Evaluating the validity of anger regulation problems, interpersonal style, and disturbed mental state for predicting inpatient violence

Research has been conducted to try to identify risk factors to help predict which patients will be violent during psychiatric hospitalization. Despite the relatively large amount of research conducted, it is difficult to draw any firm conclusions, as the studies vary considerably in study design, methods used, and choice of outcome measures. Studies also tend to focus on risk prediction, even though risk management is the primary aim of clinical practice in mental health services and few studies have focused on a theoretical basis for understanding violence. This study assessed the predictive validity of brief assessment scales in a sample of 94 forensic inpatients who had been inpatient for a median of 521 days, to test the hypotheses that anger regulation problems, interpersonal style, and disturbed mental state would be linked to increased violence risk in a forensic hospital during a hospital stay. The outcome variables for this study were physical violence against another and/or clear threats of physical violence. The results of this study provide support for the hypotheses, and this remained the case after controlling for age, gender, length of stay, and presence of major mental disorder. The findings should not only assist clinicians with assessment and management of risk but also support the reconceptualizing of risk prediction research to reflect the task of clinical risk management.     

Assessment and Intervention for PTSD in Children Exposed to Violence

Summary

Recent research has established that exposure to domestic violence is a major risk factor for posttraumatic stress disorder (PTSD) in children. However, one issue that has been relatively neglected in research conducted to date concerns developmental differences: both in the expression of PTSD symptoms across childhood and adolescence, and in the techniques appropriate for assessing and intervening with PTSD in children at different ages. The available literature is reviewed concerning the conceptualization, measurement, and treatment of PTSD in children, with special attention to the case of children of battered women. Guidelines are provided for developmentally sensitive approaches to assessment and treatment.     

Assessing threats of violence: Professional skill or common sense?

When faced with threats of violence, it is of great importance to assess the risk for actual harm to occur. Over the last decades, this task has developed into a domain of its own and professionals have specialised in threat assessment . However, it is yet unknown whether professional experience affects the quality of threat assessments. The present study examined how threat assessment professionals (N  = 44), university students (N  = 44), and laypersons (N  = 45) assessed the risk for violence in three fictitious cases. The assessments (i.e., assigning risk values to different pieces of information) were found to be strikingly similar across the three groups. Yet, professionals agreed more with one another on their assessments, and professionals identified more relevant (empirically supported) threat cues when given the opportunity to request additional information. These results suggest that threat assessment professionals know better than nonprofessionals what information to look for, and hence, they may contribute most in the process of gathering information to clarify the threat. Such knowledge can help to optimise the use of expertise, which may improve the quality of threat assessments. The current findings can be of value to those who consult threat assessment professionals, as well as to the professionals themselves.     

Judgment research: Implications for clinical practice and testimony in court

When treating a client or testifying in court, clinicians should be aware of how they make judgments and when their judgments are likely to be correct and when they are likely to be wrong. Research on the validity of judgments is reviewed along with research on the cognitive processes of clinicians. Some of the results are surprising. For example, recent research indicates that clinicians might be able to make moderately valid long-term predictions of violence. Finally, recommendations are made for improving clinical judgment, and comments are made about the appropriate use of statistical prediction rules and automated assessment test reports.     

The move from categories to process: Attachment phenomena and clinical evaluation

Despite the degree to which attachment theory and research have been embraced by clinicians in recent years, many remain unsure as to what this perspective adds to clinical understanding and psychodynamic thinking about the clinical process. In this article, I outline some ways that developments in the study of attachment have the potential to enrich our clinical work with children and families, and may be particularly illuminating with respect to certain aspects of evaluation, formulation, and diagnosis. This added value comes not from formally assessing patients' attachment classification but from sensitizing clinicians to observing the functioning of the attachment system and to the internal and interpersonal functions of attachment processes. Such awareness on the part of the therapist makes it possible for these dynamic regulatory, defense, and motivational systems to be addressed within the context of evaluation and ongoing psychotherapeutic work. Thinking about attachment processes within the clinical situation does not supplant other aspects of dynamically oriented assessment and evaluation, but rather is theoretically consistent with psychoanalytic models of development and offers new levels of richness and understanding to formulations and treatment planning.     

临床决策:医学哲学研究的一个重要领域

临床决策研究已成为临床医学中的一个重要领域.当下的临床决策问题涉及到医学信息学、循证医学、费用-效益评估、卫生技术评估、医学伦理与法律等学科领域.因此在临床决策中单一的经验-描述的研究纲领已不适应当代医学发展的需要,需要引入综合的决策方法.临床决策问题也为医学哲学研究提供了一个极佳的思想实验场所.临床决策的多维度研究,对于打通学科之间的壁垒,架构科学与人文之间的桥梁,更深刻地理解和把握医疗保健的整体性,使临床医疗达到最佳疗效具有重要意义.     

It’s NOT FAIR! Or is it? The promise and the tyranny of evidence-based performance assessment

Evidence-based medicine (EBM), by its ability to decrease irrational variations in health care, was expected to improve healthcare quality and outcomes. The utility of EBM principles evolved from individual clinical decision-making to wider foundational clinical practice guideline applications, cost containment measures, and clinical quality performance measures. At this evolutionary juncture one can ask the following questions. Given the time-limited exigencies of daily clinical practice, is it tenable for clinicians to follow guidelines? Whose or what interests are served by applying performance assessments? Does such application improve medical care quality? What happens when the best interests of vested parties conflict? Mindful of the constellation of socially and clinically relevant variables influencing health outcomes, is it fair to apply evidence-based performance assessment tools to judge the merits of clinical decision-making? Finally, is it fair and just to incentivize clinicians in ways that might sway clinical judgment? To address these questions, we consider various clinical applications of performance assessment strategies, examining what performance measures purport to measure, how they are measured and whether such applications demonstrably improve quality. With attention to the merits and frailties associated with such applications, we devise and defend criteria that distinguish between justice-sustaining and justice-threatening performance-based clinical protocols.     

An Examination of Violence Risk Communication in Practice Using a Structured Professional Judgment Framework

The increased use of violence risk assessment tools in professional practice has sparked the development of best-practice guidelines for communicating about violence risk. The present study examined 166 pre-sentence reports, authored by clinicians and probation officers, to determine the extent to which they are consistent with those guidelines. We examined the frequency with which reports contained information about five topics: the presence of risk factors; the relevance of risk factors; scenarios of future violence; recommended management strategies; and summary risk judgments. Analyses revealed that the topics addressed most frequently in reports were the presence of risk factors and recommended management strategies, but none of the five topics was addressed consistently, completely, or clearly in reports. This was especially the case for probation reports. The findings highlight the need to improve practice through better implementation of guidelines for risk communication. Also needed is research on the extent to which information in risk communications is comprehended, accepted, and used by various stakeholder groups. Copyright © 2015 John Wiley & Sons, Ltd.     

Wellness Counseling: The Evidence Base for Practice

Wellness conceptualized as the paradigm for counseling provides strength‐based strategies for assessing clients, conceptualizing issues developmentally, and planning interventions to remediate dysfunction and optimize growth. Wellness counseling models have stimulated significant research that helps to form the evidence base for practice in the counseling field. The development of these models is explained, results of studies using the models are reviewed, and implications for research needed to further inform clinical practice and advocacy efforts are discussed.     

Determinants and Predictive Value of Clinician Assessment of Short‐Term Suicide Risk

We examine the interrelations among clinicians' judgment of patients' suicide risk, clinicians' emotional responses, and standard risk factors in the short‐term prediction of suicidal thoughts and behaviors. Psychiatric outpatients (n = 153) with a lifetime history of suicide ideation/attempt and their treating clinicians (n = 67) were evaluated at intake. Clinicians completed a standard suicide risk instrument (modified SAD PERSONS scale), a 10‐point Likert scale assessment of judgment of patient suicide risk (Clinician Prediction Scale), and a measure of their emotional responses to the patient (Therapist Response Questionnaire‐Suicide Form). The Columbia Suicide Severity Rating Scale and the Beck Scale for Suicide Ideation were administered at a one‐month follow‐up assessment (n = 114, 74.5%). Clinician judgment of risk significantly predicted suicidal thoughts and behaviors at follow‐up. Both the standard suicide risk instrument and clinician emotional responses contributed independently to the clinician assessment of risk, which, in turn, mediated their relationships with suicidal thoughts and behaviors. Our findings validate the importance of clinical judgment in assessing suicide risk. Clinical judgment appears to be informed both by concrete risk factors and clinicians' emotional responses to suicidal patients, highlighting emotional awareness as a promising area for research and training.     

Assessing violence risk in Tarasoff situations: a fact-based model of inquiry.

Although significant advances in risk assessment research and practice have been made in recent years, there has not been any analysis in the professional literature regarding how and whether the emerging practice recommendations apply in Tarasoff-type situations. We suggest that, when faced with a Tarasoff-type situation, the appraisal of risk should be guided by a method that is primarily fact-based and deductive, rather than by the more inductive risk assessment approach for general violence recidivism, which is guided primarily by base rates and historical risk factors. We review the principles underlying a fact-based, or threat assessment, approach and outline six areas of inquiry that can guide the appraisal of risk: A-attitudes that support or facilitate violence, C-capacity, T-thresholds crossed, I-intent, O-other's reactions, and N-noncompliance with risk reduction interventions.     

Operationalizing the Assessment and Management of Violence Risk in the Short-term

Assessing risk of violence in the short term is crucial for managing and preventing violence, especially in institutions such as psychiatric units and prisons. Despite a lack of consensus on the definition of "short term", a number of recent tools and guidelines have been developed to aid short-term clinical decision-making. Whereas the supporting evidence for the new tools is impressive, limitations remain in terms of the focus on prediction, limited consideration of strengths, and poor integration with formulation and risk management. The Short-Term Assessment of Risk and Treatability (START) is a brief clinical guide for the dynamic assessment of risks, strengths and treatability. It focuses on short-term risks and the characteristics of the individual that, if changed, might lead to an increase or decrease in risk. The START has the potential to operationalize the structured professional judgment (SPJ) approach in order to inform the evaluation of multiple risk domains relevant to everyday psychiatric clinical practice. However, explicit guidance on integrating risk assessment, formulation and management is limited in the START and this paper describes the SPJ approach, reviews recent developments in approaches to risk, and considers how the START can be used to inform SPJ approaches and link risk assessment, formulation, and management. Copyright ? 2012 John Wiley & Sons, Ltd.     

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.     

Psychopathy in a forensic sample – the factor structure of the PCL:SV in a Danish forensic sample

The research literature reveals an ongoing debate regarding the most appropriate conceptualization of psychopathic personality disorder. Specifically, it is discussed to what degree antisocial behavior is part of the conceptualization of the psychopathy construct and what constitutes the best factor model of the Psychopathy Checklist scales. The aim of the present study is to consider the underlying factor structure of the PCL:SV (Psychopathy Checklist Screening Version) in a Danish sample as well as considering the role of antisocial behavior in the psychopathy construct. Data from a Danish forensic patient sample (N = 225) was used and item response theory (IRT), aonfirmatory factor analyses (CFA) and structural equations model (SEM) analyses were carried out. Overall, the findings suggest appropriate item and model fit for the PCL:SV as well as superiority of the three‐factor model over the four‐factor model. The results are discussed in relation to the broader concept of personality disorder as well as clinical practice in regards to violence risk assessments and treatment of psychopathy.     

Integrating research and practice in federal law enforcement: Secret Service applications of behavioral science expertise to protect the President

This paper discusses specific behavioral research needs by law enforcement and justice systems to guide forensic decision-making in areas of targeted violence. Continuing incidents of stalking, workplace violence, and threats to public figures underscore the importance of developing empirically based risk assessment and intervention strategies. Reviewing briefly the relevant literatures in these areas, this paper describes deficits in these literatures and the absence of a model for integrating research and practice in applied settings. The U.S. Secret Service Behavioral Research Program is explored as one example of how behavioral science expertise may be integrated with law enforcement responsibilities. Considerations associated with building behavioral research capacities in applied settings are examined in the context of differences in professional orientation, values, and access to information. Specific research directions to improve understanding of targeted violence are recommended along with suggestions for ways in which the psychology-law field may facilitate integration of research into practice. © 1998 John Wiley & Sons, Ltd.     

Improving forensic tribunal decisions: the role of the clinician

Three empirical investigations of forensic decision-making were conducted: a study of 104 hearings by a forensic tribunal; an evaluation of which aspects of forensic patients' clinical presentation were empirical predictors of violence; and a survey of forensic clinicians to determine which factors they said they used to assess risk of violent recidivism and which they actually used. Results showed a significant correlation between actuarial risk and clinical advice to the tribunal, and a nonsignificant trend for patients higher in actuarial risk to receive more restrictive dispositions. Psychotic diagnoses and symptoms were not indicators of increased risk of violent recidivism. Clinicians endorsed some empirically valid indicators of risk, but also relied on some invalid indicators. There was also inconsistency between factors clinicians said they used and factors actually related to their hypothetical decision-making. An automated system is presented as an illustration of how the consistency and validity of forensic decisions could be enhanced.     

Supervising Integrative Psychotherapy in the 21st Century: Pressing Needs,Impressing Possibilities

Supervisors and teachers who are interested in advancing integrative psychotherapy in the 21st century have the dual task of surveying the range of treatment approaches that have been developed and distilling these approaches down to a manageable number of influences that have been found to have the greatest impact on clinical practice over time. It has been proposed that there are four bona fide schools of psychotherapy that would be most useful for comprehensive training and supervision that would contribute to either (a) case conceptualization or (b) the process of clinical interviewing: psychodynamic psychotherapy; cognitive-behavioral psychotherapy; family systems therapy; and, humanistic/client-centered therapy. The goal for such broadly based clinical instruction would be for students, trainees, and interns to have an ability to provide a multi-level case conceptualization for any of the psychotherapy cases for which they are providing treatment. Thorough instruction in clinical reasoning and decision-making in this type of multi-level case formulation can provide some of the most valuable tools for novice and experienced clinicians alike.     

Violence risk: Re-defining variables from the first-person perspective

Over the past 25 years, there have been notable advances in violence risk assessment of mentally ill individuals using actuarial methods to define high versus low risk groups. A focus on readily observable risk factors, however, has led to a relative neglect of how the offender's subjective states may be valuable to consider in research on the ongoing assessment and prevention of violence. We argue for the relevance of considering idiographic features of subjective experience in the development of structured assessment methods. We then identify three heuristic groups of existing constructs related to aggressive and illegal behavior that may capture modifiable, time-varying aspects of mental functioning leading up to involvement in an act of violence. These hypothesized domains are: (i) construal of intent and cause; (ii) normative reference points; and (iii) emotion recognition and regulation. We suggest that risk state for violence can be studied in a parsimonious and direct manner through systematic research on coded speech samples. The coding method for such an assessment procedure would be almost identical to existing structured clinical judgment instruments with the difference that variables be defined from a first-person point of view. Some implications of this approach for the tertiary prevention of violence in high-risk individuals are described.