Psychopathy and the predictive validity of the PCL-R: an international perspective

Its controversial past notwithstanding, psychopathy has emerged as one of the most important clinical constructs in the criminal justice and mental health systems. One reason for the surge in theoretical and applied interest in the disorder is the development and widespread adoption of reliable and valid methods for its measurement. The Hare PCL-R provides researchers and clinicians with a common metric for the assessment of psychopathy, and has led to a surge in replicable and meaningful findings relevant to the issue of risk for recidivism and violence, among other things. Most of the research thus far has been based on North American samples of offenders and forensic psychiatric patients. We summarize this research and compare it with findings from several other countries, including England and Sweden. We conclude that the ability of the PCL-R to predict recidivism, violence, and treatment outcome has considerable cross-cultural generalizability, and that the PCL-R and its derivatives play a major role in the understanding and prediction of crime and violence.     

Gender,sexual harassment,workplace violence,and risk assessment:: Convergence around psychiatric staff's perceptions of personal safety

This paper reviews literature in sexual harassment, workplace violence, and risk assessment as it relates to staff in psychiatric and forensic work environments. These three areas of research overlap in their applicability to psychiatric staff in that each addresses the understanding and management of types of violence to which many staff, particularly women, are likely to be exposed while working. Employee well-being, encompassing mental and physical health, job satisfaction, and morale, has been shown to be closely tied to organizational productivity and cost. In addition, gender has been shown to be an important factor in perceptions and decision-making, and prior work has suggested that female staff often have qualitatively different experiences in traditional male workplaces such as inpatient and forensic settings. Despite these findings, research to date on psychiatric staff has typically focused only on number of assaults by patients. It has not addressed how staff's gender may impact their perceptions of personal safety and judgments of risk from patients, nor have any empirical studies been performed in naturalistic settings to investigate this issue. Given the high correlation between organizational productivity and employee well-being, it is mutually beneficial to both employers and staff to examine current understanding of how certain staff variables such as gender may influence their feelings of safety and judgments of risk from patients.     

Advances in stalking risk assessment

Over the past 15 years, forensic mental health has become more concerned with the concepts of violence prevention, management, and treatment. The development of specialist tools to aid in the assessment of a range of risks reflects this concern. This article explores contemporary thinking on violence risk assessment and how this knowledge can be applied to the relatively newer field of stalking risk assessment. The role of risk state and risk status are discussed, in addition to the way that standard structured professional judgment procedures need to be adapted to reflect the variety of risks present in stalking situations. The authors go on to describe the development and format of the Stalking Risk Profile, a set of structured professional judgment guidelines for assessing risk in stalkers. Suggestions are made for future research to enhance knowledge and improve practice in the field of stalking risk assessment.     

Hospital treatment of persons found not guilty by reason of insanity

After being found not guilty by reason of insanity (NGRI), individuals are typically admitted to a secure forensic hospital for evaluation and treatment. This patient population can pose a challenge to clinicians in the hospital setting due to significant violence risk, complex psychiatric presentations, and scrutiny from oversight boards and the public. This article reviews the scientific literature around several key aspects of hospital-based treatment of insanity acquittees, including the management of inpatient aggression, the provision of specific treatments to acquittees, the assessment of violence risk and readiness for release, and the process of community transition. The authors conclude that the existing literature is heavily weighted toward the study of risk assessment and recidivism, with relatively little attention paid to the study of therapeutic modalities and recovery-oriented care in this population.     

Mental health assessment of infants,toddlers, and preschoolers in a service program and a treatment outcome research program

This article describes the mental health assessment in preparation for treatment conducted in two University-based clinical programs that offer dyadic child-parent psychotherapy as the treatment modality. The Infant-Parent Program is a mental health program serving children between birth and 3 years of age and their families when the parent-child relationship is jeopardized by risk factors in the parent, child, or family circumstances. The Child Trauma Research Project is an intervention outcome research program serving preschool- aged children and their mothers when the child witnessed domestic violence. The programs share a similar assessment approach emphasizing the importance of a working alliance, spontaneous parental reports, and observation of child-parent interaction in a variety of settings. However, their different functions in terms of clinical service and research dictate appropriate modifications in their respective assessment procedures. The two assessment protocols and their rationale will be described in the context of the clinical and research goals of the programs. © 1997 Michigan Association for Infant Mental Health     

Long-term adverse health outcomes of physical workplace violence: a 7-year population-based follow-up study

The aim of the present study was to analyse whether physical workplace violence increases the risk of long-term adverse health outcomes (i.e., high number of visits to the general practitioner, outpatient treatment, hospital admittance, antidepressant use, and/or having a mental disorder). The study was based on representative survey data from 2006 and 2010 (entitled “How are you?”) merged with register data for a 7-year follow-up period (N = 30,812). To examine if physical workplace violence was a predictor of adverse health outcomes, logistic regression models were conducted for the total follow-up period and for each follow-up year with the different outcome measures as the dependent variables. In the follow-up period, individuals who were exposed to physical workplace violence had a higher number of visits to the general practitioner, had more often received outpatient treatment, and had more often been admitted to hospital than their non-exposed counterparts. Moreover, exposed individuals had higher odds of using antidepressants in the last three follow-up years than did non-exposed individuals. The findings call for heightened attention to securing preventive as well as rehabilitative strategies to help victims of physical workplace violence with the aim of avoiding adverse long-term health consequences.     

Assessing risk: confrontation or avoidance—what is taught on counsellor training courses

Recent mental health policy development has focused on the assessment and management of risk in vulnerable clients. Counsellors have a significant role to play in delivering mental health care in a range of settings, with clients sometimes presenting with suicidal ideation, self-injury and a risk of violence. The aim of this research was to explore the profile of risk assessment teaching within BACP accredited courses. A total of 49 BACP accredited courses were contacted and 24 responded. This response rate is discussed with particular reference to those courses that did not respond to the questionnaire. Risk assessment was viewed as an important consideration for counsellor training whilst suicide and self-harm seemed to have a higher profile than violence to others. Supervision was cited by the majority of respondents to have an important role in developing trainees' skills in assessing risk. The implications of the findings of this study for how counsellors are prepared by their training experiences to work with clients at risk are discussed and some recommendations made for future training developments.     

Using dynamic risk and protective factors to predict inpatient aggression: Reliability and validity of START assessments

The Short-Term Assessment of Risk and Treatability (START; C. D. Webster, M. L. Martin, J. Brink, T. L. Nicholls, & S. L. Desmarais, 2009; C. D. Webster, M. L. Martin, J. Brink, T. L. Nicholls, & C. Middleton, 2004) is a relatively new structured professional judgment guide for the assessment and management of short-term risks associated with mental, substance use, and personality disorders. The scheme may be distinguished from other violence risk assessment instruments because of its inclusion of 20 dynamic factors that are rated in terms of both vulnerability and strength. This study examined the reliability and validity of START assessments in predicting inpatient aggression. Research assistants completed START assessments for 120 male forensic psychiatric patients through review of hospital files. They also completed Historical-Clinical-Risk Management-20 (HCR-20; C. D. Webster, K. S. Douglas, D. Eaves, & S. D. Hart, 1997) and Hare Psychopathy Checklist: Screening Version (PCL:SV; S. D. Hart, D. N. Cox, & R. D. Hare, 1995) assessments. Outcome data were coded from hospital files for a 12-month follow-up period using the Overt Aggression Scale (OAS; S. C. Yudofsky, J. M. Silver, W. Jackson, J. Endicott, & D. W. Williams, 1986). START assessments evidenced excellent interrater reliability and demonstrated both predictive and incremental validity over the HCR-20 Historical subscale scores and PCL:SV total scores. Overall, results support the reliability and validity of START assessments and use of the structured professional judgment approach more broadly, as well as the value of using dynamic risk and protective factors to assess violence risk. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Gender Differences in the Effects of Community Violence on Mental Health Outcomes in a Sample of Low-Income Youth Receiving Psychiatric Care

Previous research suggests that community violence impacts mental health outcomes, but much of this research has not (a) distinguished between different types of community violence, (b) examined gender differences, and (c) focused on youth living in urban poverty. The current study addresses these questions. Participants were 306 youth (23 % girls) and one parent/guardian receiving outpatient psychiatric services for disruptive behavior disorders in a large urban city. Youth and parents reported on youth’s experience of different types of community violence (being a direct victim, hearing reports, and witnessing violence), and whether violence was directed toward a stranger or familiar. Outcomes included youth externalizing, internalizing, and posttraumatic stress symptoms assessed via parent and youth reports. Being a direct victim of violence accords risk for all mental health outcomes similarly for both boys and girls. However, gender differences emerged with respect to indirect violence, such that girls who hear reports of violence against people they know are at increased risk for all assessed mental health outcomes, and girls who witness violence against familiars are at increased risk for externalizing mental health symptoms in particular. There are gender differences in violence-related mental health etiology, with implications for intervention assessment and design.     

The Protective Functions of Social Support and Coping for Women Experiencing Intimate Partner Abuse

This study evaluated two alternate models exploring protective factors in the relationship between intimate partner abuse and health: one in which social support was proposed to mediate the violence-health relation, and a second in which coping was proposed to mediate this relation, while social support would moderate the abuse-coping relation. Women were administered questionnaires measuring coping, social support, violence, and health status. Relationship violence predicted mental health status only, although mental health did predict physical health. Coping was found to serve as a mediator between abuse and health. Implications for future research and clinical applications are discussed.     

Umgang mit gefährlichen Straftätern in England und Wales

Forensic psychiatric institutions exist in all western European countries. Their organisation depends on a number of factors including the legal framework and societal attitudes towards mentally disordered offenders. This article describes and critically comments on the forensic psychiatric system in England and Wales, its legal framework and approaches to dealing with dangerous offenders. England and Wales have a long forensic psychiatric tradition with the first high security hospital, Broadmoor hospital, having been established in 1863. Evidence-based treatment approaches in forensic hospitals as well as in prisons, training of forensic psychiatrists and research in the field of forensic psychiatry have gained international recognition. However, there are some worrying aspects in the system of forensic psychiatric care and the criminal justice system more generally, in particular the high and still increasing number of prisoners in comparison with other European countries, the low age of criminal responsibility, long sentences, increasing length of stay in forensic care and the increasingly risk averse culture. A number of differences to the German system can be found; one such difference relates to the role of criminal responsibility which is irrelevant for decisions regarding commitment in England and Wales. Only the mental state and need for treatment at the time of trial (or later assessment in prison) determine whether an offender is admitted to psychiatric care or receives a prison sentence. A number of new initiatives have been launched in recent years resulting in an increasing number of individuals being detained in forensic psychiatric and criminal justice institutions, in particular the initiative for the detention and treatment of individuals with so-called dangerous and severe personality disorders, the sexual offenders register and the new sentence of indeterminate imprisonment for public protection. These initiatives have been the subject of a number of complaints to the European Court of Human Rights. Nevertheless, the trend towards a more and more risk averse culture continues.     

Assessment of anger and aggression in male offenders with developmental disabilities

Systematic assessment of anger among people with developmental disabilities has been lacking, especially for hospital inpatients. Reliability and validity of anger self-report psychometric scales were investigated with 129 male patients, mostly forensic. Anger prevalence and its relationship to demographic, cognitive, and personality variables and to hospital assaultive behavior were examined. High internal and intermeasure consistency, and some concurrent validity with staff ratings, were found. Retrospective validity regarding physically assaultive behavior in the hospital was obtained. Hierarchical regressions revealed that patient-reported anger was a significant predictor of assaults postadmission, controlling for age, length of stay, IQ, violence offense history, and personality variables.     

Mental illness and violence: A brief review of research and assessment strategies

Examinations of the relationship between mental disorders and violent behavior can be found throughout history and across cultures. Many examples of the cultural and social construction of dangerousness and mental illness also have appeared during the modern era. This article examines the evolution of thought and research regarding the relationship between mental illness and violence, from studies in the early twentieth century through the more recent MacArthur Violence Risk Assessment Study. In addition, the article explores the state of knowledge and practices surrounding the assessment and management of violence risk among individuals with mental illness.     

Personality disorder and violence: making the link through risk formulation

The extant research demonstrates that the combination of personality disorder and violence implies severe dysfunction, poor responsivity to treatment, more serious and persistent violence, and higher recidivism rates. Thus, it comes as no surprise that personality disorder is included in many of the available guidelines for assessing and managing violence. Unsurprisingly, the combination of personality pathology and violence frequently presents the greatest challenge to services, even those in whom violence risk assessment and management practice is established and routine. Conceptual and methodological limitations pervade the literature and a full explanation of the nature of the association between personality pathology and violence is still awaited. Furthermore, current approaches to risk assessment fail to provide a systematic framework for assessors to use to make sense of the heterogeneous presentations typically found in individuals with personality disorder and violence. In this paper, formulation is proposed as the critical process linking risk assessment and risk management. It is argued that assessors must move beyond a simple listing of risk factors and should instead produce detailed, comprehensive, individualized explanations of risk potential and risk management needs. Personality disorder is used in this paper to illustrate the important contribution of formulation to the risk assessment process, and in doing so, the link between personality pathology and violence is explored.     

The Internet is a scary place: How does evidence source and examinee race or ethnicity influence determinations of threat?

Violent rhetoric online is becoming increasingly relevant to the practice of forensic mental health assessment as examinee's virtual lives may transform into real-world acts of violence. With the rise of a diverse subculture of violent online communities, the aim of the present study was to inform how concerns with online sources of collateral data and racial/ethnic biases may influence determinations of violence potential. Using an experimental design, jury-eligible participants (N = 278) and forensic mental health experts (N = 78) were presented with mock Twitter (now referred to as X) posts that varied by data source (i.e., how information was accessed) and the examinee's race/ethnicity. Results showed no differences in participants' ratings of data credibility, how much weight they would place on the posts in a threat assessment, or how likely the examinee was to act violently against his intended target. Implications regarding the interpretation of social media evidence, relevant limitations, and future research are discussed.     

A survey of psychological test use patterns among forensic psychologists

Clinical psychologists are frequently called on to testify in court regarding mental health issues in civil or criminal cases. One of the legal criteria by which admissibility of testimony is determined includes whether the testimony is based on methods that have gained "general acceptance" in their field. In this study, we sought to evaluate the psychological tests used in forensic assessments by members of the American Psychology-Law Society Division of the American Psychological Association, and by diplomates in the American Board of Forensic Psychology. We present test results from this survey, based on 152 respondents, for forensic evaluations conducted with adults using multiscale inventories, single-scale tests, unstructured personality tests, cognitive and/or intellectual tests, neuropsychological tests, risk assessment and psychopathy instruments, sex offender risk assessment instruments, competency or sanity-related instruments, and instruments used to evaluate malingering. In addition, we provide findings for psychological testing involving child-related forensic issues.     

Examining the Validity of the Structured Assessment of Violence Risk in Youth (SAVRY) for Predicting Probation Outcomes Among Adjudicated Juvenile Offenders

The current study examined the ability of the Structured Assessment of Violence Risk for Youth (SAVRY), a standardized risk assessment instrument, to predict probation outcomes among a sample of 158 adjudicated juvenile offenders placed on probation. Traditionally, the SAVRY has been used to measure violence risk among adolescents after release from custody. More recently, a delinquency risk measure based on SAVRY responses was developed, which could be useful for other types of outcome. This study examined the predictive validity of both summary risk ratings (SRR) for probation outcomes, including the reason for terminating probation and length of time on probation. A number of bivariate analyses and Cox regression models provided preliminary support for the ability of the nonviolent delinquency SRR, and modest support for the violence SRR, to predict probation outcomes. The implications for use of the SAVRY SRRs during juvenile justice system decision‐making and recommendations for future research are discussed. Copyright © 2013 John Wiley & Sons, Ltd.     

Physical Abuse in U.S. Children: Risk Factors and Deficiencies in Referrals to Support Services

More than 600,000 U.S. children are reported for physical abuse annually. Risk factors are proposed in the literature, but a comprehensive, national assessment of risk factors and support services has not been conducted. An analysis of national data from the National Child Abuse and Neglect Dataset revealed that domestic violence, parental alcohol and drug use, prior child abuse and neglect, public assistance receipt, and child behavior problems are associated with higher odds of substantiated physical abuse reports, compared to unsubstantiated reports. Most families, however, failed to receive relevant support services for any of these risk factors. Screening by physicians, child protection workers, and others for these risk factors could help identify children at increased risk for physical abuse and inform prevention efforts and support-service provision.     

Juror decision-making in a mock sexually violent predator trial: gender differences in the impact of divergent types of expert testimony

Despite widespread use of mental health testimony in cases where violence risk is at issue, relatively little is known about the impact of such information on juror decision-making. This study addressed the effects of testimony based on three types of risk assessment instrument or method (clinical opinion, actuarial assessment, and ratings of psychopathy) to examine whether they would have differential impact on jurors' perceptions of the defendant. In a mock sexually violent predator civil commitment trial, 172 undergraduates were presented a case summary that included prosecution and defense expert testimony related to violence risk based on one of the three methods noted above. Consistent with earlier research, the hypothesis that a defendant described as a "high risk psychopath" by the prosecution would be judged more severely than a defendant judged as "high risk" based on other evaluation procedures was supported, but only among female jurors. Unlike prior studies, little support was found for the hypothesis that clinical opinion testimony would be more influential than actuarially based testimony for either gender. Mechanisms that may underlie the observed gender differences are discussed, as are the potential implications of these findings for civil commitment proceedings.