Forensic Services in New York State

NYS Office of Mental Health (OMH) :

Provides services for individuals confined to state psychiatric hospitals whom the courts found : Not Guilty by reason of Insanity (NGBRI), and Guilty but Mentally Ill (GBMI)

2 Key Forensic Issues OMH is concerned with :

Mental Competence

Relationship Between mental Disorders and Violence

Publics perception of the link between mental illness and violence

67 % of the public believes that a diagnosis of schizophrenia indicates a dangerous person.

95 % of the public supports forcible treatment for mentally ill individuals

Public believes individuals with mental illness are more likely to be violent than "normal" people

Kendra's Law was passed in NY to allow for the involuntary medication of people with a documented history of mental illness.

An individual with paranoid schizophrenia had gone off of his medication and had pushed Kendra in front of a subway car, causing her death.

In 1998, an individual with paranoid schizophrenia had gone off his medication and killed two security officers at the U.S. Capitol Building in DC.

The anecdotal evidence above helps drive the publics perception of how mentally ill individuals behave.

Documenting the Link between Illness and Violence

One additional misconception that the public has about psychiatry is that trained professionals can determine who and who is not likely to display violent behavior in the future.

When psychiatrists and psychologists must decide whether or not to release an individual back into society, they must make a judgment of how likely the individual will be to physically harm themselves and others.

Traditionally, these decisions are made as a result of the clinical experience of the examiner.

However, numerous studies showed that clinical judgment concerning future predictions of violence were correct only about 1/3 of the time.

The Macarthur Foundation : In 1996, began a program of study to determine a better way to assess the risk of future violence. 2 major thrusts of the program :

Develop a better way to measure the future propensity of violence in the mentally ill population

Statistically identify the link between mental disorders and violent behavior.

The Macarthur Foundation Study

The study began with a thorough review of all previous studies examining risk assessment and the link between violence and mental illness.

During their review, they found four major problems with previous research :

1. Most studies used a narrow range of predictor variables.

2. Studies defined violence in many different ways

3. The samples used primarily males with histories of violent acts.

4. Studies were only conducted at a single location

Macarthur Foundation Risk Assessment Study

(pg 2)

To help overcome these problems, the researchers decided to do the following :

Take a multidisciplinary approach to the problem. Psychologists, Psychiatrists, and Sociologists were all involved in the creation and completion of their project.

Examine an exhaustive list of predictor variables previously found to have some effect in the literature.

This study examined the effect of 134 different risk factors simultaneously.

These risk factors can be described as

Fixed Domains : Personal and Historical information

Changeable Domains : Contextual and Clinical information that may change during treatment

Macarthur Risk Assessment Study (pg 3)

Defining Violence : The operational construct of violence in the Macarthur study were serious acts of violence towards others which resulted in injury or arrest.

Assessing Violence :

Was a weapon used ?

Was a threat made with a weapon in hand ?

Was there a sexual assault ?

Was there battery resulting in physical injury ?

Verbal threats did not count as violence, pushing, kicking or hitting which does not result in serious injury is not considered to be violence.

Violent acts were measured at two points in the study:

10 weeks after release from mental treatment facility.

20 weeks after release from mental treatment facility.

Who Participated in the study ?

About 1000 individuals who were admitted into treatment centers and released at three sites :

Pittsburgh, PA Kansas City, MO

Worcester, MA

Individuals were accepted into the study were :

Admitted voluntarily or involuntarily.

Previous violent history or no history of violence

Received a variety of diagnosis

Both Men and Women aged 18-40

Caucasian, African American, and Hispanic

Average Length of Stay in Mental Care Facility

In 1960 : Average stay was 20 years.

This study : Average confinement to the treatment facility was 9 days !

Macarthur Risk Assessment Study (pg. 5)

Primary Diagnosis of Study Sample :

40 % Depression

13 % Bipolar disorder (mania w/depression)

17 % Schizophrenia

24 % Substance Abuse

Remember that comorbidity is extremely common in people with mental disorders, so many patients receive more than one diagnosis. In particular, substance abuse is a secondary diagnosis commonly given.

2 Reasons given for high levels of substance abuse among mentally ill :

Substance abuse is how these individuals "self medicate" outside of an approved therapeutic setting.

Mentally Ill individuals have lower levels of sensitivity to alcohol and other drugs, and this increased sensitivity makes them more likely to abuse these substances.

17 % of the sample had some history of violence

Is that 17 % higher or lower than the violence rate among "normal" individuals ?

We have to have a "norming" group to compare the 17 % to, before we can make any conclusion about how violent the mentally ill truly are .

These researchers developed a representative sample of 500 people by drawing their sample from the same neighborhood and in the same proportions that the clinical sample came from. (Pittsburgh, PA was used as the norming site)

They conducted the 10 and 20 week follow up violence assessment of this group as well.

5% of the community sample exhibited some violent behavior

SO, 17 > 5, so mentally ill people are more violent, right? …. These two numbers are not the whole story.

Macarthur Risk Assessment Study (pg. 7)

Substance Abuse and Violence

Whether or not an individuals has a substance abuse is a major determinant in predicting future violence.

Percentage of violent acts in First 10 weeks

Community MI Patients

No Drug Abuse 3.3% 4.7%

Drug Abuse 11.1% 22 %

The rate of violence for individuals from the community and patients is equivalent, when no substance abuse exists.

When there is substance abuse, the mentally ill patient is more likely to exhibit violence than the community member with a substance abuse problem.

Substance abuse makes both populations more likely to display violent behaviors.

Overall Rate of substance abuse in the mentally ill population was 32 % and in the community

sample 18% .

Macarthur Foundation Risk Assessment Study

(pg. 8)

When multiple regression techniques were used to examine the data, no clear pattern emerged.

The researchers decided to examine the data after separating the patient sample into high and low violence risk.

High Risk : Group of patients who were at least twice as likely to commit a violent act, compared to average. >37 % of this group committed a violent act.

Low Risk : Group of patients who were only half as likely to commit a violent act as the average. <9 % of this group committed a violent act.

Now, a very different pattern of data appeared, and there were 12 significant factors which had some predictive validity in assessing the risk of future violence.

These factors allowed the researchers to develop different profiles, that match up to different levels of risk of future violence.

Macarthur Risk Assessment Study (pg. 9)

The most significant predictor of violence was the presence or absence of psycopathy.

Two Major Factor Clusters of Psychopathy :

1. Selfishness, Callous attitude towards others, lack of remorse for antisocial acts.

2. Antisocial acts and personality traits, socially deviant lifestyle.

Factor 2 accounts for more of the variance, with respect to the link between psychopathy and violence

Psycopathy & Violence

Low Psychopathy High Psycopathy

12.6 % violent acts 36 % violent acts

The second variable combined with psycopathy to further assess the risk of future violence is different for are low and high psycopathy groups.

Psycopathy and Secondary Risk Factors

For individuals low in psychopathy, The number of Prior Arrests was the second most important factor in assessing future risk.

Low Psychopathy Group

Low Prior Arrests 8.2 % violent acts

High Prior Arrests 26 % violent acts

For individuals rated high in psycopathy, whether or not they had experienced child abuse was the second most important factor in assessing future risk of violent behavior

High Psycopathy Group

No Child Abuse 15 % violent acts

Child Abuse 41 % violent acts

Profiles based partially on Psycopathy scores.

An individual : High In Psychopathy

Many Prior Arrests

Recent Violent Act

No suicidal thoughts

Gets a 59 % risk assessment, indicating that in a group of individuals who share the above characteristics, 59 % of that group can be expected to perform some violent act in the future.

In marked contrast, an individual : Low in psycopathy

Few Prior Arrests

Voluntarily committed

Has psychotic symptoms

Gets a risk assessment of 0 %.

Again, this risk assessment doesn't mean there is no chance this individual will commit a violent act, it just indicates that when comparing this individuals to a group of individuals with the same characteristics, that group very rarely (if ever) displayed violent behavior.

Problems with using psycopathy to assess risk of violence.

PCL-20 : Psycopathy Check List : Requires four hour to administer to an individual. Is too long to be used within the standard clinical assessment procedures for everyone admitted into a mental care facility.

A one-hour, clinical version of the PCL-20 has been developed to shorten the time length. However, one hour of clinical time is still too long in most instances.

Because the researchers want to develop a measure which will become widely used, they also developed models to predict violence which do not include psycopathy as a risk factor.

If we leave psycopathy out, # and quality of previous arrests was the single largest factor

No Priors Few Priors Violent Priors

9.2 % 20% 36%

Two sample profiles :

An individual with previous arrests for violence and currently has specific violent fantasies receives a risk assessment of 53 %

An individual with no priors, and whose father did not use drugs, receives a risk assessment of 3%

Macarthur Foundation Risk Assessment (pg. 13)

All together, researchers identified five different "tree structures" which gave them some predictive validity in assessing the future risk of violence.

They are currently developing the VRAD (violence risk assessment device) which combined all five of these decision trees into a single clinical instrument.

The clinician uses all five decision trees and then creates a weighted average of the 5 risk assessments to combine them into a single risk assessment quantification.

VRAD scores can range from -36 to positive 36,

Indicating positive indices of mental health are considered, as well as quantifying all the negative factors.

These scores fit into 1 of five categories, which have an associated level of expected violence for members of that specific risk class.

Risk Class Violence N

1 2% 350

2 8% 250

3 26% 200

4 56 % 100

5 76 % 74

How should we use this risk class division ?

Effects of Different Required treatment Cutoffs

Cut Off Reduction in Violent acts % Req. T

2 98% 64 %

3 91% 37%

4 67 % 18 %

5 37 % 7 %

The lower we set the cut off, the more violent acts we can prevent.

The higher we set the cut off, the smaller the size of our treatment population.

As cut off level increases, the associated costs decline.

Situation 1: To ensure that people who may be dangerous to society are not released, everybody coming into a mental health facility receives the VRAD. The higher the level, the more treatment required for those individuals, to decrease the risk of future violence.

What is an acceptable risk level ?

Risk Class 1 is less violent than society at large.

Risk Class 2 is about as violent as society.

Risk Class 3 through 5 show greater violence than the general population.

To the degree that treatment is provided through tax dollars, this can become a cost benefit type problem.

To the degree that we want to protect society from known predators (or likely future predators), this will become a question of civil liberties.

These are legal and ethical issues, not purely issues of basic research and psychological knowledge.

Does Treatment to reduce violence work ?

Researchers at the Macarthur foundation also examined the link between post-release treatment and the recurrence of violent behavior.

Rate of Violence by. Frequency of treatment

No Therapy Monthly Weekly or More

14 % 10 % 3 %

The greater the frequency of post hospitalization treatment, the lower the level of associated violent acts.

Limitations of this finding :

All treatment types were grouped together, so no evidence on the relative efficacy of different treatment methods was documented during this portion of the study.

The Relationship Between Specific Mental Illness's and violence

Antisocial Personality Disorder : Commonly given to men, there was a small positive correlation between this diagnosis and the likelihood of future violence.

70% adult male prisoners could be classified as APD.

Schizophrenia : Researchers found a negative correlation between this diagnosis and the likelihood of future violence.

The mental diagnosis most predictive of future violence was substance abuse .

From this actuarial perspective of predicting future violence, knowledge of previous violent history, history of substance abuse, and prior arrest records are much more diagnostic than the specific diagnosis.

Conclusions of the Risk Assessment Study :

Much Stronger link between substance abuse and violence than mental illness and violence.

People with mental illness, yet no substance abuse problem, are as peaceful as the general population.

We can do a good job of assessing the risk of future violence with the VRAD.

Public debate must decide how society can best use the VRAD classification scheme to reduce the possibility of future violence in mentally ill populations.

The Adult risk factors for violence identified should not be used at the adolescent level.

Clinicians need to inquire if the individual has any recurrent violent images, thoughts, or fantasies, in addition to asking about suicidal ideation.