1. Conceptual Issues in Risk Assessment Randy K. Otto, PhD Department of Mental Health Law & Policy Florida Mental Health Institute University of South Florida otto@fmhi.usf.edu

2. Agenda Legal Contexts Legal Contexts Rationale for Involving Mental Health Professionals Rationale for Involving Mental Health Professionals Complexity of Risk Assessment Complexity of Risk Assessment Approaches to Risk Assessment and Limitations Approaches to Risk Assessment and Limitations Features of a Competent Risk Assessment Features of a Competent Risk Assessment

3. Legal Contexts in Which Risk is an Issue Criminal (and Delinquency) Criminal (and Delinquency) –Sentencing –Capital Sentencing –Parole Civil Civil –Civil Commitment –Sex Offender Registration –Sexually Violent Predator Proceedings

4. Why Involve Mental Health Professionals? In my view, psychiatry represents the penultimate grey area…particularly with regard to issues of foreseeability and predictability of future dangerousness. In my view, psychiatry represents the penultimate grey area…particularly with regard to issues of foreseeability and predictability of future dangerousness. –Judge Jorgensen dissenting in Lindabury v. Lindabury, 552 So2d 1117, 1118 (Fla 3d DCA, 1989)

5. Why Involve Mental Health Professionals? Neither petitioner nor the [American Psychiatric] Association suggests that psychiatrists are always wrong with respect to future dangerousness, only most of the time. Neither petitioner nor the [American Psychiatric] Association suggests that psychiatrists are always wrong with respect to future dangerousness, only most of the time. Justice White in his opinion for the majority in Barefoot v. Estelle, 463 US 880 (1983). Justice White in his opinion for the majority in Barefoot v. Estelle, 463 US 880 (1983).

6. Why Involve Mental Health Professionals? Specialized knowledge of (individual and environmental) factors related to behaviors of interest Specialized knowledge of (individual and environmental) factors related to behaviors of interest –Non-violent criminal behavior –Violent (criminal) behavior –Sexual offending Knowledge of interventions which may diminish risk for behaviors of interest Knowledge of interventions which may diminish risk for behaviors of interest Presumption of better informed decisions Presumption of better informed decisions

7. Sexual Violence is a Complicated Construct Behavior is a function of BOTH the person and the environment Behavior is a function of BOTH the person and the environment Assessment of only one of the above limits understanding of risk for violence Assessment of only one of the above limits understanding of risk for violence Some factors may correlate with sexual violence but not cause it Some factors may correlate with sexual violence but not cause it

8. Sexual Violence is a Complicated Construct Some factors may appear to be associated or correlate with sexual violence, but may not actually be related to or correlate with violence Some factors may appear to be associated or correlate with sexual violence, but may not actually be related to or correlate with violence Correlates or predictors of some kinds of violence (e.g., non-sexual violent behavior) do not not correlate with or predict sexual violence Correlates or predictors of some kinds of violence (e.g., non-sexual violent behavior) do not not correlate with or predict sexual violence

9. Correlates of Sexual and Violent Reoffending [r] Factor Sex Reoffending Hanson et al Violent Reoffending Bonta et al. Age -.13 -.13.16.16 Race.00.00.12.12 APD.00.00.18.18 Violence History.05.05.16.16 Work Problems.00.00.22.22

10. From Violence Prediction to Risk Assessment Assessment Approach Assessment Approach Language/Communication Language/Communication –Relative Levels of Risk –Identification of Risk and Protective Factors Decision Making Responsibility Decision Making Responsibility Treatment/Management/Intervention Treatment/Management/Intervention

11. Various Approaches to Risk Assessment Clinical Assessment Clinical Assessment –Unstructured –Structured Professional Judgment –Anamnestic Actuarial Assessment Actuarial Assessment –Pure –Adjusted

12. Clinical Assessment Factors of relevance are identified by each examiner based on training and experience Factors of relevance are identified by each examiner based on training and experience Varies from clinician to clinician Varies from clinician to clinician Poor reliability Poor reliability Poor validity Poor validity Person focused, less attention paid to important environmental variables Person focused, less attention paid to important environmental variables

13. Structured Professional Judgment Clinical judgment that is structured, but still a clinical judgment Clinical judgment that is structured, but still a clinical judgment Items are identified a priori and typically based on empirical literature Items are identified a priori and typically based on empirical literature Increased reliability of judgments Increased reliability of judgments Potential for improving validity of clinical judgment Potential for improving validity of clinical judgment Can be used in various settings and with various populations Can be used in various settings and with various populations

14. Structured Professional Judgment Tools Competence Assessment Instrument Competence Assessment Instrument HCR-20 HCR-20 Sexual Violence Risk-20 Sexual Violence Risk-20 RSVP RSVP Spousal Assault Risk Assessment Guide (SARA) Spousal Assault Risk Assessment Guide (SARA) Structured Assessment for Violence Risk in Youth (SAVRY) Structured Assessment for Violence Risk in Youth (SAVRY)

15. Actuarial Assessment Items and weights are calculated based on known outcomes or relationships Items and weights are calculated based on known outcomes or relationships Empirically based Empirically based Mechanistic Mechanistic Generally reliable Generally reliable Demonstrated levels of validity Demonstrated levels of validity Relative levels of risk Relative levels of risk Rarely used in practice, if at all Rarely used in practice, if at all

16. Actuarial Assessment Concerns regarding validity when used with groups differing (in important ways) from the group on which the instrument was derived Concerns regarding validity when used with groups differing (in important ways) from the group on which the instrument was derived Reliability and validity of the clinical assessment approach most typically used with actuarial instruments-the adjusted actuarial approach-is unknown Reliability and validity of the clinical assessment approach most typically used with actuarial instruments-the adjusted actuarial approach-is unknown

17. Actuarial Assessment Tools Violence Risk Appraisal Guide Violence Risk Appraisal Guide Iterative Classification Tree (COVR) Iterative Classification Tree (COVR) Sex Offender Risk Appraisal Guide Sex Offender Risk Appraisal Guide RRASOR RRASOR MnSOST/MnSOST-R MnSOST/MnSOST-R Static-99 Static-99 CARAT CARAT

18. Methods For Assessing Technique Accuracy ROC/AUC ROC/AUC Survival Analysis Survival Analysis Sensitivity/Specificity Sensitivity/Specificity Positive Predictive Power & Negative Predictive Power Positive Predictive Power & Negative Predictive Power

19. Features of a Competent Risk Assessment Conducted by professional who can talk competently about accuracy indices Conducted by professional who can talk competently about accuracy indices Employs an acceptable assessment approach Employs an acceptable assessment approach Does not rely heavily on psychological testing Does not rely heavily on psychological testing Examines both individual and environmental/contextual factors Examines both individual and environmental/contextual factors

20. Features of a Competent Risk Assessment Identifies empirically established risk and protective factors Identifies empirically established risk and protective factors Offers relative estimates of risk Offers relative estimates of risk Acknowledges limitations of ability Acknowledges limitations of ability Identifies interventions and conditions which may increase or decrease risk Identifies interventions and conditions which may increase or decrease risk