Domestic Violence
Knowledge Sharing
Forum
Lethbridge, AB
March 24, 2011
Southern
Alberta
Forensic
Psychiatry
Services
(SAFPS)
Southern
Alberta
Forensic
Psychiatry
Centre
(SAFPC)
Forensic
Assessment
Outpatient
Service
(FAOS)
Forensic
Adolescent
Program
(FAP)
Calgary
Diversion
Services
Who Do We Serve?
Target population is adults and adolescents who are:
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12 years of age or older
In conflict with the law
Thought to have mental problems
Legally mandated for assessment or
treatment for mental health or behavioural
problems
What Do We Do?
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Assessment for the courts
Fitness To Stand Trial
Not Criminally Responsible due to Mental
Disorder (NCRMD)
Risk Assessment
Treatment
What is a Risk/Threat?
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the potential that a chosen action or
activity (including the choice of inaction)
will lead to an undesirable outcome
Complex – incorporates notions of nature,
severity, frequency, imminence, and
likelihood
Contextual – depends on
circumstances!
What is Violence?
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The actual, attempted, or threatened
physical harm to another person
Diverse – includes many acts
Intentional – deliberate or reckless
Non-consensual – unwanted by the victim
What is Assessment
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In the mental health profession,
assessment is the process of gathering
information for the use in making
decisions.
Include: interviews, psychological testing,
review of records, collateral informants
Risk Assessment
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Is the process of gathering information
about people to make decisions regarding
their risk of perpetrating/offending.
The primary decision to be made is
preventative, that is, a determination of
what steps should be taken to minimize
any risks posed by the individual.
Risk Assessment cont…
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Mental health professionals use two basic
approaches
Actuarial decision making
Professional judgement
Actuarial Risk Assessment
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Are designed not to measure anything but solely
to predict the future.
Typically, they are highly optimized to predict a
specific outcome in a specific population over a
specific period of time.
The items used in such tools are usually selected
empirically (on the basis of their association with
the outcome in past research).
The items are weighted and combined according
to some algorithm to yield a decision.
Professional Judgement
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Has evolved over the years into what is
now called structured professional
judgement or guided clinical judgement.
Decision-making is assisted by guidelines
that have been developed to reflect the
“state of the discipline” with respect to
empirical knowledge and professional
practice.
SPJ Cont…
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The guidelines attempt to define the risk
being considered, discuss necessary
qualifications for conducting the assessment,
recommend what information should be
considered as part of the evaluation and how
it should be gathered, and indentify a set of
core risk factors that according to the
scientific and professional literature should be
considered as part of any reasonably
comprehensive assessment.
SPJ Cont..
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Such guidelines help to improve the
consistency and usefulness of decisions.
The core assumption behind structured
professional judgement assessments is
that good prevention is based on
planning, not on prediction.
Planning reflects practical wisdom rather
than abstract knowledge of technical skills
The advantage is that planning doesn’t
assume a single “possible future”
General Procedures
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Gather information (purpose, history,
behaviours)
Consider relevance of risk factors
(motivators, disinhibitors, destabilizers)
Consider scenarios of violence
Develop case management strategies
(monitoring, supervision, tx, risk
management)
Document summary judgements
What is a Static Factor?
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Something that that can not be changed
Natural hair colour
Eye colour
History
Sex
Criminal record
What is a Dynamic Factor?
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Something that can change over time and
as result change a person’s risk
Relationships
Employment
Substance use
Suicidal/homicidal ideation
Mental health
Factors Predictive of Future Violence
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Actuarial instruments as well as clinical
assessments consider a number of factors
in their assessment of risk potential
magnitude, imminence and frequency.
Research has indicated that the following
factors have predictive value:
Base Rates
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refers to the frequency of violence in a
given population
one of the most highly predictive actuarial
factors
does not relate specifically to mental
disorder
can "over-predict" (e.g.,. can incorrectly
identify some offenders as potential
killers)
Demographic Factors
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men more highly represented in criminal and
violent populations (though not necessarily in
psychiatric areas)
age: crime (especially violent) tends to occur
more in younger than in older men
unemployment: low socioeconomic status, low
educational achievement correlate with violence
race and ethnicity: although these can be
factors, they tend to dissipate when the other
factors taken into account statistically
Past History of Violence
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violent history: one of most powerful
indicators of future violence potential
nature of the violence: always important
to consider (e.g.,. types of victims,
environmental and contextual issues, etc)
Substance Abuse
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drugs and alcohol are major contributors to
violence amongst both mentally disordered and
non-mentally disordered offenders
prevalence of substance abuse in mentally
disordered offender tends to be higher than in
general (non-incarcerated) population
substance abuse is important risk factor in
psychotic individuals
doubles the lifetime risk of violence among the
severely mentally disordered, particularly if
substance abuse had early onset
Psychiatric Diagnosis
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earlier research linked violence with
schizophrenic patients in particular but
later studies have been more equivocal
about this
much more relevant to look at psychiatric
symptoms as opposed to diagnosis:
Antisocial Personality Disorders
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characterized by persistent disregard for and
violation of the rights of others
begins in childhood
higher prevalence of it in severely mentally ill
population and in prison population (50-70%)
strong association with substance abuse
strong predictor of criminal recidivism,
particularly violent recidivism, and especially in
women
Psychopathy
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often overlaps with Antisocial Personality
Disorder (APD)
characterized by combination of traits from APD
and Narcissistic Personality Disorder: selfcentredness, egocentricity, lack of empathy, etc.
degree of psychopathy measured effectively by
Hare's Psychopathy Checklist-Revised (PCL-R)
high scores on PCL-R consistently correlate with
violence in incarcerated offenders and forensic
patients
Organic Disorders and Learning
Disorders (influence of)
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presence increases the risk of violence
elderly neurologically impaired responsible for
disproportionately high number of violent
incidents in health care facilities
Attention Deficit/Hyperactivity Disorder ( ADHD):
- persistent pattern of inattention or
hyperactivity-impulsivity
- in childhood, is more frequent and severe than
comparable behaviour of other children at
similar stages of development
Attachment, Mental Disorder and
Criminality
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children learn about relationships through
complex interruption with their caregivers
early disruption of this attachment can lead to
later psychopathology, mental disorders and
criminality in some individuals
fertile ground for research into relationship
between abuse/neglect and later violence:
it may well be that prison environments tend to
replicate or reflect lack of care that some
offenders may have experienced as children
Who can use the assessments?
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Professionals in a variety of disciplines
Expertise in conducting assessments
Expertise in the area of violence, spousal
assault, sexual violence.
Expertise in mental disorders
Proper training in the risk assessment tool
Refer to the User Qualifications in the risk
assessment manual
Actuarial Risk Assessment Tools
Violent Risk Appraisal Guide (VRAG)
Quinsey, Harris, Rice, Cormier (1998)
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This instrument contains a 12-item actuarial
scale which has been widely used to predict risk
of violence within a specific time frame following
release in violent, mentally disordered offenders.
Developed at Penetanguishene Mental Health
Centre, the tool uses the clinical record,
particularly the psycho-social history component,
as a basis for scoring as opposed to interview or
questionnaires. The Hare PCL-R (Psychopathy
Checklist -Revised) score is incorporated into the
VRAG calculations of risk.
-24 to -8 = low risk, -7 to 13 = medium risk, 14 to 32 = high risk
Psychopathy Checklist - Revised (PCL-R)
Hare, 1991 & 2002
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Even though it was not originally designed as a
risk assessment device, the Hare PCL-R has
gradually come to be used to assess likely future
recidivism and violent offending. It is a 20-item
rating scale, scored on the basis of both semistructured interview and collateral information.
It has been validated for use in adult male
correctional and forensic psychiatric samples.
Over recent years, research has shown that it is
a relatively good predictor of violence across
diverse populations. Hare PCL-R scores are
incorporated into a number of subsequently
developed risk assessment tools and guides.
Level of Service Inventory – Revised (LSI-R)
Andrews & Bonta, 1995
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This is a 54-item rating scale used to
assess the likelihood of general recidivism
among adult offenders. It is designed to
measure attributes of offenders and their
situations in relation to level of supervision
and treatment decisions. It has been
validated for use with adult male and
female correctional offenders.
Static-99/Static-2002
Hanson & Thornton, 1999 and 2002
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Developed subsequently to the RRASOR,
the original 10-item STATIC-99 was
designed to assess the long-term potential
for sexual recidivism among adult male
sex offenders. It incorporates RRASOR
factors. A revised version, STATIC-2002,
has so far been used predominately within
the correctional system.
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Number
1
Young
Risk Factor
Codes
Aged 25 or older
Aged 18 – 24.99
2
Ever lived with lover for at least two years?
Yes
No
3
Index non-sexual violence - Any Convictions?
No
Yes
4
Prior non-sexual violence - Any Convictions?
No
Yes
5
Prior Sex Offences
Charges Convictions
None
None
1-2
1
3-5
2-3
6+
4+
6
Prior sentencing dates (excluding index) 3 or less
0
4 or more
7
Any convictions for non-contact sex offences
No
Yes
8
Any Unrelated Victims
No
Yes
9
Any Stranger Victims
No
Yes
10
Any Male Victims
No
Yes
Add up scores from individual risk factors for Total Score
0-1 = low risk, 2-3 = moderate-low, 4-5 = moderate-high, 6+ = high
Score
0
1
0
1
0
1
0
1
0
1
2
3
1
0
1
0
1
0
1
0
1
Structural Clinical Guides
Sexual Violence Risk-20 (SVR-20)
Boer, Hart, Kropp, & Webster, 1997
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This is a 20 item guide for assessing violence
risk in sex offenders. Eleven items deal with
Psychosocial Adjustment, 7 with Sexual Offences
and 2 with Future Plans. Scoring is based on a
N (definitely not present), ? (perhaps present),
or Y (definitely present) scale with allowance for
changes over time. Little is currently known
about its effectiveness as a predictive device.
Its main current usefulness lies in its ability to
help structure clinical assessments.
Structured Assessment of Violence Risk in Youth
(SAVRY)
Bartel, Borum, & Forth, 1999
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This is a violence risk assessment scheme
designed to assess risk for violence in
adolescents. It consists of 10 historical
variables, 8 social/contextual variables, 7
individual/clinical variables and 6
protective variables.
HCR-20
Webster, Douglas, Eaves, & Hart, 1997
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Consists of 20 items. There are 10
historical variables, 5 clinical variables,
and 5 risk management factors. Each
item is scored as 0 (not present), 1
(possibly present) or 2 (definitely present)
to yield a score out of 40.
HCR-20 Cont…
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It includes variables that capture relevant past,
present, and future considerations. It can be
regarded as an important first step in the risk
assessment process. The manual provides
information about how and when to conduct
violence risk assessments, reviews the research
on which the risk factors are based, and
suggests key questions which should be
addressed when making judgments about risk.
Spousal Assault Risk Assessment Guide
(SARA)
Kropp, Hart, Webster, & Eaves, 1995
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This is a a 20 item set of risk factors for
use in the assessment of spousal assault.
It can be used to help gauge risk of future
violence in men arrested for spousal
assault.
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Gather information by interviewing
offender, victim, reviewing documents, etc
Score items either as being present (yes),
possibly or partially present (?), or absent
(no).
Speculate about the kinds of intimate
partner violence the person might commit
and plausible scenarios
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Speculate about risk management
strategies for each scenario
Monitoring
Supervision
Tx
Risk management
What does it all mean?
Management Strategies
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Incarceration
Couples counselling
Vocational assistance
Individual counselling
Specialized treatment
Psychiatric treatment
Hospitalization
Detox / substance abuse treatment
Limitations
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It should be noted that the quality of risk
assessments is limited by the quality of the
information on which it is based.
Risk is dynamic; therefore if there is an
important change in the individuals life
circumstances, it may be necessary to update
the risk assessment. Important warning signs
that should trigger a re-assessment include:
major change in relational status; abuse of
alcohol or other substances; major change in
employment; significant change in mental
status; and any commission of related offences.
The Bad News
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Not everyone who commits a violent
offence has a prior history of violence or
any prior history with mental health
services.
Risk assessments only look at the
“plausible future NOT the probable future”
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Example “risk message”:
Based on a comprehensive risk assessment, it is my opinion that,
Mr. MC currently poses a moderate risk for spousal assault should
he remain with his partner, the victim in the index offence.
Mr. MC has a criminal history that may be characterized as serious
and persistent in nature. The history is serious because it has
involved the use or threat of use of firearms. The history is
persistent because it spans over a period of 30 years.
If Mr. MC commits violence in the future, the most plausible
scenario is a repeat of his past violence: while using alcohol,
becoming angry and engaging in threatening or assaultive
behaviour to express his anger. If the threats or assaults involve
the use of weapons (e.g., guns), they could be life threatening in
nature. The likelihood of this scenario would be reduced if Mr. MC
continues to abstain from using alcohol and drugs, but increase if he
begins to use alcohol or drugs again.
Stalking
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Unwanted and repeated communication,
contact, or other conduct that deliberately
or recklessly causes people to experience
reasonable fear or concern for their safety
or the safety of others known to them.
“old behaviour, new crime”
Best person to judge whether the stalkers
behaviour has crossed the line is the
victim
Complicated Cases
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Diversity of stalking
may involve long-standing or continuing
conduct
Intimidation may be implicit or explicit
Diversity of perpetrators
May involve multiple perpetrators
Varied motivations and/or mental state
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Diversity of victims
May involve multiple victims
Varied personal and situational
vulnerabilities
Types of Stalkers
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Former Intimate Partner
Most common (50-75%)
Anger or distress over the breakup of the
relationship
Offender often has a personality, substance
abuse, or mood disorder
Often intimate partner violence preceded the
breakup
Relatively high risk for serious physical harm
Love Obsessional
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Relatively common (10-20%)
Offender is casually acquainted with the victim
Stalking communicates desire to establish an
intimate relationship
Offender usually has serious social
maladjustment
Offender may have a personality, cognitive, or
developmental disorder
Relatively low risk for serious physical harm
Young females in service industries are usually
victims (waitress, bank teller, clerks)
Grudge
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Relatively common (10-20%)
Offender has a casual or professional
relationship with the victim
Stalking communicates anger and desire for
retribution or justice
Offender may have a personality disorder or in
some cases a psychotic disorder
Risk for serious physical harm varies greatly
Never happy, always complaining
Feel entitled and demand respect
Feel disrespected
Erotomatic
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Relatively rare (5-10%)
Offender is unacquainted or only casually
acquainted (possibly through the media)
Stalking communicates belief that the victim
loves the offender
Offender suffers from a cognitive or psychotic
disorder
Risk for serious physical harm varies greatly
Delusional, out of touch with reality
Unpredictable but usually not violent
Stalking Assessment & Management (SAM)
Kropp, Hart, & Lyon, 2008
Nature of Stalking
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Communicates about victim
Communicates with victim
Approaches victim
Direct contact
Intimidates victim
Threatens victim
Violent toward victim
Stalking is persistent
Stalking is escalating
Stalking involved supervision violations
Perpetrator Risk Factors
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Angry
Obsessed
Irrational
Unrepentant
Antisocial lifestyle
Intimate relationship problems
Non-intimate relationship problems
Distressed
Substance use problems
Employment and financial problems
Victim Vulnerability Factors
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Inconsistent behaviour toward perpetrator
Inconsistent attitude toward perpetrator
Inadequate access to resources
Unsafe living situation
Problems caring for dependents
Intimate relationship problems
Non-intimate relationship problems
Distressed
Substance use problems
Employment and financial problems
Questions?
Thank You
Stanley K. Wong, M.A., R. Psych.
Clinical and Forensic Psychologist
Community Geographic Team Resources - Lethbridge
Southern Alberta Forensic Psychiatry Services
(403) 308-0005
Stanley.wong@albertahealthservices.ca