Clinician's Guide to Violence Risk Assessment

Visit the link below to download the full version of this book:

https://medidownload.com/product/clinicians-guide-to-violence-risk-assessment/

Click Download Now

© 2011 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com

All rights reserved

No part of this book may be reproduced, translated, stored in

a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, microfilming, recording,
or otherwise, without written permission from the publisher.

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

The authors have checked with sources believed to be reliable in their efforts to
provide information that is complete and generally in accord with the standards
of practice that are accepted at the time of publication. However, in view of the
possibility of human error or changes in behavioral, mental health, or medical
sciences, neither the authors, nor the editor and publisher, nor any other party
who has been involved in the preparation or publication of this work warrants
that the information contained herein is in every respect accurate or complete,
and they are not responsible for any errors or omissions or the results obtained
from the use of such information. Readers are encouraged to confirm the
information contained in this book with other sources.

Library of Congress Cataloging-in-Publication Data

Mills, Jeremy F.
Clinician’s guide to violence risk assessment / by Jeremy F. Mills, Daryl G. Kroner,
and Robert D. Morgan.
p. cm.
Includes bibliographical references and index.
ISBN 978-1-60623-984-1 (hard cover : alk. paper)
1.╇ Violence—Risk assessment.â•… 2.╇ Violence.â•… 3.╇ Risk assessment.â•…
I.╇ Kroner, Daryl G.╅ II.╇ Morgan, Robert D.╅ III.╇ Title.
RC569.5.V55M55 2011
616.85´82075—dc22
2010031636
 To my son, Nathan,
whom I have entrusted to the care of my Lord Jesus Christ
until the day that I can hold him again. Daddy loves you, son.
—Jeremy F. Mills

To Ted Kroner
—Daryl G. Kroner

To Peggy Weir
—Robert D. Morgan
 About the Authors

Jeremy F. Mills, PhD, CPsych, is a psychologist with a practice in foren-

sic, correctional, and counseling psychology in Kingston, Ontario, Canada.
In addition, he serves as Adjunct Research Professor in the Department of
Psychology at Carleton University in Ottawa. A Fellow of the American
Psychological Association, Dr. Mills’s research interests include violence risk
assessment, violence risk communication, and the assessment of suicide risk.
Dr. Mills provides consultation and training in the area of violence risk
assessment.

Daryl G. Kroner, PhD, CPsych, is Assistant Professor in the Department

of Criminology and Criminal Justice at Southern Illinois University Car-
bondale. Previously, he worked for 22 years as a prison psychologist. Dr.
Kroner’s research interests include correctional mental health, dynamic risk
assessment during community supervision, and the social-context aspects of
risk assessment.

Robert D. Morgan, PhD, is Associate Professor in the Department of

Psychology at Texas Tech University in Lubbock, Texas. In addition, he
is Director of Clinical and Forensic Services at Lubbock Regional Mental
Health Mental Retardation Center. Dr. Morgan’s research interests include
correctional mental health, forensic psychology, and professional develop-
ment and training.

vii
 Preface

T his book is an applied and practical guide to the assessment of vio-

lence risk primarily for clinicians/practitioners or those learning to become
clinicians. It should also prove helpful as an introduction for students and
early-career professionals to the practical issues surrounding the clinical
assessment of violence. We have found that the majority of clinicians who
attend our risk assessment workshops are doctoral-level practitioners who
have occasionally conducted violence risk assessments in their practice. This
anecdotal observation was supported by a survey conducted by Tolman and
Mullendore (2003), who found that although only 9% of clinical psycholo-
gists characterized their practices as forensic, 53% had conducted a risk
assessment that was used in legal proceedings or criminal justice decision
making, and 45% reported completing an assessment for criminal sentenc-
ing purposes. However, clinicians did not identify or rely on violence risk
appraisal instruments in their assessments. Similarly, Nicholson and Nor-
wood (2000) conducted a review of forensic assessments and concluded that
assessors understood the legal question at hand, but they did not consistently
use the assessment methods or instruments that had the strongest empiri-
cal basis for inclusion in the assessment process. Even among psychologists
who specialize in forensic work, there is evidence of a reliance on less-than-
optimal instruments in the assessment of risk for violence (Lally, 2003).
It is within this applied context that we have written this book to assist
the clinician in making informed and scientifically supported assessments.
We know that clinicians are pressed for time, so we have kept the historical
references in the text to a minimum and focus primarily on what the current
literature reflects, where the science of violence risk assessment seems to be
going, what clinicians need to know to conduct risk assessments, and how
to get started. We provide the reader with a broad array of risk appraisal
instruments from various approaches and list publications that support their

ix
x Preface

predictive validity. We are straightforward regarding our bias about how to

conduct risk assessments and note differences from other perspectives where
they exist. As practitioners on the front lines of a forensic practice where
risk assessments are conducted routinely, we know the challenge of keep-
ing up with the latest research and the importance of applying the best of
forensic science to the assessment of violence.
To assist clinicians and students with limited experience in violence risk
assessment, we have organized this book in a manner that coincides as much
as possible with the assessment process, such that it can truly be used as a
desk reference easily consulted for quick guidance. As a desk reference, this
book is very practical in focus but based on current research, with more than
enough references to provide any practitioner sufficient resource material to
act as a competent expert witness if called to testify. We begin in Chapter
1 with an overview of the central issues, ethics, and risk factors that arise
when assessing the risk for violence in adults. This overview is followed by
a review of risk factors for various types of offenses in Chapter 2 and cur-
rent risk assessment instruments for general, sexual, and spousal violence,
including information on choosing appropriate instruments and their limi-
tations, in Chapter 3. Chapter 4 reviews the conceptual issues and clinical
dilemmas involved in violence risk assessment, and Chapter 5 presents an
integrated–actuarial approach to assessment and management of violence
risk. We conclude with a review of the assessment process in Chapter 6 and
a step-by-step discussion of report writing in Chapter 7.
In the headlong search to improve the assessment of violence risk and
improve public safety, perhaps at times we inadvertently come to believe that
dangerous people can be identified and that harm can always be avoided.
David Carson (2008) suggests that clinicians in the risk assessment enter-
prise need to adopt precepts or “self-evident truths” (p. 141) that pertain
to risk assessment. Among these precepts are that risk is a part of life and
harm will sometimes occur, that the occurrence of harm does not mean
that a poor risk decision was made, that risk assessment relies on imper-
fect knowledge, and that risk management functions with finite resources.
These precepts are necessary to ground ourselves in the reality of what we
undertake when we conduct a risk assessment. Sometimes, in spite of our
best efforts, harm still occurs. However, in the assessment of violence risk,
only our best effort will do.

Acknowledgments

We are grateful to Catherine Serna-McDonald, Christopher Romani, and Andrew

Gray for reviewing drafts of this manuscript.
 Contents

Chapter 1. Violence Risk Assessment: An Introduction 1

The Clinician’s Knowledge and Trainingâ•… 3
Why Conduct Violence Risk Assessments?â•… 5
Therapeutic versus Violence Risk Assessmentsâ•… 11
Advancements in Risk Assessmentâ•… 15
Ethics Essentialsâ•… 24
Conclusionâ•… 32

Chapter 2. Violence Risk Factors 33

Violent Reoffending in the Criminal Recidivistâ•… 34
Offenders with Mental Disordersâ•… 36
Sexual Violenceâ•… 44
Spousal Violenceâ•… 50
Psychopathic Traitsâ•… 55
Conclusionâ•… 64

Chapter 3. Risk Appraisal Instruments 65

Instruments Specifically Developed to Predict
â•… Nonsexual Violenceâ•… 69
Instruments Developed to Predict General Reoffending
â•… That Also Predict Nonsexual Violenceâ•… 81
Instruments Developed to Predict Sexual Violenceâ•… 87
Instruments Developed to Predict Spousal Violenceâ•… 102

xi
xii Contents

Chapter 4. Issues in Risk Assessment 108

Choosing a Risk Appraisal Instrumentâ•… 109
Professional Override?â•… 118
Assessing Change from Intervention/Treatmentâ•… 120
The Perception and Communication
â•… of Risk Informationâ•… 124

Chapter 5. An Integrated–Actuarial Approach 134

to the Assessment and Management
of Risk for Violence
Anchoring the Assessment with Actuarial Estimatesâ•… 135
Integrating Dynamic Factors for Intervention/Treatment
â•… and Risk Management Purposesâ•… 136
The Two-Tiered Violence Risk Estimates Scale:
â•… An Integrated–Actuarial Approachâ•… 139
Other Examples of Integrated–Actuarial
â•… Risk Assessmentâ•… 156
Interventions to Reduce Riskâ•… 157

Chapter 6. The Risk Assessment Process 159

Transparencyâ•… 159
Information Gatheringâ•… 163
Reporting the Findingsâ•… 167

Chapter 7. Telling the Story: An Outline for the Report 172

Assessment Contextâ•… 173
Psychosocial Backgroundâ•… 177
History of Violence and Criminal Behaviorâ•… 183
Risk Assessment and Risk Managementâ•… 184
Testifying in Legal Proceedingsâ•… 189

Appendix. Sample Violence Risk Assessment 193

References 207

Index 233
 Clinician’s Guide to
Violence Risk Assessment
 . ↜. ↜.
Chapter 1

Violence Risk Assessment

An Introduction

F or a variety of purposes, and in a range of settings, clinicians may

be involved in providing formal assessments for the courts or other quasi-
judicial boards. In fact some estimates have shown that approximately half
of all psychologists in general practice will at some point provide an assess-
ment for the court (Tolman & Mullendore, 2003). Although readers of this
clinician’s guide are likely to be interested in the practice of violence risk
assessment, the assessment and management of violence risk is not limited
to forensic psychologists and psychiatrists. Approximately 25% of offend-
ers will seek community-based mental health services (Morgan, Rozycki, &
Wilson, 2004); thus, the

assessment and management of violence risk are critical issues, not just for
psychologists and psychiatrists in forensic settings but for all practicing
clinicians. Despite a long-standing controversy about the ability of mental
health professionals to predict violence, the courts continue to rely on
them for advice on these issues and in many cases have imposed on them
a legal duty to take action when they know or should know that a patient
poses a risk of serious danger to others. (Borum, 1996, p.€954)

To ensure consistency of terminology between us as writers and you as

readers, we define our use of the term risk assessment. Many times in the lit-
erature the term “risk assessment” refers to the determination of the level of
risk (risk estimation), whether actuarial (percent likelihood) or descriptive
(low, moderate, or high). When we refer to risk assessment we are referring
to the whole process of (1) determining an individual’s level of risk (risk

1
2 CLINICIAN’S GUIDE TO VIOLENCE RISK ASSESSMENT

estimation), (2) identifying the salient risk factors that contribute to that
risk, (3) identifying risk management strategies and considerations to man-
age or minimize that risk, and (4) communicating the risk information to
the decision maker.
This book will lead you through the practical steps of conducting one
type of clinical assessment, a violence risk assessment. Violence risk assess-
ments are almost always completed within the context of the competing
interests of society (public safety) and the person being assessed (freedom
and fairness). Clinicians typically form a therapeutic alliance with their cli-
ents, working jointly to improve their lives. However, within the violence
risk assessment process, we emphasize a reliance on the data (the specific
facts as they relate to the potential for violence) to avoid therapeutic bias.
The forensic assessor is partial to neither “side” in a legal proceeding, but
to whatever conclusions and recommendations to which the facts and case
specifics point. It therefore follows that forensic assessments of violence risk
will differ from other clinical assessments in approach, content, and tenor.
For example, a clinical assessment is typically conducted to aid in the reha-
bilitation of the client, whereas a forensic (violence) assessment typically
aids in answering a legal question, with the focus of protecting society at
large. These differences also lead to what appear to be competing ethical
obligations not typically experienced within clinical practice.
In this opening chapter we introduce you to some of the issues sur-
rounding violence risk assessment. The information we provide assumes a
certain level of training and experience and so we have adopted the term cli-
nician as we understand that similar training and experience may be found
in different disciplines (psychology, psychiatry, nursing, social work, etc.).
In outlining some of the essential skills the clinician needs to bring to the
process, we will identify who should be conducting a violence risk assess-
ment. Clinicians are often asked to provide an opinion regarding the poten-
tial for violence of a client. There are competing arguments for and against
conducting these types of assessments. We review some of these arguments
to answer the question of why a clinician should undertake a violence risk
assessment.
As a clinician you are very familiar with therapeutic reports and
assessments, but we introduce you to some of the similarities and differ-
ences between therapeutic assessments and violence risk assessments. Dif-
ferences between these two types of assessments include differences in the
scope, purpose, procedures, and reports. We also review the advances that
have been made in violence risk assessment over the past few decades to
set our approach within the development of the field and to demonstrate
that it represents the current direction of violence risk assessment. From
a historical perspective, violence risk assessment has moved from purely
clinical judgment of dangerousness to an actuarial approach with reliance
 An Introduction 3

on probabilities based on statistical information. We show that over time

actuarial measures have been combined with dynamic risk factors within a
risk management and intervention paradigm, resulting in what we term an
integrated–actuarial approach. We also report on an emerging approach
that integrates changes in dynamic risk factors that modify static–actuarial
estimates and is now in the forefront of violence risk assessment. We refer to
this approach as a dynamic–actuarial approach. With our review of the dif-
ferences between therapeutic and violence risk assessment and the overview
of assessment advances we hope to introduce what a violence risk assess-
ment should include. Finally, we look at the special ethical obligations that
are associated with conducting violence risk assessments. The purpose of
ethical standards is to ensure that how we conduct violence risk assessments
meets the highest standards of science and professional practice.

The Clinician’s Knowledge and Training

The purpose of this book is to provide knowledge on the specifics of vio-

lence risk assessment for professionals who already provide other types of
clinical intervention and assessment services. Clinician is the term we have
chosen to describe those professionals who have advanced knowledge and
training in a number of areas important for the conducting of violence risk
assessment. This knowledge and training is not specific to any particular
professional group but can be found in psychology, psychiatry, psychiatric
nursing, counseling, and social work. It is the clinician’s ethical responsi-

Actuarial Risk Assessment

The term actuarial means “relating to statistical calculation” (Merriam-Webster’s
Collegiate Dictionary, 1999). Confusion exists within the literature because some
researchers have equated instruments that are primarily composed of static and
historical risk factors with the term actuarial. In fact, instruments with potentially
changeable factors can and do incorporate actuarial risk estimates. Also, actu-
arial has sometimes been used to describe instruments that are not “structured
clinical/professional judgment.” So to be clear, actuarial is a term we reserve for
any instrument that has a structured scoring method and associates a statistical
or probabilistic statement with the resulting score. To run the risk of complicating
things further, instruments that employ the structured professional judgment (more
on this later in the chapter) approaches could quite easily become “actuarial” sim-
ply by applying statistical probabilities to the resulting scores. While this would be,
in our opinion, an improvement, it is not in keeping with the structured professional
judgment approach to risk assessment.
4 CLINICIAN’S GUIDE TO VIOLENCE RISK ASSESSMENT

bility to judge if he or she is competent to complete a violence risk assess-

ment. Most professional governing bodies will have specific guidance on
what would constitute competence. Similarly we assume that clinicians will
belong to a licensing body that regulates their profession through standards
of practice and ethical guidelines. In keeping with this we are assuming that
the clinician will operate within these guidelines.
Violence risk assessment requires graduate-level training or equivalent
knowledge and experience in understanding personality and psychopathol-
ogy. Similar levels of knowledge and training are necessary in the areas of
theories of behavior and interviewing skills. Experience and competence in
the area of case formulation and clinical report writing are very important.
A comprehensive knowledge of mental and personality disorders and their
relationship to behavior in general and violence in particular are essential.
While it is not necessary to be able to diagnose a mental disorder, in many
cases it is essential to have access to a professional who can diagnose a
mental disorder and/or personality disorder, as these disorders are features
of some risk appraisal instruments. Finally, knowledge of statistics and an
ability to apply and communicate their meaning in an assessment context
is also important. Terms such as receiver operating characteristic and base
rates, although cumbersome to some, are essential for analyzing and com-
municating the results of risk assessments.

A Word about Statistics

Clinicians often dislike statistics. However, we are making the assumption that you
may have to testify in court and may be called upon to express an opinion based
upon the scientific literature. The relationship of risk appraisal instruments with vio-
lence will be featured prominently throughout this book, and to that end we have
included enough statistical information for you to speak to the issue of risk assess-
ment.
Researchers employ many different types of statistics in order to communi-
cate the accuracy of a given risk appraisal instrument. Among these statistics is
the more commonly known and understood Pearson’s r (between two continuous
variables), point–biserial correlation (between continuous and dichotomous vari-
ables), or phi coefficient (which is a measure of the degree of association between
two binary variables). Other statistics used include percent correct classifications,
relative improvement over chance (RIOC), positive predictive power (which is the
proportion of those predicted to fail who actually did fail), Cohen’s d, and area
under the curve (AUC) from a receiver operating characteristic (ROC), among
many others.
For ease of understanding we will report correlation statistics and AUC statis-
tics. The latter statistic is a relatively recent development but is appealing because