Violence risk assessment is an important element of counselling and crisis intervention. Although in high-risk situations it can (and should be) performed by clinicians with specific training in violence risk, there may be situations where clinicians or others (corrections officers, private practice therapists, crisis line supervisors, etc.) need to have a understanding of the principles of violence risk assessment in order to respond appropriately.
Types of Violence Risk Assessment
There are three types of violence risk assessment, based on the way risk is estimated or “calculated.” The first is unstructured professional judgement. This is where the clinician merely listens to the client and makes their best judgement, based on their existing professional training. (Murray & Thomson, 2010) While some professionals made good predictions relative to others, some were very poor. It emerged that the reason for this disparity was that some clinicians considered factors relevant to violence while others did not. Unstructured professional judgement no longer stands up in court.
The second form of risk assessment is known as actuarial risk assessment. This is an entirely mathematical technique that examines what factors were present in offenders who later went on to commit violent crimes. (Brown & Singh, 2014) This is similar to the approach used in insurance to calculate the likelihood a person will die, and has the same flaw as that approach: you can determine over a large pool what percentage of individuals will be violent, but you risk ignoring salient risk or protective factors in an individual that may heighten or reduce their violence risk.
The final form of risk assessment is Structured Professional Judgement (SPJ; Falzer, 2013). SPJ attempts to merge the predictive ability of the actuarial approach with the flexibility of the unstructured approach by providing a list of evidence-based risk factors (elements that have been demonstrated to increase risk of violence) along with a coding or scoring method to generate a “Low”, “Moderate”, or “High” risk, and usually the freedom to modify the scoring for items or list additional contributing factors that entered into a clinician’s assessment.
Static vs Dynamic Risk Factors
Static risk factors are elements that are known to increase risk that are not changeable. An example of static risk factors for violence include sex and age. As a male, you will always have elevated risk of violence versus a female (Sorrentino, Friedman, & Hall, 2016), and as someone who is aged 18-24 you will always have a heightened risk of violence relative to someone older or younger. (Harris & Rice, 2007) There is nothing a clinician can do to change your age or sex.
On the other hand, other risk factors are called dynamic risk factors. These are factors that can be modified by the clinician or by the client (Public Safety Canada, 2010), such as one’s peer group, use of alcohol or stimulants, or access to a pool of victims.
Affective vs. Predatory Violence
Affective violence is also called impulsive or reactive violence. (Berg, 2014) This is violence that results from a threat, causes an individual to experience physiological arousal (heart racing, blood pressure increase, etc.) and then to strike back in a “fight or flight” response.
In contrast, predatory violence is more common among psychopaths and serial killers. This is violence that is not associated with an increase in physiological arousal or an identified threat. Instead, the predatory killer “stalks his prey” and then strikes without warning.
Biopsychosocial Model Items
This model comes from “Violence Risk and Threat Assessment” by Meloy (2000), but closely matches other models of violence risk.
Past History of Violence
Intelligence Below Average
Psychopathy / Other Attachment Difficulties
Family of Origin Violence
Adolescent Peer Group Violence
Weapons History/Skill/Interest and Approach Behaviour
History of CNS Trauma
Signs and Symptoms
Objective CNS Measures
Major Mental Disorder
Assessing Psychological Factors of Violence Risk
The elements in the psychological or individual domain cover static and dynamic items that relate to the person’s mental health and personal demographics. They include:
Men are up to 10x more likely to be involved in violence than women (Meloy, 2000; p.19); sex is a static variable. Significantly more crimes are committed before the age of 25 (Bureau of Justice Statistics, 2011), therefore age is an important static variable. Past history of behaviour is one of the most important future predictors of future violence. If the situations that led to violence in the past aren’t modified, we will find ourselves in them in the future, therefore Past History of Violence becomes an important static behaviour.
Other elements associated with increased violence risk include acute paranoia or a delusional state (Yang, 2008); this can cause them to genuinely believe they are in danger, and therefore Not Guilty by Reason of Insanity (NGRI) or Not Criminally Responsible (NCR). Someone in a paranoid state, with thought insertion or homicidal thoughts needs immediate psychiatric attention.
Below average intelligence and anger/fear problems are linked to the concept of affective violence above. Lower levels of intelligence are perhaps linked to violence in that people cannot think of responses quick enough to avoid violence (Freeman, 2012), and may find themselves unable to label or understand their emotions. Anger and fear problems cause an increase in violence by causing an individual to perceive threats where maybe none exists. It is the presence of these threats that causes affective violence (Helfgott, 2008)
Psychopathy and other attachment difficulties are associated with an increased risk of predatory violence. Psychopaths have difficulty perceiving empathy for others, and individuals who lack attachments may be able to cause those individuals pain without considering the impact their actions have on those people. (Brook & Cosson, 2013) A standardized assessment like the PCL-R (Hare Psychopathy Checklist–Revised; Hare, 2003) can be used to assess for the presence of psychopathy, with a score of 30 (out of 40) indicating psychopathy.
Assessing Social Factors of Violence Risk
Social factors of violence risk include those individuals that are around us who can model violent behaviour, and are caused by factors beyond mental health.
Family of origin violence (a static risk factor) and adolescent peer group violence (a dynamic risk factor) are both risk factors because of the ability of them to model answers to threats or problems that involve violence (Franklin, Menaker & Kercher, 2011), rather than non-violent alternatives. Additionally, family of origin violence can lead to a sense of detachment which can involve the attachment difficulties noted in the Psychological Factors above; finally, a family that suppresses emotional expression may prevent men from ventilating their stress until it is expressed in a maladaptive way (e.g. through violence.)
Economic instability or poverty is a static or dynamic risk factor for violence (McAra, & McVie, 2016) because of the known causal relationship between poverty and violence; additionally, for those who are at risk of or have recently lost their jobs, intense anger can cause violent acts and so should be kept in mind. (Catalano, Novaco, & McConnell, 1997)
Weapons history/skill/interest is a static variable and approach behaviour is a dynamic behaviour. The first set refers to a potentially violent individual’s history with weapons, especially firearms. Do they own any guns, have they received professional training (e.g. police, military, private instruction)? Owning guns does not make a person more violent on their own, but they do provide a violent individual with easier tools with which to carry out their violence.
“Approach behaviour” (Meloy, 2000; p.57) is the term used to describe what someone does when they cannot possess guns (for instance, because of a felony conviction or financial reasons). This could include reading about guns, owning gun accessories and being around people who own guns. Approach behaviour is a person’s ability to “approach” the off-limits items psychologically. The more approach behaviour is noted, the higher the violence risk is.
Victim pool is important in assessing violence risk because violence does not occur in a vacuum. This is especially important in predatory violence (such as sex offenders or serial killers) but may also be important for gang members or others who only become violent in specific, limited situations. Meloy (1996) discusses this in particular in violent stalkers but it applies equally to all violent crimes.
Drugs and alcohol (especially psychostimulants like cocaine) increase violence risk by reducing one’s inhibition and increasing impulsiveness. (Haggård-Grann, Hallqvist, Långström, & Möller, 2006) Additionally, stimulants like cocaine, methamphetamine and others can cause “stimulant psychosis” (Curran, Byrappa & Mcbride, 2004), a condition that can cause paranoia and homicidal thoughts.
The last element in assessing social factors of violence risk is popular culture. (De Venanzi, 2012) This is a controversial element but like suicide contagion, mass media glorifying elements of homicide can increase the risk of violence in vulnerable individuals. It’s important to pay close attention to court cases, movies or other elements that the person being assessed may identify with.
Assessing Biological Factors of Violence Risk
Biological factors are elements not related to a person’s mental health or social environment, but rather their neurological. They include a history of central nervous system (CNS) trauma (Rao et. al., 2009), signs and symptoms of CNS problems (such as headaches, dizziness, memory difficulties, and many others), objective CNS measures and the presence of a mental health diagnosis. (Rueve & Welton, 2008)
With the exception of some CNS measures which may be administered by clinicians, these items are most easily determined by a neuropsychologist or neurologist who can perform the required brain scans and administer and interpret the tests for CNS function. Major mental disorders may be diagnosed by social workers in some jurisdictions, or may be required to be diagnosed by a psychologist or psychiatrist in others.
Violence Risk Assessment Tools
Below are some tools that I’ve got articles for on my blog.
Brook, M., & Kosson, D. S. (2013). Impaired cognitive empathy in criminal psychopathy: Evidence from a laboratory measure of empathic accuracy. Journal Of Abnormal Psychology, 122(1), 156-166. doi:10.1037/a0030261
Catalano, R., Novaco, R., & McConnell, W. (1997). A model of the net effect of job loss on violence. Journal Of Personality And Social Psychology, 72(6), 1440-1447. doi:10.1037/0022-35220.127.116.110
Curran, C., Byrappa, N. & Mcbride, A. (2004) Stimulant psychosis: systematic review. British Journal of Psychiatry. 185 (3) 196-204; DOI: 10.1192/bjp.185.3.196. http://bjp.rcpsych.org/content/185/3/196
De Venanzi, A. (2012). School shootings in the USA: Popular culture as risk, teen marginality, and violence against peers. Crime, Media, Culture, 8(3), 261-278. doi:10.1177/1741659012443233
Falzer, P. R. (2013). Valuing Structured Professional Judgment: Predictive Validity, Decision-making, and the Clinical-Actuarial Conflict. Behavioral Sciences & The Law, 31(1), 40-54. doi:10.1002/bsl.2043
Sorrentino, R., Friedman, S. H., & Hall, R. (2016). Gender Considerations in Violence. Psychiatric Clinics Of North America, doi:10.1016/j.psc.2016.07.002
Yang, S. (2008) Dangerously Paranoid? Overview and Strategies for a Psychiatric Evaluation of a Highly Prevalent Syndrome. Psychiatric Times.
Rao, V., Rosenberg, P., Bertrand, M., Salehinia, S., Spiro, J., Vaishnavi, S., Rastogi, P., Noll, K., Schretlen, D.J., Brandt, J., Cornwell, E., Makley, M. & Miles, Q.S. (2009) Aggression After Traumatic Brain Injury: Prevalence and Correlates. The Journal of Neuropsychiatry and Clinical Neurosciences. 21(4):420-429
We know that men have smaller social circles than women (McPherson, Smith-Lovin & Brashears, 2006) and they seek help less often (Courtenay, 2011; p. 13). Finding male therapists is also difficult (Carey, 2011), which can complicate things for men experiencing current or historical intimate partner or sexual violence.
Below is a model for counselling men from the second chapter of “Counselling Fathers from a Strength-Based Perspective” in Counselling Fathers (Oren, et. al., 2010; p.30.) Although this model was originally designed for working with fathers I believe it is equally applicable to working with men who are not fathers.
The five stages are:
Rapport and Therapeutic Alliance
Identification of strengths
Resiliency and Termination
Each of these will be reviewed below.
Rapport and Therapeutic Alliance
The first element of any therapy or counselling is establishing a strong therapeutic relationship. The SOLER elements of active listening (Egan, 2007) can be useful, although with a change noted below. There are also some things that can be used to establish rapport when counselling men or boys (Kiselica, 2003), including:
Displaying magazines relevant to men’s issues (sports, hunting/fishing, men’s health and fitness)
Flexible scheduling for appointments (shorter or longer to allow time for building rapport without getting tiring)
Using humour and self-disclosure
Sitting side-by-side rather than across from each other
Setting goals and working collaboratively
Using client-centered language
Kiselica also notes that traditional models of engaging with clients (especially young boys) may be ineffective, and that a more instrumental, active or group-based process may be useful.
Assessment for Counselling Men
A strength-based assessment (Graybeal, 2001) acknowledges the overlooked assets that men bring into the counselling relationship, rather than focusing on problems or challenges. This continues into the next stage (identification of strengths). In addition to identifying strengths, the concept of gender role conflict should be explored.
Gender role conflict (O’Neil, 2008) is defined as “a psychological state in which socialized gender roles have negative consequences for the person or others” and involves six elements (O’Neil, 1981) that have commonly be forced upon men:
Restrictive emotionality – The inability of men to express their emotions (often because of society or familial prohibition)
Health care problems – Men are less likely to seek help for their physical or mental health problems
Obsession with achievement and success
Restrictive sexual and affectionate behavior – Related to restrictive emotionality, men are sometimes prohibited from being affectionate with other men
Socialized control, power, and competition issues – Men are socialized to pursue control, power and achievement at any cost, while men who choose a different path (for instance, by parenting) are considered weak or un-masculine
Homophobia – Men who fear being called gay may be less likely to pursue heterosexual friends
By developing a deep understanding of the conflicts your client is experiencing you will be better able to identify strengths and plan appropriate interventions in the next stages.
Identification of Strengths
Identifying strengths is paramount to a positive therapeutic environment when counselling men, especially for men who have been rejected by therapists in the past. Some positive male qualities include (Oren, et. al., 2010; p.59):
Generativity (Slater, 2003) – the concept of leaving your mark
Protection of others
These and other values (self-sufficiency, achievement, efficiency, loyalty, and pride) can help build often-fragile male self esteem and provide a framework for intervening.
Interventions for Counselling Men
Now that you’ve performed a comprehensive assessment and you have an understanding of your client’s values, strengths, and what gender role conflict they may be experiencing you are ready to begin planning effective interventions while counselling.
Exploring times in the client’s past when they were able to cope with the problems they’re experiencing now and allowing them to narrate the stories in their life. (Smith, 2006)
Employment is often an area where men succeed, even as they are challenged in their personal life. Using work as a metaphor, men can apply the attitudes of being assertive, prioritizing, building relationships, and so on. Applying these lessons and potentially hidden skills to their personal life can help men improve their ability to deal with problems at home.
Mahalik (1999) used the concept of gender role strain – the idea that men are not living up to their gender or masculinity requirements – to help assessing and working through cognitive distortions. He suggested some strategies for changing cognitive distortions:
Explore how men experience cognitive distortions as adaptive or positive instead of negative; for example, a man who values hard work in their career over everything else may experience positive career and financial benefits at the expense of their relationships with their family
Examine the connection between gender role and these cognitive distortions
Practice experiments to confirm or deny the accuracy of these distortions
Provide more accurate beliefs to replace the distorted ones
Throughout the counselling process it’s important to recognize the impact that gender roles has on someone’s behaviour. Gently challenging these and other beliefs (like those around social support or emotional expression) and encouraging new ways of men expressing themselves are ways of working through the intervention stage. (Oren, et. al., 2010; p.145)
Resiliency and Termination
The final stage in counselling men is resiliency and termination. This starts with identification of male-positive resources or institutions such as programs to promote healthy marriages or healthy children (Oren, et. al., 2010; p.38) and finding other more informal supports in the client’s life such as friends, family, coworkers and professionals like doctors, coaches and clergy.
Finally, modelling elements of good termination in general counselling can help the client terminate other relationships (such as with partners) in their personal life more effectively. These elements include (Hardy & Woodhouse, 2008):
Highlighting the positives of ending sessions
Providing an open discussion
Ensuring both client and therapist are prepared for the end of therapy
Courtenay, W.H. (2011) Dying To Be Men: Psychosocial, Environmental and Biobehavioral Directions in Promoting the Health of Men and Boys. Routledge: New York, NY.
Egan, G. (2007) The Skilled Helper: A Problem Management Approach to Helping. 8th ed. Thomson Brooks/Cole: Belmont, CA.
Graybeal, C. (2001). Strengths-Based Social Work Assessment: Transforming the Dominant Paradigm. Families In Society,82(3), 233-242.
Hardy, J. A. & Woodhouse, S. S. (2008, April). How We Say Goodbye: Research on Psychotherapy Termination. [Web article]. Retrived from http://societyforpsychotherapy.org/say-goodbye-research-psychotherapy-termination
Kiselica, M. S. (2003). Transforming psychotherapy in order to succeed with adolescent boys: Male-friendly practices. Journal of Clinical Psychology, 59(11), 1225–1236.
Mahalik, J. R. (1999). Incorporating a gender role strain perspective in assessing and treating men’s cognitive distortions.Professional Psychology: Research And Practice, 30(4), 333-340. doi:10.1037/0735-7028.30.4.333
McPherson, M., Smith-Lovin, L., Brashears, M.E. (2006) Social Isolation in America: Changes in Core Discussion Networks Over Two Decades. American Sociological Review. 71(3).
O’Neil, J. M. (1981). Patterns of gender role confl ict and strain: Sexism and fear of femininity in men’s lives. Personnel and Guidance Journal, 60 , 203–210.
O’Neil, J. M. (2008). Summarizing 25 years of research on men’s gender role confl ict using the gender role conflict scale: New research paradigms and clinical implications. The Counseling Psychologist, 36 (3), 358–445.
Slater, C.L. Journal of Adult Development (2003) 10: 53. doi:10.1023/A:1020790820868
Smith, E. J. (2006). The strength-based counseling model: A paradigm shift in psychology. Counseling Psychologist, 34(1), 13-79.
Oren, C.Z., Englar-Carson, M., Stevens, M.A. & Oren, D.C. (2010) Counselling Fathers. Routledge: New York, NY.
Organizations like the Tema Conter Memorial Trust in Canada and Reviving Responders in the US have highlighted the skyrocketing rate of suicide among first responders, including police officers, paramedics and firefighters. In 2015, there were over 100 suicides by law enforcement officers in the US. (Kulbarsh, 2016) They note the high incidence of PTSD among law enforcement officers and the stigma that prevents them from seeking support.
One way to reduce law enforcement suicide is through police academy training that provides all officers with suicide awareness training. This helps reduce the stigma of receiving mental health support and gives police the opportunity to act as peer supporters for their colleagues.
Overview of Curriculum
The material below comes from the Basic Course for Police Officers authored by the New Jersey Police Training Commission (2016). This 262-page manual provides a complete review of the curriculum that police officers in that state learn during their 24 weeks at the Academy.
One of the instructional units is named “Suicide Awareness and Prevention for the Law Enforcement Officer”. The description is as follows:
The trainee will understand the causes, symptoms, warning signs and risks associated
with officer suicide, and will identify appropriate intervention and prevention strategies
to effectively deal with this issue.
The outcomes of this module are as follows. Once completed, the police recruit will be able to:
Identify demographics associated with law enforcement suicide
Know stressors that contribute to suicide
Explain risk factors associated with suicide
Identify warning signs associated with suicide
Understand suicide myths
Explain and apply the AID LIFE acronym for intervening with suicide
Identify obstacles to effective suicide intervention
Note professional resources helpful to an officer
Identify strategies to prevention law enforcement suicide
The content from these modules is summarized below, but I’ve added references where appropriate to back up the un-cited information. The goal is to provide added-value and confirm the veracity of the material.
Suicide is defined as the intentional taking of one’s own life (Stedman, 2016).
Demographics of Law Enforcement Suicide
There are more deaths to police suicide than in the line-of-duty (Kulbarsh, 2016)
The police officer life expectancy is less than the general population (Violanti, 2013)
The suicide rate is approximately 14 deaths per 100,000 (Badge of Life, n.d.) compared to 13 per 100,000 in the general population (AFSP, 2014)
Although the curriculum maintains that the divorce rate is higher among police officers, the opposite is actually true. The divorce rate is slightly lower, at 14.47% versus 16.96% for all professions over the lifetime (Roufa, 2015)
The rate of substance abuse is higher among police officers (Cross & Ashley, 2004)
Stressors Contributing to Law Enforcement Suicide
In addition to the normal stressors such as depression, anxiety, substance abuse and relationship issues, the curriculum identifies some specific job-related stressors. These include:
Discipline issues (internal affairs and/or
criminal investigations); and
Management issues (assignment – lack of promotion – supervision);
Retirement (loss of identity and sense of belonging).
Unfulfilled job expectations;
Risk Factors Associated with Law Enforcement Suicide
Warning signs, as defined by the AAS (n.d.) are items that represent an imminent, increased risk (active factors) rather than the stable historical factors that don’t necessarily represent increased risk. For instance, being a male does not itself mean someone is suicidal, but being a man does increase the chances someone will die.
The warning signs listed in the curriculum (reproduced verbatim below) represent a mix of risk factors and AAS-type warning signs.
Attitude of hopelessness and helplessness;
Unexplained changes in appetite, weight, appearance, and/or sleep habits;
Difficulty making decisions;
Previous suicide attempt;
Increase in the use of alcoholic beverages;
Overly aggressive or violent behavior;
Any changes in mood or behavior that are out of the ordinary, including a neutral mood;
Changes in work habits;
Behavioral clues of suicidal thoughts:
Giving away possessions;
Making a will;
Talking about a long trip;
Sudden interest or disinterest in religion;
Substance abuse relapse; and
Taking inappropriate duty-related and personal risks.
Anger / irritability; and
Concern expressed by family / friends / colleagues about a specific individual;
Identifying Common Suicide Myths
The myths that are discussed here include:
People who talk about suicide won’t attempt
Talking about suicide with someone does not reduce their risk
Warning signs are not present before a person dies by suicide
Suicidal individuals must have a mental illness
Suicidal individuals are beyond help
Suicidal individuals are committed to dying
See my article on suicide myths for a more complete discussion of these
AID LIFE for Suicide Intervention
AID LIFE is an acronym that is given in the training for a simple intervention procedure. The steps in AID LIFE are as follows:
A – Ask if the individual is thinking about suicide
I – Intervene immediately. Listen and let the person know they are not alone.
D – Don’t keep their suicidal thoughts a secret. Seek assistance
L – Locate help. This can include a supervisor, chaplain, physician, or other members of their support network. (Including crisis workers or the Emergency Room.)
I – Inform the Chain of Command. This can help get important resources like counselling in place.
F – Find someone to stay with the individual. (Dustin’s note: I’m actually not a big fan of this one, it shows up in the Marine Corps suicide awareness program as well; this is more important for high-risk, imminent suicide than it is for someone who may be low or moderate risk.)
E – Expedite. Get help now, rather than delaying it.
Obstacles to Effective Suicide Intervention
These obstacles are reproduced directly from the manual and include a variety of police-specific and more general obstacles to effective intervention with police officers who are struggling with suicidal thoughts.
Fear of stigma, isolation, humiliation, suspension, job loss;
Fear of change in duty status;
The police culture; (seeking mental health support may be perceived as a character weakness)
Denial that there is a problem; (by the officer, peer officers, supervisors, the command staff)
Reluctance of the officer to seek help for fear of the officer losing control of the situation;
The officer’s fear that confidentiality will not be maintained;
The officer’s distrust of management;
Supervisors and peers who protect or shield a troubled officer; and
Lack of knowledge by a troubled individual about the availability of counseling resources, and concern about being able to afford such services.
Professional Resources for Law Enforcement Suicide
Although this is a New Jersey Police manual, the resources presented are general enough to be a good reference. The resources that are recommended include:
Employer Assistance Program (EAP)
Faith-based support (e.g. Chaplain or Church official)
Hospital emergency room
Mental Health Counselling (in person or otherwise)
Peer Support (from another officer or supervisor)
Strategies to Prevent Law Enforcement Suicide
The following 4 strategies are generally recommended for preventing suicide by both law enforcement officers and the general public. They include:
Understanding the risk factors and warning signs of law enforcement suicide
Together for Life was developed by Psychologists as a comprehensive suicide prevention program in Montreal. This program includes a half-day training session for all officers, a confidential telephone helpline, a full-day training session in more in-depth techniques for supervisors and awareness materials. Mishara & Martin’s 2012 evaluation showed:
99% of those who attended the sessions said they would recommend the sessions to a colleague
84% of supervisors were aware of the program
Positive increases in knowledge of risk factors and warning signs, and how to intervene
A nearly 80% decrease in the rate of Montreal police suicides (versus no change in the rate of police suicides in other police services in Quebec)
Badge of Life: Psychological Survival for Police Officers (Levenson, O’Hara & Clark, 2010)makes “emotional self-care (ESC)” the focus of a series of training modules delivered to police officers, along with mental health screenings and the delivery of peer support by other officers and the use of Critical Incident Stress Debriefing (CISD).
Police Organization Providing Peer Assistance (POPPA) (Dowling, et. al., 2006) is a New York Police Department (NYPD) based program for preventing suicide. It combines a confidential helpline, support groups, printed suicide awareness and intervention materials distributed to all police officers, and tools to assess resiliency and stress. Applied Suicide Intervention Skills Training (ASIST) is also provided yearly.
American Association of Suicidology. (n.d.) “Warning Signs | American Association of Suicidology” Retrieved on September 4, 2016 from http://www.suicidology.org/resources/warning-signs
American Foundation for Suicide Prevention (AFSP). (2014) “Suicide Statistics — AFSP” Retrieved on September 4, 2016 from https://afsp.org/about-suicide/suicide-statistics/
Badge of Life. (n.d.) Police Suicide Myths. Retrieved on September 4, 2016 from http://www.badgeoflife.com/myths/
Cross, C.L. & Ashley, L. (2004) Police Trauma and Addiction: Coping With the Dangers of the Job. FBI Law Enforcement Bulletin. 73(10) Retrieved on September 4, 2016 from https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=207385
Dowling, F.G., Moynihan, G., Genet, B. & Lewis, J. (2006). A Peer-Based Assistance Program for Officers With the New York City Police Department: Report of the Effects of Sept. 11, 2001. American Journal Of Psychiatry: Official Journal Of The American Psychiatric Association, (1), 151. doi:10.1176/appi.ajp.163.1.151
Kulbarsh, P. (2016) “2015 Police Suicide Statistics” Officer.com. Retrieved on September 4, 2016 from http://www.officer.com/article/12156622/2015-police-suicide-statistics
Levenson Jr, R. L., O’Hara, A. F., & Clark Sr, R. (2010). The Badge of Life Psychological Survival for Police Officers Program. International Journal Of Emergency Mental Health & Human Resilience, 12(2), 95-101.
Mishara, B. L., & Martin, N. (2012). Effects of a comprehensive police suicide prevention program. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 33(3), 162-168. doi:10.1027/0227-5910/a000125
New Jersey Police Training Commission. (2016) Basic Course for Police Officers.
Roufa, T. (2015) “What is the Divorce Rate for Police Officers?” The Balance. Retrieved on September 4, 2016 from https://www.thebalance.com/what-is-the-divorce-rate-for-police-officers-974539
Stedman, T. (2016) Stedman’s Medical Dictionary (28th ed.). Philadelphia: Lippincott Williams & Wilkins.
Childhood sexual abuse is one of the most harmful experiences an individual can go through in their entire life. Often covered up and denied, by both the offender, and society at large, we’ve made great strides in exposing these wounds to the light and developing better treatments for those who have experienced this suffering.
This article reviews a number of elements in the understanding and treatment of child sexual abuse. Because most of the resources on sexual abuse examine women exclusively or primarily, they will be the focus of this article. I hope to write one on male survivors of sexual abuse soon.
Defining Child Sexual Abuse
The World Health Organization (WHO) defines child sexual abuse as “the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared, or else that violate the laws or social taboos of society” (WHO, 2006)
Prevalence of Child Sexual Abuse
In Canada, the rate of sexual assault of those under 18 is approximately 201 per 100,000 (Statistics Canada, 2008), while an Ontario study identified approximately 13% of females and 5% of males had reported sexual abuse. (MacMillan, et. al., 1997) US studies began in the 1950s and reported between 20 and 30% of men and women reported sexual contact with children. (Draucker & Martsolf, 2006; p. 2)
Impact of Child Sexual Abuse
Child sexual abuse has been associated with life-long emotional health challenges including “the development of a range of psychiatric difficulties, including depression…self-harm…anxiety disorders…and post-traumatic stress disorder” (Barrera, Calderon & Bell, 2013) Other negative impacts can include substance abuse (Sartor, et. al., 2013) and risky sexual behaviour. (Roemmele, & Messman-Moore, 2011)
As well, survivors of childhood sexual abuse are also at greater risk for developing physical health issues, with Moeller et. al. (1993) reporting that women who were abused reported “significantly more hospitalizations for illnesses, a greater number of physical and psychological problems, and lower ratings of their overall health” than non-abused women.
False and Recovered Memories
There is a controversy in the treatment of survivors of sexual abuse about the potential for recovered memories, “the recall of traumatic events not previously remembered” (Draucker & Martsolf, 2006; p. 15) and false memories, allegedly implanted by the therapist using improper or even fraudulent techniques.
The general scientific consensus (e.g. as summed up by Ilsley (1998) is that while false memories can occur, they are the exception rather than the rule. Therefore care must be taken to avoid introducing these memories, but survivors of sexual abuse should be believed in the absence of information suggesting otherwise. This does not mean that criminal prosecution should adopt a different standard (indeed, many individuals who receive treatment for sexual abuse could never secure convictions) but merely that the potential for false memories should not dissuade a therapist from providing treatment.
The research is continuing and therefore counsellors should keep themselves informed on the latest developments in this area.
Phase Model for Treatment of Child Sexual Abuse
A phase-based model is a method of treating childhood sexual abuse that is focused on multiple distinct stages of the treatment, with specific goals for each stage. The following example of phase-treatment comes from Courtois (2004):
The goals of phase 1 are to explore the client’s motivation to get better, ensure informed consent (including the client’s rights and responsibilities), and educating the client on what psychotherapy is. This is also the time to establish an effective therapeutic alliance with the client, so that they can ensure the most success.
As Courtois notes, phase 1 doesn’t look much different from other forms of psychotherapy, though it may take much longer to establish in sexual abuse than other presenting problems. The acronym RICH is used as a short-hand for the four goals of phase 1:
Building life skills is also a significant component of phase 1. These skills can include techniques like deep breathing, communicating one’s needs, identifying one’s emotional state, coping skills, and a variety of others that may depend on the specific client deficits.
The goals of phase 2 are to begin the process of developing an integrated understanding of the abuse. The client begins to construct a narrative to objectively describe the abuse in terms of the who, what, where, why, and their own reactions to the experience.
Desensitization through graduated exposure therapy is used to help reduce the impact of dissociation and allow the client to separate themselves from the abuse experience. This has been found to be an effective way of increasing the client’s ability to control their emotional regulation and decrease other symptoms. (Cloitre, 2002)
The final phase involves fine-tuning the skills developed in stage 1 and begins to build a new life post-abuse. At this point the client can begin tackling elements typical or a more normal range of experiences including “the development of trustworthy relationships and intimacy, sexual functioning, parenting, career and other life decisions, ongoing decisions/ discussions with abusive others, and so forth.” (Courtois, 2004)
Implications for Crisis Intervention
Helpline callers or chat and text visitor may disclosure historical sexual abuse to you. If they do, there are some things you should keep in mind to respond most effectively:
Check for immediate safety if it is not clear the abuse was in the past – this is especially important in a situation where the person is still young
Adopt a supportive tone without gawking or getting shocked. This can further stigmatize the individual and heighten their sense of isolation
Consider supportive responses as noted by Draucker & Martsolf (2006; p. 44):
Acknowledging the difficult step of disclosing
Offering support and indicating one’s availability after the session during which the client disclosed
Inviting the client to discuss the abuse at his or her own pace
Evaluating the client’s mental status and determining any immediate safety concerns (e.g. suicidal thoughts)
On the phone, watch for symptoms of dissociation or Dissociative Identity Disorder (DID)
If the individual starts to dissociate, try a grounding exercise: have them identify things they can see, hear (including your voice), or smell in the room. This will help them stay focused
If a person appears to switch personalities, remain calm but do not breach confidentiality. Treat the second personality as another person but work to get them medical assistance as soon as possible
The office of Juvenile Justice and Deliquency Prevention hosted a webinar titled “Male Survivors of Sexual Abuse” which will hopefully be available on their website for viewing soon.
Barrera, M., Calderón, L., & Bell, V. (2013). The Cognitive Impact of Sexual Abuse and PTSD in Children: A Neuropsychological Study. Journal Of Child Sexual Abuse, 22(6), 625-638. doi:10.1080/10538712.2013.811141
Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal Of Consulting And Clinical Psychology, 70(5), 1067-1074. doi:10.1037/0022-006X.70.5.1067
Courtois, C.A. (2004) Complex Trauma, Complex Reactions: Assessment and Treatment. Psychotherapy. 41(4) 214-425. DOI 10.1037/0033-318.104.22.1682. Retrieved on October 8, 2016 from http://www.dhss.delaware.gov/dsamh/files/si10_1396_article1.pdf
Draucker, C.B. & Martsolf, D.S. (2006) Counselling Survivors of Childhood Sexual Abuse. 3rd Ed. London: SAGE Publications.
Ilsley, J. K. (1998). Recovered memories of childhood abuse : We must tell patients that they were not to blame. BMJ : British Medical Journal, 317(7164), 1012.
MacMillan, H.L., Fleming, J.E., Trocme, N., Boyle, M.H., Wong, M., Racine, Y.A., Bearslee, W.R. & Offord, D.R. (1997) JAMA. Prevalence of Child Physical and Sexual Abuse in the Community. 278(2). 131-135
Moeller, T. P., Bachmann, G. A., & Moeller, J. R. (1993). The combined effects of physical, sexual, and emotional abuse during childhood: long-term health consequences for women. Child Abuse And Neglect, (5), 623.
Roemmele, M., & Messman-Moore, T. L. (2011). Child Abuse, Early Maladaptive Schemas, and Risky Sexual Behavior in College Women.Journal Of Child Sexual Abuse, 20(3), 264-283. doi:10.1080/10538712.2011.575445
Sartor, C. E., Waldron, M., Duncan, A. E., Grant, J. D., McCutcheon, V. V., Nelson, E. C., & Heath, A. C. (2013). Childhood sexual abuse and early substance use in adolescent girls: the role of familial influences. Addiction, 108(5), 993-1000. doi:10.1111/add.12115
The goal of CBASP is to “teach the patient to focus on the consequences of behaviour, and to use problem solving to resolve interpersonal difficulties. (Driscoll, et. al., 2004, pg. 2)
A 2016 meta-review confirmed that CBASP is effective for the treatment of major depressive disorder, especially when combined with medication. (Negt, et. al., 2016), while a comparison of CBASP versus treatment-as-useful — other evidence-based therapies for depression — in Wiersma et. al. (2014) found that CBASP was at least as effective as the other treatments from 8 weeks up to 32 weeks but performed better by 52 weeks, suggesting it kept clients better, for longer.
Principles of CBASP
McCullough believes that depression is caused by “learned Pavlovian fears of interpersonal encounters, and maintained by a refractory pattern of Skinnerian interpersonal avoidance.” (McCullough, 2006) Essentially what this means is that clients develop a fear of relationships based on previous bad experiences that leads them to isolation and a disconnect from their environment.
CBASP involves the client completing paperwork called the Coping Survey Questionnaire (CSQ) in between each session. These CSQ forms are used to document stressful or challenging interactions with other people by exploring what happened, how the client reacted, and what the client wanted to happen. Then the CSQs are reviewed in therapy in a process known as Situational Analysis (SA).
According to Driscoll, et. al., (2004, pg. 4) analyzing one CSQ will likely take a full session in the beginning of treatment, but as a client masters the elements of the CSQ and the SA steps (described in more detail below) they will find themselves able to cover several CSQs in one session.
Five Steps of Situational Analysis
The five steps of Situational Analysis mirror the items on the CSQ.
Step 1. Describe the situation
In the first step, the client is expected to describe in 3 to 4 paragraphs a specific situation that occurred without editorializing or providing extraneous detail. The goal is for the therapist to be able to understand all of the interactions that occurred in that single instance.
Step 2. State interpretation
In step 2, the client provides their interpretations about what occurred during that conversation. Many times clients will make interpretations that are broad, based on situations that are very specific. For instance, a client who receives poor customer service from a cashier may state, “He wasn’t nice to me because I’m ugly.” Asking the client to provide two or three thoughts that occurred during the interaction, or asking the client what the situation meant to them in the moment may help spur the production of interpretations.
The most effective interpretations are those that lead to the desired outcome (DO), what the client wished had happened in that situation had it occurred again.
Step 3. Identify reactions
In step 3, the client records all of their own behaviours and reactions. These include voice tone, body language, pace, and other reactions the client may have had like walking away from the situation. This allows the client to identify avenues for changing behaviours to more easily reach the desired outcome.
Step 4. Explain the desired outcome (DO)
In step 4, the client explains the Desired Outcome (DO). The therapist can ask, “What were you trying to get out of this situation?” or “How did you want things to go” in order to spur this part of the conversation. One DO should be produced for each CSQ that is completed. These DOs should be SMART (specific, measurable, attainable, realistic and timely.)
One important element related to DOs is that they have to involve the client themselves. A DO can’t involve change in another person because we don’t have control over that person. What the client does have control over is their own reactions and responses.
Step 5. Illustrate the actual outcome (AO)
The actual outcome (AO) is perhaps the easiest step, because this explores what the client actually got out of the experience. Usually this is a negative experience but it doesn’t have to be — a positive AO may be an opportunity for the client to identify what went right and how they can repeat this in the future.
After Situational Analysis
After the SA phase is complete, the client has explained the situation, what happened, how they reacted, what they wanted to happen, and how the situation ended. This is known as the elicitation phase. The next stage of the two-part process is the remediation phase.
In the remediation phase of CBASP, the interpretations and behaviours are looked at to figure out if they’re the most useful beliefs or effective responses to the situation. If they’re not (and many times they aren’t), more effective interpretations and behaviours are suggested in order to help the client better reach the DO.
Driscoll, K.A., Cukrowicz, K.C., Reardon, M.L. & Joiner, T.E. (2004) Simple Treatments for Complex Problems: A Flexible Cognitive Behavior Analysis System Approach to Psychotherapy. Mahwah, N.J.: Lawrence Elbaum Publishers
McCullough, J. P. (1984). Cognitive-behavioral analysis system of psychotherapy: An interactional treatment approach for dysthymic disorder. Psychiatry: Journal For The Study Of Interpersonal Processes, 47(3), 234-250.
McCullough, J. P. (2000). Treatment for chronic depression: Cognitive behavioral analysis system of psychotherapy. New York, NY: Guilford.
McCullough, J. P. (2006). Treating chronic depression with disciplined personal involvement: Cognitive behavioral analysis system of psychotherapy (CBASP). New York, NY: Springer.
Negt, P., Brakemeier, E., Michalak, J., Winter, L., Bleich, S., & Kahl, K. G. (2016). The treatment of chronic depression with cognitive behavioral analysis system of psychotherapy: a systematic review and meta-analysis of randomized-controlled clinical trials. Brain And Behavior, (8), doi:10.1002/brb3.486
Wiersma, J.E., Van Schaik, D.J., Hoogendorn, A.W., Dekker, J.J., Van, H.L., Schoevers, R.A., Blom, M.B., Maas, K., Smit, J.H., McCullough, J.P., Beekman, A.T. & Van Oppen, P. (2014) The effectiveness of the cognitive behavioral analysis system of psychotherapy for chronic depression: a randomized controlled trial. Psychotherapy and Psychosomatics. 83(5): 263-9. doi: 10.1159/000360795