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