Risk/Lethality AssessmentPrediction of violence is a controversial concept in the field of psychology. Although some theoreticians say that violence prediction or lethality-risk is an immeasurable concept in clinical practice and that professionals should refrain from making such predictions, others suggest that abandoning the attempt to make accurate predictions is somewhat premature at this time. Research has indicated that we are likely to be wrong as often as we are right about predicting violent behavior in the general clinical and criminal population. However, studies looking at factors that predict violence have shown that the best predictor of future behavior is past behavior. Therefore, a person who has established patterns of physical, sexual, or psychological violence towards his spouse is likely to continue that pattern unless there is some intervention that is directed to changing these behavior patterns, such as psychological treatment (and even then, the violent behaviors can reoccur). Domestic violence offenders are more predictable for this reason. However, how does one differentiate the degrees of risk within this particular population? Mostly from common sense, and secondly from a thorough risk assessment. In general, all forms of violence are potentially lethal. One could die from a push that results in a fall down a flight of stairs or by hitting one’s head on certain types of furniture as easily as one could die from being strangled. However, some forms of violence are inherently more lethal, even though lesser forms of violence can also cause serious injury or death. However, examining the history of violence alone is often not sufficient to make a clinical determination of risk. Therefore, in order to differentiate candidates for your program you need to explore other factors, some of which have been more strongly associated with violence potential and whereas others may simply help you fill-in the picture. Additionally, certain behavior patterns may be indicative of a client’s impairment in judgment (which could result in aggressive acting-out) and therefore swift intervention may be not only appropriate but also legally and ethically required. Domestic Violence Risk/Lethality ResearchThere are emerging patterns in the empirical literature regarding risk markers for domestic violence. Numerous studies have identified risk factors associated with domestic violence such as domestic violence in the family of origin of the perpetrator, child abuse in the family of origin of the perpetrator, differences in educational and/or occupational status between members of the couple, alcohol and drug abuse by the perpetrator, perpetrator’s low self esteem, and the perpetrator’s psychiatric disorder. These studies have suggested that these factors either contribute to or are associated with domestic violence. However, these studies have limitations in that it is uncertain as to whether or not these problems predated the violence and therefore caused it, whether these problems resulted from the violence or whether these issues developed independently from the violence. On the other hand, these studies are useful for clinicians in that the existence of any one or a number of these issues with a client should alert the clinician to assessing for the presence of domestic violence. Longitudinal studies are more useful in that couples and individual patterns can be observed before and subsequent to a pattern of violence commences. Daniel O’Leary and his colleagues have found that physical aggression is preceded by verbal aggression, which in turn was proceeded by personality traits of defensiveness and aggressiveness. They also found that violence in the family of origin and violence during adolescence also contributed to a rapid escalation of violence in the adult relationship. Likewise, numerous longitudinal studies examining the long-term effects of child maltreatment have found strong links between physical abuse and the witnessing of marital violence and perpetrating violence later in life. A number of studies have looked at factors that are associated with the severity of abuse. Alcohol and drug use is not surprisingly a factor that is likely to contribute to more severe violence. Likewise, those individuals who perpetrate violence both inside and outside the family are more likely to commit more severe violence. Also, those individuals who experienced the most severe childhood abuse may develop personality disorders that are characterized by impulsivity, aggression, anger, paranoia or defensiveness and therefore may act out more aggressively. Lastly, recent studies have also indicated that certain affective disorders may lead an individual to committing lethal violence in that they are less in control of inhibiting faculties. An early, important, study by Dr. Angela Browne of forty-two family homicides in which battered women killed or seriously injured their abusive partners, showed an apparent correspondence between lethality-risk and certain characteristics of adult relationships controlled by violent men. In comparing the relationships of women who later killed their abusers with assault-only cases (in which women were battered but did not kill or seriously injure their abusive mates), the researcher found that what discriminated between the two groups were the following variables.
Although this study does not give definitive answers as to the ability to predict time and place with regard to risk, it does shed light on the ability to predict who may be at risk for committing or becoming the victim of lethal violence. What is interesting to note about this study is that all but one of these variables were based on the abusive man’s behavior. When the women in this study realized that the violence was only going to escalate and not stop, they attacked the batterer in defense of their own lives. One of the most promising areas of inquiry is in the domain of typology. Looking at categories of abusers, rather than thinking of them as one and the same, may ultimately help us develop more effective, assessment based, interventions in treatment. Typology may also help us better understand who is and who is not at risk for continued violence. For the most part, the typologies that have been developed to date are primarily oriented to diagnosis. Don Dutton, who has studies this population extensively, has categorized perpetrators into three groups - psychopathic, borderline personality organization and over-controlled. He plots these three group across two continuums, control (over controlled versus under-controlled) and violence expression (instrumental versus impulsive). The psychopathic group uses violence instrumentally and is under-controlled. The borderline group using violence impulsively and is under-controlled. The over-controlled group uses violence somewhat impulsively and instrumentally, and is over-controlled. His typology is based on psychological personality testing, history of trauma, attachment patterns and a number of other variables. Others have developed similar profiles as well. But the general pattern seems to be that a significant number of perpetrators suffer from some type of personality disorder(s), another group doesn’t evidence any severe psychopathology and the third group is psychopathic, sociopathic or otherwise living a life where violence is congruent with their values. How these profiles break down within the general population of batterers differs but nevertheless there appears to be significant numbers of each type. How does knowing a perpetrator’s profile increase our ability to predict risk? Probably no greater than any other single variable. However, making an accurate differential diagnosis is a first step to assessing risk for further violence. Researchers who have studied dangerousness have suggested that simply individual traits of the perpetrator are not sufficient to increase our ability to predict who will and who will not commit violence. Other factors must be considered, and the empirical data appears to support this idea. Ecological theories that consider biological, psychological, interactional, family, community and social factors can help professionals develop a better understanding of why violence occurs. The domestic violence field has been slow to adapt this view. Historically, feminist activists have believed that violence is a result of social forces, psychologists have tended to focus on the individual and systemic theorists have argued that family dynamics are the main contributors to violence. Each group has continued to argue vehemently in support of their theoretical orientation. In fact, public policy affecting treatment for offenders has been molded according to these unproven singular theories of the etiology of violence. Yet, when examined closely no one theory can fully explain who some people with similar social experiences, family dynamics or personal characteristics, develop problems with violence and others do not. Most recently researchers have suggested that context also plays an important role in whether or not a particular violent-prone individual will act out their aggression. In other words, there exists situational variables, such as victim characteristics, environmental factors, etc. that may trigger a particular person’s aggressive reactions. What all of this means is that when assessing risk, we must be very careful not to over simplify this complex phenomenon, thereby reacting when it’s unnecessary and not responding when the situation calls for intervention. When we become too invested in our narrow perspective, we inevitably miss other significant data that can provide us with important data necessary to more accurately assess risk and the need for clinical intervention. Lethality: The Legal PerspectiveThe 1976 California Supreme Court decision, Tarasoff v. Regents of the University of California, asserted that therapists, because of the special relationship they have with clients, have a “duty to take reasonable care to protect the intended victim.” The case involved a man who was interested in pursuing a dating relationship with a woman friend. When he discovered that she was not interested in an ongoing relationship with him, he sought psychological help. To his psychiatrist, he made a specific threat to harm the woman. Although the psychiatrist notified the police, the court found that he also had a duty to warn the victim of the patient’s threat. This well-known case established a therapist’s “duty to warn” potential victims of violence threatened by their patients. The court indicated that the reasonable care exercised by the professional could consist of other actions to protect the victim, such as involuntary hospitalization of the patient, but that directly warning the intended victim of the threat is the most effective method to fulfill this duty. Since this opinion, many states have specifically legislated guidelines for therapists in dealing with patients who present a danger to others. In 1983, another court ruling (Jablonski by Pahls v. United States) widened the Tarasoff duty to include protecting intended victims of violence even when no specific threat was made. In this case, a psychiatric patient with a serious history of violence towards women killed his wife, even though he did not make any specific threats to her. The court ruled that the psychiatrist should have known that, because of the patient’s history of violence, he was likely to commit lethal violence towards his wife, and therefore reasoned that the psychiatrist had a duty to protect her by informing her of the danger her husband posed to her. Again in 1983, another case broadened the therapist’s duty to protect by including unintended victims of violence (Hedlund v. Superior Court of Orange County). In this case, a client made a specific threat to the therapists to harm his wife, which was not communicated to the wife. The client subsequently shot the victim while she and her three-year-old child were in the car. Prior to the shooting, the women threw herself over the child to protect him. The child was not physically injured. The mother had her leg shot off by the shotgun fire. The mother sued the therapists for not warning her of the threats to her, nor of the danger to her child. The court ruled in favor of the mother and child, stating that the therapist had a duty not only to warn the mother of the threat against herself but also to warn her of the danger to her child, since the child was likely to be in close proximity to the mother when the offender would carry out his threat. The court also noted that this did not mean that the therapist must warn unidentifiable bystanders, but that common sense should dictate that certain identifiable persons in close proximity to the victim could also suffer harm and should be warned. This could be taken to include children, roommates, and other family members whom the offender had previously threatened or actually assaulted, or those in close proximity to the potential victim. It is interesting to note that all three cases involved marital or dating (in the Tarasoff case) violence. Since Tarasoff, numerous legal cases across the United States have reinforced the idea that therapists do have a duty to protect intended victims of violence, when patients make specific verbal threats of violence in the presence of the therapist and the therapist knows the identity of the intended victim. These cases, and the statistic that domestic homicide is the largest cause of death of women in the United States, indicate that domestic violence, when left unaddressed, may escalate to the death of the woman, man, or unintended victims such as children. For this reason, therapists who treat batterers need to be familiar with the standards of practice and laws and regulations concerning dangerous patients, and the duty to protect family members, friends, and other identifiable potential victims. With the courts’ tendency to considerably broaden the duty to protect identifiable victims of violence, mental health professionals in California began to feel uncomfortable with the idea of having to predict violent behavior. Research in the area of violence prediction indicated that therapists were as often wrong as they were right in predicting violent behavior. Therefore, it was argued, placing the burden of making such predictions on the therapist was unfair and unreasonable. Yet therapists indicated that under certain circumstances it would be reasonable to expect a professional to take reasonable care to protect an identifiable victim of threatened violence. For example, research does indicate that individuals who make verbal threats of violence are likely to act on those threats. In 1986, Section 43.92 of the California Civil Code was enacted through legislation. This law indicates: ... that there would be no monetary liability on the part of the therapist, if a client makes a specific threat of violence towards an identifiable victim and the therapist make a reasonable effort to communicate the threat to the victim and notifies the local law enforcement agency. This section of the code does not completely overrule Tarasoff; it simply provides a practitioner with a path for immunity. Therefore a practitioner could exercise his or her Tarasoff duty by acting in other ways to protect intended victims of violence (e.g., involuntary hospitalization of the client), yet not be immune from liability. Since these three cases, there have been numerous other cases across the country that have challenged the notion that therapist must act to protect others from the violence perpetrated by their clients, with and without specific threats to harm. Although there are exceptions, most courts appear to have used the California standard to guide their rulings. That is, when a specific threat is made to an identifiable victim, service provides must fulfill their duty to protect by contacting the intended victim and the law enforcement authorities. Although there may be situations where a specific threat has not been made, a duty to protect the client or others clearly exists for the mental health provider. Ironically, however, in domestic violence treatment instances of specific threats are usually the exception. Most persons who perpetrate family violence may not make a verbal threat at the time but subsequently perpetrate violence. Therefore, counselors working with batterers must carefully assess client’s potential and set up structures within their program that anticipates the unexpected. Likewise, past threats may also be considered real and likely to be acted and upon and therefore may be used as a basis for acting to protect potential victims of violence. What types of actions may a clinician take outside of a Tarasoff situation? Like suicide intervention, professionals need to respond to dangerous situations within an acceptable standard of care. Increased monitoring of the client may be the first level of intervention. Increasing the number of sessions may help to mitigate an emotionally stressful period. Medication evaluation and prescriptions may also reduce dysphoric affect that could potentially lead to dangerous acting out. If a clinician is concerned that violence is imminent, a voluntary or involuntary hospitalization could temporarily prevent harm to self or others. Most states permit clinicians to break confidentiality when the professionals assesses that the client is a danger to self, others or the property of others. This entails the clinician calling the local law enforcement authorities to initiate an involuntary commitment to a locked mental health facility. Risk ChecklistThe clinician should fill out the Risk Checklist (see Forms) during the assessment interview. This checklist consists of fifteen psychosocial factors that the clinician should consider when developing a comprehensive treatment plan. Each section either is either single or multiple choices. The clinician is encouraged to draw out the client’s by asking for examples, narrative descriptions and the relevant affect and note this information in the clinical chart. The Domestic Violence Assessment Software has been developed to assist mental health professionals, attorneys and investigators working perpetrators and victims of domestic violence and child abuse. The Domestic Violence Inventory can be utilized to take comprehensive histories with both victims and perpetrators of violence. Summaries can be printed and inserted into the chart for easy review. This inventory also provides a numerical breakdown of the approximate number of physical, sexual and psychological violent acts. The Domestic Violence Risk Assessment takes the user through over a dozen risk areas exploring such factors as: frequency of physical violence, severity of injuries, threats, history of child abuse, psychiatric diagnosis, proximity of victims and offender and attitudes towards violence. The user is provided both a summary of the risk factors chosen and recommendations that guide the professional in decision-making with regard to risk prevention and treatment planning. The package includes copies of the software for both Macintosh and Windows and electronic copies of the risk assessment, violence inventory and child abuse inventory forms. ReadingsRead the following online papers on dangerousness, risk assessment, and legal and ethical issues.
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