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

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

A randomized controlled trial of outpatient commitment in North Carolina.

OBJECTIVE: A randomized controlled trial of outpatient commitment was conducted in North Carolina to provide empirical data on involuntary outpatient commitment and to evaluate its effectiveness in improving outcomes among persons with severe mental illnesses. METHODS: A total of 331 involuntarily hospitalized patients awaiting discharge under outpatient commitment were randomly assigned to be released or to undergo outpatient commitment. Each received case management services and outpatient treatment. Participants in both groups were monitored for one year. After the initial 90-day outpatient commitment order, a patient could receive a renewable 180-day extension. Patients in the control group were immune from outpatient commitment for one year. Information was obtained from self-reports and reports of several informants as well as from outpatient treatment, hospital, and arrest records. RESULTS: In most bivariate analyses, outcomes for the outpatient commitment group and the control group did not differ significantly when the duration of outpatient commitment was not taken into account. However, patients who underwent sustained outpatient commitment and who received relatively intensive outpatient treatment had fewer hospital admissions and fewer days in the hospital, were more likely to adhere to community treatment, and were less likely to be violent or to be victimized. Extended outpatient commitment was also associated with fewer arrests of participants with a combined history of multiple rehospitalizations and previous arrests. The intervention was particularly effective among individuals with psychotic disorders. CONCLUSIONS: Outpatient commitment can improve treatment outcomes when the court order is sustained and combined with relatively intensive community treatment. A court order alone cannot substitute for effective treatment in improving outcomes.

Assessing violence risk among youth.

Despite recent declines in the reported rate of juvenile violence, there appears to be increasing public and professional concern about violent behavior among children and adolescents. Media accounts of school shootings and juvenile homicides have prompted a need to develop approaches for systematically assessing violence risk. This article describes the task of assessing general violence risk among youth, and argues that a somewhat different approach is required to assess cases where an identified or identifiable young person may pose a risk to a specifically identified or identifiable target (also referred to as "targeted violence"). Key risk factors for violent behavior among children and adolescents are identified, fundamental principles for conducting an assessment of violence potential in clinical and juvenile justice contexts are outlined, and an approach to assessment when an identified person engages in some communication or behavior of concern that brings him or her to official attention is briefly described.

Involuntary out-patient commitment and reduction of violent behaviour in persons with severe mental illness.

BACKGROUND: Violent behaviour among persons with severe mental illness (SMI) causes public concern and is associated with illness relapse, hospital recidivism and poor outcomes in community-based treatment. AIMS: To test whether involuntary out-patient commitment (OPC) may help to reduce the incidence of violence among persons with SMI. METHOD: One-year randomised trial of the effectiveness of OPC in 262 subjects with psychotic or major mood disorders and a history of hospital recidivism. Involuntarily hospitalised subjects awaiting OPC were randomly assigned to release or court-ordered treatment after discharge. Those with a recent history of serious assault remained under OPC until expiry of the court order (up to 90 days); then OPC orders were renewed at clinical/court discretion. Control subjects had no OPC. Four-monthly follow-up interviews with subject, case manager and collateral informant took place and service records were collected. RESULTS: A significantly lower incidence of violent behaviour occurred in subjects with > or = 6 months' OPC. Lowest risk of violence was associated with extended OPC combined with regular out-patient services, adherence to prescribed medications and no substance misuse. CONCLUSIONS: OPC may significantly reduce risk of violent behaviour in persons with SMI, in part by improving adherence to medications while diminishing substance misuse.

Comparing outcomes of major models of police responses to mental health emergencies.

OBJECTIVE: The study compared three models of police responses to incidents involving people thought to have mental illnesses to determine how often specialized professionals responded and how often they were able to resolve cases without arrest. METHODS: Three study sites representing distinct approaches to police handling of incidents involving persons with mental illness were examined-Birmingham, Alabama; and Knoxville and Memphis, Tennessee. At each site, records were examined for approximately 100 police dispatch calls for "emotionally disturbed persons" to examine the extent to which the specially trained professionals responded. To determine differences in case dispositions, records were also examined for 100 incidents at each site that involved a specialized response. RESULTS: Large differences were found across sites in the proportion of calls that resulted in a specialized response-28 percent for Birmingham, 40 percent for Knoxville, and 95 percent for Memphis. One reason for the differences was the availability in Memphis of a crisis drop-off center for persons with mental illness that had a no-refusal policy for police cases. All three programs had relatively low arrest rates when a specialized response was made, 13 percent for Birmingham, 5 percent for Knoxville, and 2 percent for Memphis. Birmingham's program was most likely to resolve an incident on the scene, whereas Knoxville's program predominantly referred individuals to mental health specialists. CONCLUSIONS: Our data strongly suggest that collaborations between the criminal justice system, the mental health system, and the advocacy community plus essential services reduce the inappropriate use of U.S. jails to house persons with acute symptoms of mental illness.

Can involuntary outpatient commitment reduce hospital recidivism?: Findings from a randomized trial with severely mentally ill individuals.

OBJECTIVE: The goal of this study was to evaluate the effectiveness of involuntary outpatient commitment in reducing rehospitalizations among individuals with severe mental illnesses. METHOD: Subjects who were hospitalized involuntarily were randomly assigned to be released (N = 135) or to continue under outpatient commitment (N = 129) after hospital discharge and followed for 1 year. Each subject received case management services plus additional outpatient treatment. Outpatient treatment and hospital use data were collected. RESULTS: In bivariate analyses, the control and outpatient commitment groups did not differ significantly in hospital outcomes. However, subjects who underwent sustained periods of outpatient commitment beyond that of the initial court order had approximately 57% fewer readmissions and 20 fewer hospital days than control subjects. Sustained outpatient commitment was shown to be particularly effective for individuals with nonaffective psychotic disorders, reducing hospital readmissions approximately 72% and requiring 28 fewer hospital days. In repeated measures multivariable analyses, the outpatient commitment group had significantly better hospital outcomes, even without considering the total length of court-ordered outpatient commitments. However, in subsequent repeated measures analyses examining the role of outpatient treatment among psychotically disordered individuals, it was also found that sustained outpatient commitment reduced hospital readmissions only when combined with a higher intensity of outpatient treatment. CONCLUSIONS: Outpatient commitment can work to reduce hospital readmissions and total hospital days when court orders are sustained and combined with intensive treatment, particularly for individuals with psychotic disorders. This use of outpatient commitment is not a substitute for intensive treatment; it requires a substantial commitment of treatment resources to be effective.

Consumer perceptions of involuntary outpatient commitment.

This study examined beliefs about the provisions of outpatient commitment and their effects among 306 people with severe and persistent mental illness who were awaiting a period of outpatient commitment. More than 80 percent of the respondents perceived that the court order for outpatient commitment required them to keep their appointments at the mental health center and to take medication as prescribed. More than three-quarters believed that the outpatient commitment order made it more likely that people would keep their mental health appointments, take their medication, and stay out of the hospital.

Assessing threats of targeted group violence: contributions from social psychology.

Recent increases in domestic and international acts of extremist violence perpetrated against American citizens have prompted an increased need for information to help understand and evaluate the threat posed to U.S. targets by extremist groups and their individual members. The purpose of this paper is to (i) suggest the potential relevance of social psychological research on group behavior for understanding and assessing threats of extremist group violence; and, (ii) encourage more systematic research on group violence to further inform assessments of group risk. Approaching the issue from the levels of group behavior, and of individual behavior within a group context, the article summarizes research on key principles of group behavior, and the effects of group membership on individual behavior; proposes specific questions derived from these principles for consideration in evaluating risk for violence by groups, and by individuals influenced by groups; and suggests further research needs.

Threat assessment: defining an approach for evaluating risk of targeted violence.

Although the field of risk assessment has made tremendous advances in the past 20 years, assessments of targeted violence continue to pose a significant challenge to law enforcement, mental health, and other professionals. These specific and critical assessments require an innovative approach. The threat assessment model, developed and refined by the U.S. Secret Service, provides a useful framework for thinking about assessments of potential for targeted violence. In this paper, we attempt to define this approach as it has been developed by the Secret Service, and apply it within the existing professional/scientific literature on risk assessment. We begin with a brief review of existing models and approaches in risk assessment, and identification of some gaps in our existing knowledge as it relates to assessments of targeted violence. We then proceed with an outline of the threat assessment approach, including a review of principles and guiding operational questions, and discussion of its use in assessment of targeted violence.

Empirical research on the insanity defense and attempted reforms: evidence toward informed policy.

The paper addresses some common questions about the insanity defense and issues raised by commonly proposed "reforms." The first section begins with a brief description of the insanity defense and the reasons for its existence in the law. It then examines some of the popular myths and public misperceptions surrounding the insanity defense. The next three sections discuss proposed "reforms" and the empirical research that addresses their effect. These reforms, including various procedural changes in definitions, burden of proof, and expert testimony, the institution of a guilty but mentally ill verdict, and the abolition of the insanity defense itself, are reviewed, along with relevant research findings and policy issues. Finally, the development of sound conditional release programs for criminal defendants found not guilty by reason of insanity is proposed as a reform option which could serve the objectives of enhancing public safety and access to appropriate treatment while continuing to meet the objectives of the insanity defense within criminal jurisprudence.

Violent behavior preceding hospitalization among persons with severe mental illness.

The need to better understand and manage risk of violent behavior among persons with severe mental illness (SMI) in community care is increasingly being recognized. Of particular concern is a subset of the SMI population characterized by a "revolving door" pattern of institutional recidivism and poor adherence to outpatient treatment. Little empirical research exists which examines the specific dimensions of violent incidents and their surrounding context in this population. The present paper describes characteristics of violent behavioral events in a sample of 331 people with psychotic or major mood disorders who were placed on involuntary outpatient commitment in North Carolina. By pooling baseline data from respondents' self-report, collateral informant interviews, and hospital records, the study found violent behavior to be a problem affecting over half the sample in a 4-month period preceding hospitalization. The study also found considerable variability in the frequency of violent events, severity, weapon use, subjective state when incidents occurred, initiation of fights, settings, relationship to others involved, and associated threat of victimization. Multivariable analyses showed that cooccurring substance abuse problems, history of criminal victimization, and age (being younger) were significantly associated with violent behavior when all sources of data were taken into account. Clinical diagnosis and symptom variables were not related to violence in this sample. Implications of these findings for service delivery priorities and future research are discussed.

Empirical research on the insanity defense and attempted reforms: evidence toward informed policy.

This paper addresses some common questions about the insanity defense and issues raised by commonly proposed "reforms." The first section begins with a brief description of the insanity defense and the reasons for its existence in the law. It then examines some of the popular myths and public misperceptions surrounding the insanity defense. The next three sections discuss proposed "reforms" and the empirical research that addresses their effect. These reforms, including various procedural changes in definitions, burden of proof, and expert testimony, the institution of a guilty but mentally ill verdict, and the abolition of the insanity defense itself, are reviewed, along with relevant research findings and policy issues. Finally, the development of sound conditional release programs for criminal defendants found not guilty by reason of insanity is proposed as a reform option which could serve the objectives of enhancing public safety and access to appropriate treatment while continuing to meet the objectives of the insanity defense within criminal jurisprudence.

Criminal victimization of persons with severe mental illness.

OBJECTIVE: The types and amounts of crime experienced by persons with severe mental illness were examined to better understand criminal victimization in this population. METHODS: Subjects were 331 involuntarily admitted psychiatric inpatients who were ordered by the court to outpatient commitment after discharge. Extensive interviews provided information on subjects' experience with crime in the previous four months and their perceived vulnerability to victimization, as well as on their living conditions and substance use. Medical records provided clinical data. RESULTS: The rate of nonviolent criminal victimization (22.4 percent) was similar to that in the general population (21.1 percent). The rate of violent criminal victimization was two and a half times greater than in the general population--8.2 percent versus 3.1 percent. Being an urban resident, using alcohol or drugs, having a secondary diagnosis of a personality disorder, and experiencing transient living conditions before hospitalization were significantly associated with being the victim of a crime. In the multivariate analysis, substance use and transient living conditions were strong predictors of criminal victimization; no demographic or clinical variable was a significant predictor. (Given the relatively high crime rates, subjects' perceived vulnerability to victimization was unexpectedly low; only 16.3 percent expressed concerns about personal safety. Those with a higher level of education expressed greater feelings of vulnerability. CONCLUSIONS: The study found a substantial rate of violent criminal victimization among persons with severe and persistent mental illness. Results suggest that substance use and homelessness make criminal victimization more likely.

Emerging partnerships between mental health and law enforcement.

Police departments in the 194 U.S. cities with a population of 100,000 or more were surveyed in 1996 to identify strategies they used to obtain input from the mental health system about dealing with mentally ill persons. A total of 174 departments responded (90 percent). Ninety-six departments had no specialized response for dealing with mentally ill persons. Among the 78 departments with special programs, three basic strategies were found: a police-based specialized police response, a police-based specialized mental health response, and a mental-health-based specialized mental health response. At least two-thirds of all departments, even those with no specialized response program, rated themselves as moderately or very effective in dealing with mentally ill persons in crisis.

Male-female differences in the setting and construction of violence among people with severe mental illness.

Data from a sample of severely and persistently mentally ill involuntary patients indicated that differences in violence between males and females in the 4 months prior to hospital admission depended on the measure. In the bivariate analysis, males had a greater prevalence of violence on the two indicators which separated more serious violence from lesser and no violence; but there was no gender difference on the more inclusive measure which incorporated threats and fights not involving weapons or injuries. In multivariate analysis when other relevant predictors were controlled, gender was significant in predicting only the most inclusive indicator of violence and only in interaction with substance abuse problems.

Taking the wrong drugs: the role of substance abuse and medication noncompliance in violence among severely mentally ill individuals.

Increasing numbers of severely mentally ill individuals are being treated in nonhospital, community-based settings and public concern about potential violence by these individuals has increased, often as a result of tragic, albeit uncommon events. The present study examines potential predictors of serious violence among persons with severe mental illness (SMI), with a specific focus on the joint effect of substance abuse and medication noncompliance. Subjects in the study are involuntarily admitted inpatients with SMI awaiting a period of court-ordered outpatient treatment, termed "involuntary outpatient commitment". During enrollment in a longitudinal outcome study of the effectiveness of OPC, 331 subjects and, whenever feasible, family members or other informants were interviewed. In addition, complementary data were gathered by review of involuntary commitment records and hospital records. Data collection included sociodemographic characteristics, illness history, clinical status, medication adherence, substance abuse and violent behavior during the 4 months preceding hospitalization. Descriptive and multivariable logistic regression procedures were used to examine the association between serious violent acts and a number of personal, social, and clinical characteristics. The combination of medication noncompliance and substance abuse was a significant predictor of serious violent acts in the community. Individuals who had problems with both alcohol and illicit drug abuse appear to be at greatest risk for violence. These results suggest that reducing violence risk among persons with SMI requires an aggressive approach to improving medication adherence in the context of integrated mental health and substance abuse treatment.