How to risk assessment tools compare to other medical tools?

Answer 52

comparison with diagnostic tools is mostly inappropriate because risk assessment instruments attempt to predict the likelihood of a future outcome, whereas diagnostic instrument attempt to detect the presence of a current condition

implications of positive predictive values need to be considered in evaluating any comparisons

• -> Violence risk assessment potentially leads to detention of individuals for longer than necessary, with its related economic, social, and civil rights consequences
• -> predictive accuracy of violence risk assessment needs to be higher because of these consequences, which extend beyond the person to other people
• -> low positive predictive values may not be as important as the ability of these instruments to predict those that are not at risk

studies report associations between predicted and observed risks, which may be helpful for future research in violence risk assessment

standard by which these instruments are compared will differ depending on their setting
–> in forensic psychiatry, a more meaningful comparison will be with unstructured clinical judgment, and clinical trials are needed to test whether structured risk assessment reduces adverse outcomes

Question 53

In what two categories do protective and risk factors fall?

Answer 53

1. Static Factors
   - -> associated with the probability of future violence but are generally unchangeable
2. Dynamic Factors
   - -> are associated with the likelihood of future violence and can change over time, whether naturally or as the result of some intervention

Question 54

What are static risk factors in risk assessment?

Answer 54

1. Gender
   - -> Male gender is consistently associated with heightened rates of violence in the general population
   - -> presence of severe mental illness appears to mitigate these gender differences
   - -> males had a higher prevalence of violence immediately following discharge, these differences dissipated over one year
2. Age
   - -> Younger age (late teens and early twenties) is consistently found to be associated with higher rates of violence in the general population, violent offender populations, and mentally ill offenders
3. Age at first offense
   - -> young age at first offense was a consistent predictor of both general and sexual violence
   - -> earlier age of first contact with the legal system and earlier age of first commitment as predictors of recidivism
4. History of Violence
   - -> a robust predictor of future violence across community, offender, and psychiatric samples
   - -> single strongest predictors of future violence from among a variety of demographic, clinical, and criminal variables
   - -> type of previous violence perpetrated might moderate the association between previous and future violence
5. Arrest History
   - -> research supports both a history of juvenile delinquency and an adult criminal history as significant predictors of violence
   - -> arrests for violent crime are more strongly predictive of subsequent violence than arrests in general
6. ASPD & Psychopathy
   - -> psychopathy is the most heavily weighted risk factor on the VRAG and accounts for a substantial portion of the VRAG’s variance

Question 55

What are dynamic risk factors for risk assessment?

Answer 55

1. Major Mental Illness
   - -> those with severe mental illness — defined as schizophrenia, bipolar, and major depression — were two to three times more likely to be violent
   - -> link is indirect and explained, at least in part, by the fact that individuals with severe mental illness are more likely to possess other modifiable risk factors (substance abuse, perceived threats, recent divorce, unemployment, and recent victimization)
   - -> attributable to specific symptom clusters rather than the presence of a diagnosis per se (specific positive symptoms (hostility, suspiciousness/ persecution, hallucinatory behaviour, grandiosity, and excitement)
   - -> risk for community violence was lower when they
   (a) perceived a need for treatment,
   (b) adhered to treatment, and
   (c) endorsed positive perceptions of treatment effectiveness
2. Substance Abuse
   - -> stronger risk factor for violence than severe mental illness, although the two often co-occur
   - -> substance abuse increased the risk of violence among both mentally ill participants and community comparison groups
   - -> might differ across individuals with mood versus psychotic disorders, with alcohol enhancing risk more for those with mood disorders
3. Anger
   - -> anger emerged as the single best predictor of institutional violence
   - -> male perpetrators consistently report higher levels of anger than their non-violent counterparts
   - -> anger as proximally related to domestic violence perpetration
4. Social Support
   - -> linkage between violence, social contact, and social support is a complex one
   - -> living with their family were found to engage in more violence than those living elsewhere
   - -> nature of the social network might be more important than the presence or absence of a network, per se
5. Weapon Availability
   - -> considerable indirect evidence for an association between weapon access and risk of violence
   - -> keeping a gun in the home not only failed to provide a protective benefit but in fact nearly tripled the risk of homicide victimization in the home, generally by a family member or intimate partner
   - -> abusive men with access to firearms were eight times more likely to kill their partner than abusive men without access
6. Victim Availability
   - -> Threats against readily accessible individuals generally present more risk than threats against targets that are not readily accessible
   - -> victim availability might not necessarily lower an individual’s overall risk so much as cause their violence to be displaced

Question 56

What is the relation of threats to violence?

Answer 56

relatively minimal empirical attention has been given to the association between threats and subsequent violence in risk assessment research

vast majority of those who make homicidal threats will not follow through on it, but also that as a group, those who threaten homicidal violence are far more likely to commit homicide than those who do not

those who threatened mass homicide were much more likely to have an affective disorder (62.5% versus 18.4%)

Four risk factors for violence in the next 12 months were identified in this sample of individuals who had uttered homicidal threats:

(1) those with a history of substance misuse were 3.9 times more likely to be violent
(2) those with history of violence were 3.3 times more likely to be violent
(3) those with ten years or less of education were 3.2 times more likely to be violent, and
(4) those who did not receive mental health treatment during follow-up were 2.4 times more likely
- -> presence of all four risk factors combined showed good specificity (87.4%) but weak sensitivity (48.5%) in the prediction of future violence

Question 57

What are the typologies of threats according to Meloy?

Answer 57

instrumental threats, which are intended to control or coerce others

expressive threats, which function to regulate the threatener’s own affect

Question 58

What is a true threat?

Answer 58

true threat = “a reasonable person would foresee that the statement would be interpreted as a serious expression of intention to inflict bodily harm upon or take the life of another person”

Question 59

What are the typologies of threats according to Warren et al.?

Answer 59

screaming, is similar to expressive threats and function to regulate affect

scheming, is similar to instrumental threats and function to control or influence others

shocking threats are intended primarily to elicit an emotional response in others

Question 60

What is the FBI’s threat assessment approach?

Answer 60

direct threats – those made directly to the intended target or law enforcement

leakage, which entails a communication to a third party of an intent to do harm

• -> Meloy and O’Toole (2011) note that leakage is sometimes, but not always intentional and link threats made in psychotherapy to the concept of leakage
• -> evaluation of leaked threats should be evaluated in the context of general risk factors for violence and risk factors specific to those who have made homicidal threats, including substance abuse, prior violence, lower educational attainment, and untreated mental illness

Question 61

What is the realtion of fantasised to enacted violence?

Answer 61

Fantasies can be defined as conscious thought fuelled by emotion, and the ability for patients to express these thoughts without repercussion is a cornerstone of the therapeutic relationship

violent fantasies were normative, with more than half of the patients experiencing them in the year following discharge

• -> small but significant association between violent fantasies and actual violence
• -> physically and sexually violent fantasies are not uncommon in the general population

authors conclude that (a) violent fantasies are common, (b) do not specifically signal the potential for violent behavior, and (c) should not be considered to be particularly predictive of future dangerousness

Question 62

Why have protective factors not been included in most risk assessments?

Answer 62

classification accuracy studies of the measures derived from combinations of empirically supported risk factors, such has not been the case thus far in the literature on protective factors

Question 63

Which two SPJ instruments are primarily comprised of dynamic and protective factors?

Answer 63

Short-Term Assessment of Risk and Treatability

• -> includes 20 dynamic items (e.g., social skills, occupational, impulse control, social support, insight, medication adherence, and coping)
• -> scored for their status as vulnerabilities and then strengths in a given individual
• -> strongly predictive of violence toward others in clinical population
• -> a good predictor of self-harm among psychiatric patients
• -> easy to use and view it as a valuable tool for organizing and revealing any gaps in information relevant to assessing and managing violence risk

Structured Assessment of Protective Factors for Violence Risk
–> 17-items identified as protective factors, 15 of which are dynamic factors
–>Dynamic items are organized under three categories, including internal factors, external factors, and motivational factors – all of which can be identified as representing key protective factors or treatment goals
–> Research supports
(a) an association between total SAPROF scores and future violence
(b) the sensitivity of the SAPROF to capturing change over the course of treatment,
(c) an association between improvement on SAPROF scores over the course of treatment and reduced risk of future violence, and
(d) the incremental validity of the SAPROF above and beyond risk-only SPJ instruments such as the Historical Clinical Risk-20
–> a randomly selected patient that did not become violent has an 85% probability of scoring higher on the SAPROF (i.e., has more protective factors present) than a randomly selected patient that was violent
–> Essential to the SAPROF serving as a guidepost for treatment planning, research has shown that it is sensitive to capturing changes over the course of treatment and that these changes predict future violence
–> interventions had the intended effect of enhancing patients’ protection from future risk
–> research cannot pinpoint whether specific protective factors on the SAPROF are more or less responsible for decreasing violence risk
–> supplementing risk measures with structured measures of protective factors adds incremental validity in the prediction of violence
–> SAPROF added incremental predictive validity to the HCR-20, and the dynamic protective factors were particularly strongly associated with decreased risk
> integration of protective factors “narrow[s] the gap between risk assessment and risk management”

Question 64

What is the difference between historical and clinical factors?

Answer 64

historical and clinical factors differ in their relative predictive power depending on the sample and the time frame utilized, and awareness of these differences can enhance the accuracy of violence risk assessments

distinction between imminent and time-unlimited risk models
–> Static/historical factors have tended to provide the greatest predictive power in time-unlimited risk models

Criminal history variables were the best predictors [of future violence], and clinical variables showed the smallest effect sizes

Conclusions deemphasizing clinical variables in the context of time-unlimited risk, however, research examining risk for imminent violence in psychiatric samples finds the opposite

• -> clinical risk factors, have the potential to improve decision making about violence in the context of behavioural emergencies
• -> clinical variables—such as impulsivity, anger, and psychiatric symptoms—to be most useful for identifying patients at highest risk for inpatient violence

Question 65

What is evidence based violence risk practice?

Answer 65

defined as “the process of gathering information about people in a way that is consistent with and guided by the best available scientific and professional knowledge to

• -> understand their potential for engaging in violence against others in the future
• -> determine what should be done to prevent this violence from occurring

Question 66

What should the practice of violence risk assessment in general clinical practice optimally involve and why?

Answer 66

an integrative, three-step process

• -> comprehensive evaluation of empirically derived violence risk factors with particular attention to dynamic clinical factors
• -> individualized anamnestic analysis
• -> identification of dynamic protective factors to guide risk management

provides a framework for the integration of nomothetic data derived from the best available research with idiographic information, allowing for highly individualized risk formulations that provide clear avenues for intervention

Question 67

What should clinicians be familiar with at a minimum in practice?

Answer 67

at a minimum clinician should be familiar with the HCR-20 V3 (Douglas et al., 2013), the most widely used structured professional judgment (SPJ)
–> particularly relevant for clinicians whose primary task is risk management

Question 68

What was recommended by Otto (2000) for the practical use of risk assessment?

Answer 68

recommended that clinicians supplement structured and empirically derived approaches to violence risk assessment with an anamnestic analysis

• -> involves an individualized analysis of the specific conditions under which an individual has become violent in the past in an effort to identify highly personalized risk and protective factors
• -> seek to identify past triggers, stressors, or patterns that have resulted in violence in the past and that might provide relevant targets for risk management efforts

sample of screening questions as well as detailed anamnestic follow-up questions for clinicians evaluating patients’ risk of violence

• -> Screening questions included “What kind of things make you mad?”
• -> Anamnestic queries included items such as, “In what setting or environment did the altercation(s) take place?”

Question 69

What was the recommendation of Moahan*s (1981) in reference to practical use of risk assessment?

Answer 69

consider the extent to which the current context approximates that under which the patient has become violent under stress in the past

Question 70

How is risk management in practice?

Answer 70

certain risk factors have received considerably more attention than others (e.g., anger unique among the risk factors for the amount of research devoted to)

single-factor approach, while providing information relevant to risk management, has generally overlooked strengths-based approaches aimed at increasing protective factors

multi-determined nature of violence as well as the multiple pathways for intervention
–> difference score of risk minus protective factors aided the prediction of violence

Question 71

What does the five-step model IVRAM recommend for practice in order to step towards effective risk management?

Answer 71

1. clinicians to monitor all cases for potential violence risk management needs
   - -> questions regarding patients’ histories of violence victimization and perpetration are included as part of clinicians’ standard intake procedures
   - -> inform clinical decision-making about the need to target violence risk, but they can also provide a touchstone for further violence risk assessment
   - -> contextualizing current situations through the lens of previous incidents, clients are often more likely to not only reflect on the possible risk of their current situation, but also to reflect on the possible consequences
2. conduct a comprehensive assessment of risk and protective factors
   - -> Use of established SPJ instruments
   - -> recommended that clinicians develop comprehensive checklists to serve as a structured memory aid
   - -> should be able to arrive at an informed estimate of the patient’s overall level of risk (i.e., low, medium, high)
   - -> clinicians will generally not be able to determine which risk and protective factors are likely to be most relevant to their particular patient and, in turn, which risks and protections warrant initial clinical attention.
3. anamnestic analysis to determine the idiographic factors
   - -> tactful discussions about patients’ past acts of violence perpetration are essential
   - -> interviewing approach utilized in the MacArthur Violence Study, which was based on the Conflict Tactics Scale
   - -> asked questions about a wide range of violent behaviors of varying levels of severity, with each behavior beginning with a question regarding victimization (“has anyone ever slapped you with an open hand?”), followed by perpetration (“have you ever slapped anyone with an open hand?”)
   - -> clinician’s primary aim is to evaluate which risk factors were present (and protective factors absent) when the patient was violent in the past
   - -> previously decontextualized risk factors can be anchored in a patient’s history and prioritized
   - -> targets for risk management interventions will differ depending on the idiographic violence history obtained
4. strengths-based anamnestic analysis to identify key protective factors
   - ->entails a focus on times in the past in which the patient was able to remain nonviolent under stressful circumstances, with particular attention to the protective factors that were present
5. guide empirically informed risk management efforts
   - -> as the likelihood and severity of violence risk increases, so too should clinicians’ consideration to involve external supports
   - -> External supports, such as contacting family members to assist with mitigating risk, detainment by law enforcement, and/or psychiatric hospitalization, can be conceptualized as external protective factors within the SAPROF scheme
   - -> primary focus of intervention should be directly informed from the risk and protective factors (except if imminent risk identifiable third party)
   - -> have to accommodate the psychosocial needs of the individual
   - -> clinician must choose where to begin, consideration should be given to which of the potential treatment options are most closely aligned with the patient’s presenting concerns and goals
   - -> likelihood of maintaining treatment adherence and positive expectations is increased as interventions targeting specific risk and protective factors are employed to mitigate risk