Risk Assessment of Violence as it relates to mental health assessment of risk of harm to self or others, includes schizophrenia-related psychosis.

1. Risk Assessment of ViolenceRisk Assessment of Violence
Adell M. Dolban, BA, MACP (c)Adell M. Dolban, BA, MACP (c)

2. TopicsTopics
• Risk: Defining the problem
• Why assess risk?
• Limits of confidentiality related to
risk
• Duty to warn
– Tarasoff case (U.S.)
– Smith case (B.C., Canada)
• Who is at risk?

3. Topics continuedTopics continued
• What types of violence are there?
– Forms as related to psychopathology
• Staying safe
– Stalking concerns
• How to assess?
– Risk assessment forms

4. What is ‘Risk’?What is ‘Risk’?
• the possibility that something bad or
unpleasant (such as an injury or a
loss) will happen
• someone or something that may
cause something bad or unpleasant
to happen
– http://www.merriam-
webster.com/dictionary/risk

5. What is Risk? - continuedWhat is Risk? - continued
• Risk to harm someone or self
• Risk of re-offending or relapsing
• Risk of fleeing, escaping, non-
complying
• Risk of remaining in a violent
situation
• Can you think of others?

6. Why assess risk?Why assess risk?
• Promote public safety
• Intervention measures
• Identify need for resources
• Effective case management
• Recovery measures
• Can you think of other reasons?

7. Confidentiality & RiskConfidentiality & Risk
• The CCPA’s Code of Ethics (2007) states:
– B2. Confidentiality
– Counselling relationships and information resulting therefrom
are kept confidential.
– However, there are the following exceptions to confidentiality:
– (i) when disclosure is required to prevent clear and imminent
danger to the client or others;
– (ii) when legal requirements demand that confidential material
be revealed;
– (iii) when a child is in need of protection. (See also B15, B17,
E6, E7, F8)

8. Duty to WarnDuty to Warn
• B3. Duty to Warn
• When counsellors become aware of the
intention or potential of clients to place
others in clear or imminent danger,
they use reasonable care to give
threatened persons such warnings as
are essential to avert foreseeable
dangers.
– http://www.ccpa-
accp.ca/_documents/CodeofEthics_en_n
ew.pdf

9. Duty to Warn continuedDuty to Warn continued
• Tarasoff v. University of California
(1974)
– Tatiana Tarasoff, killed by 26-year old
male that disclosed desire to kill her
during a session he had
• Smith v. Jones (1999)
– Jones disclosed to Dr. Smith his “detail,
his plans to kidnap, rape and kill
prostitutes”.
• http://www.ccpa-accp.ca/_documents/NotebookEthics/Duty%20to%20Warn.pdf

10. Who is at risk?Who is at risk?
• Levels to be considered include:
– Risk to self
– Risk to others
Family members
Therapist/counsellor
Agency
Community members

11. Violence & PsychosisViolence & Psychosis
• Schizophrenia & Violence
– Positive symptoms increase risk
• delusions
• hallucinations
• disorganization (thoughts/behaviour)
• grandiosity
• suspiciousness
– Negative symptoms decrease risk
• blunted affect
• emotional withdrawal
• poor rapport
• apathy
• lack of spontaneity
• poor abstract thinking

12. From Dr. Phillip J. ResnickFrom Dr. Phillip J. Resnick
• Violence risk factors
– Age – late teens and early 20s
– Gender – male
– IQ – lower = higher risk
– Social class – lower = higher risk

13. Other factorsOther factors
• 41% intoxicated with alcohol
• 36% on illegal drugs
– 2000, U.S. Dept. of Justice.
• Stimulants & Violence
– Lead to disinhibition
– Feelings of grandiosity
– Paranoia thoughts & behavior

14. Psychotic symptomsPsychotic symptoms
• Paranoid
– More violent in community
– Less violent in hospitals
– Violence is well-planned
– Target is misperceived persecutors
– Higher magnitude
• Disorganized
– More assaultive in hospitals
– Violence less well-planned
– Cause less serious harm
– Demented strike out haphazardly
– Lower magnitude

15. Hallucinations & ViolenceHallucinations & Violence
• Negative emotions (anger, anxiety,
sadness)
• Less successful strategies to cope
with voices
• Command hallucinations
– Important focal of assessment

16. Command HallucinationsCommand Hallucinations
• Risk:
– Suicide 52%
– Homicide 5%
– Injury to self/others 12%
– Non-violent acts14%
– Unspecified 17%
• Hellerstein, D., Frosch, W., & Koenigsberg, H. W. (1987). The clinical significance of command
hallucinations. Am. J. Psych., 144: 219.

17. Who’s voice is identifiedWho’s voice is identified
most??most??

18. Compliance with HarmfulCompliance with Harmful
CommandsCommands
• Hallucination-related delusion
• Familiar voice
– 60% identifiable
• More likely to obey
• History of compliance
• Personal superiority
• Beneficial to hallucinator

19. Delusions & ViolenceDelusions & Violence
• Delusions can be theme-related:
– Persecution
– Systemic
– Fear- or anger-driven
– Poisoned
• Wessely, S., Buchanan, A., Reed, A., Cutting, J., Everitt, B.,
Garety, P., & Taylor, P. J. (1993). “Acting on delusions. I:
Prevalance.” British journal of psychiatry, 163, 69-76.

20. Paranoid Violence MotivesParanoid Violence Motives
• Homosexual panic
• Defense of manhood
• Defense of children
• Defense of the world

21. Case example:Case example:
• In 1992 32-year old Michael Krystal was
released from mental health facility in
Saskatchewan after 21 days commitment
for symptoms and behavior consistent
with paranoid schizophrenia.
• He self-discharged then drove to a family
member’s home, and picked up his 8-year
old daughter Samantha from care.
• That night he shot her dead and then died
from a self-inflicted gunshot wound to the
head.

22. Michael was my brother andMichael was my brother and
Samantha was my nieceSamantha was my niece

23. Types of ViolenceTypes of Violence
• Affective aggression
– Patterned activation of the autonomic nervous
system
• Clenched fist, tightened jaw, expanded chest,
staring, feet apart
– Grievance, idea/emotion/attack
• Over reaction to stimulus
• Predatory aggression
– Planned, goal-directed, emotional detachment
• Anti-social personality disorder diagnosis
– Grievance, idea, research/planning, preparation, attack
Meloy, J. R. (1988). The psychopathic mind: Origins, dynamics, and
treatment. Jason Aronson, Inc.: Northvale, NJ.

24. Important questions:Important questions:
• Types of violence
– Violent crimes
– Hospitalizations for violence
– Spousal or child abuse incidents
– Fights in schools or bars
– Violent highway disputes
• Assessment:
– Why did it occur?
– Who said what?
– Drugs/alcohol involved?
– Degree of injury? Whom?
– How did the victim feel?
• Unable to answer = poor prognosis for empathy

25. Questions continuedQuestions continued
• Weapons assessment
– Ownership of weapons
– Affect about weapons
– Threats with weapons
– Movement of weapons increase risk
• Sexual aggression
– Violent masturbation fantasies
• If used before prior acts
• If increased immersion/
pre-occupation/obsession
– Behaviour rehearsal

26. Risk Screening ToolsRisk Screening Tools
• HCR-20 Violence Risk Assessment Scheme
– Empirically-supported risk factors that can
apply to any cases
– Includes 20 factors, each scored 0 (absent), 1
(possibly absent), or 2 (definitely present);
total score = 0-40
– Promotes reliability and validity with room for
flexibility
– Comprehensive
– Informs risk reduction & management

27. Don’t ever go to bed with someone more disturbed thanDon’t ever go to bed with someone more disturbed than
you are. -you are. - Oscar WildeOscar Wilde

28. Assessment ofAssessment of
DangerousnessDangerousness
• Anger displayed without empathy
• Offer food to help de-escalate
situation
• Elucidation of threats
– More intimate the relationship between
the client and the victim, the more likely
the threat is to be carried out

29. Dangerousness FactorsDangerousness Factors
• Magnitude
• Likelihood
• Imminence
• Frequency

30. Risk of ThreatsRisk of Threats
• When made face-to-face
• Increase in specifics/details
• Identity of target revealed
• Introduced late in controversy
• To partners, family members,
clinicians

31. ThreatsThreats
• Take seriously in jealous partners
• 70% who killed partners made prior
threats to kill them
• 40% of convicted threateners were
convicted of violent acts within 10
years
• Warren, L. J., et al. (2008). “Threats to kill: A
follow-up study.” Psychological medicine, 38:599-
605.

32. Threats to CliniciansThreats to Clinicians
• Do not ignore!
• Label the threat
• Acknowledge concern
• Don’t be macho!
• Seek consultation immediately
• Caution: Your emotions can become
activated as well.

33. Be Safe!Be Safe!
• Avoid individual
• Seek protection
• Decrease visibility
• Enhance vigilance
• Don’t:
– Underestimate female violence
– Overestimate minority violence
– Underestimate violence in attractive patients
– Overestimate if you see crime details

34. Consultation mattersConsultation matters
• 2 heads (or more) are better than 1
• More likely to be accurate than single
opinion
• Less likely to be successfully sued

35. Risk Screening continuedRisk Screening continued
• Whether using standardized tool or
information tool remember to ask
about:
– History
– Current state
– Recent change, stressors/losses
– Resources in place
– Risk factors
– Strengths

36. Risk assessment continuedRisk assessment continued
– Develop individual risk plan
Their narrative
Their motivation
What do they want?
What do they need?
What has worked before?
set SMART goal

37. Risk Management PlanRisk Management Plan
• Identified Risk
– Safety to self, others, depends, and HRC-20 results
• Risk Management Plan
– Specific steps highlighting how risk will be
addressed
• Warning Signs
– How and when will we know to activate the Risk
Management Plan
• Monitoring/Supervision
– Who is responsible to monitor aspects of plan? Is
there community supervision?
– Source: Canadian Mental Health Assoc. & Peel Human Services
& Justice Coordination Committee

38. Something to think about…Something to think about…
How concerned should you be
that your client might be violent
in the next 2 months? Next
month? Next week? Tomorrow?

39. Duty to Protect optionsDuty to Protect options
• Notify intended victim
• Notify law enforcement
• Discharge duty in Canada
– Hospitalize patient
– Inform victim and/or police
– Take other reasonable steps?

40. Life Inspired SongLife Inspired Song
Every breath you take
Every move you make
Every bond you break
Every step you take
I’ll be watching you….

41. StalkingStalking
• Stalking of clinicians
• Classification of stalkers
• Violence risk
• Management
• Prevention

42. Incidence of StalkingIncidence of Stalking
• 1 in 12 women over lifetime
• Women stalked 4x more than men
• 59% of female victims are stalked by
partners

43. Stalking Clinicians continuedStalking Clinicians continued
• Clinicians:
– Highest risk to psychiatrists and
psychologists
– Female 2x the risk
– Male 5x the risk
• Cluster B Personality Disorders
• Minority are psychotic
– 66% are female
– 80% are single

44. MotivesMotives
• More intimacy
• Minority seek revenge for perceived wrongs
• Types:
– Rejected 36%
– Intimacy seekers 34%
– Incompetent 15%
– Resentful 11%
– Predators 4%
• 64% made threats
• 36% assaulted the victim
• 40% damaged property
• 40% had prior convictions

45. Stalking Risk FactorsStalking Risk Factors
• Substance use/abuse
• Criminal offenses
• Making threats
• Suicidality
– Want name linked to public figure in death
– Spousal homicide-suicide
• Seen at victim’s home
• Major depression
• Threatening messages to victim
• Threats to harm victim’s children and/or pets
• Watch for warning signs!
– No regard for consequences!

46. Restraining OrdersRestraining Orders
• Works with non-violent, ‘reasonable’
stalkers, not psychotic ones
• Only one option
• False sense of security
• Earlier rather than later

47. References and RecommendedReferences and Recommended
ReadingsReadings
• Meloy, J. R., Violence Risk & Threat
Assessment: A Practical Guide for
Mental Health & Criminal Justice
Professionals [Paperback].
Amazon.ca
• Resnick, P. J. (Mar. 31, 2014). Risk
Assessment of Violence Workshop.
Toronto, ON.

48. Questions?Questions?