Concept FORMAT Mental Disorder and Violence Webinar aWebinar+2017... · 2017-01-25 · Incident...
Transcript of Concept FORMAT Mental Disorder and Violence Webinar aWebinar+2017... · 2017-01-25 · Incident...
KevinS.Douglas,LL.B.,Ph.D.Sim
onFraserUniversity&
ProtectInterna>onalRiskandSafety
Services
Me
nta
l Diso
rde
r an
d
Vio
len
ce R
isk
Top
ics
• Controversyoverroleofmentalillnessandviolence
• Es>ma>ngtheassocia>on
• Directlinktoviolence?• Roleofm
entalillnesswithinviolenceriskassessm
entandmanagem
ent
Co
mm
on
Ap
plica
8o
ns
Forensic
Correc>ons
Civil
Private
Admission
Inst.monitor
Discharge
Community
Policing
Manage
Co
ntro
versy
So
me
be
lieve
it ma
=e
rs…
• Silver(2006)�Thevastbodyofresearchconducted…
suggeststhat:[a]lthoughmostpeoplew
ithmajorm
entaldisorderdonotengageinviolence,thelikelihoodofcom
miV
ngviolenceisgreaterforpeoplewitha
majorm
entaldisorderthanforthosewithout.�
• Hodginsetal.(1998)• �hassom
esocietalsignificance�
So
me
be
lieve
it do
esn�
t…
• Quinseyetal.(1998/2006)�Psychosis,psycho>csym
ptoms,andexacerba>onofthosesym
ptomshave
li_levalueasindicatorsoftheriskofviolenceinoffenderpopula>ons�
• Bontaetal.(1998;2014)meta-analyses
Ø 11(15)effectsizesforpsychosis
Ø Meancorrela>on(1998)?
Ø Meand(2014)?
-.04.09
Ro
le o
f MD
in R
isk A
ssessm
en
t Instru
me
nts
Instru
ment
RoleofM
D
VRAGInverse
VRAG-RAbsent
LSI-R,LS/CMI
AbsentVRS
Posi>ve*HCR-20
Posi>ve*
• VRAG(-R
):ViolenceRiskAppraisalG
uide(-R
evised)
• LSI-R
:LevelofS
erviceIn
ventory-Revised
• LC/CMI:L
evelofS
ervice/CaseM
anagementIn
ventory
• VRS:V
iolenceRiskScale
• HCR-20:H
istoric
al,C
linicalR
iskM
anagement-2
0
Vio
len
ce R
isk F
acto
rs am
on
gst O
ffe
nd
ers w
ith
MD
• Generally,theriskfactorsforviolencearethesam
eregardlessofm
entaldisorderØ Bontaetal.m
eta-analyses(1998;2014)
Ø CentralEight
Centra
lEight
CriminalHistory
An>socialPersonalityPa_ern
ProcriminalAV
tudesandCogni>ons
ProcriminalCom
panions
Family/M
arital
Educa>on/Employm
ent
SubstanceAbuse
Leisure/Recrea>on
WhattodoaboutM
D?
Bo
nta
et a
l. (20
14
, p. 2
85
)
�Althoughtherearecertainlycaseswhenacrim
eiscommi_edduring
apsycho>cstate,psychosisdoesnotappeartobeausefulpredictorofrecidivism
….becausepsychosisistransitory…
andamenableto
treatment�
�Majorm
entalillnessesareunreliablepredictorsofgeneralandviolentrecidivism
��
Bo
nta
et a
l. (20
14
, p. 2
85
), �slig
htly
mo
difi
ed�
“Therearecertainlycaseswhenacrim
eiscommi_edduringa
psycho>cstate;psychosis[appearsto
beausefulassessmentta
rget
inris
kassessment]…
.becausepsychosisistransitory…and
amenabletotreatm
ent”[Thatis
,itappearsto
beadynamicris
kfa
ctor]
Bo
nta
et a
l. (20
14
, p. 2
85
)
Inmodera>onanalyses…
Psychosisandviolence,inM
DOs
d=.18
Comparabletotw
oCentralEightfactors--Educa>on/em
ployment,
d=.14
--Substanceabuse,
d=.20
Evid
en
ce fro
m E
pid
em
iolo
gy
Ø Severalpopula>on-basedstudiesfindthatm
ajor(psycho>c)mentalillnessisassociatedw
ithanincreaseinviolentcrim
inality
Study
Sample
+Odds
Hodginsetal.(1996)All(130,000+)personsborninDenm
ark,1944-78.0
Hodgins(1992)UnselectedSw
edishbirthcohort(15,117),1953
4.0
Tiihonenetal.(1997)UnselectedN
.Finlandbirthcohort(12,058),1966
5.0–10.0
Swanson(1994)
10,000randomlysam
pledUSA
residents5.0
Ho
we
ver…
• Elbogen&Johnson(2009),N
=34.7kØ Nosignificantassocia>onforSZandviolence(buttw
icetheobservedviolence)
Ø Com
orbiditywithSU
Delevatedodds
• VanDornetal.(2011),samedataset
Ø Associa>oninbivariate(O
R=3.6)andmul>variate(O
R=1.6)analysesØ Strongerassocia>onforSU
Dcomorbidity
Wh
y th
e D
isag
ree
me
nt?
MD
MH
CJ
FMH
�TheW
orld�
Syn
the
sizing
the
Litera
ture
(Do
ug
las, G
uy, &
Ha
rt, 20
09
; Psych
olo
gica
l Bu
lle8
n)
• Meta-analysisof204studies
• Ques>ons1.
Whatistheoverallrela>onshipbetw
eenpsychosisandviolence?2.
Arethereimportantm
oderatorsofthisrela>onship?
Ge
ne
ral F
ind
ing
s
• Overallassocia>onØ Meanoddsra>o=3.49
Ø Medianoddsra>o=1.69
• ~25%ofstudies:nega>veassocia>on(O
R<1)• ~25%
ofstudies:largeassocia>on(OR>3)
• Whatexplainsthisheterogeneity?
Mo
de
rato
rs: Sa
mp
le
0
0.5 1
1.5 2
2.5 3
3.5
Civil
Forensic P
rison C
omm
unity
Odds
Mo
de
rato
rs: Co
mp
ariso
n G
rou
p
0
0.5 1
1.5 2
2.5 3
3.5 4
Other M
I N
o MI
Odds
Mo
de
rato
rs: What o
the
r MI?
0
0.5 1
1.5 2
2.5
INT
EXT
Odds
Mo
de
rato
rs: Su
bsta
nce
Use
Co
mo
rbid
ity
0 2 4 6 8
10
12
Com
orbid P
sychosis Alone
Odds
Note: Sm
all k (12)
Mo
de
rato
rs: Ho
w D
efin
e Psyc
ho
sis?
0
0.5 1
1.5 2
2.5
SZ-Spectrum
A
ffective M
ixed/NS
Symptom
-Level
Odds
Mo
de
rato
rs: Wh
at S
ym
pto
ms?
0
0.5 1
1.5 2
2.5
Positive
Negative
Disorganized
Odds
Note:N
oDifferenceBetweenTypeofPosi>veSym
ptom
Acco
un
8n
g fo
r He
tero
ge
ne
ity
OR =
7.5 M
ult R = .51
Do
ug
las e
t al (2
00
9, p
. 69
6)
�Posingtheques>on,�Areindividualswithpsychosism
orelikelytobeviolentthanindividualsw
ithoutpsychosis?�issortoflikeaskingwhether10-yearoldsaretall.Com
paredwithtoddlers,theycertainly
are.Comparedw
ithadults,theyaredecidedlyshort.Andsoitiswith
psychosis.�
MD
an
d V
iole
nce
• Onaverage,sm
all(butreal)effectsizeØ r�.15–20
Ø “M
oderate4”criminogenicneeds,m
eanr=.17(Andrews,2012)
• Oddsra>osfrom
epidemiologicalstudiestendtobelarger
“Ce
ntra
l Eig
ht” R
isk F
acto
rs (Le
vel o
f Se
rvice
ap
pro
ach
; An
dre
ws, 2
01
2)
“Big4”• Hxan>socialbeh• An>socialpersonalitypa_ern• An>socialaV
tudes• An>socialassociates
“Moderate4”
• Family/m
aritalprobs• Educ/em
ployprobs• Leisure/recrea>onprobs• Substanceabuse
r=.26
r=.17
MD
an
d V
iole
nce
• Inanygivencase,MDm
aybelinkedw
ithviolence• Ac>vesym
ptomskey
Ø Especiallyposi>vesym
ptoms(Sw
ansonetal.,2006)
• Comorbidityw
ithSUDim
portant• O
therformsofm
odera>on
MD
may b
e M
od
era
ted
(S
ha
ffe
r, Bla
nch
ard
, & D
ou
gla
s, 20
15
)
• 261communityresidents;baseline+6m
FU
• Psychosis;neighbourhooddisadvantage• M
aineffectforpsychosis=.02(ns)
0
0.1
0.2
0.3
0.4
0.5
0.6
Low Psychosis
High Psychosis
Incident Rate of Violence
Low N
D
High N
D
Dyn
am
ic Risk
: Ch
an
ge
ove
r Tim
e
• Fischeretal.(2008),207peoplewithM
DØ 9m
easurementpoints,6m
onthsapartØ Bothdiagnosis(sta>c)andsym
ptomchange(dynam
ic)predictedviolence
• Hodginsetal.(2003;2007;2011)Ø 128m
enwithSZ
Ø IncreasesinTCO
andposi>vesymptom
sassociatedwithhigherfuture
violence
Dire
ct Link?
Whenapersonw
ithMDisviolent,how
ozendoestheMD
haveanythingtodowiththeviolence?
How
ozenisitakey,contribu>ngfactor?
Ro
le o
f MD
• Jungingeretal(2006)Ø 113m
entallyilldiversionarresteesØ 8%
a_ributabletopsychosisorotherSxØ Mainlynon-violent
• Petersonetal(2010)Ø 111m
entallyillparoleesØ 7%
of�offencepa_ern�duetopsychosis
Ø Morelikelytohave�reac>ve�m
o>vesØ Concluded~10%
ofcrime,includingviolence,isa_ributabletotheM
Ditself
“Mo
de
rate
d M
ed
ia8
on
” (S
kee
m e
t al., 2
01
1)
• For~10%ofM
Ioffenders,directeffect• For~90%
,indirect(mediated)ornoeffect
Mental Illness
Hostility, X, Y
Violence
Bu
t…E
arlie
r Re
sea
rch
• Taylor(1985)Ø 212violentoffendersadm
i_edtoBrixtonremandprison,U
KØ Oversam
pledMD
Ø 75%
symptom
a>cat>meofoffence
Ø 20%
,�definite�causalroleØ 26%
,�probable�causalroleØ 50%
alsohad�ra>onal�reasons
Ad
di8
on
al R
ese
arch
• Nolanetal.(2003)Ø 70assaultsby43pa>ents
Ø Videoobserva>on,interview
Ø 20%
psycho>cmo>va>on
• Quanbecketal.(2007)Ø Forensicandcivilpa>ents
Ø 1000random
lyselectedassaultsØ 17%
psycho>cmo>va>on
Ø 29%
organizedØ 54%
impulsive
Dire
ct Ca
use
Ap
pro
ach
• Thesearchforone,andoneonly,directproximatecauseofviolence
amongstpersonsw
ithMD
• Bestes>mate:10%
to20%(to46%
)
Ho
we
ver…
• Focusoncrime,notviolenceperse
• ForJunginger,justoneoffence• Ifpsychosisism
ediatedbyX,ispsychosisnolongerimportant?
• Musttherebeonlyone“cause?”
• Aren’tallriskfactorsonlyimportantinam
inorityofviolentincidents?
Dire
ct Ca
use
Ap
pro
ach
…P
rob
lem
?
C
8.1 (12.5)
C
8.2 (12.5)
C
8.3 (12.5)
C
8.4 (12.5)
C
8.5 (12.5)
C
8.6 (12.5)
C
8.7 (12.5)
C
8.8 (12.5)
CentralEight,averagepropor8onasdirectcause
Wh
en
MD
is Ad
de
d…
C
8.1 (11.2)
C
8.2 (11.2)
C
8.3 (11.2)
C
8.4 (11.2)
C
8.5 (11.2)
C
8.6 (11.2)
C
8.7 (11.2)
C
8.8 (11.2)
MD
(10)
Averagepropor8onasdirectcause,MDat10%
Wh
en
MD
is Ad
de
d…
C
8.1 (10)
C
8.2 (10)
C
8.3 (10)
C
8.4 (10)
C
8.5 (10)
C
8.6 (10)
C
8.7 (10)
C
8.8 (10)
MD
(20)
Averagepropor8onasdirectcause,MDat20%
Maybeweshouldallo
wm
ul[plecauses,
includingM
D?
Ro
le w
ithin
Asse
ssme
nt
Ro
le o
f MD
with
in A
ssessm
en
t?
• ForapersonwithM
D,thereisa1in5to1in10chancethatviolenceiscausedbyM
DØ Thisw
illvarybyselec>onfactors
• MDm
ustbeincludedwithinriskassessm
ents• W
eneedtodetermineforw
homitisrelevant,andforw
homitisnot
Ro
le o
f Th
eo
ry
• But,whydoesM
D(oranyriskfactor)leadtoviolencenow?
• DecisiontheorywithinStructuredProfessionalJudgm
entRiskAssessm
entapproachØ Felson(2009):BoundedRa>onalChoice
Ø Wikström
&Treiber(2009):Situa>onalAc>onTheory
Ca
usa
l Ro
les (D
ecisio
n T
he
ory
)
Mo>vator
DisinhibitorDestabilizer
RiskFactors
Violence
Mo
8va
tors
PerceivedRew
ardDefenseDistance
Jus>ceHonor
GainProfit
ControlChange
StatusEsteem
ReleaseExpressionArousal
Ac>vity
Proximity
Affilia>on
Disin
hib
itors
PerceivedCost
Nega>ve
AVtudes
Nega>veSelf-
Concept Aliena>on
Nihilism
LackofInsight
LackofEm
pathyLackofAnxiety
LackofGuilt
De
stab
ilizers
CarefulDecisions
DisturbedA_en>on
DisturbedPercep>on
Impaired
IntellectIm
pairedMem
ory
Impulsive
Thinking
InflexibleThinking
Wh
y m
igh
t MD
incre
ase
risk?
• Affect-distress/BeliefMaintenanceFactors(Taylor,1998,2008)
• �Psycho>cMo>va>on
�(Junginger,2004)Ø Sym
ptom-consistentviolence
• �TenseSitua>ons�(Hiday,2006)• Vulnerabilitytootherrisks
Ø �geographic/dow
nwarddriz
�
• Strain;socialdisorganiza>ontheoriesØ Markow
itz(2011)
Wh
y?
• SZandempathydeficits(em
o>onalrecogni>on)Ø (Bragago-Jim
inez&Taylor,2012)
• SZandhos>lea_ribu>onalbiasesØ (StephanieHarrisetal.,2014)
SPJ D
ecisio
n S
tep
s (H
CR
-20
Ve
rsion
3, D
ou
gla
s et a
l., 20
13
)
1• Gatherrelevantinform
a>on
2• Determ
inepresenceofriskfactors
3• Determ
inerelevanceofriskfactors
4• Developform
ula>onofviolencerisk
5• Developprim
aryscenariosofviolence
6• Developcasem
anagementplans
7• Developfinalriskjudgm
ents
Wh
at R
ole
Sh
ou
ld M
D P
lay in
the
Risk
Asse
ssme
nt F
ield
?
�Psychosis[M
D]shouldbeevaluatedin
allv
iolenceris
kassessments�
(Douglaset
al.,2
009,p
.696),in
orderto
determ
ine
whetheritis
,oris
not,re
levantto
violenceinth
eindividualcase.
Re
du
cing
Risk
• Determinew
hethermentaldisorderisadynam
icriskfactorinagivencase
• Focuson“CentralEight”aswell
• Par>culara_en>ontoposi>ve,ac>vesymptom
s,changesincourse,corm
orbidSUD,otherstressors(neighborhood;affect)
• Ask,whyisM
Drelevanttoviolenceforthisperson?• Doesitm
o>vate,disinhibit,ordestabilize?
Re
du
cing
Risk
?
(revie
we
d in
Do
ug
las e
t al., 2
01
6)
• First,don’tforget“alltheotherfactors”• Risk-N
eed-Responsivity• SocialLearning,cogni>vebehavioral,cogni>veskillsapproaches• Angerm
anagement
• Dialec>calBehaviorTherapy• Com
munitysupervision/engagem
entØ (Leveraged)outpa>entcom
mitm
ent;mentalhealthcourts;asser>vecase
managem
ent;housing?• M
edica>on(clozapine)• (Alm
ostnoRCTs!)
In S
um
• Controversial• ConvergingevidencethatM
Disadynamicriskfactor(“crim
inogenicneed”)
• Notalw
aysrelevant• Ac>ve,posi>vesym
ptoms,TCO
• Interac>onsw
ithSUD,affect,stressors
• Ask,whym
ightitberelevanttoaperson’sviolence?• M
anagementispossible
Is Me
nta
l Diso
rde
r Ign
ora
ble
with
in
Vio
len
ce R
isk A
ssessm
en
t an
d
Ma
na
ge
me
nt?
Ke
vin
Do
ug
las
Thank you