Mad, bad or dangerous

to know?: Violence risk

assessment and

management DANIELLE MATSUO, M. PSYCH (FORENSIC), MAPS

STATE-WIDE MANAGER PROGRAMS, CORRECTIVE SERVICES NSW

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

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).

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)

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)

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

General Aggression Model (Anderson &

Bushman, 2002) Preparedness to aggress. E.g.

personality traits, values, attitudes,

beliefs, scripts, gender, genetic

predisposition.

E.g. cues,

provocation, pain,

drugs, incentives.

E.g. mood,

emotion,

expressive

motor

responses. E.g. Hostile

thoughts/

interpretations,

scripts. Low v. high.

Involves both automatic (appraisal) and

controlled (re-appraisal) processes

General Aggression Model (Anderson &

Bushman, 2002)

Other considerations:

Opportunity (i.e. context or situation)

Disinhibiting factors – moral disengagement, substances

Threat to hierarchy of needs

Role of anger? – don’t assume that anger is the cause of

the aggression

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

Violence risk assessment – from

dangerousness to risk management

Can we predict violent behaviour?

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.

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

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) risk factors,

2) harm,

3) risk level

Fourth generation – specific purpose such as measuring change after treatment, e.g. VRS

Risk factors for violence (Douglas &

Skeem, 2005)

Static:

Instability of upbringing

Violence throughout life span

Age of first violent conviction

Previous violence convictions

Prior supervision failure

Risk factors for violence

Dynamic:

Impulsiveness

Negative affect – anger; negative mood

Psychosis

Antisocial attitudes

Personality

Substance abuse

Interpersonal relationships

Treatment alliance and adherence

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.

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)

Conceptualising psychopathy – are

they more dangerous?

What do you think of when you think of a

psychopath?

What do they look like?

Common misconceptions about

Psychopathy

Psychopath = serious violent offender

Psychopathy is equivalent to anti-social personality

disorder

Psychopaths are born not made

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)

Primary vs. Secondary psychopathy

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

Psychopathy as defined by the PCL

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

Use of the PCL in risk assessment

Psychopaths as more

“dangerous”?

Are psychopaths more dangerous than other

offenders?

If so, why?

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.

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

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

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)

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

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?

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 self-presentation 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

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)

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).

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 self-regulating individuals

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 self-identification of problems

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

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

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)

Questions

Danielle.Matsuo@dcs.nsw.gov.au