A Case of Misdiagnosis? Gang Members’ Mental and Emotional Health Needs

A meta-analysis of available literature on gang members’ mental health and emotions reveals that gang members may be at increased risk of suffering from mental illnesses and negative emotions. However, there remains a limited understanding of how gang members’ self-conscious emotions may relate to persistent offending and violence. Gang members may benefit from more clinically tailored interventions that support their mental and emotional health. This is the bottom line of a recently published article in The International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | The International Journal of Forensic Mental Health| 2018, Vol. 17, No. 3, 223-246

Gang membership, Mental Illness, and Negative Emotionality: A Systematic Review of the Literature

Authors

Sarah Osman, Centre for Research and Education in Forensic Psychology, Keynes College, University of Kent, Kent, Canterbury, UK
Jane Wood, Centre for Research and Education in Forensic Psychology, Keynes College, University of Kent, Kent, Canterbury, UK

Abstract

Gang-related violence poses detrimental consequences worldwide. Gang members suffer a range of adverse experiences, often as victims who then transition to adolescence and early adulthood as offenders. Such experiences may negatively affect their mental health. Yet, the relationship between gang membership and mental illness is, to date, not well understood. This systematic review synthesized the literature on gang members’ mental health and emotions.
A two-part search strategy of electronic and hand searches, dated from: January
1980–January 2017, was conducted. A total of n = 306 peer papers were included in a preliminary scoping review, of which n = 23 met the inclusion criteria and study outcomes. Narrative synthesis revealed how gang members may be at increased risk of suffering from mental illnesses and negative emotions, such as anger and rumination. Yet, synthesis showed that understanding remains limited regarding gang members’ experiences of self-conscious emotions and how such emotions might link to persistent offending patterns and violence. The results suggest gang members may benefit from clinically tailored interventions to support their mental and emotional health. Clinical and research implications are discussed to inform future empirical, intervention, and prevention work with gang members and individuals at risk of gang involvement.

Keywords

Emotions, gangs, mental illness, psychological, violence

Summary of the Research

“To date, gang membership has received scholarly attention, both theoretically and empirically, from an array of disciplines…In this breadth of literature, researchers have frequently examined how proclivity for gang involvement may be heightened by risk factors spanning five core domains: community, family, individual, peer, and school…examining links between gang membership and mental illness could deepen our understanding of gangs and as such, is a nexus, which warrants further investigation…The aim of this review is to synthesize current literature on gang members’ mental health and their emotions. Consideration of how mental illness and emotions link to gang involvement before, during, and/or following gang membership may have significant implications for theory development, empirical directions, and prevention and intervention programs that seek to reduce gang membership” (p. 223-224).

“Findings from [prior researchers] show that gang involvement relates to a range of problems such as antisocial personality disorder (ASPD), anxiety, conduct disorders, posttraumatic stress disorder (PTSD), paranoia, and psychosis…gang members, compared to violent and non-violent men suffer from higher levels of, and seek more professional help for, mental health difficulties such as anxiety, psychosis, and substance abuse” (p.225).

“…Narrative synthesis reveals gaps in the literature and methodological issues that preclude conclusions regarding the casual mechanisms between variables…Nonetheless, our findings suggest that gang members are a vulnerable sub-group of offenders who have a range of mental health and potentially, emotional needs. This review also included female gang members yet they appeared in only a handful of studies. For instance, despite the lack of clarity regarding the causal mechanism between gang membership and mental health, the findings by Kerig et al. (2016) revealed how PTSD symptoms among gang members was associated with the perpetration of violent crimes, but only female gang members had levels of symptoms relevant to the criteria for post-traumatic stress diagnosis. This suggests that gender differences may have significant implications for gang research and interventions, especially given the current reported increase in female gang participation…” (p.233).

Translating Research into Practice

“The measures for diagnosing mental health in studies also employed differential measures which were designed for varying populations (e.g., measures for clinical vs. community samples). This has clinical implications since some gang members may, dependent on the assessment used, be wrongly, or not, diagnosed. Inaccurately identifying the mental health needs of gang members, who may have a range of unmet needs, may contribute further to maladaptive behavior and contribute to the onset and/or persistence of mental illness…Any diagnosis with this population should be approached with caution given that most gang members reside in urban neighborhoods characterized by significant socio-economic deprivation, where delinquency and gang membership may be used as a means of coping…gang members’ elevated fear of victimization, anxiety, and reported increased service use suggests that their needs are several. Thus, future research should learn from existing studies and engage in multi-agency work including systematic practice between the criminal justice system and mental health services to develop appropriate mental health screening tools specific to gang members” (p.233).

“Indeed, the extent to which current interventions in the CJS [criminal justice system], such as gang exit programs include targeting the emotional and mental health needs of gang-affiliated individuals and members is unclear…with trauma-related interventions for gang members only introduced in recent years…It is also imperative that emotions are given more attention in the gang literature. The examination of gang members’ emotional experience has important implications for their treatment, in addition to, prevention work among vulnerable individuals at risk of gang involvement. For instance, we do not know how emotional experiences, such as guilt and shame, vary according to differential involvement and status within a gang. We also do not know if gang affiliates become increasingly prone to experiencing guilt due to their fleeting, as opposed to fixed, involvement with gang-related criminality…Thus, there are significant clinical, research, and policy implications invested in conducting research related to the mental and emotional health of gang members…Nonetheless, methodological issues such as the measurement of mental health and study designs must be addressed if gang research is to influence clinical and policy settings and benefit individuals and communities” (p.234).

Other Interesting Tidbits for Researchers and Clinicians

“Furthermore, affiliate gang members (who have loose association to the gang) have been found to be as at risk of mental illness are core gang members (committed to the gang…)…this seems to suggest that as gang membership deepens, so too do mental health problems. Comparisons between gang and non-gang prisoners also shows that gang members suffer higher levels of anxiety, paranoia, and PTSD – and that each relates strongly to exposure to high levels of violence before incarceration…Although research suggests that gang membership generally attracts discontented adolescent males…it also shows increasing levels of female gang involvement…Given the relationship between gang membership and violent offending, and the association between offending and the increased risk of violent victimization…both males and females can suffer violence due to gang connections. Moreover, due to the consistent evidence regarding the relationship between how childhood and/or adolescent exposure to violence, particularly when coupled with community violence exposure, is related to mental illness…investigating the relationship between gang involvement and mental illness in male and female gang members seems crucial for effective tackling of gang membership” (p.225).

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Authored by Amber Lin

Amber Lin was a volunteer in Dr. Zapf’s research lab at John Jay College of Criminal Justice. She graduated from New York University in 2013 with a B.A. (honors) and is a third year Masters student at Fairleigh Dickinson University. Her research interests include forensic assessment, competency to stand trial, and the refinement of instruments used to assess the psychological states of criminal defendants.

Understanding the Developmental Course and Severity of Criminality Among Individuals with SMI

This study, published in Law and Human Behavior, examines differences in criminal, health, demographic, and social functioning characteristics among several groups of forensic mental health clients. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | Law and Human Behavior | 2018, Vol. 42, No. 1, 83-93

Expanding the Early and Late Starter Model of Criminal Justice Involvement for Forensic Mental Health Clients

Authors

Anne G. Crocker, Université de Montréal and Institut Philippe-Pinel de Montréal
Michael S. Martin, University of Ottawa
Marichelle C. Leclair, Institut Philippe-Pinel de Montréal and McGill University
Tonia L. Nicholls, University of British Columbia and BC Mental Health and
Substance Use Services, Vancouver, British Columbia, Canada
Michael C. Seto, Royal Ottawa Health Care Group, Ottawa, Ontario, Canada

Abstract

The early and late starter model provides one of the most enduring frameworks for understanding the developmental course and severity of violence and criminality among individuals with severe mental illness. We expanded the model to account for differences in the age of onset of criminal behavior and added a group with no prior contact with the justice or mental health systems. We sampled 1,800 men and women found Not Criminally Responsible on account of Mental Disorder in 3 Canadian provinces. Using a retrospective file-based study, we explored differences in criminal, health, demographic, and social functioning characteristics, processing through the forensic psychiatric system and recidivism outcomes of 5 groups. We replicated prior research, finding more typical criminogenic needs among those with early onset crime. Those with crime onset after mental illness were more likely to show fewer criminogenic needs and to have better outcomes upon release than those who had crime onset during adulthood, before mental illness. Individuals with no prior contact with mental health or criminal justice had higher functioning prior to their crime and had a lower risk of reoffending. Given little information is needed to identify the groups, computing the distribution of these groups within forensic mental health services or across services can provide estimates of potential intensity or duration of services that might be needed. This study suggests that distinguishing subgroups of forensic clients based on the sequence of onset of mental illness and criminal behavior and on the age of onset of criminal behavior may be useful to identify criminogenic needs and predict outcomes upon release. This updated framework can be useful for planning organization of services, understanding case mix, as well as patient flow in forensic services and flow of mentally disordered offenders in correctional services.

Keywords

typology, recidivism, violence, criminality, mental illness

Summary of the Research

Background
“The criminal justice system has become a common gateway to mental health care for individuals with serious mental illness (SMI). Both forensic and civil psychiatric services provide care to growing numbers of individuals with SMI who have come into conflict with the law. With this increase comes a much more heterogeneous population of mentally ill individuals who are stigmatized with combined psychiatric and forensic labels. The variability in mental health and criminogenic needs in this evolving population has direct implications for the
organization of services in terms of intensity and breadth of services, resource allocation, as well as safety and security of patients, care providers and the community” (p. 84).

“The early and late starter model is one of the earliest and most enduring for understanding criminality among individuals with SMI . . . In the most recent version of the model, Hodgins (2008) posited three trajectories: (a) individuals who exhibit antisocial behavior during adolescence, usually prior to mental illness onset, and persist into adulthood; (b) individuals who first exhibit antisocial behavior in adulthood, after the onset of their mental illness; and (c) individuals who suddenly engage in serious violence, later in life, sometimes many years after the onset of mental illness. This revised model divided the late starter group into two groups: individuals with an atypical onset of criminal activity in mid- or late-life and those whose criminality began during the more typical periods of adolescence or early adulthood. This new group accounts for the important distinction in terms of typical versus atypical timing of onset of criminal behavior. However, to date there has been little consideration of atypical onset of mental illness” (p. 84).

“The early and late starter model suggests that mental illness may be an important risk factor for criminality for those individuals whose criminality occurs around or after the onset of mental illness. For individuals whose criminal onset precedes the illness, traditional criminogenic factors such as substance abuse or criminal associates are thought to be more important than clinical factors. Studies have found that people in the early starter trajectory display more violent behavior, more versatile criminal behavior, are more likely to have substance use problems, and have higher scores on psychopathy and antisocial personality scales compared with those who fall in the late starter trajectory. Many authors have continued to hypothesize that symptoms of mental illness would be more important drivers of violence among late compared with early starters, despite variability observed across studies. The early and late starter model can help define subgroups of individuals differing in etiologies, needs, and risk for future mental health and criminal justice involvement” (p. 84).

Current Study
“We sought to expand the testing of the early and late starter model to explore its utility across the full spectrum of severe mental disorders found in the forensic population. Our specific objective was to compare different starter groups according to their onset of criminality and mental illness on their sociodemographic, mental health and criminological characteristics, as well as their pathways through the forensic system . . . Data from this study were extracted from the National Trajectory Project, a longitudinal study of individuals found NCRMD in the three largest provinces of Canada—Québec, Ontario, and British Columbia . . . The sample included 1,800 adults found NCRMD between 2000 and 2005” (p. 85).

“Our application of the model included five groups based on two dimensions: (a) the sequence of onset of mental illness and criminal behavior, and (b) the age of onset of criminal behavior . . . Based on the first dimension, we identified two groups, which we further split based on the age of onset of criminal behavior. Preillness starters (traditionally labeled “early starters”) had a first criminal charge before their first contact with mental health services. They were divided into adolescent preillness starters (criminal onset before 18 years old) and adult preillness starters (criminal onset at 18 years old or older). Postillness starters (traditionally labeled “late starters”) had a first criminal charge after their first contact with mental health services. They were divided into younger postillness starters (criminal onset before 35 years old) and older postillness starters (criminal onset at 35 years old or older) . . . Finally, we labeled those whose NCRMD verdict was the first formal contact with both the mental health and criminal justice system as first presenters, regardless of their age” (p. 85).

Results
“Adolescent preillness starters had 0.3 times the odds of high school completion compared with younger postillness starters. They had similar primary diagnoses, but had 63% increased odds of having a comorbid substance use disorder and two times the odds of having a comorbid personality disorder or traits. They had a lower rate of prior psychiatric hospitalization per year lived, but over three times the rate of prior charges compared with younger postillness starters. Among those with at least one prior charge, adolescent preillness starters displayed greater criminal diversity than younger postillness starters” (p. 86).

“Adult preillness starters had two times the odds of being in a relationship and of earning an income at the time of the index offense compared with younger postillness starters. There were few differences in terms of diagnoses, with the exception that the relative odds of having “other” primary diagnoses rather than psychotic spectrum disorder were 85% higher in adult preillness starters than in younger postillness starters. Similar to adolescent preillness starters, adult preillness starters had under half the rate of prior psychiatric hospitalization, but an increased rate of prior charges compared with younger postillness starters. However, they displayed lower criminal diversity. Older postillness starters had three times the odds of being in a relationship compared with younger postillness starters. The relative odds of having a primary diagnosis of mood spectrum disorder rather than psychotic spectrum disorder were over 50% higher in this group than in younger postillness starters. They also had half the odds of having a comorbid substance use disorder and of having a comorbid personality disorder or traits. They had lower rates of psychiatric hospitalizations and prior charges, and those with at least one charge showed lower criminal diversity compared with younger postillness starters” (p. 87-88).

“First presenters had three times the odds of being in a relationship and six times the odds of earning their income compared with younger postillness starters. They also had half the odds of being homeless at the time of the index offense. They differed in terms of diagnosis: the relative odds of having a primary diagnosis other than mood spectrum or psychotic spectrum disorders rather than psychotic spectrum disorder were 2.7 times higher in first presenters than in younger postillness starters, and they had half the odds of having a comorbid substance use disorder” (p. 88).

“There were few differences between the groups in terms of psychiatric symptoms at the time of the index offense. Adolescent preillness starters were similar to younger postillness starters with respect to all characteristics of the index offense. Adult preillness starters had lower odds of having a mention of psychotic symptoms at the time of the index offense compared with younger postillness starters. They also had lower odds of weapon use, and 50% increased odds of victimizing an acquaintance. Older postillness starters had lower odds of drug/alcohol use at the time of the index offense compared with younger postillness starters. They also had lower relative odds of having perpetrated an index offense against a person and of having perpetrated an administrative offense rather than an “other” type of offense. First presenters were those that showed the strongest differences from younger postillness starters in terms of index offense characteristics. They had lower odds of drug/alcohol use at the time of the offense, but twice the odds of suicidal ideation. They also had 1.5 times the odds of weapon use and had almost twice the odds of victimizing a family member and of victimizing an acquaintance” (p. 88).

“We hypothesized that the postillness starters would have a shorter trajectory through the Review Board system than preillness starters. Similarly, when compared with the preillness starters, the postillness starters were expected to experience more successful community reintegration in terms of recidivism. Findings were generally consistent with these expectations. In fact, differences were observed regarding outcomes while under the purview of the Review Board and in the reoffense rates after the NCRMD verdict. Adolescent preillness starters were similar to younger postillness starters, with the exception that they were more likely to recidivate. Adult preillness starters had lower relative odds of receiving a detention order in hospital as their first Review Board disposition and higher relative odds of receiving an absolute discharge as their first Review Board disposition rather than a conditional discharge compared with younger postillness starters. They also had higher rates of absolute discharge and release from detention before the end of the follow-up. Older postillness starters and first presenters showed similar patterns in terms of outcomes compared with younger postillness starters. They both had higher relative odds of receiving an absolute discharge as their first Review Board disposition rather than a conditional discharge compared with younger postillness starters. They were both less likely to display violent behaviors, suicidal behaviors, and to use substances between Review Board hearings. Their rates of absolute discharge and release from detention were also higher than for younger postillness starters. They were also less likely to recidivate” (p. 88).

Translating Research into Practice

“Our results replicated findings from prior studies, which point toward traditional criminogenic needs (e.g., substance abuse, personality disorder, extensive criminal history) among forensic patients with preillness onset of crime. Our findings also reinforce prior research revealing the heterogeneity among adult criminal-onset individuals that could not have been observed in studies using the original two-group model. These findings help to disentangle unique and important needs among subgroups of forensic psychiatric patients that could be targeted in prevention, rehabilitation and risk management strategies” (p. 89-90).

“As expected from previous studies, comorbid substance use disorder was less common among adult postillness starters and first presenters and more common among adolescent preillness starters. Older postillness starters and first presenters were also less likely to have used alcohol or drugs at the time of the offense. The role of mental health symptoms vis-a`-vis substance use in relation to the index offense requires further consideration for a verdict of NCRMD. While substance use may be an indicator of antisociality and moderate the relationship between mental illness and crime, it can also be a consequence of mental illness because of self-medication or increased vulnerability to substance use. Thus, consistent with prior research, the added presence of substance use disorders and personality disorders appears to be important in differentiating mentally ill individuals who are at elevated risk of criminal versatility and recidivism (i.e.,early starters/preillness offenders)” (p. 90).

“Younger postillness starters had similar risk of problem behaviors while under the Review Board to preillness starters, and were less likely than all the other groups (except for adolescent preillness starters) to be discharged by the end of the study. However, their risk of recidivism is not particularly high which bears the question regarding the justification of time spent under the Review Board purview. They seem to be getting into trouble for noncompliance and substance use issues but do not seem to pose a particularly great risk of violence. As hypothesized, the older postillness starters and the first presenters had very low risk of problem behaviors while under the Review Board, and a low risk of recidivism” (p. 90).

“Lastly, this study sheds light upon a little-known group of offenders, who had no prior contact in either the justice and mental health systems. Although Hodgins (2008) had discussed and examined “first offenders,” a group of mentally ill offenders who unexpectedly commit a very serious crime without any prior signs of antisociality, they seemed to have already had contact with mental health services, which is not the case of the first presenters. First offenders and first presenters are similar in that they both have better psychosocial functioning than the other groups. This group is of particular clinical interest and requires more investigation. This group is more likely to be found NCRMD following a tragic event involving a family crisis or in a highly emotionally distressed situation, including suicidality” (p. 90).

Other Interesting Tidbits for Researchers and Clinicians

“These results suggest that the early and late starter model is relevant to risk management, as it is associated with violence and criminal recidivism. The new five-group model provides more refinement in potential developmental and services trajectories of this heterogeneous population. Examining potential typologies can be helpful in attempting to understand pathways to offending among individuals entering forensic services and targeting intervention strategies. For example, a clear focus on antisocial attitudes and behavior would be optimal for the adolescent preillness starters whereas more focus may be put on illness management for the older postillness starters and the first presenters. The model is associated with dynamic risk factors such as failure to comply with conditions, substance use, and medication noncompliance, which are all potential targets for ongoing intervention” (p. 90-91).

“It is an accepted principle of the risk-need-responsivity model that low-risk individuals should receive minimal or less intense services because providing more intense services is unnecessarily costly and raises the potential of iatrogenic effects. Given the costs of forensic hospitalization from an economic perspective and in terms of potential loss of employment, income, housing, and relationships, which are all protective against further crime, particular attention to duration of forensic hospitalization for the the older postillness starters and first presenters would appear warranted. Consideration should be given to the potential iatrogenic effect of undue (lengthy) hospitalization or Review Board purview if the patient responded well to medications and psychiatric symptoms have abated; particularly, if the patient does not have prior criminal justice involvement and/or other antisocial behavior. While they were more likely to be absolutely discharged by the end of the study, it is possible that forensic services are “over managing” these two groups by keeping them under the Review Board mandate longer than necessary” (p. 91).

“Although individualized risk assessments are essential to address specific needs and responsivity issues, knowledge of case-mix can potentially guide resource allocation and flag whether alternative, less expensive responses (e.g., diversion from the justice system to mental health services, even greater use of absolute or conditional discharge) might be warranted. Appropriate discharge from forensic services may be important to ensure optimal health and prevent escalation of criminal risk, reduce to the greatest extent possible the stigma associated with the forensic label and from a system-level can help to reduce the considerable back-log of beds common in forensic contexts. The model could provide a clinical-administrative tool in service planning at the organizational level” (p. 91).

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Authored by Becca Cheiffetz

Becca Cheiffetz is a master’s student in the Forensic Psychology program at John Jay College of Criminal Justice. She graduated in 2015 from Sam Houston State University with a BS in Psychology and plans to continue her studies in a Clinical/Forensic Psychology PhD program in the near future. Her professional interests include providing clinical evaluations and treatment for individuals in prison as a prison psychologist and conducting forensic assessments for defendants in criminal court.

Keep out of trouble: Validation of a risk assessment measure in a correctional sample

Despite high interrater reliability and relative ease of administration, caution is advised when utilizing VRAG–R measure in predicting and managing recidivism risk. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | Law and Human Behavior | 2017, Vol. 41, No. 5, 507–518

A Cross-Validation of the Violence Risk Appraisal Guide—Revised (VRAG–R) Within a Correctional Sample

Authors

Anthony J.J. Glover, Correctional Services Canada, Kingston, Ontario, Canada
Frances P. Churcher, Carleton University
Andrew L. Gray, Simon Fraser University
Jeremy F. Mills, Carleton University
Diane E. Nicholson, Correctional Services Canada, Kingston, Ontario, Canada

Abstract

The Violence Risk Appraisal Guide—Revised (VRAG–R) was developed to replace the original VRAG based on an updated and larger sample with an extended follow-up period. Using a sample of 120 adult male correctional offenders, the current study examined the interrater reliability and predictive and comparative validity of the VRAG–R to the VRAG, the Psychopathy Checklist—Revised, the Statistical Information on Recidivism—Revised, and the Two-Tiered Violence Risk Estimate over a follow-up period of up to 22 years postrelease. The VRAG–R achieved moderate levels of predictive validity for both general and violent recidivism that was sustained over time as evidenced by time-dependent area under the curve (AUC) analysis. Further, moderate predictive validity was evident when the Antisociality item was both removed and then subsequently replaced with a substitute measure of antisociality. Results of the individual item analyses for the VRAG and VRAG–R revealed that only a small number of items are significant predictors of violent recidivism. The results of this study have implications for the application of the VRAG–R to the assessment of violent recidivism among correctional offenders.

Keywords

VRAG–R, risk assessment, violence, recidivism, offenders

Summary of the Research

“Risk assessment of offenders, particularly the assessment of violence risk, has long played a role within the criminal justice process. Use of structured risk assessment measures is increasing among clinicians, with 50% to 75% of clinicians using structured risk measures during forensic assessments. […] Structured risk assessment should serve four goals. First, salient risk factors for an individual should be identified. Second, an appropriate level of risk, known as a risk estimate, should be determined. Third, clinicians should identify strategies to reduce or manage risk. Finally, risk information should be effectively communicated.” (p. 507)

“Actuarial risk assessment measures are commonly used to appraise risk for various forms of recidivism (e.g., sexual, violent, and general). For the purposes of the current study, actuarial methods will be defined as measures that use empirically relevant items where their aggregate scores are then associated with a probability of future recidivism.” (p. 507)

“A recent update of the VRAG (i.e., the Violence Risk Appraisal Guide—Revised [VRAG–R; Rice, Harris, & Lang, 2013]) was undertaken to simplify scoring, integrate the VRAG and an actuarial measure designed to predict sexual recidivism (i.e., the Sex Offender Risk Appraisal Guide [SORAG; Quinsey et al., 2006]), and reduce time spent on scoring items.” (p. 508)

“A revised version of the VRAG, referred to as the VRAG–R, was recently developed, and has since been incorporated into clinical practice. […] A major strength of the revision was the extended length of the follow-up period for the sample (which ranged up to 49 years in length), which now afforded the inclusion of several participants who had yet to be released at the time of the earlier follow-up studies. […] Preliminary evaluations have found similar predictive validity for the VRAG–R relative to the VRAG. In the validation sample the VRAG–R obtained an AUC value of .75 for violent recidivism and an AUC [area under the curve] value of .76 for the entire sample. […] These values were similar to those obtained in using the VRAG in the same sample group. Furthermore, the authors tested the predictive validity of the VRAG–R after removing the Antisociality item, as this item requires training to score and may not always be readily available using file data. The VRAG–R obtained an AUC value of .75, indicating that its predictive accuracy is not limited if this item is missing. In contrast, however, preliminary research of the VRAG–R in psychiatric samples has shown that it is not predictive of inpatient aggression. Given the mixed results, it is important that the VRAG–R undergo cross-validation if it is to be used by clinicians in a broader forensic context.” (p. 508)

“The current study is a cross-validation of the VRAG–R in a correctional sample of adult male offenders that includes a comparative analysis with existing risk assessment measures (i.e., the VRAG, PCL–R, SIR–R1, and the Two-Tiered Violence Risk Estimates) […] In addition, our study will evaluate the interrater reliability of the VRAG–R among trained clinicians, which has not been previously examined for this measure. Establishing interrater reliability is important as it examines the consistency of the scoring and poor interrater reliability has been found to be associated with lower predictive accuracy. Finally, we will examine the predictive utility of the VRAG–R without the Antisociality (Facet 4) item, as well as with a substitute measure of antisociality.” (p. 508–509)

The sample included 120 federal male offenders from Canadian correctional facilities. The majority were Caucasian (78.3%), with age ranging from 19 to 48 years (M=30.37, SD=7.48). A little over 49% of the sample had an index offense of robbery. At the time of the outcome data collection, 71.7% have completed their sentence. In addition to the aforementioned measures, recidivism information and was collected from Canadian Police Information Centre records, and time-at-risk was calculated as the number of days from the offender’s release to the date of the first postrelease conviction. The first author scored the items for all the measures apart from SIR–R1 during the original incarceration. SIR–R1 was administered at the time of admission by the parole staff. TTV was scored using archival information postrelease by one of the authors. VRAG–R was scored similarly to TTV by the lead author. An independent rater coded 30 randomly selected files to assess interrater reliability.

“Results of the current study demonstrated an overall modest predictive validity of the VRAG–R within our correctional sample, but failed to support its application using the associated risk likelihood bins. Although the VRAG–R showed a high level of association with other measures utilizing historical items, it demonstrated only a moderate degree of predictive validity for both general and violent recidivism. […] It is interesting to note that little change in predictive validity was observed when Facet 4 was both removed from the VRAG–R, as well as replaced with the ARE of the TTV suggesting that the Antisociality item of the VRAG–R could be removed without changing the predictive utility of the measure.” (p. 514)

“When the predictive validity of the VRAG and VRAG–R was examined over time, both measures displayed poor short-term predictive accuracy. […] Despite the performance of the two measures appearing to increase over time and maintaining a relatively moderate level of predictive accuracy, the poor short-term performance of the two measures is worrisome as the greatest proportion of recidivism occurs early after the initial release from an institution. It may be that the fluctuation in predictive validity seen within the short-term is reflective of the impact of environmental factors on risk (e.g., community supervision, short-term treatment effects). Such factors may diminish with the passage of time, resulting in greater predictive accuracy in the long-term due to the influence of the underlying risk (i.e., static risk) posed by the offender (e.g., the offender reaches the expiry of his sentence and is no longer under the jurisdiction of the criminal justice system).” (p. 514)

“The VRAG–R’s high level of interrater reliability in the present study was consistent with the values found for actuarial measures in previous prediction studies. The items of the VRAG–R are clearly defined, easy to score, and less prone to scoring error. Moreover, the ability to remove the Antisociality item from the measure without compromising predictive accuracy could facilitate more efficient administration and less need for intensive training (e.g., PCL–R training). […] As the VRAG–R has replaced [the total PCL-R score] with the simpler Facet 4 (Antisociality) score, it may prove to have more consistent scoring between raters. Similarly, the VRAG–R does not contain the diagnostic items of the original VRAG such as schizophrenia and personality disorder which, like the PCL–R, require clinical judgment.” (p. 514)

Translating Research into Practice

“The VRAG–R may hold some promise in terms of clinical practice for risk assessment purposes. Much like the SIR–R1, it identifies salient historical risk factors that contribute to an offender’s likelihood of risk, provides a risk estimate of future offending, and effectively communicates this risk estimate by stating it as a percentage of reoffending at two future time points. However, as it is a measure that relies solely on static risk factors, the VRAG–R does not meet the criteria of helping to provide strategies for managing or reducing an offender’s level of risk, and is therefore unsuitable for this purpose. It must therefore be used in conjunction with a measure that would provide this information.” (p. 515)

“Overall, while providing some support for the use of the VRAG–R with male offenders, results of the current study have implications for clinical practice. With respect to positive aspects of the VRAG–R, first, results of the current study demonstrate that the predictive validity of the revised VRAG is comparable to that of the original version. Second, our results replicate earlier research findings regarding the limited utility of the PCL–R as part of the VRAG. Third, the strong interrater reliability of the measure between trained clinicians shows that the VRAG–R is both relatively easy to score and can be scored consistently across raters. This is important, as this consistent scoring reflects the stringent scoring criteria intended by the authors as described by Harris et al. (2015). Despite these positive aspects, caution is warranted when interpreting the results for short-term outcomes given the low AUC values observed for both the VRAG and VRAG–R following initial release from custody. However, given the increase in AUC values over time, clinicians may be somewhat more confident in using the VRAG and VRAG–R for making long-term predictions. However, we recommend that cross-validation with a larger sample is required before the VRAG–R can be adopted for clinical use in correctional settings.” (p. 515)

Other Interesting Tidbits for Researchers and Clinicians

“There are several limitations in the current study. For instance, the use of file information to retrospectively code some of the measures for the current study may limit the usefulness of the results due to missing information or a lack of opportunity to clarify file information. Despite this, every effort was made to ensure that all data could be accurately coded. […] Larger sample sizes will be required to provide reliable estimates of risk among correctional offenders be accurately coded.” (p. 515)

“Concerning statistical power, attempts were made to account for the sample size through the statistical methods selected (e.g., nonparametric statistical analyses). […] The sample size for the current study was sufficient for these types of analyses. Indeed, statistical significance was achieved for effect sizes considered small to moderate in magnitude and the sample size of the current study is not unlike the sample sizes in applied risk assessment studies previously conducted with Canadian offenders.” (p. 515)

“Another potential limitation concerns the generalizability of the results, which may be limited due to the homogenous nature of the sample given that the majority of the offenders within the current cross-validation sample were Caucasian. Validations with samples that are more racially diverse are needed before conclusions about the breadth of effectiveness of the VRAG–R can be drawn.” (p. 515)

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Authored by Kseniya Katsman

Kseniya Katsman is a Master’s student in Forensic Psychology program at John Jay College of Criminal Justice. Her interests include forensic application of dialectical behavior therapy, cultural competence in forensic assessment, and risk assessment, specifically suicide risk. She plans to continue her education and pursue a doctoral degree in clinical psychology.

New Fordham Risk Screening Tool May Be Able to Accurately Identify Patients In Need Of A Full Violence Risk Assessment

The Fordham Risk Screening Tool may be able to identify patients in need of further violence risk assessment and screen out patients who would receive low risk ratings. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | Law and Human Behavior | 2017, Vol. 41, No. 4, 325-332

Determining When to Conduct a Violence Risk Assessment: Development and Initial Validation of the Fordham Risk Screening Tool (FRST)

Authors

Barry Rosenfeld Fordham University
Melodie Foellmi Fordham University
Ali Khadivi Albert Einstein College of Medicine
Charity Wijetunga Fordham University
Jacqueline Howe Fordham University
Alicia Nijdam-Jones Fordham University
Shana Grover New School for Social Research, New York, New York
Merrill Rotter Albert Einstein College of Medicine

Abstract

Techniques to assess violence risk are increasingly common, but no systematic approach exists to help clinicians decide which psychiatric patients are most in need of a violence risk assessment. The Fordham Risk Screening Tool (FRST) was designed to fill this void, providing a structured, systematic approach to screening psychiatric patients and determining the need for further, more thorough violence risk assessment. The FRST was administered to a sample of 210 consecutive admissions to the civil psychiatric units of an urban medical center, 159 of whom were subsequently evaluated using the Historical Clinical Risk Management-20, version 3, to determine violence risk. The FRST showed a high degree of sensitivity (93%) in identifying patients subsequently deemed to be at high risk for violence (based on the Case Prioritization risk rating). The FRST also identified all of the patients (100%) rated high in potential for severe violence (based on the Serious Physical Harm Historical Clinical Risk Management-20, version 3, summary risk rating). Sensitivity was more modest when individuals rated as moderate risk were included as the criterion (rather than only those identified as high risk). Specificity was also moderate, screening out approximately half of all participants as not needing further risk assessment. A systematic approach to risk screening is clearly needed to prioritize psychiatric admissions for thorough risk assessment, and the FRST appears to be a potentially valuable step in that process.

Keywords

violence, risk assessment, screening, triage, psychiatric patients

Summary of the Research

“The use of structured instruments that can help guide clinical decisions about violence risk is well established. In some settings, a thorough violence risk assessment is a required element of the clinical or forensic evaluation (e.g., determining whether a patient acquitted not guilty by reason of insanity if suitable for release into the community). In many settings; however, the decision as to whether a thorough evaluation of violence risk is necessary is made on a case-by-case basis. Unfortunately, little guidance exists as to how clinicians or administrators should make the decision to utilize a risk assessment instrument. Although tools to assess violence risk are readily available, a thorough violence risk assessment requires considerable time and resources, both of which are in short supply in most clinical settings. [It has been] estimated that a thorough violence risk assessment requires approximately 15 hours for a trained evaluator, far exceeding the resources available in most clinical settings (although a less thorough assessment can certainly be done more quickly). Hence, institutions are likely forced to triage admissions to determine where to focus their resources. To date, the process of determining when or whether to conduct a violence risk assessment has been largely unstructured, untested, and inconsistent, with considerable potential for error” (p. 325).

“Several published instruments have been described as violence screening tools; however, these instruments are more accurately characterized as brief measures that gauge the likelihood of future violence. Instruments such as the V-RISK-10, the Clinically Feasible Iterative Classification Tree, and the Violence Screening Checklist do not provide a true screening function, which is typically conceptualized as casting a broad net to identify a subgroup of individuals who require further examination. Rather, these instruments are intended to efficiently differentiate higher and lower risk individuals, a goal more consistent with triage—a rapid approach designed to determine how to prioritize assessment or intervention resources. In the context of violence risk, a triage approach would determine which patients need a violence risk assessment most urgently. A violence risk-screening instrument, on the other hand, would identify those patients who need further evaluation—that is, a comprehensive violence risk assessment. Hence, screening tools are most effective when the have a very high degree of sensitivity (i.e., identifying all or most of the individuals with a designated condition) and a meaningful level of specificity (i.e., to eliminate a sufficient number of cases as not needing further attention) or the reverse (near perfect specificity and an adequate level of positive predictive accuracy). Other indices of classification accuracy, such as the tool’s positive predictive value, are less useful in the context of screening because they are unduly influenced by the base rate of the condition under investigation” (p. 326).

“In response to the need for a systematic approach to violence risk screening and following the recommendations of the New York State/New York City Mental Health-Criminal Justice Panel’s report, our research team created the Fordham Risk Screening Tool [FRST]. Drawing on face-valid content, the FRST is a flow chart designed to help clinicians decide which patients need a thorough violence risk assessment” (p. 326).

“[T]he FRST is an algorithm intended to determine the need for a comprehensive violence risk assessment in psychiatric inpatients. Based on face-valid variables that should raise concerns about the possibility of violence, the FRST classifies an individual as needing a violence risk assessment when the patient displays recent and severe violent behavior, threats or ideation. Recent is operationalized as the preceding 6 months, and severe reflects behavior, threats, or ideation that has or could plausibly result in physical harm that requires medical attention. In addition to the historical FRST risk factors that form the basis of the core algorithm, the tool also elicits clinician ratings of three current risk factors that should be considered: agitation/hostility, paranoia or threat/control override symptoms, and refusal of medication” (p. 327).

“Given that the goal of screening is to identify cases in which a condition might be present (in this case, high risk of future violence), the criterion that the FRST is designed to predict is a high risk rating on a well-validated risk assessment instrument. This criterion is ideal for a screening instrument, given that a wide range of intervening variables can impact whether an individual actually engages in violence (e.g., intervention, incapacitation). Indeed, one result of a thorough risk assessment is the identification and implementation of effective risk-management strategies, hopefully resulting in a lower risk of violence in the future. It follows that individuals deemed to represent a high risk of future violence should receive aggressive interventions intended to reduce the likelihood of actual violence, whereas individuals deemed to be low risk may require little or no further intervention” (p. 326).

“Study participants were a nonoverlapping, consecutive sample of psychiatric patients (N 210) admitted to a large, private, nonprofit hospital in New York City. Most participants were brought to the hospital by the police (n = 34, 16.0%) or emergency medical personnel (n = 97, 45.5%), and the vast majority of patients were involuntarily hospitalized (n = 158, 75.2%)… The sample included 120 males (57.1%) and 90 females (42.9%), ranging in age from 18 to 68 years old (M 37.5, SD 14.2). Half of the participants were African American (n = 108, 53.5%), whereas 62 (30.7%) identified as Hispanic and 17 (8.4%) as Caucasian, non-Hispanic; 15 individuals (7.4%) were classified as an other racial/ethnic group, and these data were missing for eight individuals (3.8%)” (p. 327).

“Following admission to one of the study institution’s three psychiatric units, patients were interviewed using the FRST by a study research assistant (all of whom were doctoral students in clinical psychology). Approximately 1 week after admission, each patient was also interviewed by a second graduate student using a structured interview developed for this study to rate the HCR-20V3 and generate risk estimates” (p. 327).

“The results of this study provide preliminary support for the FRST, demonstrating a very high degree of sensitivity in identifying high-risk individuals. Moreover, the FRST identified more than 80% of those individuals rated as moderate or high risk. Simultaneously, the screening process guided by the FRST eliminated approximately half of all patients from needing further evaluation regarding risk of violence. Indeed, even when the criterion was expanded to include individuals identified as posing a moderate risk of violence on the summary risk ratings, the FRST retained sensitivity rates of approximately 80%. Thus, this study provides strong support for the FRST in differentiating those psychiatric patients who require a more comprehensive risk assessment from those who do not” (p. 329).

Translating Research into Practice

“Few issues generate as much concern in mental health settings as the potential for violence. Many expect that mental health professionals will be able to identify those individuals who represent a serious risk of violence and thereby prevent or minimize the occurrence of violence. Although important advances have occurred in the field of violence risk assessment, the time and resources needed to adequately assess whether an individual poses a significant risk of violence are substantial. Given this dilemma, there is a clear need for an effective method of screening psychiatric patients to determine where to apply those scarce resources. The FRST is intended to provide this function by utilizing a structured, reliable, and objective approach to identifying those psychiatric patients that are most likely to require a further, more comprehensive assessment” (p. 328-329).

“Given the time and resources needed to conduct a violence risk assessment, it may be impractical to evaluate even half of all admissions to a psychiatric facility… administrators and clinicians will need to determine whether a tool such as the FRST is appropriate for their setting. These decisions involve weighing the risks and benefits of not only sensitivity and specificity rates but also the cost of maintaining the status quo… Of course, the FRST need not (and should not) necessarily be considered a final judgment; decisions not to conduct further assessment can always be revisited if additional information or behavioral changes heightened concerns about possible violence” (p. 329).

Other Interesting Tidbits for Researchers and Clinicians

“Obviously, determining an adequate level of sensitivity for a screening instrument is far more complex than simply generating seemingly strong classification accuracy. Even a single false-negative result (i.e., the failure to identify an individual who poses a high risk of violence) could result in severe consequences, both for the individuals who are the target of the violence as well as the clinicians and administrative staff who might be held responsible for failing to prevent the harm. Ideally, a risk-screening instrument would have perfect sensitivity, but that goal is likely impossible unless virtually all individuals are screened in. Indeed, the results of this study are perhaps as close to perfect accuracy as could be hoped for, albeit not eliminating as many false-positive cases as might be desired. Nevertheless, continued research is necessary to identify additional indicators that might help identify those high-risk individuals who are missed by the FRST” (p. 329).

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Authored by Amanda Reed

Amanda L. Reed is a doctoral student in John Jay College of Criminal Justice’s clinical psychology program. She is the Lab Coordinator for the Forensic Training Academy. Amanda received her Bachelor’s degree in psychology from Wellesley College and a Master’s degree in Forensic Psychology from John Jay College of Criminal Justice. Her research interests include evaluator bias and training in forensic evaluation.

Mixed Findings on the SAVRY’s and YLS/CMI’s Sensitivity to Short-term Changes in Risk

Although internal and external sensitivity to change on the SAVRY and YLS/CMI are partially supported, both measures were not more dynamic in assessing risk than the PCLR:YV. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | Law and Human Behavior | 2017, Vol. 41, No. 3, 244-257

Are Adolescent Risk Assessment Tools Sensitive to Change? A Framework and Examination of the SAVRY and the YLS/CMI

Authors

Jodi L. Viljoen, Simon Fraser University
Catherine S. Shaffer, Simon Fraser University
Andrew L. Gray, Simon Fraser University
Kevin S. Douglas, Simon Fraser University

Abstract

Although many adolescent risk assessment tools include an emphasis on dynamic factors, little research has examined the extent to which these tools are capable of measuring change. In this article, we outline a framework to evaluate a tool’s capacity to measure change. This framework includes the following: (a) measurement error and reliable change, and (b) sensitivity (i.e., internal, external, and relative sensitivity). We then used this framework to evaluate the Structured Assessment of Violence Risk in Youth (SAVRY) and Youth Level of Service/Case Management Inventory (YLS/CMI). Research assistants conducted 509 risk assessments with 146 adolescents on probation (101 male, 45 female), who were assessed every 3 months over a 1-year period. Internal sensitivity (i.e., change over time) was partially supported in that a modest proportion of youth showed reliable changes over the 3-, 6-, and 12-month follow-ups. External sensitivity (i.e., the association between change scores and reoffending) was also partially supported. In particular, 22% of the associations between change scores and any and violent reoffending were significant at a 6-month follow-up. However, only 1 change score (i.e., peer associations) remained significant after the Bonferroni correction was applied. Finally, relative sensitivity was not supported, as the SAVRY and YLS/CMI was not more dynamic than the Psychopathy Checklist: Youth Version (PCL:YV). Specifically, the 1-year rank-order stability coefficients for the SAVRY, YLS/CMI, and PCL:YV Total Scores were .78, .75, and .76, respectively. Although the SAVRY and YLS/CMI hold promise, further efforts may help to enhance sensitivity to short-term changes in risk.

Keywords

adolescence, dynamic risk factors, offending, risk assessment, violence

Summary of the Research

“Risk assessment tools for violence and offending have gained widespread use (Singh, Desmarais, Hurducas, et al., 2014). Considerable research has shown that these tools can predict subsequent convictions with moderate effect sizes (Skeem & Monahan, 2011; Yang, Wong, & Coid, 2010). However, little research has examined the extent to which risk assessment tools are able to assess changes in risk (Douglas & Skeem, 2005). Measuring change is important, because it might help professionals to better predict and prevent reoffending” (p. 244).

“A primary challenge in measuring change is disentangling real change from measurement error (Jacobson & Truax, 1991; Table 1). For instance, if a youth changes a few points on a risk assessment tool, this may not be reflective of true change. Instead, it might stem from imperfect interrater reliability. As such, in evaluating the ability of a tool to measure changes in risk, an important starting point is to consider measurement error and the extent to which change is reliable (Riddle & Stratford, 2013)… For instance, no published research has investigated reliable change on the YLS/CMI, and only one study, to our knowledge, has examined reliable change on the SAVRY (Viljoen et al., 2015). The authors of that study reported that, after taking into account measurement error, a youth had to show a change of 7 to 8 points on the SAVRY Risk Total Score to be able to confidently classify this change as reliable” (p. 245).

“In evaluating a tool’s ability to measure change, another important criterion is sensitivity to change (Table 1)… According to one model, there are two forms of sensitivity to change, namely internal and external (Husted et al., 2000). Internal sensitivity refers to the “ability of a measure to change over a particular pre-specified time frame” (Husted et al., 2000, p. 459). Oftentimes, internal sensitivity is examined by evaluating the extent to which a tool differentiates individuals who have received various levels of treatment. For instance, if youth who received
services showed greater reductions in SAVRY and YLS/CMI scores than youth who did not receive services, it would suggest that these tools show internal sensitivity to change…Whereas internal sensitivity to change focuses on within individual or group-level change over time, external sensitivity to change refers to “the extent to which changes in a measure over a specified time frame relate to corresponding changes in a reference measure” (Husted et al., 2000, p. 459)” (p. 245).

“Despite growing research on adult tools’ sensitivity to change, only a small number of studies have examined sensitivity to change in widely used adolescent risk assessment tools, such as the SAVRY and YLS/CMI… In the current study, we used the above-described framework to extend research on the ability of the SAVRY and YLS/CMI to measure change. First, we investigated measurement error and reliability of change. Second, we tested sensitivity to change, including the following: (a) internal sensitivity (i.e., the extent to which SAVRY and YLS/CMI scores changed over time); (b) external sensitivity (i.e., whether adolescents who showed decreases in risk scores were less likely to reoffend); and (c) relative sensitivity (i.e., whether the SAVRY and YLS/CMI detected more change than a measure of psychopathic features)” (p. 246).

“Participants included 146 youth on community probation in a large city in Western Canada. All participants had been assessed by research assistants (RAs) on at least two occasions…This study was conducted as part of a larger study on risk assessment (Viljoen et al., 2016). Although that study also includes a 9-month reassessment, we focused on the baseline, 3-, 6-, and 12-month follow-ups, as researchers have recommended reassessments at these time points (Viljoen, Cruise, et al., 2012; Vincent et al., 2012)… For each assessment, RAs conducted a standardized interview with the youth at a probation office or a quiet public place (e.g., coffee shop) and then examined youths’ justice records prior to rating the SAVRY, YLS/CMI, and PCL:YV” (p. 247).

Results

“Overall, level of measurement error appeared acceptable. Specifically, youth’s score had to have increased or decreased by 7 points on the SAVRY Risk Total Score (14% of the maximum possible score), and 9 points on the YLS/CMI Risk Total Score (21% of the maximum possible score) in order to conclude that the change was reliable. This is similar to previous research on the SAVRY (Viljoen et al., 2015) and on adult risk assessment tools (Draycott et al., 2012). Thus, as is expected, small changes in SAVRY and YLS/CMI scores may reflect measurement error rather than true change” (p. 253).

“Internal sensitivity to change (i.e., the ability to detect change over time) was partially supported. Some youth showed reliable increases or decreases in SAVRY and YLS/CMI scores across the follow-up periods. Specifically, at the 12-month follow-up, 8% to 22% of youth showed reliable change on SAVRY and YLS/CMI Risk Total Scores. However, rates of short-term change were more modest than expected” (p. 253). One possibility is that the youth in our sample truly were not demonstrating very much change…Another possibility is that youth were, in fact, changing but the tools did not fully detect these changes” (p. 253).

“External sensitivity to change (i.e., associations with an external criterion, namely reoffending) was, again, partially supported. We found some significant associations between change scores and reoffending. For instance, youth who showed decreased risk in Peer Associations were less likely to engage in any reoffending. However, in most cases (i.e., 78% of the analyses), the associations between change scores and reoffending were not significant. For example, changes in summary risk ratings did not significantly predict reoffending. Also, only 2% of the analyses remained significant after a Bonferroni correction was made for the large number of comparisons. Given that prior research is mixed (i.e., Clarke et al., 2016; Viljoen et al., 2015), the SAVRY’s and YLS/CMI’s external sensitivity to change may vary depending on the context in which tools are used (e.g., probation vs. treatment settings)…. Finally, with respect to relative sensitivity, the SAVRY showed fairly similar sensitivity to change as the YLS/CMI. However, contrary to expectations, the putatively ‘dynamic’ scales on the SAVRY and YLS/CMI generally did not appear to be more
dynamic than the historical factors scales. Also, contrary to expectations, neither tool was any more dynamic than the PCL:YV” (p. 254).

Translating Research into Practice

“Researchers should continue to investigate sensitivity to change for the SAVRY, YLS/CMI, and other tools (e.g., Violence Risk Scale: Youth Version [Wong, Lewis, Stockdale, & Gordon, 2011], the Risk-Sophistication-Treatment Inventory [Salekin, 2004], Short-Term Assessment of Risk and Treatability: Adolescent Version [Viljoen, Nicholls, Cruise, Desmarais, & Webster, 2014]). However, given that measuring change may be difficult, researchers should also identify approaches by which to further improve tools’ sensitivity to change (see Table 9 for a list of potential strategies). Finally, it will be important to investigate if assessing changes in risk holds clinical utility, such as whether it enhances professionals’ ability to plan treatment. Ultimately, such efforts may help move the field of risk assessment beyond prediction, and closer to effective risk management and prevention” (p. 254).

Other Interesting Tidbits for Researchers and Clinicians

“Given that most participants were male, it was difficult to draw conclusions about gender differences. Moreover, although we compared sensitivity to change for youth from ethnic minority and nonminority groups, we were unable to conduct more refined analyses on any one particular ethnic group (e.g., Indigenous, Southeast Asian), given the small sample sizes. However, this is an important area for future research, especially as tools may not necessarily function equally across groups (Gutierrez, Wilson, Rugge, & Bonta, 2013; Shepherd, Adams, McEntyre, & Walker, 2014)” (p. 254).

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Authored by Sarah Hartigan

Sara Hartigan is a second year Forensic Psychology Master’s student at John Jay and hope to obtain a Ph.D. in Clinical Forensic Psychology in the future. My main areas of interest include clinical evaluations and developing treatment interventions within the forensic population.

Gender Differences on the PCL-R Indicate that Lower Cut-off Scores and Broader Definitions of Violence may Increase Predictive Validity for Females with Psychopathy

Forensic Training Academy

Compared to men, females with psychopathy obtain lower PCL-R scores, are more likely to offend out of relational frustration, and are more manipulative and self-destructive. This is the bottom line of a recently published article in the International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.

International Journal of Forensic Mental HealthFeatured Article | International Journal of Forensic Mental Health | 2016, Vol. 15, No. 1, 97-110

 

Gender Differences in the Assessment and Manifestation of Psychopathy: Results from a Multicenter Study in Forensic Psychiatric Patients

Authors

Vivienne de Vogel, Research Department, De Zorgspecialisten, Utrecht, The Netherlands
Marike Lancel, Research Department, Forensic Psychiatric Hospital, GGZ Drenthe, Assen, The Netherlands

Abstract

Gender differences were explored in PCL-R codings and the manifestation of psychopathy in 197 female and 197 male patients admitted between 1984 and 2013 to one of four Dutch forensic psychiatric hospitals. Four groups were compared with respect to criminological characteristics, historical violence risk factors and psychiatric characteristics including incidents during treatment. The lowered PCL-R cut-off score of 23 as applied in the Female Additional Manual (FAM; de Vogel, de Vries Robbe, van Kalmthout, & Place, 2012) was used to define women with psychopathy. The four groups were: (1) women without psychopathy (PCL-R < 23), (2) women with psychopathy (PCL-R > 23), (3) men without psychopathy (PCL-R < 30), and (4) men with psychopathy (PCL-R > 30). Overall, it was found that women and men with psychopathy show multiple similarities in their personal and criminal histories, but there were also several gender differences. Women with psychopathy compared to men with psychopathy committed more fraud, offended more often out of relational frustration, were more often diagnosed with the Borderline Personality Disorder, and showed less physical violence, but more manipulative and self-destructive behavior during treatment. Overall, women obtained lower scores on the PCL-R than men. Predictive validity of the PCL-R for physical violence during treatment was good for men and moderate for women. When verbal violence was included in the definition of violence, the predictive validity of the PCL-R was good for both the female and male sample. Implications of this study for forensic practice are discussed and several directions for future research are provided.

Keywords

Psychopathy, PCL-R, gender, manifestation, violence risk

Summary of the Research

“Psychopathy is generally considered one of the most serious and potentially harmful personality disorders that can bear severe consequences for victims and high costs for society. Most of the research into psychopathy has been conducted in male samples, but in the past 10 years research into possible gender differences in the assessment and prevalence rate of psychopathy has expanded. This research has yielded several important insights into the assessment of psychopathy in women, mainly with the Psychopathy Checklist-Revised (PCL-R). Overall, lower scores on the PCL-R and lower prevalence rates of psychopathy have been found for women compared to men” (p. 97).

“The PCL-R is assumed to have relevance, for instance, in violence risk assessment in both women and men. However, concerns have been expressed about whether the PCL-R captures the construct of psychopathy satisfactorily in women. It has been suggested that because women demonstrate fewer antisocial behaviors and generally have a later onset of antisocial behavior several PCL-R items are less suitable to assess the core traits of psychopathy in women” (p. 97).

“Although there have been a number of studies on the prevalence and assessment of psychopathy with the PCL-R and on the criminal background in female populations, little is known about gender differences in the etiology and manifestation of psychopathy. Gender-role socialization, psychological and biological sex differences might result in psychopathic traits being expressed differently in women and men” (p.98).

“This study is part of a retrospective multicenter study into gender differences in violence and risk factors in forensic psychiatric patients. The aim of the present study … is twofold: (1) to explore gender differences in several criminological and psychiatric variables in relation to psychopathy, and (2) to examine gender differences in PCL-R scores and predictive validity of the PCL-R. The lowered PCL-R cut-off score of 23 as applied in the Female Additional Manual was used to define women with psychopathy. It should be emphasized that this cut-off score is experimental and mainly for research purposes.” (pp. 98-99). “The present study focuses on gender differences in psychopathy in a sample of 197 women and 197 men. For men, the official PCL-R cut-off score of 30…was used. The relation will be studied between psychopathy and several criminological and psychiatric characteristics, incidents during treatment and historical violence risk factors in four groups: (1) women without psychopathy (PCL-R < 23), (2) women with psychopathy (PCL-R > 23), (3) men without psychopathy (PCL-R < 30), and (4) men with psychopathy (PCL-R > 30)” (p. 99). “The following hypotheses were formulated: (1) women with psychopathy were older at the first conviction compared to men with psychopathy and show less previous convictions; (2) women with psychopathy will differ from men with psychopathy on psychiatric variables, more specifically, they will show more impulsive, emotionally unstable behavior; (3) women will have lower scores on the PCL-R and a lower predictive validity of PCL-R scores for registered incidents during the most recent treatment” (p.99).

“Overall, it was found that women and men with psychopathy show many similarities in their criminal histories. Both women and men with psychopathy had a younger age at first conviction, were more often previously convicted, showed more previous convictions and were more often driven by antisocial motives for offending compared to women and men without psychopathy. In addition, there were also several similarities in their personal and psychiatric histories: they more often grew up without their biological parents, were more often unemployed, more often diagnosed with ASPD, showed more treatment dropout, more manipulative behavior and less self-destructive behavior during treatment compared to women and men without psychopathy. However, there were also several important gender differences and our hypotheses could be confirmed. Compared to men with psychopathy (PCL-R > 30), women with psychopathy (PCL-R > 23): (1) were older at first convictions and showed less previous convictions; (2) differed on several psychiatric variables, for example, they showed more treatment dropout, were more often diagnosed with BPD and less often with ASPD and NPD; and (3) obtained lower scores on the PCL-R and predictive validity for violent incidents was lower for them. Overall, these results are in line with previous studies and conceptual and prototypical analyses into gender differences in psychopathy” (p.105).

“A notable finding was that women with psychopathy compared to men with psychopathy offended more often out of relational frustration motives, like revenge or jealousy. Overall, women with psychopathy seem more often involved in relationships or intimate contacts and it may be that these contacts have a larger impact on them compared to men with psychopathy” (pp. 105-106).

“Furthermore, women with psychopathy were significantly less often reported as being violent during treatment, but they showed more manipulative and self-destructive behavior compared to men with psychopathy. It can be concluded that male patients with psychopathy are more visible during treatment, since they show high levels of violent behavior and are often transferred to other wards because of serious behavioral problems. On the contrary, the female patients with psychopathy are less visible during treatment as they show more subtle, manipulative behavior and less physical violence both compared to their male counterparts and compared to women without psychopathy…Overall, the findings suggest that psychopathy in women is more complex, subtle and less directly visible compared to psychopathy in men” (p.106).

“With respect to the predictive validity of the PCL-R for incidents during treatment, we found lower predictive validity for women compared to men. Interestingly, when verbal violence was included in the definition of violence, the predictive validity of the PCL-R for women was good, while for physical violence it was only moderate. Taken together, the predictive validity of the PCL-R for women is acceptable, but less strong than for men, except when the definition of violence is broader than physical violence alone” (p.106).

Translating Research into Practice

“As many similarities were found between women and men with psychopathy as well as differences between women with psychopathy and women without psychopathy, it could be suggested that this lowered cut-off score may be useful. However, much more research is needed into the accuracy of this lowered PCL-R cutoff score for female offenders, for example with Item Response Theory (IRT) analyses. Research into the factor structure of the PCL-R for women may be highly valuable. Overall, it is still advised to be careful using a lowered cut-off score because it may lead to stigmatization of women with elevated PCL-R scores. Hence, a high PCL-R score should never automatically lead to higher sentences or exclusion of treatment. Furthermore, it is advised that for decision making, for instance, with respect to discharge or treatment admission, the PCL-R should never be used in isolation. For clinical practice however, the lowered cut-off can be helpful, as it may provide more insight and understanding into the more subtle behavior of women with psychopathic traits and may help to be more attentive to manipulative behavior and effects of this behavior on staff and other patients. This may help to better set treatment goals, for instance, not only focus on empathy but focus more on providing insight into the disadvantages of the woman’s maladaptive behavior for herself. Overall, women are more sensitive and aware of their social environment than men, and thus are adept at determining what is socially desirable and they usually have better verbal skills compared to men. Therefore, self-insight and treatment motivation may be more easily overrated for women than for men. Possibly this is even more so for women with psychopathy” (p. 107).

Previous research has had “several good suggestions for the treatment of women with psychopathy, for instance, with respect to one-to-one meetings (e.g., prepare strategy and verify with colleagues), group processes (e.g., structured observation) and the acknowledgment of challenges/burden for staff (being cognizant about the toll on staff, staff needs to have insight in their own behavior and feelings)” (p.107). Other treatment suggestions are to “provide feedback to women about the results of the PCL-R, see psychopathy as a responsivity factor (e.g., emotional bonding and empathy training are not effective), and be alert to signals of psychopathic behavior and the effect on group/climate and intervene when needed. The above described strategies will take highly skilled professionals as well as clear policies in treatment settings, for instance, with respect to intimate relationships. Training staff in recognizing manipulative behavior is important, as well as frequent team interactions, supervision, coaching, and support from managers” (p.107).

Other Interesting Tidbits for Researchers and Clinicians

“Adaptation of the PCL-R for females could possibly be useful, for instance, put less weight on items relating to antisocial behavior, such as Early behavior problems and Juvenile delinquency, and adapt some item descriptions that are very male focused. For example, in the item Glibness/Superficial charm the term ‘macho men’ is applied. Furthermore… the CAPP provides a more gender-sensitive conceptualization of psychopathy and for future studies it would be interesting to further test this instrument” (p. 107).

“Since the present study showed that women with psychopathy demonstrate more manipulative behavior and were more often convicted for fraud, it could be hypothesized that there are female equivalents of these corporate psychopaths in workplaces and that they are just as harmful as their male counterparts. It would be interesting to test this hypothesis in different workplaces, like business organizations, but also in more typical female workplaces, such as health care settings. Furthermore, case studies or qualitative studies could provide valuable insight into the behavioral expression of psychopathy in women. Research into the effects of psychopathic behavior by women on their environment, more specifically their children, partner, or family, but also on treatment staff could be valuable. These types of research are important for theoretical, clinical, and ethical reasons, most importantly, with respect to the prevention of harmful behavior by women and men with psychopathy, especially against vulnerable others, like their children” (p.108).

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Authored by

Megan Banford is a master’s student in the Forensic Psychology program at John Jay College. She graduated in 2013 from Simon Fraser University with a B.A. (Honors) and hopes complete a PhD in clinical forensic psychology. Her main research interests include violence risk assessment and management, juvenile offenders and public policy.

Non-Illness Based Motivations for Violence Require Consideration among Persons with Major Mental Illness

Forensic Training AcademyWhile illness-based motivational influences appear to be the primary influence for violence in persons with MMI, non-illness based motivations require consideration in legal and clinical decision-making. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | Law and Human Behavior | 2016, Vol. 40, No. 1, 42-49 Law and Human Behavior

Assessing Illness- and Non-Illness-Based Motivations for Violent Persons with Major Mental Illness

 

Authors

Stephanie R. Penney, Centre for Addiction and Mental Health, Toronto, Ontario, Canada, and the University of Toronto
Andrew Morgan, Ontario Shores Centre for Mental Health Sciences, Whitby, Ontario, and the University of Toronto
Alexander I.F. Simpson, Centre for Addiction and Mental Health, Toronto, Ontario, Canada, and the University of Toronto

Abstract

Research on violence perpetrated by individuals with major mental illness (MMI) typically focuses on the presence of specific psychotic symptoms near the time of the violent act. This approach does not distinguish whether symptoms actually motivate the violence or were merely present at the material time. It also does not consider the possibility that non–illness-related factors (e.g., anger, substance use), or multiple motivations, may have been operative in driving violence. The failure to make these distinctions clouds our ability to understand the origins of violence in people with MMI, to accurately assess risk and criminal responsibility, and to appropriately target interventions to reduce and manage risk. This study describes the development of a new coding instrument designed to assess motivations for violence and offending among individuals with MMI, and reports on the scheme’s interrater reliability. Using 72 psychiatric reports which had been submitted to the court to assist in determining criminal responsibility, we found that independent raters were able to assess different motivational influences for violence with a satisfactory degree of consistency. More than three-quarters (79.2%) of the sample were judged to have committed an act of violence as a primary result of illness, whereas 20.8% were deemed to have offended as a result of illness in conjunction with other non–illness-based motivating influences. Current findings have relevance for clarifying the rate of illness-driven violence among psychiatric patients, as well as legal and clinical issues related to violence risk and criminal responsibility more broadly

Keywords

interrater reliability, major mental illness, motivation, violence

Summary of the Research

Epidemiological and meta-analytic studies have demonstrated that persons with major mental illness (MMI) are at elevated risk for engaging in violence toward others when compared with the general population. Simply documenting a relationship between MMI and violence, however, does not explicate the underlying mechanisms that are responsible for this association. Several hypotheses have been proposed to explain the link, including the effects of organized delusions in driving violent behaviors, as well as the disorganizing and disinhibiting effects of psychosis on behavior” (p.42).

“The notion that psychiatric symptoms exert a causal effect on behavior aligns with the popular belief that most instances of violence among individuals with MMI are symptom-driven. Despite the pervasiveness of this notion, there is little empirical evidence to support it. In fact, research suggests that the strongest risk factors for violence and criminality are shared by offenders with and without MMI, and that even individuals adjudicated as not criminally responsible (e.g., Not Criminally Responsible on account of Mental Disorder [NCRMD] in Canada) may commit an array of “sane” and “insane” offenses over time. Furthermore, other established risk factors for violence, such as neurocognitive impairments, early behavioral problems, substance misuse, and antisocial personality traits are found to be more common in people with schizophrenia, and may partly explain the increased prevalence of violence in MMI. Persons with MMI are also found to have greater levels of social and economic related risk factors for offending, such as living in impoverished neighborhoods and having lower levels of personal support. Therefore, among the population of individuals with MMI who offend, heterogeneity in contributing risk factors and motivations for violence beyond the effects of illness appears likely” (p. 42).

“Motivation is commonly defined as a process that initiates, guides, or maintains goal-oriented behaviors… as referenced above, several studies have investigated the co-occurrence of MMI and violence, whereas fewer have identified the motivational influences or causal processes that may link MMI to these behaviors. This is a significant gap in knowledge, given the centrality of the concept of motivation in both law and current advances in violence risk assessment” (p.43). “Admittedly, motives are ‘elusive, subjective, and often difficult to define,’ leading some scholars to describe conclusions about motivations for crime, such as those underpinning criminal responsibility evaluations, as little more than informed speculation. Further, most behavior is multidetermined and can be influenced by both illness- and non–illness- motives. This has impacted the reliability with which researchers have been able to measure motivational influences, and has also likely contributed to the variability in estimates of MMI-driven violence” (p.43).

“The proportion of individuals with MMI who are judged to have acted violently as a direct result of illness varies across studies, likely because of variations in sample type (e.g., psychiatric, correctional), in the quantification of symptoms and violence, and in how motivational factors are elicited and rated” (p. 44). “The current study introduces a coding scheme for the assessment of illness- and non–illness-based motivations for violence and offending in a MMI sample, and reports on the scheme’s interrater reliability. Additionally, we present data on the proportion of offenses motivated by illness-based factors, as well as the frequency of non–illness-based motivations in our sample.  Lastly, we examine whether there is a relationship between different types of motivation and the level of severity/potential for harm represented by the offending behavior” (p.44).

“We reviewed 72 psychiatric reports which had been submitted to the court to assist in determining criminal responsibility, as well as the supplementary record of arrest” (p.44). The reports described patients who were undergoing psychiatric assessment at a psychiatric hospital in Canada. “We developed a coding instrument to record the presence/ absence of specific psychiatric symptoms (i.e., hallucinations, delusions, thought/behavioral disorganization, depressed or elevated/ expansive mood) at the time of the index offense, and the degree to which each of these variables was judged to have directly motivated the offending behavior in question…we distinguished the presence of symptoms from their motivational impact, to accurately capture those instances where symptoms are present but not motivating the behavior in question” (p. 45). “Two raters with experience in forensic psychology/ psychiatry independently coded each report. After an initial batch of reports had been coded, the raters met to discuss their ratings and resolve any discrepancies that arose. The remaining reports that are the subject of the reliability analyses presented here were then coded” (p.45).

“Results from the current study, taken from a sample of individuals undergoing an assessment of criminal responsibility, align most closely with [previous] research in a high security hospital setting, and suggest that approximately three-quarters of individuals offended as a primary result of illness, and that symptoms were of a primarily psychotic nature. It is reasonable to expect that the rate of psychotic motivation in samples such as these would be higher as compared to justice-involved samples” (p.47).

“The primary motivation variable also allowed us to determine the proportion of individuals who were judged to have offended primarily as a result of illness, as opposed to primarily as a result of non–illness-based factors. We found that the majority of the sample were judged to have offended as a primary result of positive symptoms of psychosis, with fewer judged to have offended as a result of thought or behavioral disorganization linked to MMI or as a primary result of mood symptoms” (p.46).

“Importantly, the current estimate of illness-based motivation was generated from a structured coding scheme that appears to possess satisfactory interrater reliability. Results from this study suggest that the presence of specific psychiatric symptoms, as well as problems related to substance use near the time of a patient’s index offense, were reliably coded based on comprehensive psychiatric reports for the courts, detailed arrest information, and collateral sources” (p.47). “Judgments regarding the degree to which certain symptoms of MMI motivated the offending behaviors in question also demonstrated good consistency across raters. Similar to the pattern of results obtained for the presence/absence judgments, judgments regarding the likelihood of offenses being motivated by more obvious symptoms of psychosis (e.g., a command hallucination, delusions) achieved higher reliability as compared with judgments reflecting the motivational influences of relatively more ambiguous symptoms (e.g., behavioral disorganization)”(p.47).

“The reliability estimates obtained in the current study are comparable with those reported by [previous research] pertaining to estimates of delusional motivation, as well as for estimates of the direct effects of MMI and substance use on offending. In contrast, the level of agreement reflecting primary motivation achieved here was higher than the estimate in [a previous] study classifying offenders into broad motivational categories based on their lifetime pattern of offending…Although the number of cases rated for reliability purposes was significantly higher in this study, our reliance on two raters has implications for the generalizability of results presented here” (pp. 47-48).

Translating Research into Practice

“The study of motivational influences among those with MMI who have offended can inform the clinically and legally relevant question of whether specific symptoms of MMI have directly motivated an act of violence or offending for a given individual, and if so, the relative degree of influence they exerted as compared with non–illness-based factors” (p. 46).

“Unlike positive symptoms of psychosis, certain mood-based symptoms appear to share a higher degree of conceptual overlap with conventional motivations such as anger and irritability, or grandiosity and risk-taking behavior. Further study of the reliability of motivational influences for offending is thus needed, particularly in diagnostically heterogeneous samples” (p.47).

“When we collapsed our motivational subtypes to more broadly reflect symptom-based versus conventional motives, raters demonstrated a high level of agreement with respect to the primary motivation judged to be operative at the time of the index offense. This type of broad distinction is arguably most relevant from a psycholegal perspective, where binary decisions must often be made (e.g., in regards to an individual’s criminal responsibility)” (p.47).

“We did not find evidence to support the idea that different types of primary motivation were associated with more versus less severe offending behavior. However, primary mood and conventional motives were infrequent; it is possible that in a larger sample we may see significant effects, for example, whereby offenses driven by mood symptoms possess significantly higher potential for harm as compared with conventional motives. This is an important avenue to pursue, as findings could have direct implications for the assessment of violence risk, and in particular, risk for imminent or serious forms of violence” (p.48).

“The current study is a preliminary effort to develop a reliable method for indicating the extent to which different symptoms of MMI motivate violent and offending behavior, and disentangle symptom-based offending from violent and antisocial behaviors that may have other motives. This type of research can help to clarify legal and clinical issues related to violence risk and criminal responsibility, in part by better defining the nature and origins of each person’s offending and corresponding treatment needs. A reliable approach to assessing motivation can also enhance clinical understanding and improve the consistency of clinical formulations regarding violence risk and criminal responsibility, including individualized risk management plans that incorporate hypotheses about motivation: that is, how specific symptoms or risk factors caused or contributed to a person’s previous offending, and how they may influence a person’s decision to offend in the future” (p. 48).

Other Interesting Tidbits for Researchers and Clinicians

“It is important to note that psychiatric assessments of criminal responsibility in Canada do not require the assessor to address motivation, or to tackle the task of proving that the offending behavior in question was caused by symptoms of MMI directly. Rather, symptoms of the MMI must typically be shown to have incapacitated the individual with respect to the relevant competencies of appreciating the consequences of his or her actions and/or knowing their wrongfulness” (p. 48).

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Authored By Megan Banford

Megan Banford is a master’s student in the Forensic Psychology program at John Jay College. She graduated in 2013 from Simon Fraser University with a B.A. (Honors) and hopes complete a PhD in clinical forensic psychology. Her main research interests include violence risk assessment and management, juvenile offenders and public policy.

Juvenile Offenders with Subclinical Depression Display Similar Delinquent Behaviors as those Diagnosed with Major Depression

Forensic Training AcademyStructured clinical interviews show an increased level of aggression, substance use, and suicidal behavior among juvenile offenders with subclinical depression. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

Law and Human BehaviorFeatured Article | Law and Human Behavior| 2015, Vol. 39, No. 6, 593-601

Aggression, Substance Use Disorder, and Presence of a Prior Suicide Attempt among Juvenile Offenders with Subclinical Depression

Authors

Tamara Kang, The University of Texas at El Paso
Jennifer Eno Louden, The University of Texas at El Paso
Elijah P. Ricks, The University of Texas at El Paso
Rachel L. Jones, The University of Texas at El Paso

Abstract

Juvenile justice agencies often use the presence of a Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis as a criterion for offenders’ eligibility for mental health treatment. However, relying on diagnoses to sort offenders into discrete categories ignores subclinical disorders—impairment that falls below the threshold of DSM criteria. The current study used structured clinical interviews with 489 juvenile offenders to examine aggression, presence of a prior suicide attempt, and substance use disorders among juvenile offenders with subclinical depression compared with juvenile offenders with major depression or no mood disorder. Analyses demonstrated that juvenile offenders with subclinical depression reported significantly more aggression, abuse of substances, and the presence of a prior suicide attempt compared to juvenile offenders with no mood disorder, but did not differ significantly on aggression and substance abuse compared with juvenile offenders with major depression. These results have implications for correctional agencies’ policies through which offenders are offered mental health treatment, and provide a first step in identifying early signs of problematic behavior before it worsens. Specifically, the results support the notion that depressive disorders should be viewed along a continuum when determining how to allocate services.

Keywords

aggression, juvenile offenders, subclinical depression, substance abuse, suicide

Summary of the Research

“In response to growing awareness of the high rates of serious mental disorders (e.g., major depression and bipolar disorder) in criminal justice settings when compared with the general population, many juvenile justice agencies have developed, are considering, or are planning to use specialty services to reduce reoffending among juvenile offenders with severe mental illnesses. Specialty services include mental health courts and specialized probation caseloads, which have demonstrated efficacy at preventing recidivism. However, because access to community treatment providers is often limited, specialized mental health courts for juveniles often have eligibility requirements based on whether the offender has a diagnosable serious mental disorder” (p. 593).

The current diagnostic system overlooks individuals with subclinical depression—those who experience some symptoms of major depression and have impairment in their daily lives, but the duration, severity, or number of symptoms does not meet the threshold to warrant a formal diagnosis. For example, a juvenile who does not present with five symptoms for most of day nearly everyday for at least two weeks, however severe, would not be diagnosed with major depression according to the DSM–IV–TR or DSM–5” (p. 594).

“Delinquency, a general term for minor crime, misbehavior, disruptive behavior problems, and wrongdoing, appears to interact with major depression among adolescents because of a shared diathesis. The irritability from major depression seems to exacerbate the already high levels of aggression found in many delinquent adolescents in the community, which increases the likelihood of continued delinquency, and violence… Juvenile offenders with subclinical depression likely have many of the same problematic behaviors as juvenile offenders with major depression, but lack the minimum number of symptoms needed for a diagnosis, and are typically ineligible for specialized services. The lack of treatment for subclinical depression may increase the likelihood that the juvenile offender’s delinquency, suicidal ideation, and substance use progress to clinical levels and result in future rearrest” (p.594).

To examine the distinction between delinquent behaviors associated with major clinical depression versus subclinical depression, the present study compared juvenile offenders with a diagnosis of major depression and juvenile offenders with no mood disorder diagnosis.

“Data were derived from routine intake procedures at a juvenile probation agency, where juvenile offenders received a comprehensive semistructured mental health assessment. The semistructured interview yielded diagnoses based on DSM–IV–TR criteria. As  described later, the information from these interviews was used to sort juvenile offenders into three categories based on the absence or presence of symptoms and/or the duration and severity of the symptoms of major depression the juveniles endorsed” (p.595). The three groups were: no symptom present, presence of a symptom that did not meet full criteria, and presence of a symptom that met full criteria. Both past and present symptoms were placed into a single category of “lifetime occurrence” (p.595). A total of 489 juvenile offenders from a juvenile probation agency in the Southwestern U.S. were interviewed by master or doctoral students using the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) over a 20-month period.

Results

“Juvenile offenders with subclinical depression tended to report behaviors that were similar to juvenile offenders with major depression, and reported higher rates of prior suicide attempts, greater amounts of aggression, and greater rates of substance use disorder than did juvenile offenders with no mood disorder. It appears that juvenile offenders with subclinical depression experience considerable impairment that is similar to that experienced by juvenile offenders with major depression, even without meeting diagnostic criteria for a mental disorder.” (p.597).

“Recidivism risk is complicated to predict, and prior research suggests that the combination of disruptive disorders (e.g., symptoms include initiating physical fights, bullying, aggressively stealing, etc.) and substance use is even more predictive of rearrest than either component alone. Affective disorders on their own do not predict recidivism, but when combined with both disruptive behavior and substance use, the odds of recidivism are more than 2 times more likely than the odds of reoffending for juvenile offenders with no disorder. The present study supports the notion that juvenile offenders with subclinical depression are a special subgroup that may be at a higher risk of reoffending and substance use issues even though they do not have enough symptoms of depression to warrant a diagnosis” (p. 598).

“Juvenile offenders with mental health symptomology, even without meeting criteria for a DSM diagnosis, may be at a disproportionate risk of recidivism and become more deeply embedded in the criminal justice system” (p.598).

Translating Research into Practice

The authors argued against the categorical use of a DSM diagnosis of major depression as the primary determinant for mental health treatment among juvenile offenders. Instead, juvenile offenders should be diverted from the juvenile justice system and assessed for mental health needs.

The use of the Risk-Need-Responsivity (RNR) model for offender populations addresses mental illness under the responsivity model during treatment planning. “When mental illness is addressed during treatment planning, it appears that the offender has a higher likelihood of successfully abstaining from crime, as mental illness is a barrier to effective rehabilitation for criminal behavior” (p.598). If juveniles with subclinical depression are diverted away from the juvenile justice system and receive adequate mental health treatment via the RNR model, they may have a better chance of desisting from future criminal behavior.

“The present study highlights the need for juvenile justice agencies to screen all juveniles for suicidal risk and mental health symptoms…In addition, correctional staff should be educated on the symptoms that overlap and co-occur so that they can better identify the youth who are in need of services, in need of more intensive interventions, or are at a high risk for future delinquency” (p.599).

Juvenile offenders with subclinical depression are a potential high-risk group for delinquent behavior and thus warrant the necessary mental health care, whether or not they have a diagnosis of major depression.

Other Interesting Tidbits for Researchers and Clinicians

Although these findings suggest juveniles with subclinical depression are similar with those diagnosed with major depression in terms of treatment need, “only a small proportion of juveniles with major depression were represented in the sample (8.0% had major depression), whereas juvenile offenders with no mood disorder were overrepresented in the sample” (p.598). Additionally, the study consisted of mainly Latino participants and collapsed past and present symptoms of major depression, aggression, substance use, and suicidality into one single category. Future research may want to address these limitations to both replicate the findings and note any differences in outcomes for other, non-Hispanic ethnicities or when symptom presentation is coded differently.

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Authored by Sara Hartigan

6Sara Hartigan is a second year Forensic Psychology Master’s student at John Jay and hope to obtain a Ph.D. in Clinical Forensic Psychology in the future. My main areas of interest include clinical evaluations and developing treatment interventions within the forensic population.

Sexually Violent Person Statutes Differ Considerably Throughout the United States

Forensic Training AcademySVP statutes differ on definitional and procedural grounds, contributing to misapplication and misinterpretation by clinicians, policymakers, and courts. This is the bottom line of a recently published article in International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.

International Journal of Forensic Mental HealthFeatured Article | International Journal of Forensic Mental Health | 2015, Vol. 14, No. 4, 245-266

A National Survey of United States Sexually Violent Person Legislation: Policy, Procedures, and Practice

Authors

David DeMatteo, Department of Psychology and Thomas R. Kline School of Law, Drexel University, Philadelphia, Pennsylvania, USA
Megan Murphy, Department of Psychology and Thomas R. Kline School of Law, Drexel University, Philadelphia, Pennsylvania, USA
Meghann Galloway, Department of Psychology and Thomas R. Kline School of Law, Drexel University, Philadelphia, Pennsylvania, USA
Daniel A. Krauss, Department of Psychology, Claremont McKenna College, Claremont, California, USA

Abstract

Sexually Violent Person (SVP) commitment statutes provide for indeterminate civil confinement of certain sex offenders after completion of their criminal sentences. In the United States, SVP laws raise important concerns relating to due process, ex post facto claims, and protection against double jeopardy. However, it is unclear to what extent current legislation addresses or neglects these issues. Without a systematic review of SVP legislation and related case law, it remains unknown to what degree U.S. states have incorporated different strategies to protect individual rights outlined by the U.S. Supreme Court. In this study, SVP statutes from each U.S. state, the federal government, and the District of Columbia, along with related case law, were examined to evaluate (1) the requirements of SVP confinement, (2) the procedures by which SVP hearings occur, and (3) the degree to which the requirements enumerated by the U.S. Supreme Court have been followed.  Although nearly half of all states have SVP statutes, findings reveal that statutes differ considerably regarding standards of proof, commitment procedures, appeals standards, definitions of important terms, and procedural safeguards. Moreover, case law provides important information on how SVP laws actually operate. Findings are discussed in light of psychological, legal, and policy implications.

Keywords

sexually violent person, sexually violent predator, legislation, statute

Summary of the Research

“Sexually Violent Person (SVP) laws (or Sexually Violent Predator laws) provide for the indeterminate post-incarceration confinement in psychiatric facilities of individuals who are identified as likely to reoffend sexually. Today, slightly less than half of all U.S. states and the federal government have enacted some form of SVP statute. Most SVP commitment statutes require that the state prove at least three elements: (1) the defendant was convicted of or charged with a sexual offense, (2) the defendant has a mental disorder or abnormality, and (3) the defendant is likely to engage in sexually violent behavior in the future.  Despite similarities in terms of legislative purpose, SVP statutes differ considerably across jurisdictions” (p. 245). “The purpose of this study was to identify and catalog the SVP commitment statutes in U.S. states that have adopted this form of civil confinement. After identifying the SVP commitment statutes in each state that has enacted such a law, we compared the statutes on various elements” (p. 249).

“Using comprehensive electronic legal databases, we conducted a survey of state and federal SVP commitment laws, and related case law, in the United States. Two advanced graduate students with legal training coded each SVP statute on 18 elements: procedures for determining volitional impairment or serious difficulty controlling behavior, whether the definition of mental illness included personality disorders and paraphilias, definition of “likely,” burden of proof for commitment, standard of proof for release, age limitations, existence of a probable cause hearing, evidentiary admissibility standard, appellate standard of review, trial procedures, existence of an automatic appeal, enactment date, location of trial/hearing, parties who can request a jury trial, whether actuarial instruments are required, whether previous sexual conduct is required, whether a low probability of recidivism but high degree of sexual offense severity is allowed in the definition of “likely”, and whether individuals determined to be SVP are granted confidentiality… Because courts are responsible for interpreting the SVP statutes enacted by the legislature in the context of specific cases, we also examined case law in all jurisdictions with SVP statutes. Only examining statutes could be misleading because it does not provide information on how the SVP laws actually operate. Given the volume of SVP cases across jurisdictions, we focused on cases decided by the highest court in each jurisdiction, and four students with training in reading and interpreting case law identified how the courts interpreted the various elements of the SVP statutes.” (p.249)

“The results of this legislative survey suggest that, in many aspects, states with SVP statutes have modeled their statutes after the statute upheld in Kansas v. Hendricks  (1997)… [however], there are significant definitional differences across jurisdictions” (p.253). “The failure to adequately define this term limits its usefulness in terms of narrowing the class of individuals targeted by SVP laws” (p.253).

“Statutes also differ considerably regarding the operationalization of “likely” to engage in future sexual offenses” (p.253). “The ambiguity or complete absence of clarification is problematic in light of the perception of jurors left unguided by instruction… in effect, absent any specification some jurors would find that all individuals facing commitment are “likely” to recidivate. Once again, this calls into question how significantly this requirement narrows the class of individuals targeted by these laws” (pp. 253-254).

“Procedurally, states have enacted vastly different SVP commitment statutes. For example, states differ greatly regarding the inclusion/exclusion of juveniles in SVP commitment…The long-term detention of juveniles, combined with the vulnerability of juveniles and the labeling effect that may occur by designating a juvenile as an SVP, could produce unintended negative consequences…Given that the majority of state SVP laws are silent regarding the inclusion of juveniles, state legislatures are encouraged to clarify whether juveniles in their jurisdictions are subject to SVP commitment” (p. 254).

“Additionally, states are split regarding burden of proof necessary for SVP commitment. Nine states require clear and convincing evidence and 10 states require evidence beyond a reasonable doubt for SVP commitment. Three states require a lower burden of proof to be released from SVP confinement than what is needed to be committed. Two states do not specify a burden of proof necessary for SVP release and instead rely on unique criteria for SVP release. One state is silent regarding the burden of proof necessary to be released from SVP confinement. It is unclear the extent to which the standard of proof actually impacts the decision-making of jurors… It is likely jurors would need additional guidance to understand and quantify what exactly constitutes a particular level of proof” (p. 254).

“States also differ procedurally in terms of probable cause hearings… it is unclear how a jury would impact the outcome of SVP commitment proceedings because jurors are less likely to have a sophisticated understanding of recidivism risk and treatment amenability, and they may have strong prejudices against sexual offenders” (p. 254).

“States also differ considerably regarding reliance on psychological evaluations and assessments. Three states require the use of psychological instruments during SVP proceedings. Some states require psychological assessment to aid in determining whether an individual has a mental abnormality that makes them likely to engage in repeat acts of sexual violence, while other states require the use of psychological assessments as a screening method for SVP consideration” (p. 254).

“States have adopted widely varying definitions and procedures for SVP commitment. Many of these statutes are vague or silent regarding important definitional or procedural elements, such as “mental abnormality,” determination of “likely,” inclusion of juveniles, and the existence of probable cause hearings. This could result in misapplication and misinterpretation of SVP laws by the courts. Moreover, extremely vague and ambiguous language can be unconstitutional” (p. 254).

Translating Research into Practice

“Because of the significant differences among state SVP statutes, clinicians must be familiar with the SVP laws in their jurisdiction because even minor terminology differences could impact SVP determinations…Addressing the proper legal standard in an SVP case is particularly important due to the significant deprivation of liberty that is at stake. At a minimum, clinicians should know the definition of “mental abnormality” used in their jurisdiction and how “likely” to reoffend sexually is defined. Clinicians should also know whether the definition of mental abnormality includes personality disorders and paraphilias. This familiarity entails knowledge of statutory definitions and case law that may have modified the definitions” (p.255).

“As with any forensic mental health assessment, clinicians must utilize procedures and psychological assessments that will withstand judicial scrutiny… several of the psychological measures commonly used in SVP evaluations have been shown to be problematic because the measures are not relevant to the determination of whether someone is an SVP” (p.255)

“To comply with relevant professional standards, evaluators reporting sex offender risk assessment results should convey the results in a manner that accurately portrays group-related risk information, measurement error, and potential threats to validity…Specifically, risk assessment results should include the specific outcome, over a specific period of time, in a specific population. Mental health professionals conducting SVP evaluations must be familiar with the limitations of psychological tests and only use instruments that are well validated and appropriate for the SVP context” (p.255).

“Because base rates are essential to prediction models, the absence of reliable base rates, or the neglect of known base rates, impairs an evaluator’s ability to predict the likelihood of future offending behavior. As such, evaluators should clearly explain all accuracy limitations and be prepared to discuss these limitations in court” (p.255).

“For mental health practitioners, it is essential that evaluators understand the relevant definitions, procedures, and standards for SVP commitment in their jurisdiction and conduct evaluations using reliable procedures. This is particularly important in light of the limited clarification from lawmakers and the resulting potential for both scientifically rigorous and poorly conducted evaluations. Practitioners must take some degree of responsibility for refraining from accepting improper evaluation requests. For legislators, it is crucial to recognize that incomplete and/or vague SVP statutes can contribute to potential misapplication and misinterpretation by the courts, which is particularly undesirable when there are such significant liberty interests at stake” (p.256).

Other Interesting Tidbits for Researchers and Clinicians

“The majority of states include personality disorders in their SVP commitment laws. The inclusion of personality disorders within the mental abnormality component is problematic because it goes beyond traditional notions of civil commitment, which was originally designed for mental health disorders not classified as personality disorders. Including individuals with personality disorders in effect captures the majority of individuals facing SVP commitment, particularly because 40%–80% of male prison inmates meet criteria for Antisocial Personality Disorder. This raises the concern of whether SVP commitment is really limited to a “subclass of dangerous offenders” in accordance with constitutional requirements” (p.253)

“The treatment of SVPs could be significantly improved by using evidence-based treatment models. The Supreme Court in Hendricks stated that states may be obligated to provide available treatment for treatable disorders, although the Court made it clear that effective treatment is not required to justify civil commitment. Unfortunately, there is a dearth of research on successful therapy addressing sex offending specifically, and it is not clear what would constitute “effective” therapy, but this should elicit more research rather than more restrictions. Perhaps a straightforward and easily assessed metric of effective therapy would be reductions in recidivism, and this is an area that is ripe for research. Additionally, commitment should be based on risk factors supported by research rather than in response to public fears” (p.256).

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Megan BanfordAuthored by Megan Banford

Megan Banford is a master’s student in the Forensic Psychology program at John Jay College. She graduated in 2013 from Simon Fraser University with a B.A. (Honors) and hopes complete a PhD in clinical forensic psychology. Her main research interests include violence risk assessment and management, juvenile offenders and public policy.

Childhood Trauma and Risk Factors for Institutional Violence

Forensic-Training-AcademyThis large study of a cohort of all admissions to a national prison service showed that childhood trauma is very common among inmates and often co-occurs with other risk factors such as substance abuse, youth crime, and distress. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | Law and Human Behavior | 2015, Vol. 39, No. 6, 614-623lhb

Risk of Violence by Inmates With Childhood Trauma and Mental Health Needs

Authors

Michael S. Martin University of Ottawa
Kwame McKenzie
 Centre for Addiction and Mental Health, Toronto, Ontario, Canada, and University of Toronto
Gordana Eljdupovic
 Correctional Service of Canada, Ottawa, Ontario, Canada
Ian Colman University of Ottawa

Abstract

Inmates who experienced childhood trauma have higher rates of institutional violence. However, the potential intermediate roles of co-occurring mental health and substance use needs and early justice involvement have not previously been considered. The current study examined the relationships between trauma, mental health, substance abuse, youth criminal charges, and institutional violence during the first 180 days of incarceration. As secondary aims, we explored whether these associations differed by sex or differed for inmates of Aboriginal ethnicity. Secondary data from prison records for all 5,154 inmates admitted to a federal prison during 2011 were collected. Path analysis was used to estimate the direct and indirect associations between trauma and institutional violence. Approximately 45% of inmates reported childhood trauma, which was associated with a higher prevalence of co-occurring mental health and substance abuse needs, and youth criminal charges. Although mental health, substance abuse, and youth criminal charges interacted with one another in predicting violence, their associations were similar for those with and without histories of trauma. A direct association between trauma and institutional incidents remained (Relative Risk [RR] ? 1.38, 95% CI [1.07, 1.78]) after accounting for indirect associations through these co-occurring risk factors. There was insufficient evidence to suggest that these associations differed between men and women or between Aboriginal and non-Aboriginal inmates. Given the high co-occurrence of multiple health and behavioral risk factors for inmates with traumatic histories, clarifying which factors are causally associated and reversible is needed to inform effective trauma informed care.

Keywords

trauma, violence, prisons, mental health, substance abuse

Summary of the Research

“Inmates with childhood trauma are more likely to engage in violent behaviors while incarcerated. These associations between trauma and violence appear quite strong in unadjusted models, but are substantially attenuated when controlling for important co- occurring needs such as criminal history, substance abuse, and mental health. While there has been a growing interest in trauma-informed care in correctional settings to better respond to the needs of these inmates, the processes underlying the associations between childhood trauma and violence in prison remain speculative. This article explores the associations between trauma, mental health, substance abuse, and age of onset of criminal history to better understand how these variables are associated with one another and the risk of violence within prisons” (p. 614).

Trauma

“Inmates with trauma histories have higher rates of important risk factors for violence in prison. Lake (1995) reported that, on average, inmates with histories of physical abuse by their parent were approximately 3 to 4 years younger at the time of first arrest, had approximately four more arrests, and committed approximately 12 additional criminal acts compared with inmates who were not physically abused. Specific to violent behaviors, Dutton and Hart (1992) reported that the odds of having an adult conviction for physical or sexual violence were between 2 and 7 times greater among inmates who reported that they were the victim of physical or sexual abuse in childhood or reported that they witnessed family violence. Similarly, the odds of substance use and mental health issues have been estimated to be roughly 2 to 4 times greater among those with histories of childhood trauma. Systematic reviews have reported that criminal history and substance abuse are among the strongest predictors of institutional violence and misconduct, whereas personal distress and mental health needs have weaker associations” (p. 615).

“Although interactions between risk factors and trauma have received less attention in the correctional literature, trauma may influence adult behaviors such as violent behavior as a result of impacts of childhood trauma on developmental processes. Individuals with traumatic pasts may develop a response that is specific to a given situation, which, over time, may develop into a more permanent response set. The individual may begin to perceive and interpret new situations as threatening, which may shape interactions with others. For instance, an individual may interpret new situations as hostile and respond with violence, aggression, and/or fear. These tendencies may be magnified in a highly regimented and confined environment such as prison. Individuals who experience childhood adversity also perceive stressors to be more stressful than those who did not experience childhood adversity. Thus, stressful aspects of the prison environment may be more distressing to those who have experienced childhood adversity” (p. 615).

“Men and women differ in the nature of traumas experienced and in terms of behavioral manifestations…Similarly, in the Canadian context, in which the current research was conducted, Aboriginal people have experienced unique historical events, such as the removal from families and placement in residential schools in which many students were victims of physical and sexual abuse…In light of these differences between the sexes and ethnic groups, there have been calls for sex- and culturally responsive services and risk assessment. However, there is limited empirical evidence that the associations between various risk factors and institutional violence differ between men and women or between different cultural or ethnic groups… Many of the ‘gender specific’ risk factors that have been identified have been based on findings from samples of women only, or from studies that have compared risk factors for men and women solely on the basis of statistical significance (i.e., a factor is significant for one sex but not the other)” (p. 616).

The Current Study

“The present study aimed to estimate the association between childhood trauma and violence in prison, including indirect associations with psychological distress, substance abuse, and age at first arrest. As a secondary objective, we explored whether these associations differed for women or Aboriginal inmates” (p. 616).

This study utilized secondary data from 5,154 federal Canadian inmates, representing nearly all admissions into federal prison, during the 2011 calendar year. Numerous data sources were collected throughout the inmates’ first 180 days within the prison. The dependent variable in this study was the amount of recorded violent incidents, if any, the inmate had within their first 6 months of incarceration. The researchers excluded threats from their analyses and violent incidents were only included when the inmate was the instigator.

“This large study of a cohort of all admissions to a national prison service showed that childhood trauma is very common among inmates, and that trauma often co-occurs with other risk factors such as substance abuse, youth crime, and distress” (p. 619). The results of this study indicate that inmates with a history of trauma were more likely to exhibit multiple risk factors than those without a reported history of trauma. Inmates with a history of trauma were less likely to have no risk factors and they were less likely to report solely distress, substance abuse, or youth criminal charges. “After accounting for distress, substance abuse, and youth criminal charges, individuals with trauma had a small but significantly increased risk of violence” (p. 618).

The researchers tested for “interactions between substance abuse, distress, and youth criminal charges, given that interactions among these factors were most strongly supported by past literature, and that the distribution of these factors appeared to differ based on inmate’s trauma histories… There was a significant improvement in model fit when interactions between distress, substance abuse, and youth criminal history were included compared with the model with only main effects of these variables, indicating that there were significant interactions among at least some of these factors” (p. 618). Additionally, when each interaction term was analyzed independently, they all led to a statistically significant improvement in model fit.

Additionally, they “considered possible interactions between trauma and the three intermediate risk factors, to test whether risk factors were more strongly associated among those with histories of trauma compared with those who did not have such histories… there was insufficient evidence to suggest that the relative risk of violence associated with the various combinations of distress, substance abuse, and youth criminal charges differed for inmates who had experienced childhood trauma from those who had not” (p. 618-619). “Thus, our findings suggest a higher prevalence of these intermediate risk factors among inmates with histories of trauma, but that their associations with institutional violence appear to be similar for all inmates” (p. 620).

Lastly, “the model fit did not statistically significantly improve with the inclusion of interactions with either sex or Aboriginal status compared with models without these interactions” (p. 619). “Although women and Aboriginal inmates generally had higher rates of the risk factors studied and higher rates of violence in prisons, the associations between these factors and institutional violence was similar across all groups” (p. 620).

Translating Research into Practice

“Although risk factors were equally predictive regardless of inmates’ childhood histories, the majority of inmates with a history of trauma also had co-occurring mental health, substance abuse, and/or youth criminal charges (and, conversely, the majority of those with co-occurring needs had a history of childhood trauma). This highlights the multiple social, health, and behavioral needs of inmates who are at highest risk of violence that should be considered as treatment targets. It also reinforces the need for interventions for inmates with trauma histories to be integrated (i.e., target multiple needs simultaneously rather than sequentially by requiring inmates to address one need before progressing to the next treatment target) in order to be effective” (p. 619).

The findings in this study shine light on “the need to consider the joint associations between many variables rather than considering them in isolation. In particular, in light of the ongoing debate about the extent to which mental health needs increase the risk of violence or criminal behavior, it is noteworthy that distress alone was unrelated to institutional violence. However, distress interacted with other factors, including synergistic interaction between distress and youth criminal charges, and between distress and substance abuse” (p. 619).

“Differences in how variables interact in the community versus in prison may highlight the importance of social- environmental predictors of violence by persons with mental health needs in particular. These differences also reinforce the importance of considering the dynamic nature of risk factors and considering the individual’s current situation (or risk state) compared with their historical risk factors” (p. 620).

“Our findings highlight the challenges of addressing the multiple needs of inmates. They highlight that the majority of inmates with co-occurring risk factors that attract considerable attention of correctional institutions, such as mental health, substance abuse, and youth criminal charges, also have histories of childhood trauma. Clarifying developmental pathways to criminal behavior following traumatic experiences is needed to identify modifiable risk factors to be targeted through programming and to disentangle causal relationships from associations. Evaluating interventions that seek to address these risk factors is a necessary next step to determine the extent to which risk of violence in prison by inmates with histories of childhood trauma can be mitigated. As childhood trauma was associated with increased risk of institutional violence among all inmates, regardless of sex or ethnicity, all inmates who experienced childhood trauma may benefit from such research and practice efforts to develop and implement trauma informed care” (p. 621).

Other Interesting Tidbits for Researchers and Clinicians

“Given that there was no evidence of differences in the fit of the final model by either sex or ethnicity, there may be benefits to targeting the co-occurring trauma, mental health, and substance abuse needs of all inmates. In this regard, services in corrections that are responsive to the unique needs of women and cultural/racial minorities may be primarily a question of quantity of services available (to account for differences in prevalence) as opposed to a difference in the types of services. Further research to replicate these findings may be warranted, given that the small number of women who are incarcerated limits power to detect differences in patterns of associations between the sexes” (p. 620).

“Our findings may inform further work to test mediation models more fully, or to test interventions that may be appropriate for inmates with multiple co-occurring treatment needs and risk factors for violent behavior. They may also suggest areas for further research among community samples to examine potential risk and protective factors that distinguish those who experience childhood trauma who initiate criminal behavior from those who do not. Research such as this may be of great value to identify preventative measures to reduce the incidence of criminal behavior among people with histories of trauma” (p. 620).

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Authored By Amanda Beltrani

Amanda BeltraniAmanda Beltrani is a current graduate student in the Forensic Psychology Masters program at John Jay College of Criminal Justice in New York. Her professional interests include forensic assessments, specifically, criminal matter evaluations. Amanda plans to continue her studies in a doctoral program after completion of her Masters degree.