1. Dead Right, Dead Wrong, or the Jury is Still Out: The Complex Worlds of Violence and Mental Illness Sally C. Johnson MD Professor UNC Department of Psychiatry Forensic Psychiatry Program and Clinic

2. Learning Objectives Appreciate the complexity of the relationship between violence and mental illness Appreciate the complexity of the relationship between violence and mental illness Understand the current state of risk assessment Understand the current state of risk assessment Translate this understanding into a practical approach to risk management Translate this understanding into a practical approach to risk management

3. 75% of people believe that people with mental illness are dangerous.

4. Literature: Mental illness and Violence From Nursery Rhymes….

5. Lizzie Borden took an axe and gave her mother forty whacks. When she saw what she had done she gave her father forty-one.

6. To recent best-sellers…

7. “These were the lovely bones that had grown around my absence…” Susie Salmon cutting through a cornfield after school is persuaded by George Harvey, a man in his mid-40s who lives alone and builds dollhouses for a living, to have a look at his underground den. He rapes and kills her, dismembers her body, puts the parts in a safe and dumps it into a sinkhole.

8. We are led to believe that “crazy” people do crazy and frightening things.

9. Film Portrayal: Mental Illness and Violence The idea of the insane killer….

10. Takes a real life story like that of Ed Gein

11. … and makes him into Norman Bates in Alfred Hitchcock’s “Psycho”

12. In the News: Mental Illness and Violence Whether it is the poor handyman in need of a job…

13. Bryan David Mitchell Elizabeth Smart Kidnapping

14. Or workplace violence that hits close to home…

15. The murder of an NIMH administrator while trying to help a psychotic patient sent shockwaves through the mental health community, forcing clinicians to remember the rare—but ever present—risk of violence. It is a rare scenario, the potential nightmare in the life of a psychiatrist: a patient becomes violent…while the psychiatrist and the patient are alone in the psychiatrist's office. Wayne Fenton, M.D. October 3, 2006

16. …or a psychiatrist (possible terrorist) turned mass murderer…

17. Nidal Malik Hasan Ft. Hood Killing Rampage

18. We are surrounded by possible links between violence and mental illness, and it’s frightening.

19. We are looking for a way to give names and faces to our fears…

20. …we want to know who is going to be violent and be able to stop them from being violent.

21. Cesare Lombroso’s “Atavism”: violent criminals were throwbacks to primitive humans / identifiable by physical characteristics / so could just permanently detain or execute them

22. What’s the message?

23. Physical Signs of Imminent Violence (Berg, Bell, and Tupin, 2000) Chanting Chanting Clenched Jaw Clenched Jaw Flared Nostrils Flared Nostrils Flushed face Flushed face Clenched or Gripping hands Clenched or Gripping hands Darting Eye Movements Darting Eye Movements Increased proximity of patient to Clinician Increased proximity of patient to Clinician Inability of Patient to Comply with reasonable Limit setting Inability of Patient to Comply with reasonable Limit setting

24. Core Issues to Consider Definitions Violence / Mental Illness Violence / Mental IllnessAssessment What’s adequate? How often? What’s adequate? How often?Prediction Of what? For how long? Of what? For how long?Prevention Responsibility / Cost Responsibility / Cost Liability / Blame

25. Violence: what does it mean? Actual physical violence? Actual physical violence? Potential for violent behavior? Potential for violent behavior? Threat of violent behavior? Threat of violent behavior? Breaking the law? Breaking the law? Psychological or emotional harm? Psychological or emotional harm? Risk to property? Risk to property? Does it have to be a specific act or just a general propensity towards violence? Does it have to be a specific act or just a general propensity towards violence?

26. Does it have to be imminent? Does it have to be imminent? Does frequency matter? Does frequency matter? Does severity matter? Does severity matter? What about the setting? What about the setting? Does it matter toward whom or what it is directed? Does it matter toward whom or what it is directed?

27. What about defining Mental Illness or Mental Disorder? Clinically… ICD-10 : “the existence of a clinically recognizable set of symptoms or behavior associated … with … interference with personal functions”. ICD-10 : “the existence of a clinically recognizable set of symptoms or behavior associated … with … interference with personal functions”. DSM-IV-TR : “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual …associated with present distress … disability … or a significantly increased risk of suffering death, pain, disability, or an important loss of freedom … DSM-IV-TR : “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual …associated with present distress … disability … or a significantly increased risk of suffering death, pain, disability, or an important loss of freedom …

28. BUT… Within the legal/judicial system, mental illness or disorder is viewed as a legal, moral or policy judgment or definition- not a clinical one. not a clinical one.

29. Our legal system has long connected mental illness and violence and looked to clinicians to predict likelihood of future violence:

30. Civil Commitment Civil Commitment O’Connor v. Donaldson (1975) / Addington v. Texas (1979) Civil Liability Civil Liability Tarasoff v. Regents of the University of CA (1976) Death Penalty Cases Death Penalty Cases Jurek v.Texas (1976) / Barefoot v. Estelle (1983) Juveniles Juveniles Shall v Martin (1984) Preventive Detention Preventive Detention U.S. v. Salerno (1987) Sex Offender Commitment Statutes Sex Offender Commitment Statutes Kansas v. Hendricks (1997) / US v Comstock (2010) “ Legal Areas of Violence Risk Prediction

31. This legal dependence on clinical prediction of risk has persisted despite data suggesting that clinicians are often wrong in their predictions.

32. Natural experiments suggested clinicians were wrong more often than not: Baxstrom v. Herald, (1966)- release or transfer of “dangerous” patients. In 4 yr. follow-up only 20% assaultive Baxstrom v. Herald, (1966)- release or transfer of “dangerous” patients. In 4 yr. follow-up only 20% assaultive Dixon v. Attorney General of Commonwealth of PA (1971/1979-review)- 86% false positive rate among those originally predicted to be dangerous Dixon v. Attorney General of Commonwealth of PA (1971/1979-review)- 86% false positive rate among those originally predicted to be dangerous 1976-Cocozza/ Steadman-257 incompetent felons released: 14% of those predicted as dangerous were rearrested; 16% of those not viewed as dangerous were rearrested! 1976-Cocozza/ Steadman-257 incompetent felons released: 14% of those predicted as dangerous were rearrested; 16% of those not viewed as dangerous were rearrested! 1977-Patients released from Patuxent Institute/ MD -58% false-positive rate in predictions of violence 1977-Patients released from Patuxent Institute/ MD -58% false-positive rate in predictions of violence

33. In the wake of early legal decisions, research efforts increased with the aim to improve violence risk assessment in clinical practice and the criminal justice context by: –identifying empirically-validated risk factors –developing risk assessment instruments based on empirically-validated risk factors

34. Methodological problems in earlier studies were identified … Large #s of patients were lost to follow-up Large #s of patients were lost to follow-up Many had been treated for years Many had been treated for years Reviews relied on official criminal records which grossly under-estimated violence Reviews relied on official criminal records which grossly under-estimated violence Definition of violence was inconsistent Definition of violence was inconsistent Original predictions had not all been clinical: many were administrative or legal Original predictions had not all been clinical: many were administrative or legal Turns out that Clinicians were actually right more often than not - but just barely Turns out that Clinicians were actually right more often than not - but just barely

35. Review of History of Study of Relationship between Violence and Mental Illness Pre-deinstitutionalization studies showed no increased risk of violence Pre-deinstitutionalization studies showed no increased risk of violence Post-deinstitutionalization studies began to show increased risk Post-deinstitutionalization studies began to show increased risk It appeared that increased risk might be more connected to active symptoms rather than to diagnoses It appeared that increased risk might be more connected to active symptoms rather than to diagnoses There was more and more evidence that the relationship between mental illness and violence was actually quite complex There was more and more evidence that the relationship between mental illness and violence was actually quite complex

36. MacArthur Violence Risk Assessment Study (1994) Civil Admissions from inpatient psychiatric hospitals: Western Psychiatric/ Pittsburgh, PA; Western Missouri Mental Health Center/ Kansas City, MO; Worcester State hospital and University of Massachusetts Medical Center / Worcester, MA Civil Admissions from inpatient psychiatric hospitals: Western Psychiatric/ Pittsburgh, PA; Western Missouri Mental Health Center/ Kansas City, MO; Worcester State hospital and University of Massachusetts Medical Center / Worcester, MA Ages 18-40 Ages 18-40 English Speaking / White or African-American (Hispanic at Worcester) English Speaking / White or African-American (Hispanic at Worcester) Chart Dx of Schizophrenia, schizophreniform, schizoaffective, depression, dysthymia, mania, brief reactive psychoses, delusional disorder, alcohol or drug abuse or dependence, or personality disorder. Research and clinician interviews in hospital; two research interviews of patient and collateral informant with next 20 weeks. Review of hospital, arrest and rehospitalization records Chart Dx of Schizophrenia, schizophreniform, schizoaffective, depression, dysthymia, mania, brief reactive psychoses, delusional disorder, alcohol or drug abuse or dependence, or personality disorder. Research and clinician interviews in hospital; two research interviews of patient and collateral informant with next 20 weeks. Review of hospital, arrest and rehospitalization records

37. MacArthur Study-18.7 % of patients were involved in violent altercations: Significant Findings Men no more likely to be violent than women; drinking, SA and medication non-compliance > in men / women directed violence against family and at home Men no more likely to be violent than women; drinking, SA and medication non-compliance > in men / women directed violence against family and at home All measures (self report, hospital and arrest records)- previous violence and criminality strongly related to future violence All measures (self report, hospital and arrest records)- previous violence and criminality strongly related to future violence Prior physical abuse, but not sexual abuse as child was associated with post-DC violence Prior physical abuse, but not sexual abuse as child was associated with post-DC violence Parents history of substance abuse or criminal behavior: strong relationship Parents history of substance abuse or criminal behavior: strong relationship All races in same disadvantaged neighborhood had same risk: crime rate of neighborhoods pts. are discharged into may be important factor All races in same disadvantaged neighborhood had same risk: crime rate of neighborhoods pts. are discharged into may be important factor Personality disorder/ adjustment disorder had greater risk than all other Dx; schizophrenia than non-disordered population Personality disorder/ adjustment disorder had greater risk than all other Dx; schizophrenia than non-disordered population

38. MacArthur Study Findings continued…. Co-occurring Dx of Substance Abuse or Dependence strongly predictive Co-occurring Dx of Substance Abuse or Dependence strongly predictive Psychopathy (the antisocial component) as measured by PCL predicted violence Psychopathy (the antisocial component) as measured by PCL predicted violence Delusions were not predictive (even threat-control-over-ride) but suspiciousness was Delusions were not predictive (even threat-control-over-ride) but suspiciousness was Hallucinations/ command hallucinations were not predictive unless voices specifically commanding violent acts Hallucinations/ command hallucinations were not predictive unless voices specifically commanding violent acts Persistent violent thoughts during hospitalization and afterwards were predictive Persistent violent thoughts during hospitalization and afterwards were predictive Anger: high scores on Novaco Anger Scale at hospitalization were twice as likely to engage in violent acts post DC Anger: high scores on Novaco Anger Scale at hospitalization were twice as likely to engage in violent acts post DC

39. : So where are we now, So where are we now, more than 25 years later? more than 25 years later?

40. National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) We employed a nationally representative, longitudinal dataset from this two wave, face-to- face survey conducted by the National Institute on Alcohol Abuse and Alcoholism. N= 34,653 subjects Wave 1 (2001-2002) Wave 2 (2004-2005). Our questions were: 1) Does severe mental illness (SMI) predict future violent behavior? 2) What risk factors prospectively predict violent behavior?

41. Multivariate Predictors of Violent Behavior Perpetrated Between Waves 1 and2 Dispositional Factors: age, education, sex, race, income Dispositional Factors: age, education, sex, race, income Historical Factors: parental criminal history, witnessing parental fighting, history of any violence, history of juvenile detention Historical Factors: parental criminal history, witnessing parental fighting, history of any violence, history of juvenile detention Clinical Factors: Schizophrenia, Bipolar Disorder, Major Depression, Substance abuse/Dependence, Schizophrenia+SA/D, Bipolar Disorder+SA/D, Depression+SA/D, Perceives hidden threats in others Clinical Factors: Schizophrenia, Bipolar Disorder, Major Depression, Substance abuse/Dependence, Schizophrenia+SA/D, Bipolar Disorder+SA/D, Depression+SA/D, Perceives hidden threats in others Contextual Factors: Victimized in past year, family or friend died in past year, fired from job in past year, divorced or separated in past year, Unemployed for past year Contextual Factors: Victimized in past year, family or friend died in past year, fired from job in past year, divorced or separated in past year, Unemployed for past year

42. Top Ten Predictors of Any Violent Behavior Between Waves 1 and2 Age (younger) Age (younger) History of any violent act History of any violent act Male Male Divorce or separation in the past year Divorce or separation in the past year History of physical abuse History of physical abuse Parental criminal history Parental criminal history Unemployment for the past year Unemployment for the past year Co-occurring severe mental illness and substance abuse Co-occurring severe mental illness and substance abuse Victimization in the past year Victimization in the past year

43. SMI did not predict severe/serious violence, even when combined with substance use disorders. SMI did not predict severe/serious violence, even when combined with substance use disorders. SMI was significantly associated with physical abuse by parents, parental arrests, substance disorders, recent victimization, and unemployment. SMI was significantly associated with physical abuse by parents, parental arrests, substance disorders, recent victimization, and unemployment. 46% of those with SMI had co-morbid substance abuse/dependence. Violence risk was higher in this group than substance use without SMI. 46% of those with SMI had co-morbid substance abuse/dependence. Violence risk was higher in this group than substance use without SMI. People with SMI were more vulnerable to past histories that elevate violence risk and more prone to experience environmental stressors that also elevate violence risk. People with SMI were more vulnerable to past histories that elevate violence risk and more prone to experience environmental stressors that also elevate violence risk.

44. Severe mental illness did NOT rank among the strongest predictors of violent behavior. Severe mental illness did NOT rank among the strongest predictors of violent behavior. Severe mental illness alone was NOT statistically related to future violence, in bivariate or multivariate analyses. Severe mental illness alone was NOT statistically related to future violence, in bivariate or multivariate analyses. People with any type of severe mental illness were NOT at increased risk of committing serious/severe violent acts. People with any type of severe mental illness were NOT at increased risk of committing serious/severe violent acts.

45. Evolution from Violence Prediction to Risk (or threat) Assessment Violence Prediction Violence Prediction -focuses on the individual -focuses on the individual -portrays dangerousness as a state -portrays dangerousness as a state Risk Assessment Risk Assessment -focuses on person-situation interactions -focuses on person-situation interactions -portrays dangerousness as -portrays dangerousness as dynamic, contextual and continuous dynamic, contextual and continuous

46. We continue to be asked to assess risk of violence: Need for admission/ suitability for discharge Need for admission/ suitability for discharge ER evaluations ER evaluations Civil Commitment/ Release Civil Commitment/ Release Workplace/ school threats Workplace/ school threats Juvenile justice management Juvenile justice management Sentencing/ Parole/ Probation/ Early Release Sentencing/ Parole/ Probation/ Early Release Sex Offender Commitments Sex Offender Commitments Specialty Court Treatment Plans Specialty Court Treatment Plans

47. Approaches to Risk Assessment Unstructured Clinical Judgment Unstructured Clinical Judgment Actuarial Actuarial Structured Professional Judgment Structured Professional Judgment Anamestic Anamestic

48. Clinical Judgment More accurate than chance (Mossman 1994) AUC=.67 More accurate than chance (Mossman 1994) AUC=.67 Does facilitate aspects of data gathering and data interpretation Does facilitate aspects of data gathering and data interpretation

49. Actuarial Formal / equation-formula-graph- table used to arrive at a probability of some outcome Formal / equation-formula-graph- table used to arrive at a probability of some outcome Objective, mechanistic, reproducible combination of predictive factors, selected and validated through empirical research against known outcomes Objective, mechanistic, reproducible combination of predictive factors, selected and validated through empirical research against known outcomes BUT clinicians have not embraced this BUT clinicians have not embraced this Hard to go from the abstract to the individual Hard to go from the abstract to the individual

50. Structured Professional Judgment Presentation of specific risk factors derived from broad review of literature not specific data set- factors are well operationalized so their applicability can be coded: yes-possibly-no-/ multiple data sources/ evaluator draws conclusion weighing risk factors and intensity of management

51. Anamestic Process of gathering detailed information about individual’s history of violence. Question in detail about each particular violent event (preceding, subsequent, during)- thoughts, feelings and behaviors - to identify risk and protective factors that recur across violent events- identify target interventions

52. A Practical Guide to Risk Assessment… Build structure into your approach Build structure into your approach Remember that violence is not a common event, so prediction is not easy Remember that violence is not a common event, so prediction is not easy Start by thinking about the base rate for your clinical situation Start by thinking about the base rate for your clinical situation

53. “Knowledge of the appropriate base rate is the most important single piece of information necessary to make an accurate [violence] risk prediction.” (Monahan 1981) (Monahan 1981)

54. Base Rate The proportion of a particular population who commit violence in a particular period of time The proportion of a particular population who commit violence in a particular period of time Starting point for subsequent evaluation of probability Starting point for subsequent evaluation of probability Varies by type of violence, by method of detection, over time, and usually underestimates the true extent of violence Varies by type of violence, by method of detection, over time, and usually underestimates the true extent of violence

55. Practical Assessment of potential for violence toward others involves considering… Risk and Protective Factors: variables associated with the probability that violence will or will not occur Risk and Protective Factors: variables associated with the probability that violence will or will not occur Harm: the nature and severity of the probable results of the violent behavior Harm: the nature and severity of the probable results of the violent behavior Risk Level: the probability that violence will occur Risk Level: the probability that violence will occur Potential Victims: who are the likely objects of the violence Potential Victims: who are the likely objects of the violence

56. Standardized Risk Assessment Tools Assist the Clinician in gathering appropriate data Assist the Clinician in gathering appropriate data Anchor assessment to established research Anchor assessment to established research Access factors that are known to be associated with particular types of violence in specific populations. Access factors that are known to be associated with particular types of violence in specific populations. Should be used in conjunction with clinical risk assessment Should be used in conjunction with clinical risk assessment May not be as objective in application as we would hope. May not be as objective in application as we would hope.

57. When you think about using Risk Assessment Tools: Context Context Purpose Purpose Population Population Parameters Parameters Approach Approach Applicability Applicability Heilbrun, et al. Violence Risk Assessment Tools: Overview and Analysis/ Otto and Douglas Handbook of Violence Risk Assessment

58. Structured Risk Assessment Tools Hare Psychopathy Checklists Hare Psychopathy Checklists (PCL, PCL-R, PCL:SV, PCL:YV) (PCL, PCL-R, PCL:SV, PCL:YV) Historical-Clinical Mangement-20 (HCR-20) Violence Risk Assessment Scheme Historical-Clinical Mangement-20 (HCR-20) Violence Risk Assessment Scheme COVR-Classification of Violence Risk COVR-Classification of Violence Risk

59. Hare Psychopathy Checklists (PCL, PCL-R, PCL:SV, PCL:YV) PCL-R: 20 item construct rating scale PCL-R: 20 item construct rating scale Used in research and clinical settings Used in research and clinical settings Assesses psychopathy in adults Assesses psychopathy in adults Involves semi-structured interview and review of file/collateral data Involves semi-structured interview and review of file/collateral data PCL-SV: 12 item PCL-SV: 12 item PCL:YV: 20 items PCL:YV: 20 items

60. Psychopathic Personality Construct Personality traits and socially deviant behaviors: Glib and superficial charm Glib and superficial charm Egocentricity Egocentricity Selfishness Selfishness Lack of empathy, guilt and remorse Lack of empathy, guilt and remorse Lack of enduring attachment to people, principles, or goals Lack of enduring attachment to people, principles, or goals Impulsive and irresponsible behavior Impulsive and irresponsible behavior Tendency to violate explicit social norms Tendency to violate explicit social norms

61. PCL Ability to predict violent behavior depends on type of behavior being predicted( general v violent v sexual), context in which offender is or will be located ( corrections or community) and time frame of prediction ( 1 or 10 years)- and demographic variables – age/ gender/ race and ethnicity; need specific referral question to determine if should be used Ability to predict violent behavior depends on type of behavior being predicted( general v violent v sexual), context in which offender is or will be located ( corrections or community) and time frame of prediction ( 1 or 10 years)- and demographic variables – age/ gender/ race and ethnicity; need specific referral question to determine if should be used Has modest to moderate relationship with future community violence and weak to modest with future institutional violence Has modest to moderate relationship with future community violence and weak to modest with future institutional violence

62. Historical-Clinical Mangement-20 (HCR-20) Violence Risk Assessment Scheme Structured Professional Judgment model / translated into 16 languages Structured Professional Judgment model / translated into 16 languages Intended to facilitate assessments of risk for interpersonal violence (actual, attempted or threatened), clear unambiguous threats of harm, including psychological harm, to person or persons. Intended to facilitate assessments of risk for interpersonal violence (actual, attempted or threatened), clear unambiguous threats of harm, including psychological harm, to person or persons. Intended to provide a structured assessment of the risk factors that are present in a given case, the relevance of the risk factors for a given individual’s violence risk, and what risk management strategies might be put into place in order to mitigate that risk. Intended to provide a structured assessment of the risk factors that are present in a given case, the relevance of the risk factors for a given individual’s violence risk, and what risk management strategies might be put into place in order to mitigate that risk. Historical / Clinical and Risk Management Scales Historical / Clinical and Risk Management Scales

63. Checklist from HCR-20 Historical: previous violence, young age at first violent incident, relationship instability, employment problems, substance use problems, major mental illness, psychopathy, early maladjustment, personality disorder, prior supervision failure Historical: previous violence, young age at first violent incident, relationship instability, employment problems, substance use problems, major mental illness, psychopathy, early maladjustment, personality disorder, prior supervision failure

64. Checklist from HCR-20 Clinical: lack of insight, negative attitudes, active symptoms of major mental illness, impulsivity, unresponsiveness to treatment Clinical: lack of insight, negative attitudes, active symptoms of major mental illness, impulsivity, unresponsiveness to treatment Risk Management Items: plans lack feasibility, exposure to destabilizers, lack of personal support, noncompliance with medication, stress Risk Management Items: plans lack feasibility, exposure to destabilizers, lack of personal support, noncompliance with medication, stress

65. COVR- Classification of Violence Risk Computer-based program to determine category of risk Computer-based program to determine category of risk Iterative Classification Tree (ICT) Iterative Classification Tree (ICT) Designed to mirror clinical decision making process Designed to mirror clinical decision making process Differentiates between low and high risk populations Differentiates between low and high risk populations

66. Violence Risk Assessment Decision-Making Models Flipping a Coin -> AUC=.50 Clinical Decision-Making -> AUC=.66 History of Violence -> AUC=.71 Psychopathy Checklist -> AUC=.75 Violence Risk Appraisal Guide -> AUC=.76 HCR-20 -> AUC=.80 MacArthur Risk Assessment Study -> AUC=.82 Perfect Accuracy -> AUC=1.0

67. No risk assessment should rely solely on the results of any one instrument: information gleaned from use of these structured instruments should be used to inform risk assessment and assist in risk communication.

68. Given all we now know… What is a practical approach to risk management?

69. LEAD: A Four-Step Approach to Assessing Violence Risk LOOK at static, individual-level factors known to empirically relate to violent behavior in your population (dispositional and historical factors) LOOK at static, individual-level factors known to empirically relate to violent behavior in your population (dispositional and historical factors) EXAMINE for presence of protective factors or unique individualized factors from both the micro and macro environments (contextual factors) EXAMINE for presence of protective factors or unique individualized factors from both the micro and macro environments (contextual factors) ADJUST your risk assessment by considering dynamic individual variables (clinical factors) ADJUST your risk assessment by considering dynamic individual variables (clinical factors) DOCUMENT your assessment and risk management plan and communicate it to those who need to know DOCUMENT your assessment and risk management plan and communicate it to those who need to know

70. Specific Tasks: Identifying/quantifying the risk Identifying/quantifying the risk Modifying the acute risk Modifying the acute risk Managing the chronic risk Managing the chronic risk Balancing the seriousness of potential outcome with the probability of it’s occurrence Balancing the seriousness of potential outcome with the probability of it’s occurrence

71. Keep in Mind: Time frame of prediction Time frame of prediction Structure of setting Structure of setting –Institution v. Community Impact of aging / group involvement Impact of aging / group involvement

72. Think about identifying: Behaviors that are not a product of illness but likely to be patient choice Behaviors that are not a product of illness but likely to be patient choice Lifestyle choices and issues that are going to be difficult to modify and about which you have no direct ability to modify Lifestyle choices and issues that are going to be difficult to modify and about which you have no direct ability to modify Patient’s competence to be making decisions that might influence ability to carry out violent act Patient’s competence to be making decisions that might influence ability to carry out violent act

73. Share the Risk Collect collateral information Collect collateral information Consult with your peers Consult with your peers Tackle limiting confidentiality head-on Tackle limiting confidentiality head-on Engage your patient and their support system in establishing a risk management plan and in ongoing management of risk Engage your patient and their support system in establishing a risk management plan and in ongoing management of risk

74. Develop a Violence Prevention Plan Distinguish Static ( Demographic and Past History) and Dynamic Factors (Subject to change with intervention such as access to weapons, psychotic symptoms, active substance abuse, living setting and situation) Distinguish Static ( Demographic and Past History) and Dynamic Factors (Subject to change with intervention such as access to weapons, psychotic symptoms, active substance abuse, living setting and situation) Focus on current status of each dynamic factor Focus on current status of each dynamic factor Develop a plan to address the combination of factors unique to the individual Develop a plan to address the combination of factors unique to the individual Determine the setting and parameters necessary to safely implement the plan Determine the setting and parameters necessary to safely implement the plan Document this process Document this process

75. Communicate the risk and the management plan to those who need to know Guided By: Research Data / Instrument Construction Research Data / Instrument Construction Ethical Standards Ethical Standards Laws Laws Admissibility Standards / Decisions Admissibility Standards / Decisions Professional Guidelines Professional Guidelines Clinical experience Clinical experience

76. Manage Your Liability by the quality of your risk assessment, the thoughtfulness of your risk management and the excellence of your documentation.

77. Improving Your Understanding of Violence and Mental Illness Just Might… Help to eliminate destructive and common myths about mental illness and violence Help to eliminate destructive and common myths about mental illness and violence Reduce the overall incidence of violence in our communities Reduce the overall incidence of violence in our communities Enhance the safety in clinical settings Enhance the safety in clinical settings Improve how the criminal justice system responds to people with mental illness Improve how the criminal justice system responds to people with mental illness Keep you out of the courtroom, where the question could be… Keep you out of the courtroom, where the question could be…

78. Was your risk assessment and your risk management… Dead Right or Dead Wrong?

79. The Jury is still out! The Jury is still out!