Introduction to Homicide Risk Assessment
All mental health professionals in the US and Canada have an ethical duty to warn, the requirement to warn someone who is at risk of harm of that harm. This leads clinicians to conduct homicide risk assessments to determine the level of danger to others.
In therapy or crisis intervention, the clinician is required to breach a client’s confidentiality in order to make notifications for both homicide risk and suicide. The homicide notification was codified in Tarasoff v. Regents of the University of California (1976), a famous case where a psychologist was held liable after failure to take adequate steps to protect a woman that a client had confessed the desire to kill, when he did.
Borum & Reddy (2001) enumerated a variety of steps to performing a homicide risk assessment in a Tarasoff-style risk assessment, which is differentiated from a more long-term risk assessment by a focus on on clinical judgement than on an examination of actuarial risk factors. The ACTION steps below are used to perform the assessment.
To start, it’s important to clarify the difference between making a threat, and posing a threat. Someone who says they wish to hurt someone may not pose intent or take action that demonstrates an actual risk. Preparatory behaviours help guide the risk assessment, and include selecting a target, choosing the method, time and place of violence, acquiring means, and so on.
The goals of the Tarasoff homicide risk assessment will be:
- Is the client headed towards a violent act?
- How fast is the client moving towards that act, and do opportunities exist for intervention?
ACTION Steps for Tarasoff Homicide Risk Assessment
Attitudes in support of violence
Is the client demonstrating any antisocial attitudes or beliefs? If the client is at risk of harming their partner, do they hold misogynistic or patriarchal beliefs? The goal here is to determine whether the client believes that violence is a justified or normal response to this situation. The more justified the client believes he or she is, the higher the risk of violence.
Borum & Reddy also identify other factors to explore under attitudes:
- Hostile attribution bias
- Violent fantasies
- Expectations about success of violence
- Whether the client feels it will accomplish their goal
Capacity to carry out threat
Does the client have access to the means, and the intellectual capacity to carry out a criminal, violent act? They also need access to the target and opportunity. Stalking often precedes violent acts (Meloy, 2002) and this can lead to an individual learning about the target’s schedule and whereabouts.
Thresholds crossed in progression of behaviour
Any presence of lawbreaking indicates a “willingness and ability to engage in antisocial behavior to accomplish one’s objective.” Additionally, any kind of plan and preparatory behaviours to achieve this plan should be explored.
Intent to act vs. threats alone
It’s important to clarify the difference between an actual intent to act versus simple threats. On the distress line, we clarify with callers who make violent comments whether they actually intend to harm the person they’re speaking about, or whether their comments are a result of frustration.
Questioning the client helps suss out their intent, in addition to any preparatory behaviours, alternative plans to accomplish their aim (that may or may not involve violence.) A client who believes there is no other way to meet their goals are more likely to turn to violence.
Other’s knowledge of the client
Knowing how others respond to the client’s planned actions will help assess their potential for action. If many people around them respond negatively to their plan they may be less likely to follow through. On the opposite side, if their supports provide little resistance this can increase risk. The client’s self-report can also help inform their attitudes.
Non-compliance with strategies to reduce risk
Is the client willing and interested in reducing their chance of committing a violent act? If they have previously breached legal requirements like parole or court orders, or demonstrate a willingness to do so in the future, this raises their risk.
Appreciating the gravity of their mental health status and desire for treatment may also be important.
See the original article by Borum & Reddy for a more detailed review of the risk factors and additional items, or a book like Clinician’s Guide to Violence Risk Assessment by Mills, Kroner & Morgan.
Borum, R. & Reddy, M. (2001) Assessing violence risk in tarasoff situations: A fact-based model of inquiry. Behavioral Sciences and the Law. 19:375-385. doi: 10.1002/bsl.447
Meloy, J. (2002). “Stalking and violence.” In J. Boon and L. Sheridan (eds.) Stalking and psychosexual obsession: Psychological perspectives for prevention, polcing, and treatment. West Sussex, UK: John Wiley & Sons, Ltd
Tarasoff v. Regents of the University of California, 131 Cal. Rptr. 14 (Cal. 1976)
In order to develop basic crisis intervention skills it is necessary to have a model on which one can work from, allowing you to understand the situations that bring a person into crisis (chiefly things that overwhelm a person’s coping strategies, where they find themselves unable to take further positive action), and the tasks that must be completed to help them successfully navigate such a crisis.
The Six Stage Model of Crisis Intervention
This model of crisis intervention is from James (2008) who has adapted it from Gilliland (1982). These steps form the foundation of intervening with an individual to help give them a sense of control and help to restore basic coping skills.
Step 1. Defining the Problem
The first step in crisis intervention process is to determine exactly what the problem is. This part of the process helps establish a connection between yourself and the client. The active listening process is important here: open-ended questions and the core factors of empathy, genuineness and positive regard.
Step 2. Ensuring Client Safety
The next step is to ensure the safety of the client. This involves suicide risk assessment, as well as checking homicide risk. Removing access to lethal means of suicide as well as other items that can be used to hurt yourself and the client are important. For instance, in an average office, scissors, paper cutters, staplers and three-hole punches can all be used to injure self or others.
Step 3. Providing Support
After the client is physically safe and the problem has been adequately defined, the next step is for the crisis worker to accept the client as a person of value and communicate that they care about them. This can involve simply talking to the client about what’s going on in their life, taking care of basic needs (e.g. food and shelter.)
Once the client has their basic needs met, the next part of providing support is ensuring the client has enough information to understand their available options for dealing with their situation.
Step 4. Examining Alternatives
In step 4, Examining Alternatives, the client is encouraged to explore potential solutions to what they’re dealing with. A client whose coping skills are suspended will have difficulty coming up with options and this is where the crisis worker comes in.
James identifies three categories of potential alternatives:
- Situational Supports – individuals around the client who “might care about what happens to the client”
- Coping mechanisms – “Actions, behaviours or environmental resources” the client can draw on to help get through their situation. Assessing coping skills is a key part of telephone crisis intervention, which should explore what they did in the past, present, and then future
- Positive and constructive thinking patterns – New ways of thinking about the client’s situation that can help them reframe
Step 5. Making Plans
Now that the client trusts the crisis worker, they have provided immediate safety and met basic needs, explored alternatives, it’s time to make a plan. The goal of this step is to focus on concrete steps that can help restore control in the client’s life, and identify other referral resources that can help provide the client additional support.
Making sure the plans are realistic and not overwhelming is a key part of step 5. Clients must feel empowered by the plan in order for them to proceed with it, therefore working collaboratively is extremely important. Many clients have been disempowered or oppressed before seeking (or being forced into) treatment, and continuing this pattern will lead to poor outcomes.
Step 6. Obtaining Commitment
The final step of the process, is obtaining commitment. If you’ve worked together with your client, obtaining commitment should be easy. You may need to write down the plan for the particularly overwhelmed client to keep track of it, and follow up with them to ensure that they have followed through with the plan.
Moving Through the Model
Although the model is presented in a linear fashion, in actuality a client may move between these steps, moving forward and then regressing back as their situation changes. It is important for the worker to be at least somewhat certain of the stage his client is in so that he can respond appropriately.
Gilliland, B.E. (1982) Steps in crisis counseling. Memphis: Memphis State University, Department of Counseling and Personnel Services. (Mimeographed handout for crisis intervention courses and workshops on crisis intervention.)
James, R.K. (2008) Crisis Intervention Strategies. Brooks/Cole: Belmont, CA.
I recently watched a documentary called “Shy Boys: IRL“, involving individuals who identify as experiencing involuntary celibacy (incel), also called forever alone (FA), true forced loneliness (TFL), love shy or a number of other terms. This describes an inability to get a romantic partner despite trying and over a certain age (usually by 18, when most individuals have experienced some romantic contact with their peers.) It is closely linked to overall loneliness, though it’s possible for people to have general life satisfaction outside of a lack of romantic relationships.
As an individual who once struggled with women (although no longer), I found the concept intriguing and decided to explore it further. While this article is written from the perspective of men pursuing women, but women can be FA/incel as well.
Loneliness is defined as a difference between an individual’s desired social relationships and their actual relationships (either in quantity or emotional quality.) Researchers have identified three dimensions of loneliness, intimate loneliness, relational loneliness, and collective loneliness. (Cacioppo, et. al., 2015)
Intimate loneliness refers to your romantic partners, relational loneliness to friends and acquaintances, while collective loneliness refers to loneliness in the context of being part of a larger community like students or professionals.
There is a direct link between between loneliness and depression (Bekhet & Zauszniewski, 2012) while Victor & Yang (2012) determined that before the age of 25 the quantity of friendships is most associated with loneliness while as individuals proceed into middle age fewer, deeper relationships become more important.
Luhmann, et. al. (2016) found that self report ratings were the best source of how lonely an individual actually feels, and that romantic partners (where they exist) were more accurate than friends or parents in predicting this in a sample of first year college students.
Involuntary celibates, then, can be theorized to have high levels of intimate loneliness, and many also struggle with depression.
Model and Causes of Loneliness
Roekel et. al. (2016) and Bangee et. al. (2014) identified that people with high levels of loneliness experienced hypersensitivity to social threat (they were extra sensitive to negative social environments and more likely to assume people around them were judging them) but also, contrary to their initial hypothesis hyposensitivity to social reward. This means that they responded well to positive social interaction when they could obtain it.
Yao & Zhong (2014) found that internet addiction was associated with increasing levels of loneliness, while online contacts did not reduce loneliness as was expected. Odaci & Kalkan (2010) found internet use over 5 hours a day was significantly related to both loneliness and dating anxiety.
Involuntary celibates are likely to interpret social situations as negatively as possible, which can impair their ability to befriend the opposite sex. They may interpret neutral stimuli as negative and therefore become hopeless, believing that they are being rejected when no such rejection has occurred.
Potential Interventions to Reduce Loneliness
Cacioppo, et. al., (2015) in their meta-review explored a number of potential targets of existing work to reduce loneliness. Providing social support to lonely people through programs like mentoring or one-to-one befriending led to a small improvement in loneliness, while increasing opportunities for social interaction by providing group therapy led to no improvement.
Therapy to correct distorted thinking was found to be the most effective, which was confirmed through a study by Masi et. al. in (2011) that used CBT. Involuntary celibacy frequently involved distorted thinking (either about themselves or about women.)
Autism Spectrum Disorder and Loneliness
Autism causes unique difficulties for individuals struggling with loneliness and involuntary celibacy. Their difficulty interpreting social cues means they can be unintentionally asocial and this can exacerbate their feelings of disconnection. Bishop-Fitzpatrick, Minshew & Eack (2013) in their metareview found that social skills training and Applied Behavior Analysis (ABA) were both effective in reducing loneliness.
A second study by Gantman et. al. (2012) looked at a 12-week social skills training called PEERS for Young Adults in particular led to sharply decreased loneliness and increased ratings of social skills by parents or other social supports around them.
Relationship Status and Loneliness
Adamczyk, & Segrin, C. (2015) found that, as expected, young adults in relationships were far likely to be lonely and to identify low social support.
Sexual Inexperience in Young Adults
Some young adults may not feel lonely, but may still be frustrated by their lack of sexual experience, and virginity in particular. By 12th grade, 62% of adolescents have engaged in vaginal intercourse, while about 5% of males and 3% of females 25-29 are virgins.
Interestingly, over 50% of 18 year old virgins went on to lose their virginity by 19-21. (Haydon et. al., 2014) This suggests that while involuntary celibacy or being “Forever Alone” (which is most commonly perceived by males 18-24) as a life-long problem, many of these same individuals will in fact have sex within a few years of their peers.
Donnelly, et. al. (2001) conducted a qualitative review of late-life virgins and discovered that differences began in adolescence, a failure to gain a first kiss and other formative sexual experiences led to a persistent feeling of being “behind” which exacerbated attempts to catch up.
Factors related to late-life virginity as summarized Boislard, van de Bongardt, & Blais (2016) include:
- Being overweight
- Perceived as physically unattractive
- Having never been in a romantic relationship
Treatments for Involuntary Celibacy
Treatments for involuntary celibacy are few and far in between, because such a small portion of the population struggles in this way. Anecdotally it appears that a combination of a lack of risk-taking combined with shyness and maldadaptive cognitions lead lonely individuals to pre-emptively fear rejection and therefore not pursue romantic partners, leading to increased loneliness in a vicious cycle.
Those that do purse partners may find themselves unable to cope with the natural levels of rejection that everyone goes through and therefore give up before they find a willing partner.
As noted in previous sections, Cognitive Behavioural Therapy (CBT) is the most effective treatment to reduce loneliness and depression. CBT can help correct distorted thinking which is extremely common in individuals who are incel or ForeverAlone.
Social skills training for adults with autism has been shown to fix social skills deficits (and would likely assist adults not on the spectrum as well.) Additionally, improving physical attractiveness, particularly through weight loss for overweight individuals has been associated with an increase in sexual behaviour.
Finally, therapy can also be used to improve low self esteem and confidence.
There is a large internet community focusing on (mostly) young men who have been unable to crack the intimacy code. Do you have suggestions for how to improve your situation? Please write in the comments.
Adamczyk, K., & Segrin, C. (2015). Direct and Indirect Effects of Young Adults’ Relationship Status on Life Satisfaction through Loneliness and Perceived Social Support. Psychologica Belgica, 55(4), 196. doi:10.5334/pb.bn
Bangee, M., Harris, R. A., Bridges, N., Rotenberg, K. J., & Qualter, P. (2014). Loneliness and attention to social threat in young adults: Findings from an eye tracker study. Personality And Individual Differences, 6316-23. doi:10.1016/j.paid.2014.01.039
Bekhet, A.K., & Zauszniewski, J.A. (2012). Mental health of elders in retirement communities: Is loneliness a key factor? Archives of Psychiatric Nursing, 26(3), 214–224.
Bishop-Fitzpatrick, L., Minshew, N., & Eack, S. (2013). A Systematic Review of Psychosocial Interventions for Adults with Autism Spectrum Disorders. Journal Of Autism & Developmental Disorders,43(3), 687-694 8p. doi:10.1007/s10803-012-1615-8
Boislard, M., van de Bongardt, D., & Blais, M. (2016). Sexuality (and Lack Thereof) in Adolescence and Early Adulthood: A Review of the Literature. Behavioral Sciences (2076-328X), 6(1), 1-24. doi:10.3390/bs6010008
Cacioppo, S., Grippo, A. J., London, S., Goossens, L., & Cacioppo, J. T. (2015). Loneliness: Clinical Import and Interventions.Perspectives On Psychological Science (Sage Publications Inc.), 10(2), 238-249 12p. doi:10.1177/1745691615570616
Donnelly, D., Burgess, E., Anderson, S., Davis, R., & Dillard, J. (2001). Involuntary Celibacy: A Life Course Analysis. Journal Of Sex Research, 38(2), 159.
Gantman, A., Kapp, S., Orenski, K., & Laugeson, E. (2012). Social Skills Training for Young Adults with High-Functioning Autism Spectrum Disorders: A Randomized Controlled Pilot Study. Journal Of Autism & Developmental Disorders, 42(6), 1094-1103 10p. doi:10.1007/s10803-011-1350-6
Hagan, R., Manktelow, R., Taylor, B. J., & Mallett, J. (2014). Reducing loneliness amongst older people: a systematic search and narrative review. Aging & Mental Health, 18(6), 683-693 11p. doi:10.1080/13607863.2013.875122
Haydon, A.A., Cheng, M.M., Herring, A.H., McRee, A-L., Halpern, C.T. (2014) Prevalence and Predictors of Sexual Inexperience in Adulthood. Archives of Sexual Behavior. 43:221-230. DOI 10.1007/s10508-013-0164-3
Luhmann, M., Bohn, J., Holtmann, J., Koch, T., & Eid, M. (2016). I’m lonely, can’t you tell? Convergent validity of self- and informant ratings of loneliness. Journal Of Research In Personality, 6150-60. doi:10.1016/j.jrp.2016.02.002
Mahmoud, J. R., Staten, R. ‘., Lennie, T. A., & Hall, L. A. (2015). The Relationships of Coping, Negative Thinking, Life Satisfaction, Social Support, and Selected Demographics With Anxiety of Young Adult College Students. Journal Of Child & Adolescent Psychiatric Nursing, 28(2), 97-108 12p. doi:10.1111/jcap.12109
Masi, C. M., Chen, H.-Y., Hawkley, L. C., & Cacioppo, J. T. (2011). A meta-analysis of interventions to reduce loneliness. Personality and Social Psychology Review, 15, 219– 266. doi:10.1177/1088868310377394
Odaci, H., Kalkan, M. (2010) Problematic Internet use, loneliness and dating anxiety among young adult university students. Computers & Education. 55, 1091-1097
Roekel, E., Ha, T., Scholte, R. J., Engels, R. E., & Verhagen, M. (2016). Loneliness in the Daily Lives of Young Adults: Testing a Socio-cognitive Model. European Journal Of Personality, 30(1), 19-30. doi:10.1002/per.2028
Victor, C. R., & Yang, K. (2012). The Prevalence of Loneliness Among Adults: A Case Study of the United Kingdom. Journal Of Psychology, 146(1/2), 85-104. doi:10.1080/00223980.2011.613875
Yao, M.Z., & Zhong, Z-j. (2014) Loneliness, social contacts and Internet addiction: A cross-lagged panel study. Computers in Human Behaviour, (30), 164-70