A Story of OklahomaA Story of OklahomaA Story of OklahomaA Story of Oklahoma

bybyDebbie Spaeth, LMFT, LPC, LADCDebbie Spaeth, LMFT, LPC, LADC

Quest MHSA, LLCQuest MHSA, LLC20152015

bybyDebbie Spaeth, LMFT, LPC, LADCDebbie Spaeth, LMFT, LPC, LADC

Quest MHSA, LLCQuest MHSA, LLC20152015

OklahomaOklahoma

#3 in Murder Rate #3 in Murder Rate of Women in U.S.of Women in U.S.

*only surpassed by Alaska and South Carolina*only surpassed by Alaska and South Carolina

Pride of Pride of OklahomaOklahoma

#1 for a woman experiencing Rape, Physical Violence, and/or

Stalking by a partner in her lifetime.

Maximum time in jail for 1st DV conviction = 1 YR

Estimated #Victims = 697K

Reported 23K Victims

Hotline Calls = 15K

# DV Shelters = 29

13K served, 25K turned away due to capacity

OK STATISTICS (2013)

TRO -Temporary Restraining

Order

Child Stats - OK*Child Stats - OK*

*This presentation is focused on assessment and treatment of adult victims, but wanted to share some basic info on kids, since they are often involved.

We Must Educate ALL Oklahomans about Domestic Violence, Stalking, and Sexual

Assault

A Positive Note for A Positive Note for OklahomaOklahoma

HB 2526 - DV Act - 2014 on DV Victims Rights:

Contact info for DA, Victim-Witness Coord., 24 hr hotline

Website for Victim Rights and Compensation Assistance

Right to press charges against assailant, request protection from harm/threat arising from your cooperation with law enforcement, right to a free forensic medical examination, right to contact DA’s office, financial assist/social services info, file an emergency protective order.

Directs Police to do the Lethality Assessment (shortened version of the Danger Assessment), and then give referrals to shelters, DV Programs, and other Social Services.

DV Awareness DV Awareness GuideGuide

OKDHS Family Support OKDHS Family Support Services DivisionServices Division

Statewide Resource Lists

https://www.ok.gov/dac/documents/Domestic%20Violence%20Awareness%20Guide.pdf

for

YOUR RESPONSIBILITYYOUR RESPONSIBILITYAS THE THERAPIST

TO THE VICTIM, PERPETRATOR, OR HEARING 3RD PARTY INFORMATION

Tarasoff vs. Regents of Tarasoff vs. Regents of the Univ of California (1976)the Univ of California (1976)

The Supreme Court of California held that mental health professionals have a duty to protect individuals who are being threatened with bodily harm by a patient. The original 1974 decision mandated warning the threatened individual, but a 1976 rehearing of the case by the California Supreme Court called for a "duty to protect" the intended victim. The professional may discharge the duty in several ways, including notifying police, warning the intended victim, and/or taking other reasonable steps to protect the threatened individual.

Prosenjit Poddar graduate student at Univ of Calif/Berkeley w/Schizo-Paranoid Type, was rejected by his dance teacher Tatiana Tarasoff. He told his Psychologist at UCB that he intended to stab and kill her, this psychologist informed the police, but his supervising doctor at UCB said to drop it. Potter killed Tarasoff and her family sued UCB staff for not warning her of the danger she was in. Poddar got out of his second-degree murder charge by agreeing to return to India.

Duty to Warn/Protect -Duty to Warn/Protect -Jablonski by Pahls v. US (1983)Jablonski by Pahls v. US (1983)

Determined that a mental health professional's duty to predict dangerousness includes consulting a patient's prior records, and that their duty to protect includes the involuntary commitment of a dangerous individual; simply warning the foreseeable victim is insufficient.

Mr. Jablonski was dating Ms. Kimball and threatened to kill her and her mother (Ms. Pahls). After one incident that culminated in a threat towards her mother, she took him to the Loma Linda VA Hospital, where the doctor conducted a risk assessment, but did not consult Jablonski’s prior records; which documented a history of violent behavior. Based on incomplete data, he determined erroneously that Jablonski was not a danger to himself/others and released him. He warned Ms. Kimball to leave Jablonski but did not warn her of his potential for violence. When he was released, he killed her.

The court ruled that the doctor's failure to secure the patient's previous records constituted negligence, as the information in his files would have affected the risk assessment and thus the actions taken to protect the foreseeable victim.

The legal precedent set by this case extends the duty of the mental health professional to secure previous records when conducting a risk assessment, and the duty to protect to include the involuntary hospitalization of a dangerous individual.

Ewing v. Goldstein (2004)

Extended California mental health professional's duty to protect identifiable victims of potentially violent persons, as

established by Tarasoff v. Regents of the University of California, to include acting

upon communications from third parties that indicate a possible

threat.

Police officer Gene Colello received treatment from David Goldstein, after breaking up with his ex-girlfriend, who had become involved with Keith Ewing. During the course of treatment, Colello told his father about considering harming Ewing, which the father claims to have relayed to Goldstein. There was never any evidence that he did tell Goldstein or anyone else. Goldstein encouraged voluntary hospitalization but did not warn Ewing or law enforcement officials of Colello's hostile intentions, because of not having the information that the father withheld. When Colello was released, he murdered Ewing and then committed suicide.

Determined that the duty to protect was not sufficiently discharged by initiating involuntary commitment and could be discharged only by warning the identifiable victims. This case created a clear distinction between the duty to protect and the subordinate duty to warn and made communications by a third party indicating threatening statements equivalent to statements made directly by that person.

SO WHAT CAN YOU DO?SO WHAT CAN YOU DO?

LEARN THE RISK FACTORS,

ASSESS FOR DANGER & LETHALITY RISK

KNOW YOUR LEGAL RESPONSIBILITY

INFORM - WARN - PROTECT

FOLLOW-UP AND DOCUMENT

Perpetrator Risk Factors Perpetrator Risk Factors •Low self-esteem•Low income•Low academic achievement•Young age•Aggressive or delinquent behavior as a youth•Heavy alcohol and drug use•Depression•Anger and hostility•Antisocial personality traits•Borderline personality traits•Prior history of being physically abusive•Having few friends and being isolated from other people•Unemployment•Emotional dependence and insecurity•Belief in strict gender roles (e.g., male dominance and aggression in relationships)•Desire for power and control in relationships•Perpetrating psychological aggression•Victim of physical or psychological abuse (one of the strongest predictors of perpetration)•History of experiencing poor parenting as a child•History of experiencing physical discipline as a child

Relationship FactorsRelationship Factors

• Marital conflict-fights, tension, and other struggles• Marital instability-divorces or separations• Dominance and control of the relationship by one partner over the other• Economic stress• Unhealthy family relationships and interactions

Community and Societal Community and Societal FactorsFactors

• Poverty and associated factors (e.g., overcrowding)• Low social capital-lack of institutions, relationships, and norms that shape a community's social interactions• Weak community sanctions against IPV (e.g., unwillingness of neighbors to intervene in situations where they witness violence)• Traditional gender norms (e.g., women should stay at home, not enter workforce, and be submissive; men support the family and make the decisions)

WHEN THE WHEN THE VICTIM VICTIM IS IS

YOUR CLIENTYOUR CLIENT

DANGER ASSESSMENTDANGER ASSESSMENTBYBY

JACQUELYN C CAMPBELL, PHD, RNJACQUELYN C CAMPBELL, PHD, RN

1 page assessment tool

Assesses the Victim’s Level of Potential Harm from the Perpetrator

Quick & Easy to Score

Researched

Anyone can use

Copyrighted, but can use thru Quest MHSA, LLC

Several risk factors have been associated with increased risk of homicides (murders) of women and men in violent relationships. We cannot predict what will happen in your case, but we would like you to be aware of the danger of homicide in situations of abuse and for

you to see how many of the risk factors apply to your situation.

Using the calendar, please mark the approximate dates during the past year when you were abused by your partner or ex partner. Write on that date how bad the incident was

according to the following scale:

1. Slapping, pushing; no injuries and/or lasting pain2. Punching, kicking; bruises, cuts, and/or continuing pain3. "Beating up"; severe contusions, burns, broken bones

4. Threat to use weapon; head injury, internal injury, permanent injury5. Use of weapon; wounds from weapon

(If any of the descriptions for the higher number apply, use the higher number.)

Mark Yes or No for each of the following. ("He" refers to your husband, partner, ex-husband, ex- partner, or whoever is currently physically hurting you.)

____ 1. Has the physical violence increased in severity or frequency over the past year?____ 2. Does he own a gun?____ 3. Have you left him after living together during the past year?

3a. (If have never lived with him, check here___)____ 4. Is he unemployed?____ 5. Has he ever used a weapon against you or threatened you with a lethal weapon? (If yes, was the weapon a gun?____)____ 6. Does he threaten to kill you?____ 7. Has he avoided being arrested for domestic violence?____ 8. Do you have a child that is not his?

____ 9. Has he ever forced you to have sex when you did not wish to do so?____ 10. Does he ever try to choke you?____ 11. Does he use illegal drugs? By drugs, I mean "uppers" or amphetamines, “meth”, speed, angel dust, cocaine, "crack", street drugs/mixtures.____ 12. Is he an alcoholic or problem drinker?____ 13. Does he control most or all of your daily activities? For instance: does he tell you who you can be friends with, when you can see your family, how much money you can use, or when you can take the car? (If he tries, but you do not let him, check here: ____) ____ 14. Is he violently and constantly jealous of you? (For instance, does he say "If I can't have you, no one can.")____ 15. Have you ever been beaten by him while you were pregnant? (If you have never been pregnant by him, check here: ____)____ 16. Has he ever threatened or tried to commit suicide?____ 17. Does he threaten to harm your children?____ 18. Do you believe he is capable of killing you?____ 19. Does he follow or spy on you, leave threatening notes or messages, destroy your property, or call you when you don’t want him to? ____ 20. Have you ever threatened or tried to commit suicide?

________ Total "Yes" Answers

Thank you. Please talk to your nurse, advocate or counselor about what the Danger Assessment means in terms of your situation.

Scoring InstructionsScoring Instructions

Add total number of “yes” responses: 1 thru 19

Add 4 points for a “yes” to question 2

Add 3 points for a “yes” to 3 and 4

Add 2 points for each “yes” to 5, 6, and 7

Add 1 point to each “yes” on 8 and 9

Subtract 3 points if 3a is checked.

Interpreting the Danger Level Interpreting the Danger Level ScoresScores

Less than 8 (Variable Danger) - Routine safety planning and monitoring. Inform victim that the level of risk can change quickly, to trust their instincts and to watch for additional signs of danger.

8 to 13 (Increased Danger) - Safety Planning and increased monitoring are important. Advise victim of increased risk and to watch for other signs of danger.

14 to 17 (Severe Danger) - Advise victim that danger is severe. Be assertive with safety planning, consult with judges, high level of supervision recommendations.

18 or more (Extreme Danger) - Advise victim of serious danger. Take assertive actions to protect victim-call for criminal justice or other professional help-recommend highest level sanctions for perpetrator such as highest level of probation supervision.

WHEN THE WHEN THE PERPETRATORPERPETRATOR

IS IS YOUR CLIENTYOUR CLIENT

Homicide Risk Assessment Homicide Risk Assessment - -

Univ of Calif, Berkeley School of SW (2013)Univ of Calif, Berkeley School of SW (2013)

Suggested Clinician Style:

Friendly = compassionate, warm, concerned, supportive, client-centered

Frank = direct, candid, unafraid to ask or talk about risks plainly, and

Firm = asking in a confident tone and insisting that this discussion is essential, imperative, and necessary.

These help establish therapeutic trust, clear expectations, & relational honesty.

HRA Question #1HRA Question #1

HOMICAL IDEATION (Normalize)

When someone feels as upset as you do, they may have thoughts about hurting the person who has upset or hurt them.

What thoughts have you had like this?

HRA Question #2HRA Question #2

PLANNING (Means)

If you decide to try to hurt _______, how would you do it?

Tell me about the plans you’ve made.

HRA Question #3HRA Question #3

ACCESS TO MEANS

You mentioned that if you were to hurt _______, you’d probably do it by __________________ (describe method).

How easy would it be for you to do this?

HRA Question #4HRA Question #4

PROTECTIVE FACTORS (Normalize)

People often have very mixed feelings about harming other people.

What are some reasons that would stop you or prevent you from trying to hurt ______?

What is it that most holds you back from actually doing this?

HRA Question #5HRA Question #5

PAST EXPERIENCES

What have been your past experiences related to hurting people who have hurt you?

HRA Question #6HRA Question #6

FUTURE EXPECTATIONS

What are some of the things happening in your life or likely to happen in your life right now that would either make you more or less likely to want to hurt _______?

How do you think people who know you would react if you actually did this?

what would that say, think, or feel?

What would be some of the consequences if you did this?

Continuum of RiskContinuum of RiskReview Perpetrator Risk Factors on slides 16-18.

Given the severity and specificity of the ideation, given the presence of risk and protective factors, and given recent and/or anticipated stressors, what is the current level of imminent (“about to occur”) risk?

LOW MODERATE HIGH

0 1 2 3 4 5 6 7 8 9 10

Assault & Homicidal Danger Assault & Homicidal Danger Assessment Tool - Assessment Tool -

((People in CrisisPeople in Crisis-LeeAnn Hoff & Centers for Disease Control)-LeeAnn Hoff & Centers for Disease Control)

Key to Dange

r

Immediate Dangerousn

ess to Others

Typical Indicators

1No predictable risk of assault or homicide

Has no assaultive or homicidal ideation, urges, or history of same; basically satisfactory support system; social

drinker only.

2Low risk of assault or homicide

Has occasional assault or homicidal ideation (including paranoid ideas) with some urges to kill; no history of impulsive acts or

homicidal attempts; occasional drinking bouts and angry verbal outbursts; basically satisfactory support system.

3Moderate risk of assault or

homicide

Has frequent homicidal ideation and urges to kill but no specific plan; history of impulsive acting out and verbal outbursts while drinking, on other drugs, or otherwise; stormy relationship with significant

others with periodic high-tension arguments.

4 High risk of homicide

Has homicidal plan; obtainable means; history of substance abuse; frequent acting out against others, but no homicide

attempts; stormy relationships and much verbal fighting with significant others, with occasional assaults.

5Very high risk of assault or

homicide

Has current high-lethal plan; available means; history of homicide attempts or impulsive acting out, plus feels strong urge to control

and “get even” with a significant other; history of serious substance abuse; also with possible high-lethal suicide risk.

Quest ProtocolQuest Protocol

PROTOCOL FOR PROTOCOL FOR DOMESTIC VIOL/SEXUAL ASSAULT/STALKINGDOMESTIC VIOL/SEXUAL ASSAULT/STALKING

It is the policy of QUEST to assess for and monitor potential domestic violence/sexual assault/stalking situations in our consumers’ lives. When the BPS or CAR Update screen indicates the need for further assessment, utilize the following protocol:

1) LBHPs - For Victims, complete the Danger Assessment with the consumer to assess the current level of lethality and risk. For Perpetrators, complete the Domestic Violence Inventory with the potential perpetrator to assess the current level of potential violence.

2) Any consumer scoring higher than 4 requires a QUEST Safety Plan being completed and emailed/ mailed into main office.

3) For those in imminent danger (higher than 7) contact local law enforcement, the Oklahoma Statewide Safeline at 1-800-522-7233, and make a report to DHS.

4) For those in Severe/Extreme Danger, contact local law enforcement, assist in getting them to a Shelter http://www.aardvarc.org/dv/states/okdv.shtml, and make a report to DHS.

5) For cases 7 and higher, complete a Health and Safety Critical Incident Report form and email/mail to main office.

6) Contact a Quest Clinical Director and copy them on the Critical Incident and Safety Plan email. 7) Perform ongoing continuity of care by re-assessing, contacting, engaging, and supporting the

consumer (and caregivers) to ensure the consumer’s safety. Quest case managers must actively and aggressively assist to shelter, during shelter, and back out to community transition support services, follow up contacts, ensuring the consumer makes their follow-up appoints w/ therapist, physic, resources, etc.

REMEMBER, WE’RE HERE FOR REMEMBER, WE’RE HERE FOR SUPPORT AND CLINICAL ASSISTANCESUPPORT AND CLINICAL ASSISTANCE

Quest Clinical Directors:Tiffany Couch, LMFT, LADC

Loydena Beck, LPC Alisa Longnecker, LPC

Debbie Spaeth, LMFT, LPC, LADC - Supervisor