Assessment of Dangerousness

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Assessment of Dangerousness

  1. 1. “ To Commit or Not to Commit” Barry Mills MD Cambridge Health Alliance Forensic Psychiatry Update
  2. 2. Forensic Psychiatry <ul><li>Types of Forensic Psychiatry </li></ul><ul><li>Civil/Legal </li></ul><ul><li>Criminal/Correctional </li></ul>
  3. 4. <ul><li> Dr. Hannibal Lecter, Psychiatrist </li></ul><ul><li>“ Most memorable villain in film history” (AFI) </li></ul> Silence of the Lambs (1991)
  4. 5. Requirements to Assess Danger <ul><li>The patient is mentally ill </li></ul><ul><li>By virtue of said disorder, there is a likelihood of serious harm </li></ul><ul><li>A substantial risk of physical harm to the person, manifested by threats of, or attempts to suicide, or to cause serious bodily harm </li></ul><ul><li>A substantial risk of physical harm to other persons , manifested by homicidal or other violent behavior, or by others being placed in reasonable fear of violent behavior and serious physical harm </li></ul><ul><li>A very substantial risk of physical impairment or injury to the person, manifested by evidence that the person’s judgment is so affected that he is unable to protect himself in the community </li></ul>
  5. 6. Key Terms for Documentation <ul><ul><li>Use these terms when documenting </li></ul></ul><ul><ul><li>presence/absence of danger: </li></ul></ul><ul><ul><li>“ substantial” AND “imminent” danger </li></ul></ul><ul><ul><li>dangerous “as a result of mental illness” </li></ul></ul><ul><ul><li>(not just mentally ill AND dangerous) </li></ul></ul><ul><ul><li>“ with reasonable medical certainty” </li></ul></ul><ul><ul><li>“ least restrictive alternative” </li></ul></ul><ul><ul><li>“ violence prediction is not highly accurate” </li></ul></ul><ul><ul><li>“ based upon available information” </li></ul></ul>
  6. 7. Special Complications in Assessing Dangerousness <ul><li>Violence = Rare Statistical Event (High False Positives) </li></ul><ul><li>Magnitude vs Likelihood vs Imminence vs Frequency, Mentally Ill vs Non-Mentally Ill; Hospitalized vs Non-Hospitalized; Property vs Persons; Merely Assaultive vs Lethal Violence; Dynamic vs Static Factors; Clinical vs Research Populations; Crime vs Violence; Threats vs Action; Long-term vs Short-term Risks </li></ul><ul><li>APA opposed Legal transformation of psychiatric hospitalization criterion to dangerousness </li></ul><ul><li>Double Bind - LAW (and MANAGED CARE) require Psychiatry to accomplish something (accurately predict dangerousness) while SCIENTIFICALLY we admit it cannot be done </li></ul>
  7. 8. DangerousnessMental Health <ul><li>“ In forty years, all psychiatric hospitals will be forensic hospitals ” </li></ul><ul><li> – Tom Gutheil MD </li></ul><ul><li>ISSUES: </li></ul><ul><li>Patients presenting to public mental health systems are more dangerous </li></ul><ul><li>A primary criterion for inpatient hospitalization is increasingly becoming the presence/absence of ‘imminent’ danger </li></ul><ul><li>QUESTIONS: </li></ul><ul><li>THEORITICAL: WHY are we required to assess/manage dangerousness? </li></ul><ul><li>PRACTICAL: HOW do we become better at assessing/managing dangerous? </li></ul>
  8. 10. “To Commit or Not to Commit” <ul><li>Leroy Hendricks, Pedophilia </li></ul><ul><li>Convicted of sexual assaulting two children (1984) </li></ul><ul><li>Served Maximum sentence of 10 years (1994) </li></ul><ul><li>Kansas Sexually Violent Predator Act </li></ul><ul><li>(very politically popular) </li></ul><ul><li>Indefinitely committed (with 150+ other pedophiles) to Larned State Hospital </li></ul>
  9. 11. Kansas v. Hendricks 521 U.S. 346 (1997) <ul><li>U.S. Supreme Court (Justice Clarence Thomas) </li></ul><ul><li>Allows transfer of convicted sex offenders to hospitals after completing maximum prison sentence </li></ul><ul><li>MD examination, Diagnosis, Mental illness or Treatment not required for commitment </li></ul><ul><li>Allows indefinite commitment based upon past (not current) behavior </li></ul><ul><li>150+ such persons now committed in Kansas </li></ul><ul><li>17 other states now have similar statutes </li></ul><ul><li>Massachusetts: U.S. v Shields affirmed this week </li></ul><ul><li>Expansion of psychiatry’s collaboration with police power </li></ul><ul><li>Conflicts with JCAHO directive (will not accredit hospital) </li></ul>
  10. 13. Two Generations of Violence Assessment <ul><li>First Generation </li></ul><ul><ul><li>Clinical/Individual </li></ul></ul><ul><ul><li>VERY POOR ability to predict violence </li></ul></ul><ul><ul><li>Scandals/APA </li></ul></ul><ul><li>Second Generation </li></ul><ul><ul><li>Experimental/Groups </li></ul></ul><ul><ul><li>Mild Improvements in Ability to Predict Violence </li></ul></ul><ul><ul><li>Actuarial Contributions </li></ul></ul>
  11. 14. First Generation <ul><li>Baxstrom v Herald (1966) </li></ul><ul><ul><li>966 violent patients in maximum security </li></ul></ul><ul><ul><li>suddenly released to community by Court Order </li></ul></ul><ul><li>Steadman & Coccoza (1974) </li></ul><ul><ul><li>Only 20% of these ‘dangerous’ patients rearrested, most for non-violent offenses </li></ul></ul><ul><li>Monahan (1984) </li></ul><ul><ul><li>Upper Bound of Accuracy = .33 </li></ul></ul>
  12. 15. <ul><li>“ If a child had bedwetting, fire setting and </li></ul><ul><li>cruelty to animals as well as difficulty getting </li></ul><ul><li>along with peers and authority figures, this </li></ul><ul><li>this indicates future dangerousness” </li></ul><ul><li>- Dr. James Grigson, Danish TV </li></ul><ul><li>“ 100% and absolute” predictions of dangerousness </li></ul><ul><li>Always testified defendant was incorrigibly dangerous </li></ul><ul><li>Named in multiple U.S. Supreme Court Decisions </li></ul><ul><li>Thousands of forensic evaluations (hundreds on death row) </li></ul><ul><li>Expelled from APA in 1995 (made him more popular) </li></ul><ul><li>Medical License and Board Certification Intact </li></ul>JAMES GRIGSON MD (aka Dr. Death)
  13. 17. Barefoot v. Estelle 463 US 880 (1983) <ul><li>James Grigson MD testified defendant was </li></ul><ul><li>future danger without examination </li></ul><ul><li>Two Issues for Psychiatry </li></ul><ul><ul><li>Ability of Psychiatrists to Predict Dangerousness </li></ul></ul><ul><ul><ul><li>APA Amicus Curiae Brief (testimony almost entirely unreliable) </li></ul></ul></ul><ul><ul><ul><li>Supreme Court rejected argument Psychiatrists unable to predict dangerousness - “not always wrong.” </li></ul></ul></ul><ul><ul><li>Whether Psychiatrists can testify to Hypothetical Fact Situation </li></ul></ul><ul><ul><ul><li>Court (Yes) vs APA (No) </li></ul></ul></ul><ul><li>Thomas Barefoot executed on Oct 30, 1984 </li></ul>
  14. 18. Barefoot v. Estelle 463 US 880 (1983) <ul><li>“ To accept such an argument (i.e. inability of </li></ul><ul><li>psychiatrists to predict dangerousness) would </li></ul><ul><li>call into question predictions of future behavior </li></ul><ul><li>that are constantly made in other contexts ” </li></ul><ul><li>- Justice Byron White </li></ul>
  15. 20. “ Thin Blue Line” Directed by Errol Morris (1988) <ul><li>“ The Thin Blue Line is a colloquial term referring </li></ul><ul><li>to the thin division between order and anarchy </li></ul><ul><li>maintained by the police. Alternatively, the term </li></ul><ul><li>is used pejoratively to refer to police corruption” </li></ul><ul><li>Randall Dale Adams </li></ul><ul><li>Expert Testimony of Dr. James Grigson </li></ul><ul><li>Sentenced to death for murder of police officer (1976) </li></ul><ul><li>Case overturned 8:1 by U.S. Supreme Court (1989) upon evidence DA fabricated evidence </li></ul><ul><li>Mr. Adams now works as anti-death penalty activist </li></ul>
  16. 22. Two Generations of Violence Assessment <ul><li>First Generation </li></ul><ul><ul><li>Clinical/Individual </li></ul></ul><ul><ul><li>VERY POOR ability to predict violence </li></ul></ul><ul><ul><li>Scandals/APA </li></ul></ul><ul><li>Second Generation </li></ul><ul><ul><li>Experimental/Groups </li></ul></ul><ul><ul><li>Mild Improvements in Predictions </li></ul></ul><ul><ul><li>Actuarial Contributions </li></ul></ul>
  17. 23. Clinical vs Actuarial Assessment Higher Lower Practicality Higher Lower Lower Clinical Lower Higher Higher Actuarial Individualized Reliability Validity
  18. 24. Actuarial Risk Assessment <ul><li>More Scientific but Less Individual Clinical Application </li></ul><ul><li>‘ Grocery List’ Approach to Violence Assessment </li></ul>
  19. 25. <ul><li>What is the single best </li></ul><ul><li>predictor of future violence? </li></ul>QUIZ TIME! WRONG! “ PAST VIOLENCE”
  20. 26. Recidivistic Violence <ul><li>Least Recidivistic Crimes </li></ul><ul><ul><li>Murder </li></ul></ul><ul><li>Most Recidivistic Crimes? </li></ul><ul><ul><li>? </li></ul></ul>
  21. 27. Recidivistic Violence <ul><li>Least Recidivistic Crimes </li></ul><ul><ul><li>Murder </li></ul></ul><ul><li>Most Recidivistic Crimes? </li></ul><ul><ul><li>Pedophilia, Arson, Car Theft </li></ul></ul>
  22. 29. Risk Factors for Violence <ul><li>Paranoia (especially violence-related delusions) </li></ul><ul><li>Child History: (not enuresis) </li></ul><ul><li>ADHD, fire-setting, cruelty to animals </li></ul><ul><li>Ten (or more) psychiatric admissions </li></ul><ul><li>CATIE: </li></ul><ul><ul><li>Positive Symptoms ↑ RISK </li></ul></ul><ul><ul><li>Negative symptoms ↓ RISK </li></ul></ul><ul><li>Disorganization ↓ RISK (Paradox of Atypicals) </li></ul><ul><li>Mania: Inpatient (but not for serious violence) </li></ul>
  23. 30. Risk Factors for Violence <ul><li>Substance Abuse as Risk Factor for Violence </li></ul><ul><ul><li>Stimulants, Stimulants, Stimulants </li></ul></ul><ul><ul><li>ETOH intoxication </li></ul></ul><ul><ul><li>Disinhibition </li></ul></ul><ul><ul><li>Akathisia ( “Prozac made me do it”) </li></ul></ul><ul><li>Hallucinations as Risk Factor for Violence </li></ul><ul><ul><li>Command </li></ul></ul><ul><ul><li>Familiar Voice </li></ul></ul><ul><ul><li>Associated with Negative Emotion (anger, anxiety, etc) </li></ul></ul>
  24. 31. MacArthur Foundation Violence Risk Assessment Study <ul><li>Most valid predictive factors in assessing </li></ul><ul><li>violence risk among mentally ill: </li></ul><ul><ul><li>Co-Morbid Substance Abuse </li></ul></ul><ul><ul><li>(especially stimulants) </li></ul></ul><ul><ul><li>Non-Compliance with Medications </li></ul></ul><ul><ul><li>Psychopathy (not Sociopathy) </li></ul></ul>
  25. 33. Affective vs Predatory Violence <ul><li>Affective Violence </li></ul><ul><ul><li>Grievance  Emotion  Attack </li></ul></ul><ul><li>Predatory Violence </li></ul><ul><ul><li>Grievance  Idea/Plan  Attack </li></ul></ul>
  26. 34. Psychopathy- Jack Nicholson <ul><li>The Shining One Flew Over the Cuckoo’s Nest The Departed </li></ul>
  27. 35. Psychopath vs Sociopath? <ul><li>Antisocial Personality Disorder </li></ul><ul><ul><li>Behavioral/Sociological </li></ul></ul><ul><ul><li>Categorical (All-Or-Nothing) </li></ul></ul><ul><ul><li>NOT synonymous with criminality </li></ul></ul><ul><ul><li>APD = 1/3 prison population </li></ul></ul><ul><li>Psychopathic Personality Disorder </li></ul><ul><ul><li>Intrapsychic/Dynamic </li></ul></ul><ul><ul><li>Dimensional (Low, Medium, High) </li></ul></ul><ul><ul><li>PPD = 1/10 of prison population </li></ul></ul>
  28. 36. Psychopath vs Sociopath? <ul><li>Antisocial Personality Disorder </li></ul><ul><ul><li>Behavioral/Sociological </li></ul></ul><ul><ul><li>Categorical (All-Or-Nothing) </li></ul></ul><ul><ul><li>NOT synonymous with criminality </li></ul></ul><ul><ul><li>APD = 1/3 prison population </li></ul></ul><ul><li>Psychopathic Personality Disorder </li></ul><ul><ul><li>Intrapsychic/Dynamic </li></ul></ul><ul><ul><li>Dimensional (Low, Medium, High) </li></ul></ul><ul><ul><li>PPD = 1/10 of prison population </li></ul></ul>
  29. 37. Robert Hare PhD <ul><li>PCL-R (Hare Psychopathic Checklist) </li></ul><ul><li>Factor 1 – Aggressive Narcissism </li></ul><ul><li>Factor 2 – Socially Deviant Lifestyle </li></ul><ul><li>Factor 3 – Miscellaneous (no internal correlations) </li></ul><ul><ul><ul><li>Promiscuous sexual behavior </li></ul></ul></ul><ul><ul><ul><li>Many short-term marital relationships </li></ul></ul></ul><ul><ul><ul><li>Criminal Versatility </li></ul></ul></ul>
  30. 38. Hare Psychopathic Personality Checklist (PCL-R) <ul><li>Factor 2 – Socially Deviant Lifestyle </li></ul><ul><ul><li>Need for stimulation/proneness to boredom </li></ul></ul><ul><ul><li>Parasitic lifestyle </li></ul></ul><ul><ul><li>Early behavioral problems </li></ul></ul><ul><ul><li>Lack of realistic, long-term goals </li></ul></ul><ul><ul><li>Impulsivity </li></ul></ul><ul><ul><li>Irresponsibility </li></ul></ul><ul><ul><li>Juvenile Delinquency </li></ul></ul><ul><ul><li>Revocation of Conditional Release </li></ul></ul>
  31. 39. Hare Psychopathic Personality Checklist (PCL-R) <ul><li>Factor 1 – Aggressive Narcissism </li></ul><ul><ul><li>Glibness/superficial charm </li></ul></ul><ul><ul><li>Grandiose sense of self-worth </li></ul></ul><ul><ul><li>Pathological Lying (not goal-focused) </li></ul></ul><ul><ul><li>Conning/Manipulative (goal-focused) </li></ul></ul><ul><ul><li>Lack of remorse or guilt </li></ul></ul><ul><ul><li>Shallow affect </li></ul></ul><ul><ul><li>Callous/lack of empathy </li></ul></ul><ul><ul><li>Failure to accept responsibility for own actions </li></ul></ul>
  32. 40. Hare Psychopathic Personality Checklist (PCL-R) <ul><li>Hare PCL-R Scoring ( www.hare.org/training ) </li></ul><ul><ul><li>Structured Interview and Review of Records </li></ul></ul><ul><ul><li>Items 0,1 or 2 based upon standard scale </li></ul></ul><ul><ul><li>Prison Average = 22 vs Normal Population = 5 </li></ul></ul><ul><ul><li>Scores > 30 = Psychopath </li></ul></ul><ul><ul><li>(highly associated with future violence) </li></ul></ul>
  33. 42. ‘ Myths’ of Psychopathy <ul><ul><li>Key = Pervasive Aggressive Manipulation </li></ul></ul><ul><ul><li>“ Contemptuous Delight” - Reid Meloy PhD </li></ul></ul><ul><ul><li>‘ Burn-Out’ at 40 (only Factors 2 and 3 appears to ameliorate) </li></ul></ul><ul><ul><li>Management vs Treatment (specialized Forensic Programs) </li></ul></ul><ul><ul><li>Very High/Low IQ – BOTH indicate Poor prognosis </li></ul></ul><ul><ul><li>High Counter-Transference Risks (Negative and Positive ) </li></ul></ul><ul><ul><li>Differentiate from Organic Pseudo-Psychopathy (Phineas Gage) </li></ul></ul><ul><ul><li>Mentally ill can have high degrees of Psychopathy </li></ul></ul><ul><ul><li>Psychopathy is NOT necessarily associated with incarceration </li></ul></ul>
  34. 43. “ The Corporation” by Joel Bakan <ul><li>2003 Documentary Film </li></ul><ul><li>Applies ‘Psychopathy’ to Modern Corporation </li></ul><ul><ul><li>Callous unconcern for the feelings of others </li></ul></ul><ul><ul><li>Incapacity to maintain enduring relationships </li></ul></ul><ul><ul><li>Reckless disregard for the safety of others </li></ul></ul><ul><ul><li>Repeated lying to and deceiving of others for profit </li></ul></ul><ul><ul><li>Incapacity to experience guilt </li></ul></ul><ul><ul><li>Failure to conform to the norms for lawful behaviors </li></ul></ul>Haliburton Inc.
  35. 44. Robert Hare PhD
  36. 46. “ To Commit or Not to Commit” Barry Mills MD Cambridge Health Alliance Forensic Psychiatry Update

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