1. ASSESSING RISK OF HARM: ETHICAL AND PRACTICE ISSUES UPDATE PPA CE AND ETHICS CONFERENCE Harrisburg, PA March 31, 2011

2. Bruce E. Mapes, Ph.D. PO Box 1028 Exton, PA 19341 610-696-8740 maroje@hotmail.com

3. The frustrated judge asked … “How can two competent and respected PhD psychologists review the same data and reach two diametrically opposed opinions?” “For every PhD there is an equal and opposite PhD”

4. PREDICTION V. ASSESSMENT Person will or will not do something Probability statements Nomethetic data Individually based

5. WHAT IS RISK? Hazard forecasted with uncertainty. Ideas of nature, severity, frequency, imminence, and likelihood Context specific Only estimated

6. RISK ASSESSMENT? Process of gathering information to assist decision-making. It is not simply a diagnosis or prognosis. It is not predetermined test items or risk factors. It is an individualized process to assist in decision-making.

7. GOALS? To contain and reduce risk. To guide interventions. To improve consistency of decisions. To improve the transparency of decisions. To protect the rights of the individual, the community, and potential victims.

8. POPULATIONS STUDIED Outpatient settings Inpatient settings Minimum security prisons Moderate security settings Maximum security settings Supermax Settings Forensic settings

9. CRITERION VARIABLE Re-hospitalization (violence v. nonviolence) Re-arrest (violence v. non-violence) Re-conviction (violence v. nonviolence)

10. RESEARCH ISSUES Low base rates Correlations Retrospective v. Prospective studies Changing base rates (decrease in violent crime) What do low and high risk mean? Imminent v. longer-term risk Sample sizes First offense v. recidivism Self - Report

11. VIOLENCE HETEROGENEITY Risk level varies as a function of instrument used Sexual Deviancy v. Chronic Antisociality Wingspread Conference – Situational Couples Violence – Separation Instigated Violence – Coercive – Controlling Violence

12. MHP - HISTORY Prior violence and criminality more strongly associated with post-discharge violent behavior among all psychiatric patients, regardless of the diagnosis (Monahan, et.al., 1996, 2001, 2003)

13. MHP – CHILDHOOD ABUSE Physical abuse as a child and as an adolescent presented higher risk of post-discharge violence than did childhood limited abuse. No significant relationship between sexual abuse as child and violence.

14. MHP - DIAGNOSIS Patients with co-occurring personality disorders and adjustment disorders were higher risk than those with just major mental illness. The presence of significant character pathology with antisociality was the most critical factor

15. MHP – CHARACTER PATHOLOGY Limited traits of psychopathy and / or antisocial behavior more predictive of future violence for all patients. On Hare PCL-R, antisocial factor was more predictive of violence than was the emotional detachment factor. Presence of Childhood Conduct Disorder and Schizophrenia 2X more likely to commit a violent offense than Schizophrenics without history of Conduct Disorder

16. HORMONES Testosterone levels may not be related to violence, but may influence whether violence is directly or indirectly expressed. (Streuber, 2007). Competitive attitudes

17. NEUROLOGICAL FACTORS Is frontal lobe related to violence or getting caught? (Adrian Raine, et al, 2004) Role of technology (Small and Vorgan, 2008) Complex interaction between brain functioning and environment.

18. NEUROCRIMINOLOGY Amygdala - 18% volume reduction Middle Frontal Gyrus – 18% volume reduction Orbital Frontal Gyrus – 9% volume reduction Lack of fear conditioning in 3 year olds

19. PSYCHOLOGICAL FACTORS - HANSON General family problems Degree of physical contact Presence or absence of empathy / remorse Social Skill level Sexual or physical abuse as child General psychological problems Substance abuse

20. Psych factors - continued Denial Cognitive Distortions Low self-esteem Psychological test results (Hanson et. al.)

21. ATTACHMENT “It may become an empirically grounded truism years from now that attachment pathology is a centrally necessary but insufficient component to explain violence.” (Meloy, 2003)

22. D&A – SEX OFFENDERS “Substance abuse does not often, if ever – at least by itself – predispose a person to commit sexually violent acts.” “Although alcohol for example may increase one’s desire for sex, there is no known ‘pathological intoxication’ that causes sexual fantasies or urges of an illegal nature.” (Doren, 2002, pp. 101-102)

23. D&A – NONSEXUAL VIOLENCE Substance abuse in and of itself does not have a strong relation to violence. Chronic substance use exposes the individual to antisocial peers, attitudes, and environments. It is this complex interaction which is important. (Andrews and Bonta, 2010, pp. 293 – 294)

24. PROFILES? There was no accurate or useful profile. Rarely sudden, impulsive act. Others often knew of plans / idea Rarely was plan directly communicated to victim Most displayed some type of behavior of concern prior to the attack Most had difficulty coping with significant losses or personal failures.

25. Profiles Many attackers had previously considered or attempted suicide. Many attackers felt bullied, persecuted, or injured by others prior to the attack. Most had access to and had used weapons prior to the attack. (Safe School Initiative, 2002)

26. COMPUTERS Chatrooms Education on any type of violence Many “sick people” willing to help May normalize violent behavior Increasing role in violent behavior

27. INTERNET PORNOGRAPHY Loss of satisfaction with current partner Normalize very deviant acts Chatrooms normalizing Pedophilia File sharing Accidently downloading is rare

28. CHILD PORNOGRAPHY If the interest in child pornography meets the DSM-IV TR criteria for the diagnosis of Pedo- philia, it is appropriate to give this diagnosis. (Seto, et. al., 2010) 59% + who are Pedophiles based on child pornography have had a contact offense.

29. A COMPLEX ALGEBRA Sexual and nonsexual violent behavior involve the complex, cumulative interaction of bio- chemical, genetic, structural brain, psychological, and environmental factors across the lifespan.

30. ANTISOCIAL DECISION-MAKING Rarely a random act – one decides to engage in antisocial behavior. Considers the potential for success. Considers potential to overcome internal inhibitions. Considers potential to overcome external obstacles.

31. DECISION-MAKING EVOLVES Our own experiences and those of others. Decision-making process reflects adaptations to changing circumstances as different behavioral options are considered.

32. THREE COMPONENTS 1.To formulate and use equations. 2.The ability to learn from experience. 3.The ability to see different options.

33. DECISION-MAKING PATTERNS Normal Avoider Limit Testers Opportunist Antisocial Generalist

34. RISK FACTORS Static – historical factors (don’t change) Dynamic – can be modified but are stable for weeks, months, years (e.g., association with violent individuals). Acute – immediate situations (e.g., associates) or immediate emotional state such as anger, resentment, revenge.

35. CENTRAL EIGHT RISK-NEED FACTORS Chronic history of antisocial behavior Conduct Disorder / Antisocial Personality Pattern Antisocial Cognitions (attitudes, justification) Antisocial Associates

36. Central Eight Family / Marital Relationship quality School / Work: quality of relationships and performance Leisure / Recreation: level of involvement and satisfaction in prosocial activities Substance Abuse (especially environmental factors such as associates) (Andrews and Bonta, 2010)

37. ASSESSING RISK What precipitated referral? What is the intent or goal? Does the person have a plan? Does the person have the means? Does the person have the opportunity?

38. DESIRED INFORMATION BASE History of violent and nonviolent antisocial behavior Internal factors External Factors

39. WHAT PRECIPITATED REFRRAL? Verbal or written comment? Some type of action by the subject? What was the situation?

40. INTENT? What does person gain? Let off steam? Attention? Harass? Expression of anger? Hostility or Instrumental Aggression? Revenge?

41. PLAN? Does the person have a plan? How detailed is the plan? How long has it been developing? What resources have aided the development? How realistic is the plan? What is the pool of potential victims?

42. MEANS Does the person have the means to carry out the plan? How quickly can the person access the means? How serious might the violence be (level of lethality?) Has the person practiced?

43. OPPORTUNITY? Availability of victim(s)? Likelihood of situation presenting itself? Ability to make situation occur? Likelihood of detection?