Tag Archives: violence

Dear Karen: I have a professional and personal responsibility to speak out against Unacceptable behaviors

Last week I received a comment on this blog. Getting a comment is always very exciting, partly because I don’t get all that many and partly because the comments are usually positive and affirming. In this case the comment was neither positive nor affirming.

Although getting critical comments isn’t nearly as fun and ego-boosting as affirming comments, receiving criticism is important to self-examination and growth. The person who commented last Thursday was upset about my “politics.” As many of you know, I’ve occasionally written about Mr. Trump and lamented his behavior. Sometimes, I’ve felt nervous posting critiques of Mr. Trump, worrying that I may have been behaving in ways that were less that professional and worrying that perhaps I shouldn’t openly express my negative opinions about his behavior. However, in the end, I’ve often ended up deciding that my critiques of Mr. Trump aren’t really about politics anyway.

Digesting Thursday’s comment has helped me clarify my position on political commentary. Here’s a version of what I wrote back to my blog commenter.

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Dear Karen,

Thanks for your message.

Many years ago when I interviewed Natalie Rogers, I recall her telling me something very compelling about her father, Carl Rogers. She said, in her family, all feelings were accepted, but not all behaviors.

Although some of my judgments about Mr. Trump have political components, most of my judgments about him focus on his personality and behavior. Politics aside, I wouldn’t care if he was a democrat, an independent, a republican, a corporate mogul, a teacher, a coach, or a rock star. I find his behavior to be an unacceptable example for children. From my perspective it’s clear that Mr. Trump is much more focused on using and abusing power than he is on empowering others. To return to Carl Rogers: Rogers believed the best use of power was to empower others. My perception of Mr. Trump is that he’s invested in accumulating power, and not on empowering others.

I could make a list of video evidence of Mr. Trump mocking disabled people, calling women “fat pigs,” disrespecting war veterans (including John McCain, whom I’ve never written a negative judgmental word about, despite his politics), paying off prostitutes, saying positive and supportive things about dictators and racists, and his continuous flow of lies. If Mr. Trump was my neighbor or a colleague at my University, it would be wrong for me to let his behavior pass without making it clear that I find his behaviors to be a potentially destructive and negative influence on children in the neighborhood or the culture at the University. Not only do I have a responsibility to be non-judgmentally accepting in therapeutic contexts, I also have a responsibility to speak up and speak out against racism and the promotion of violence. I believe there’s ample evidence that Mr. Trump has promoted racism and incited violence. My rejection of those behaviors isn’t particularly political; I simply believe that it’s morally wrong to promote racism and foment violence.

I can see we have different views of Mr. Trump. You may not see the evidence that I see, or you may find his behaviors less offensive and less dangerous. Although it’s challenging for me to understand your perspective, I know you’re not alone, and I know you must have reasons for believing the ways you believe. I can accept that.

But to articulate my perspective further, here’s a therapy example. If I was working with a client who exhibited no empathy or said things to others that were likely to incite violence, as a psychotherapist, I would work toward a greater understanding of the client’s emotions. In addition, I would consider it my professional responsibility to question those behaviors . . . for both the good of the client and the good of people in the client’s world.

Again, thanks for your message. It’s important to hear other perspectives and to have a chance to question myself and my own motives. I appreciate you providing me with that opportunity.

Happy Sunday,

John SF

Can Mental Health Professionals Predict Violent Behavior in Schools and Agencies?

Not surprisingly, violence has been on my mind lately. And so when I reached the Violence Risk Assessment section of the Clinical Interviewing text revision, I decided to cut and paste it here. It doesn’t immediately answer the question of whether mental health professionals can predict violence and so if you’re impatient and prefer to stop reading now, the answer to that question is, more or less, “No.”

Assessment and Prediction of Violence and Dangerousness

During an assessment interview, John had the following exchange with a 16-year-old client.

John: I hear you’ve been pretty mad at your shop teacher.

Client: I totally hate Mr. Smith. He’s a jerk. He puts us down just to make us feel bad. He deserves to be punished.

John: You sound a little pissed off at him.

Client: We get along fine some days.

John: What do you mean when you say he “deserves to be punished”?

Client: I believe in revenge. Really, I feel sorry for him. But if I kill him, I’ll be doing him a favor. It would end his miserable life and stop him from making other people feel like shit.

John: So you’ve thought about killing him?

Client: I’ve thought about walking up behind him and slitting his throat.

John: How often have you thought about that?

Client: Just about every day. Whenever he talks shit in class.

John: And exactly what images go through your mind?

Client: I just slip up behind him while he’s talking with Cassie [fellow student] and then slit his throat with a welding rod. Then I see blood gushing out of his neck and Cassie starts screaming. But the world will be a better place without his sorry ass tormenting everybody.

John: Then what happens?

Client: Then I guess they’ll just take me away, but things will be better.

John: Where will they take you?

Client: To jail. But I’ll get sympathy because everyone knows what a dick he is.

During an initial interview or ongoing therapy, clients may describe aggressive thoughts and images. Some clients, as in the preceding example, will be concise about their thoughts, feelings, and images. Others will be less clear. Still others will be evasive and will avoid telling you anything about violent thoughts or intentions.

Assessing for violence potential is similar to assessing for suicide potential; it’s a stressful responsibility and predicting violence is extremely difficult. However, similar to suicide assessment, we still have a legal and ethical responsibility to conduct violence or dangerousness assessments that meet professional standards.

Over the years, there have been arguments about how to most accurately predict violence (Hilton, Harris, & Rice, 2006). Essentially, there are three perspectives.

1. Some researchers contend that actuarial prediction based on specific, predetermined statistical risk factors is consistently the most accurate procedure (Quinsey, Harris, Rice, & Cormier, 2006).

2. Some clinicians believe that because actuarial variables are dimensional and interactive with individual and situational characteristics, prediction based on the clinician’s experience and intuition is most accurate (Cooke, 2012).

3. Others take a moderate position, believing that combining actuarial and clinical approaches is best (Campbell, French, & Gendreau, 2009).

Researchers have consistently reported that actuarial approaches to violence prediction are more accurate than clinical judgment (Monahan, 2013). However, actuarial violence prediction is not without its flaws (Szmukler, 2012; Tardiff & Hughes, 2011).

Narrowing in on Particular Violent Behaviors

Researchers who investigate actuarial assessment protocols have reported that different violent behaviors are associated with unique predictor variables. Below, we provide three examples of violence predictors for three different specific violent behaviors or populations. The goal is to sensitize you to different violent behavior patterns.

Fire-setting. Fire-setting is a particular dangerous behavior that may or may not be associated with interpersonal violence. Nonetheless, depending on your work setting and the clinical population you serve, you may find yourself in a situation in which you need to decide whether to warn a family or potential victim about possible fire-setting behavior.

Mackay and colleagues (2006) reported on specific behaviors included on a fire-setting prediction assessment. They identified the following variables—in decreasing order—as predictive of fire setting:

  •  Younger age at the time of the first fire-setting behavior.
  • A higher total number of fire-setting offenses.
  • Lower IQ.
  • Additional criminal activities associated with the index (initial) fire.
  • An offender acting alone in setting the initial fire.
  • A lower offender’s aggression score. (Interestingly, offenders with higher aggression scores were more likely to be violent, but less likely to set fires.)

We focus first on fire setting here because fire-setting predictors illustrate a general violence-prediction principle. Past violence is a reasonably good predictor of future violence only with regard to specific past and future violence. For example, future fire-setting potential is best predicted by past fire-setting behavior. Similarly, future physical aggression is best predicted by past physical aggression. But a history of physical aggression is not a good predictor of fire setting.

Homicide Among Young Men. Loeber and associates (2005) conducted a large-scale landmark study of homicide among young men living in Pittsburgh. This study is notable because it was both prospective and comprehensive; the authors tracked 63 risk factor (predictor) variables in 1,517 inner-city youth. Obviously, even this large-scale study is limited in scope, and technically the results cannot be generalized beyond inner-city Pittsburgh youth. Nevertheless, the outcome data are interesting and lend insight into risk factors that might contribute to homicidal violence in other populations.
Results from the study indicated that violent offenders scored significantly higher than nonviolent offenders on 49 of 63 risk factors across domains associated with child, family, school, and demographic risk factors. The range and nature of these predictors were daunting. The authors reported:

. . . predictors included factors evident early in life, such as the mother’s cigarette or alcohol use during pregnancy, onset of delinquency prior to 10 years of age, physical aggression, cruelty, and callous/unemotional behavior. In addition, cognitive factors, such as having low expectations of being caught, predicted violence. Poor and unstable child-rearing factors contributed to the prediction of violence, including two or more caretaker changes prior to 10 years of age, physical punishment, poor supervision, and poor communication. Undesirable or delinquent peer behavior, based either on parent report or self-report, predicted violence. Poor school performance and truancy were also among the predictors of violence. Finally, demographic factors indicative of family disadvantage (low family SES, welfare, teenage motherhood) and residence in a disadvantaged neighborhood also predicted violence. Among the proximal correlates associated with violence were weapon carrying, weapon use, gang membership, drug selling, and persistent drug use. (p. 1084)

Homicidal violence was best predicted by a subset of general violence predictor variables. Specifically, homicide was predicted by “the presence or absence of nine significant risk factors:

• Screening risk score
• Positive attitude to substance use
• Conduct disorder
• Carrying a weapon
• Gang fight
• Selling hard drugs
• Peer delinquency
• Being held back in school
• Family on welfare (p. 1086).

In particular, boys who had at least four of these nine risk factors were 14 times more likely to have a future homicide conviction than violent offenders with a risk score less than four.

Violence and schizophrenia. In and of itself, a diagnosis of schizophrenia doesn’t confer increased violence risk. Instead, research indicates there are specific symptoms—when seen among individuals diagnosed with schizophrenia—associated with increased risk. These symptoms include severe manifestations of:

  • Hallucinations
  • Delusions
  • Excitement
  • Thinking disturbances. (Fresán, Apiquian, & Nicolini, 2006)

This research suggests that clinicians should be especially concerned about violence when clients diagnosed with schizophrenia have acute increases in the intensity and frequency of their psychotic symptoms.

Research versus Practice

For a short guide to predicting violence, see a previous post: https://johnsommersflanagan.com/2013/02/25/guidelines-for-violence-risk-assessment/

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Guidelines for Violence Risk Assessment

Predicting violence is notoriously very difficult. Nevertheless, sometimes counselors, social workers, psychologists and psychiatrists are faced with situations where they need to make estimates or predictions of violence potential. The material below is a short preview from Clinical Interviewing, 5th edition. http://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1118270045/ref=dp_ob_title_bk

Research findings imply that therapists who hope to conduct accurate violence assessments should know actuarial violence prediction risk factors. However, as is often the case, scientific research doesn’t always parallel real-life situations faced by therapists. For example, while much of the actuarial violence research has been conducted on forensic or prison populations—with the designated outcome measure being violent recidivism—therapists typically face situations in schools, residential treatment centers, and private practice (Juhnke, Granello, & Granello, 2011). Consequently, although actuarial violence prediction risk factors may be helpful, they probably don’t generalize well to situations where a counselor is making a judgment about whether there’s duty to protect (and therefore warn) a shop teacher about a boy (who has never been incarcerated) who reports vivid images of slitting his shop teacher’s throat.

Given these limits, it’s best for us to call clinical interview-based assessments in school and agency settings violence assessment, rather than violence prediction. This distinction helps clarify the fact that what most clinicians do in general practice settings, including public and private schools, falls far short of scientific, actuarial-based violence prediction.

A Reasonable Approach to Violence Risk Assessment

Predicting violence is a challenging proposition. Despite the many shifting variables that change based on the specifics of any given situation and despite the low base rate, and therefore inherent unpredictability of violent behavior, this section provides general guidelines that may be helpful should you find yourself in a situation where violence assessment is necessary. Of course, in addition to this guide you should always pursue consultation and supervision support when working with potentially violent clients.

Table 12.2 includes a general guide to violence assessment. It doesn’t include common actuarial risk factors from two common instruments, the Violent Rate Appraisal Guide (Harris, Rice, & Quinsey, 1993) or the Psychopathy Checklist-Revised (Hare et al., 1990; Harpur, Hakstian, & Hare, 1988). If you find yourself intrigued with violence risk assessment you may want to explore a career in forensic psychology.

Table 12.2. A General Guide to Violence Assessment
The following checklist is offered as a general guide to conducting violence assessment. It should not be used as a substitute for actuarial prediction.
____1.  Ask direct and indirect questions about violent behavior history. Be especially alert to physical aggression and cruelty. If the violent behavior that’s being threatened is similar to a past violent behavior the risk of violence may be higher.

_____2. Because potentially violent individuals aren’t always honest about their violence history, you may need to ask collateral informants—someone other than the client—about the client’s history of violent behavior (assuming you have a release of information signed or have determined you have an ethical-legal responsibility to protect someone from harm).

____3.  You should listen for details that might help you identify potential victims. If the details are not forthcoming, you may need to ask specific questions in an effort to obtain those details. Identification of a specific victim increases violence risk (and provides you with information about whom you should warn).

____4. As clients talk about violent urges, you should listen for specifics about the plan. As needed, you may, through curious and indirect questioning, make efforts to further assess the specificity of the client’s violence plan. More specific plans are associated with increased violence risk.

____5. If clients don’t tell you about his or her access to a weapon or means for committing his or her planned violent act, you should ask. Similar to suicidal situations, access to lethal means increases violence risk.

____6. Historical information is doubly important. Generally speaking, the sooner violent behavior patterns began, the more likely they are to continue and clients raised in chaotic and violent environments (including gang involvement) are at higher risk for violence.

____7. Diagnostic information may be helpful. When looking at DSM diagnoses, the best violence predictors include items from list B** of the **DSM’s Antisocial Personality diagnostic criteria (see DSM-IV-TR**).

____8. Evaluate current cognitions. If clients have low expectations of being caught or of having consequences, risk may be higher.

____9. Consider substance use. Positive attitudes towards substance use and substance use when carrying weapons confer greater risk.

____10. Notice your intuition. Intuition isn’t a great predictor of anything, but if you have images of violence linked to a particular client, it’s reasonable to err on the conservative side and begin the process of warning potential victims.

**This information may change in the DSM-5