Expert approaches to communicating violence risk.

There has been virtually no empirical study of the way in which evaluating clinicians communicate their conclusions about the risk of violence toward others. Risk communication has become particularly important in recent years, serving as the link between empirical data from recent studies and the understanding and use of such data by evaluators and decision makers. The present study considered how psychologists and psychiatrists, identified as experts in violence risk assessment, responded to eight vignettes that systematically measured preferences for risk communication. The vignettes involved the presentation of the following factors in a 2 x 2 x 2 within-subjects design, counterbalanced for order: (1) risk model (prediction vs. management), (2) risk level (high vs. low risk of the individual being assessed), and (3) risk factors (the predominance of static vs. dynamic risk factors). A total of 71 individuals (41 psychologists, 2 sociologists, and 28 psychiatrists) responded to a survey mailed to 100 individuals, for a response rate of 71%. Participants were asked to rate the value of six forms of risk communication for each of the eight vignettes. There were few significant differences between the ratings assigned by psychologists and those assigned by psychiatrists. The most highly valued form of risk communication involved identifying risk factors applicable to the individual and specifying interventions to reduce risk. A repeated-measures multivariate analysis of variance yielded a main effect for risk level and an interaction between risk level and risk factors. The implications of these findings for research and practice are discussed.

Risk communication: clinicians' reported approaches and perceived values.

Despite significant conceptual and empirical advances in research on the risk assessment of violence during the last decade, there has apparently been no empirical research in the related area of risk communication. After summarizing the major theoretical and practical justifications for studying risk communication, this article describes the results of two studies of clinicians' risk communication practices. In Study 1, practicing clinicians (psychiatrists and psychologists; n = 55) were surveyed. Only one clinician indicated that he employed numerical probability figures in communicating risk; a total of nine reasons for not using numerical probabilities were cited, in varying combinations, by participants. Risk communication practices that were reportedly employed included a total of 11 approaches, endorsed in varying combinations. In Study 2, a separate sample of clinicians (n = 59) rated (1) the importance of the Study 1 reasons against using numerical probability figures in risk communication and (2) the value of the different forms of risk communication derived in Study 1. These data apparently offer the first empirical description of how clinicians communicate the results of risk assessments of violence and their reasons for communicating in such ways.

Special perspective an immodest proposal: should treating mental health professionals be barred from testifying about their patients?

Notwithstanding ethical rules that address therapeutic and forensic role conflicts for psychologists and psychiatrists, overzealous patient advocacy by therapists, tightened reimbursement for therapy, and a growth market for forensic psychology and psychiatry, have led many therapists to appear willingly as forensic experts on behalf of their patients. Existing ethical rules, as well as other proposed approaches to address this problem, assume that it can be resolved by modest changes in existing practice that permit therapists to testify as long as their testimony avoids psycholegal opinions. This essay questions whether these modest changes can adequately address this problem and advances consideration of a more radical proposal to address this problem, prohibiting therapists from testifying about their patients.

Prediction versus management models relevant to risk assessment: the importance of legal decision-making context.

Most of the theoretical and empirical literature on violence risk to date has focused on the task of predicting who will behave violently. In the present article, it is argued that at least two models of risk assessment may be applied to the varying legal decisions in which violence risk is a consideration: prediction (with an emphasis on overall accuracy) and management (with an emphasis on risk reduction). These two models are described, and discussed in the contexts of the literatures on forensic assessment and therapeutic jurisprudence. The implications for research, policy, and practice are considered.

A national survey of U.S. statutes on juvenile transfer: implications for policy and practice.

A survey of the statutes on juvenile transfer and decertification in the U.S. federal and 50 state jurisdictions, and the District of Columbia, was performed. Relevant information was obtained on the procedures in each jurisdiction by which a juvenile can be tried in criminal court, whether there are applicable decertification ("transfer back") procedures in jurisdictions permitting criminal court processing through automatic file or prosecutorial discretion, and the burden and allocation of proof in relevant proceedings. We also identified four criteria relevant to the mental, emotional, and developmental functioning of juveniles that are used in various jurisdictions in making transfer and decertification decisions: treatment needs and amenability, risk assessment of future criminality, the presence of mental retardation or mental illness, and certain kinds of offense characteristics. The majority of jurisdictions now allow 14-year-old juveniles to be tried in criminal court. Treatment needs/amenability and risk assessment are set forth as criteria relevant to transfer in the majority of jurisdictions as well, with the presence of mental retardation or mental illness explicitly relevant in a small number of jurisdictions. The patterns of these findings are discussed in their implications for social policy and for the forensic mental health assessment of juvenile transfer and decertification, with needed areas of research identified within each.

Physical control of patients on an inpatient setting: forensic vs. civil populations.

The current study examines the use of physical control (seclusion and restraint) in a sample of patients hospitalized in a public mental hospital during 1989. A total of 243 patient records involving physical control were examined; of these, 124 had been civilly committed and the remaining 119 were forensic (Incompetent to Stand Trial or Not Guilty by Reason of Insanity). Some 870 physical control events occurred in the sample, a rate that is intermediate when compared with other facilities described in the literature. Seclusion was employed most often (46% of events), with the combination of seclusion and restraint used in 32% of events and the remaining 22% of physical control events being restraint. Seclusion tended to be used more often with civilly committed patients, with restraint more frequently employed with forensic patients. Forensic patients differed from civil subjects in their greater frequency of threats, agitation, and verbal hostility. However, civil patients were more frequently aggressive toward others and destructive of property. These findings are discussed in the context of previous evidence also describing forensic patients as being perceived as more dangerous, but behaving in a fashion no more physically aggressive than civil patients.

The use of third-party information in forensic assessments: a two-state comparison.

There is virtually no research on the normative characteristics of forensic mental health assessment, despite the significant increase in conceptual and empirical attention devoted to such assessment within the last 10 years. The present study addressed this deficit by examining the use of third-party information, a crucial component of forensic mental health assessment, by forensic clinicians in two states: Florida (a total of 277 evaluations on the issues of competency to stand trial and sanity at the time of the offense) and Virginia (316 evaluations addressing the same legal issues). Evaluations in each state were performed in either a community or a hospital setting. Basic information about the offense, records of prior mental health evaluation or treatment, and specific statements by victims or witnesses were the variables examined comprising "third-party information" in this study. More than three fourths of all evaluations across states and settings incorporated this information. There was less consistency in the use of mental health records and victim/witness statements, with significant differences observed across settings and states. Results are discussed in light of potential influences of state, setting, and study methodology.

Community placement for insanity acquittees: a preliminary study of residential programs and person-situation fit.

The present study, one of the first of its kind, describes the characteristics of community living placements for insanity acquittees conditionally released following hospitalization, along with the "fit" between living placement and individual characteristics. Although the small number of insanity acquittees (n = 13) and community placements (n = 9) precluded meaningful statistical analyses of results, the study provides a model for studying the characteristics of placements as well as personal characteristics of acquittees, and the interaction between the two. It also suggests the possible importance of this interaction, operationalized as "fit" between characteristics and placement. Consistent with research findings for other criminal defendants and for nonforensic psychiatric patients released from hospitalization, a better fit between acquittee and community placement may be associated with increased likelihood of success on conditional release.

The debate on treating individuals incompetent for execution.

The question of whether to provide mental health treatment to prisoners under death sentence who have been judged incompetent for execution presents a powerful ethical dilemma for mental health professionals. Arguments that favor or oppose the provision of treatment are discussed in the context of the nature of the disorder to be treated, the type of treatment to be provided, the goals of treatment, and the relevant legal standard for determining competency for execution. Arguments against treating the incompetent include 1) the need to avoid harming those who are treated, 2) the risk that disclosures in therapy will be used for assessment purposes, 3) the need for paternalism when sufficient harm is necessary, 4) the adverse impact on the clinician, 5) the potential undermining of patient and public perceptions of mental health professionals, and 6) the poor allocation of limited resources. Arguments for treating the incompetent include 1) respect for the wishes of the prisoner, 2) the need to clarify the values underlying the refusal to treat, 3) the low risk of harm from some forms of treatment, and 4) the adverse impact on the milieu stemming from failure to treat. The authors conclude that treating incompetent prisoners may not violate ethical standards under some circumstances, and that some forms of treatment will require the informed consent of the prisoner.

The treatment of mentally disordered offenders: a national survey of psychiatrists.

A nationwide (U.S.) survey of major public mental hospitals treating patients who are incompetent for trial, not guilty by reason of insanity, mentally disordered sex offenders, or mentally ill inmates was conducted. Responses were received from 71 percent of the 115 facilities surveyed. Respondents were the directors of psychiatry from the respective facilities. The pattern of treatments delivered generally appeared clinically appropriate. However, behavioral and cognitive-behavioral treatments were reported infrequently, even in areas in which they would be particularly useful.

Pretrial evaluations for criminal courts: contemporary models of service delivery.

Pretrial forensic evaluations are provided for the criminal courts throughout the United States. A variety of models of service delivery exists, and these models vary in ways that are important to the organization and finding of state mental health services. The first part of this paper describes several models of service delivery, which vary primarily in terms of centrality (central state institution vs. community service provider) and the use of inpatient vs. outpatient procedures. The second part compares these models on a number of important measures, including cost and efficiency. The final section of the paper indicates the importance of specialized forensic training and describes important components of such training.

Designing conditional release systems for insanity acquittees.

Monitored treatment in the community, also known as conditional release, has been described as the most important advance in the treatment of insanity acquittees in the last decade. Despite the importance of the development of conditional release, however, there has been relatively little written about relevant issues and planning principles important in designing and implementing conditional release systems. The present paper discusses important considerations relevant to conditional release that are associated with key decision points within systems for persons found not guilty by reason of insanity (NGRI). Four planning principles, generalizable to all NGRI systems, are then presented in a way that integrates the previous discussion. It is concluded that conditional release plays a crucial role in the treatment of insanity acquittees and that mental health administrators may either proactively modify their systems, in a way that balances public safety with individual rights and treatment needs, or wait for the modification mandate to be forced upon them in the wake of a highly publicized, heinous offense.

Assessment of competency for execution? A guide for mental health professionals.

Assessment of competency for execution presents two compelling ethical questions for mental health professionals: whether clinicians can ethically provide such assessment, and if so, how it should be done in order to maximize quality and minimize ethical conflict. In this article we address the issue of whether to participate and, if so, how. The question of whether to participate is discussed by summarizing the arguments for and against participation and offering guidelines for making a decision. The question of how to proceed is discussed in two contexts: preadjudication (before a formal decision about competency) and postadjudication (following a determination of "incompetent" and transfer of the offender to another facility for treatment and further assessment). Finally, recommendations are made regarding research that would improve the quality of execution competency assessments.