VRAs, Civil Competencies, Forensic Tx Flashcards
Barefoot v Estelle
1983
Psychiatric opinions about dangerousness were valid and acceptable in court
Coble v Texas (2010) - Must provide evidence that such testimony meets Daubert standards
Kansas v Hendricks
1997
Courts can impose a civil means of lengthening commitment post-sentence for certain populations (SVPs), noting that risk assessment must demonstrate uncontrollable bxs and the person be at high risk
(Solidified appropriateness of risk assessment in court, some states began requiring the use of risk assessment measures in these cases)
History of risk assessment
Monahan 1981 - psychologists and psychiatrists are accurate no more than 33% of the time
Then came the MacArthur Study, other studies by Monahan reevaluated, and while were still not great at risk prediction, we have many more clinical indicators with which to go off
Actuarial Risk Assessment Measures
VRAG - 600 men from a max security hospital with “serious offenses,” regression models revealed 12 variables for inclusion
HCR-20 - contains 20 items addressing historical, clinical, and risk management variables; scores above the media on can indicate 6-13xs more likely to be violent
MacArthur Violence Risk Assessment Study
In general
Large group of inpatients from acute civil inpatient facilities
18-40yo, multiple ethnicities, male and female
Looked at demographic variables, historical variables (work hx, hx of violence, family hx), contextual variables (social support, stress, presence of weapons), and clinical variables (sxs, type of disorder, substance abuse, level of functioning)
Some variables from the MacArthur Study
Sex (men), prior violence, childhood experience of violence (physical abuse only), dx (co-occurring substance disorder increased risk), psychopathy (not predictive!), delusions (not associated), hallucinations (commands to commit violent acts specifically), violent thoughts, anger
Ideal approach to violence risk assessment
Using a combination approach…over any single actuarial assessment
When can you allow clinical judgement into actuarial risk assessment
When there is questionable validity generalization - when your person falls outside the norm group (white men)
Rare risk or protective factors - broken leg countervailings
Four steps to the VRA process
Identifying empirically valid risk factors
Determine the method for scoring the risk factors
Establishing a procedure for combining the scores
Producing an estimate of violence risk
Pure clinical judgement uses none of these, VRA based on a list of risk factors uses one, SPJ uses two, VRAG has all four
Communicating risk assessment
Use multiple methods
Utilize probabilistic descriptors (%) for common events
Utilize categorical descriptors (low, med, high) for rarer events
Tarasoff v Board of Regents
1976
Therapists DO have a duty to protect
Kansas v Crane
2002
Dangerous individuals needn’t be COMPLETELY unable to control their behavior in order to be committed by the state
(SVP case)
Sexual Offender Risk Assessment Tools
Static-99-R
10 items, AUC .69-.79, doesn’t include all factors relevant
SVR-20
SPJ measure, 20 factors, AUC .56-.83, less research than the STATIC
What is guardianship
A legal mechanism by which the state delegates authority over an individuals person or estate to another party
Guardian - health decisions
Conservator - finances
Guardians can be oversee everything (plenary) or limited to a certain need
What is a commonly used, less restrictive alternative to guardianship?
An advanced directive
Created to avoid the stigma of being a ward
Guardianship hearings
Less rigorous than civil commitment Most last 15 minutes or less Proposed ward didn’t attend 2/3 of them Reports lacked detail Expert was present at 8% of them
States set forth ambiguous benchmarks for what is required (“mental illness”)
In re Boyer
Guardianship
Utah statute was too vague and state Supreme Court pressed for an inability-to-care-for-self standard (grave disability)
Many states take a slightly better approach, looking at functional impairment
Evidentiary standard for guardianship
Some states require considerable evidence of incompetence, others just ask for proof that the person made an incompetent decision (like foolishly spending a lot of money)
Many states don’t require guardianship evaluations prior to a court proceeding, but they can be granted if demanded by the petitioner
Things to consider with guardianship evaluations
Whether incapacity is due to deficits in hearing, sight, processing speed, etc.
Effect the environment may have on perceived incapacities (atrophy in a skill set due to environment discouraging to do so)
Direct Assessment of Functional Status
Guardianship, highly studied instrument
Contains items that assess a variety of functional domains, requires the individual to perform sets of activities that the evaluator assigns points to
Assessment Capacity for Everyday Decision Making
Assesses persons capacity to make a decision with regard to solving their own functional problems
Includes semi structured interview, competency rubric developed by Grisso and Appelbaum
Advanced directive
Instructions from a competent individual, directing or authorizing certain actions if the person becomes unable to make their own decisions
Intended to protect autonomy by delegating wishes to someone else
Durable Power of Attorney
Used to cover nonterminal situations as well as directions concerning property
Competence to make treatment decisions
Requirements of informed consent
Promote autonomy
Encourage rational decision making
Protect safety/welfare of patients or research subjects
