Danielle Matsuo - Dept Attorney General & Justice - Mad, Bad or Dangerous to Know? Understanding Violence Risk


Published on

Danielle Matsuo, College of Forensic Psychologists A/ Director, Sex & Violent Offender Therapeutic Programs, Corrective Services NSW, Department of Attorney General and Justice presented this at the 2nd Annual Forensic Nursing Conference.

This is the only national even of its kind promoting research and leadership for Australia's Forensic Nursing Community. The program addresses future training of forensic nursing examiners, forensic mental health consmers, homicide and its aftermath, ethical dilemmas in clinical forensic medicine, child sexual abuse, providing health care to indigenous patients in the forensic arena and more.

To find out more about this conference, please visit http://www.healthcareconferences.com.au/forensicnursing

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Danielle Matsuo - Dept Attorney General & Justice - Mad, Bad or Dangerous to Know? Understanding Violence Risk

  1. 1. Mad, bad or dangerous to know?: Violence risk assessment and management DANIELLE MATSUO, M. PSYCH (FORENSIC), MAPS STATE-WIDE MANAGER PROGRAMS, CORRECTIVE SERVICES NSW
  2. 2. Overview  Theories of aggression and violent behaviour - how does violence occur?  Development of violence risk assessment – from dangerousness to risk management  Risk factors for violence – what is the relationship between mental illness, personality disorder and violence?  Conceptualising psychopathy – are psychopaths more dangerous?  Managing challenging and violent behaviour  Concluding comments & questions
  3. 3.  The World Health Organization (WHO) has identified violence as a public health issue and had urged “the health sector (in conjunction with the criminal justice sector) … to take a much more proactive role in violence prevention…” (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002, p. 246).
  4. 4. Theories of aggression and violence  Early theories of aggression hypothesised that human aggression was the result of a frustrated attempt at goal attainment   Made no reference to the role of mental processes within the sequence (Dollard et al. 1939) Since then it has become clear that cognitions play an increasingly critical role in mediating instinct-response sequences (Berkowitz, 1989)
  5. 5. Theories of aggression and violence  Social learning theory (Bandura, 1983)  Cognitive neo-association theory (Berkowitz, 1984, 1989, 1990) Script theory (Huesmann, 1988; 1998)  Excitation transfer theory (Zillman, 1983)  Social interaction theory (Tedeschi & Felton, 1994)  Neuropsychological deficits (Bartholomew & Sestir, 2007) 
  6. 6. Theories of aggression and violence  General Aggression Model (Anderson & Bushman, 2002):  multi-factor model that accounts for variability in aggression across time, people and contexts as different knowledge structures develop and change, and different contexts prime different knowledge structures  Top-down model: Focuses on how development of knowledge structures influences early, downstream psychological processes e.g. visual perception, judgment/decision-making  Better explains aggressive acts based on multiple motives e.g. instrumental and reactive violence
  7. 7. General Aggression Model (Anderson & Bushman, 2002) Preparedness to aggress. E.g. personality traits, values, attitudes, beliefs, scripts, gender, genetic predisposition. E.g. Hostile thoughts/ interpretations, scripts. Involves both automatic (appraisal) and controlled (re-appraisal) processes E.g. cues, provocation, pain, drugs, incentives. E.g. mood, emotion, expressive motor responses. Low v. high.
  8. 8. General Aggression Model (Anderson & Bushman, 2002)  Other considerations:  Opportunity (i.e. context or situation)  Disinhibiting factors – moral disengagement, substances  Threat  Role to hierarchy of needs of anger? – don’t assume that anger is the cause of the aggression
  9. 9. Schemas or Implicit theories – Polaschek, Calvert & Gannon (2009)  Four schema variations which captured dominant themes in offenders’ violent cognition  1. Normalisation of violence  2. Beat or be beaten  a) to protect oneself, and  b) to achieve social status/power  3. I am the law  4. I get out of control
  10. 10. Violence risk assessment – from dangerousness to risk management  Can we predict violent behaviour?
  11. 11. Base rates for violence     Much easier to predict a behaviour with a higher base rate Meta-analyses: base rates for violent recidivism around 21%-25% (Campbell, French & Gendreau, 2009; Yang, Wong & Coid, 2010) Violent offences such as assault and armed robbery have much higher base rates than more serious offences such as homicide NSW statistics (Jones et al., 2006):  31% of those who had been incarcerated for a most serious offence of violence as their index episode reoffended (any type) on parole.
  12. 12. Generations of risk assessment  First generation – clinical judgment  Second generation – Actuarial/Static: designed to provide a baseline risk for violence     Cannot be used to measure change; clinical utility? Referred to ‘dangerousness prediction’ (Monahan, 1981) ‘Dangerousness’ connotes a dichotomous state – either one is or is not dangerous (Ogloff & Davis, 2005) Third generation – Incorporating dynamic risk factors   Structure professional judgment tools – no algorithmic rules for combining items to come to a clinical decision Specify a list of empirically derived risk factors related to violence
  13. 13. Generations of risk assessment  Third generation (continued)…  Provide scoring guidelines and a guide for a final decision about risk (low, moderate, high)  Attend to other features of risk apart from likelihood e.g. imminence, severity, targets, nature and management (Ogloff & Davis, 2004; Hart & Logan, in press)  Prediction of dangerousness was no longer the task – the term risk assessment incorporates 3 components (of dangerousness):  1)  2) harm,  3)  risk factors, risk level Fourth generation – specific purpose such as measuring change after treatment, e.g. VRS
  14. 14. Risk factors for violence (Douglas & Skeem, 2005)  Static:  Instability of upbringing  Violence throughout life span  Age of first violent conviction  Previous  Prior violence convictions supervision failure
  15. 15. Risk factors for violence  Dynamic:  Impulsiveness  Negative affect – anger; negative mood  Psychosis  Antisocial attitudes  Personality  Substance abuse  Interpersonal  Treatment relationships alliance and adherence
  16. 16. Violence and psychosis  The emergence of persecutory delusions in untreated schizophrenia explains violent behaviour (Keers, Ullrich, Destavola & Coid, 2013).  Maintaining psychiatric treatment after release can substantially reduce violent recidivism among prisoners with schizophrenia.  Temporal proximity is crucial when investigating relationships between delusions and violence (Ullrich, Keers & Coid, 2013; Coid, Ullrich, Kallis, Keers, Barker & Cowden, 2013).  Highly prevalent delusional beliefs implying threat were associated with serious violence, but they were mediated by anger.
  17. 17. Violence and personality disorder  PDs consistently found to be associated with aggression & violence – ASPD, BPD, NPD, PPD and psychopathy (Gilbert & Daffern, 2011)  For subjects who had hx of aggression, ASPD accounted for most variance in the study; BPD alone was weak but those with BPD + high trait anger + aggression supportive beliefs + frequent rehearsal of aggressive scripts = increased risk of violence (Gilbert, Daffern, Talevski & Ogloff, 2013)
  18. 18. Conceptualising psychopathy – are they more dangerous?  What do you think of when you think of a psychopath?  What do they look like?
  19. 19. Common misconceptions about Psychopathy  Psychopath = serious violent offender  Psychopathy is equivalent to anti-social personality disorder  Psychopaths are born not made
  20. 20. Debate in the literature  Should adaptive features be included in the definition?  Are anxious, emotionally reactive people fundamentally psychopathic? Does secondary psychopathy exist?  Should anti-social behaviour be in the definition?  Psychopathy is unchangeable  (Skeem, Polaschek, Patrick & Lilienfeld, 2011)
  21. 21. Primary vs. Secondary psychopathy
  22. 22. Psychopathy as defined by the PCL  Original construct doesn’t actually require violent or criminal behaviour  It doesn’t capture low anxiety or fearlessness  Therefore when you use the PCL you create a picture of someone more aggressive or dysfunctional than Cleckley intended
  23. 23. Use of the PCL in risk assessment  Evidence shows that the predictive power of the PCL comes from Factor 2 (Yang, Wong & Coid, 2010)  Kennealy et al. (2010) demonstrated that it is not the case that when you add Factor 1 scores to Factor 2 it creates someone of greatly higher risk of violence = no interaction
  24. 24. Psychopaths as more “dangerous”?  Are psychopaths more dangerous than other offenders?  If so, why?
  25. 25. Does Treatment make a Psychopath worse?  Rice et al. (1992): unstructured patient-run therapeutic community increased violent recidivism rates  Hare et al (2000) obtained similar results in the UK ( Factor 1 =  recidivism)  Any treatment does run the risk of improving skills in deception, manipulation etc.
  26. 26. Treatment program for psychopaths (Wong & Hare, 2005)       Interventions should target Risk, Needs, Responsivity principles Psychopathic personality is not the treatment target Psychopathic traits will however influence the course of treatment The skill is in the delivery, not the content! Training, support and supervision is required for clinicians working with psychopathic offenders Integrated team management
  27. 27. Polaschek (2011)  138 high risk violent male offenders  70% completed the full 28 week intensive CBT based program  330 hours, closed groups of 10 men with 2 therapists  PCL score did not predict non-completion  Moderate to high PCL scorers demonstrated a subsequent reduction in recidivism
  28. 28. Treatment approaches – what works?  Interventions for aggressive adult offenders must be grounded in theory as to the kinds of cognitions that need targeting and how this might be achieved (Polaschek et al., 2009)  Must be specialized, intense and comprehensive enough to treat the entrenched cognitions specific to violent behavior (McGuire, 2008; Gilbert & Daffern, 2010) = CBT based 300+ hours  Violent offender treatment has been shown to reduce violent behavior for many participants (Di Placido, Simon, Witte, Gu, & Wong, 2006; Polaschek et al., 2005; Polaschek, 2011)
  29. 29. Treatment approaches – what works?  Mindfulness associated with less impulsiveness, anger and hostility (Brown & Ryan, 2003; Heppner et al, 2008; Borders, Earleywine & Jajodia, 2010; Fix & Fix, 2013)  DBT reduces violent episodes in: forensic patients (Evershed et al, 2003)  incarcerated juvenile offenders (Quinn & Shera, 2009)  offenders with an intellectual disability (Morrissey et al, 2011; Sakdalan et al, 2010)  domestic violence offenders (Rathus et al, 2006)   Wright, Day & Howells (2009) – mindfulness as anger management
  30. 30. Managing violent and challenging behaviours in treatment  What are some of the things you find difficult in working with an aggressive or behaviourally challenging client?
  31. 31. Therapeutic alliance    “Task, bond and goal” (Bordin, 1979) Ross, Polaschek & Ward (2008) suggested knowing these are high risk violent offenders, cluster B personality, or high psychopathy plus general suspicion about the veracity of offender selfpresentation in therapy fuels therapist suspicion about the genuineness of their behaviour and makes it hard to form a bond Key skills: treat the person not the offence (or the label), every one has an individualised treatment plan
  32. 32. Increasing motivation – Cognitive distortions  ‘Resistant’ (Hemphill & Hart, 2002)  Cognitive distortions - minimise and deny; blame others; mislabel; justify (Chambers et al, 2008)  Mistrustful, paranoid and hostile  Key skill: Motivational Interviewing (Miller & Rollnick, 2013)
  33. 33. Increasing motivation – Cognitive distortions  Key skills:  Give feedback that hostility is understandable but inappropriate whilst you maintain a positive therapeutic position  Reduce hostility by encouraging respect and trust  If disagreements can be resolved, not only will appropriate behavior be modeled, but also efficacy can be gained through the therapeutic process (Deffenbacher, Lynch, Oetting, & Kemper, 1996).
  34. 34. Increasing motivation – Cognitive distortions Monitor your own behaviors to ensure you do not blame the offender, adopt a confrontational approach, project yourself as ‘experts’, or focus on entrenched underlying problems too early in the therapeutic process  Listen and reflect back to the offender (Marshall & Serran, 2004). Aim to teach pro-social cognition skills to restore offenders to the position of autonomous, self-disciplined, and selfregulating individuals 
  35. 35. Increasing motivation – Emotional responsivity  Key skills: Low levels of client emotional responsivity can be effectively treated, but it is likely that this requires higher levels of therapist responsivity and skill (Howells & Day, 2006)  Talking explicitly about anger and violence with offenders who use antecedent focused regulation strategies may be experienced as too confronting or irrelevant  Rather, locate their experiences within a broad developmental framework that builds on the selfidentification of problems 
  36. 36. Engaging the Psychopath      Key skills: Focus on tasks and goals and not on bond (NB: Ross, Polaschek & Wilson, 2011 – bond may improve) Working relationship must be respectful and professional Attempts at boundary violations need to be addressed immediately (boundaries among staff extremely important) Manage treatment interfering behaviours in firm and fair way before proper treatment can proceed
  37. 37. Engaging the psychopath     Key skills: “Strategy of choices” (Harris, Atrill & Bush, 2004) uses psychopathic offenders need for control and choice as a way of promoting self-responsibility and self-management Conscious choice between learning/practicing the skills required to understand the links between old patterns of thinking and behaving, and those needed to engage in self-serving but pro social alternative behaviours Moral reasoning will have little impact
  38. 38. Maintaining professional boundaries and self-care  What indications are there for counter-transference issues?  How do you ensure that you remain professional and respectful?  Supervision, support and training  Integrated management – treatment team  Expect difficulties – be proactive in managing them (important for managers/supervisors)
  39. 39. Questions  Danielle.Matsuo@dcs.nsw.gov.au