Sequential Intercept Model

Introduction

The Sequential Intercept Model was developed by Mark Munetz and Patricia Griffin (2006) to help communities understand the way people with mental health issues interact with the criminal justice system and to target interventions to prevent people from getting deeper involved in the system.

The Sequential Intercept Model is usually focused around 5 broad target points, or areas where people with mental health issues may find themselves in contact with police or legal officials.

The five Intercepts are:

  1. Law Enforcement
  2. Initial Detention / Court Hearings
  3. Jail / Court
  4. Re-Entry
  5. Community Corrections

The model was based on ensuring that people with mental health issues are not forced into the criminal justice system at greater rates than people without mental health issues.

Law Enforcement and Emergency Services

Noting that up to 10% of police calls by patrol officers involve mental health issues (Cordner, 2006), the first interception point is front-line police and emergency services workers. Munetz & Griffin (2006) describe several strategies to help intervene at this point:

  • Mobile Crisis Teams of mental health workers
  • Employing mental health workers as civilians in the Police Service
  • Pairing police officers with mental health workers to go on patrol calls
  • Specially trained mental health police officers

All of these approaches involve combining front-line policing with mental health support to ensure that sensitivity is respected. Emergency services may also respond to mental health issues where individuals are psychotic or otherwise struggling with a connection to reality, which can put these staff in danger.

Initial Detention / Court Hearings

After an individual has been arrested, the next interception point of the sequential intercept model is initial detention and hearings post-arrest. Individuals may be diverted at this point to programs for non-violent, low level crime (such as petty theft or trespassing) based on the symptoms of their mental illness.

Diverting this individual to mental health treatment can avoid exacerbating their mental health issues. Additionally the court may “employ mental health workers to assess individuals after arrest in the jail or the courthouse and advise the court about the possible presence of mental illness and options for assessment and treatment, which could include diversion alternatives or treatment as a condition of probation.”

Jail / Court

Individuals who have mental illnesses and get involved in the criminal justice system are likely to spend a significantly longer jail term than individuals with the same charges who do not have mental illnesses. (Hoke, 2015) For this reason, the third intercept point is the jail or court system, where many individuals with mental illness are managed.

One important opportunity is the establishment of Mental Health Courts set up specifically for people with diagnosed mental illnesses relevant to their crimes.

Re-Entry

After an individual has exited the court system (if on probation) or jail (if sentenced to serve time), it is time for them to re-enter society. Transition points like this are times where an individual may be feeling the least supported and at greatest risk of suicide (Pease, Billera & Gerard, 2016) or of reoffending. (Caudill & Trulson, 2016) Discharge planning is common in hospitals but not in jail, which can make continuing care difficult for clients who are released from jail.

One potential model for solving this noted by Munetz & Griffin is the APIC (Assess, Plan, Identify, and Coordinate) Model by Osher, Steadman & Barr (2003). This plan “highlights the importance of collaboration among multi-sectoral community partners to ensure that the community is committed to the transition process.” (Evidence Exchange Network, 2014)

Community Corrections

The final intercept in the Sequential Intercept Model is community corrections, which is probation or parole. Since mental health treatment is often a condition of staying out of jail, these individuals represent an excellent opportunity to help those in the criminal justice system continue to access care, despite the adversarial nature of the parole/probation relationship.

References

Evidence Exchange Network for Mental Health and Addictions. (2014). “The Assess, Plan, Identify, and Coordinate (APIC) Model.” Retrieved on March 15, 2017 from http://eenet.ca/wp-content/uploads/2014/04/APIC-summary-addendum_March2014.pdf

Caudill, J. W., & Trulson, C. R. (2016). The hazards of premature release: Recidivism outcomes of blended-sentenced juvenile homicide offenders. Journal Of Criminal Justice, 46219-227. doi:10.1016/j.jcrimjus.2016.05.009

Cordner, G. (2006) “People with Mental Illness”. Center for Problem-Oriented Policing. No 4. Retrieved on March 17, 2017 from http://www.popcenter.org/problems/mental_illness/print/

Pease, J. L., Billera, M., & Gerard, G. (2016). Military Culture and the Transition to Civilian Life: Suicide Risk and Other Considerations. Social Work, 61(1), 83-86. doi:10.1093/sw/swv050

Hoke, S. (2015). Mental Illness and Prisoners: Concerns for Communities and Healthcare Providers. Online Journal Of Issues In Nursing, 20(1), 1. doi:10.3912/OJIN.Vol20No01Man03

Osher, F., Steadman, H. J., & Barr, H. (2003). A Best Practice Approach to Community Reentry From Jails for Inmates With Co-Occuring Disorders: The APIC Model. Crime & Delinquency, 49(1), 79.

Munetz, M.R. & Griffin, P.A. (2006) Use of the Sequential Intercept Model as an Approach to Decriminalization of People With Serious Mental Illness. Psychiatric Services. 57(4) Accessed electronically on March 25, 2016 from http://ps.psychiatryonline.org/doi/pdf/10.1176/ps.2006.57.4.544

Cite this article as: MacDonald, D.K., (2017), "Sequential Intercept Model," retrieved on November 17, 2017 from http://dustinkmacdonald.com/sequential-intercept-model/.
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Childhood and Adolescent Taxon Scale (CATS)

Introduction

The Childhood and Adolescent Taxon Scale (CATS) worksheet was originally created to accompany the Violence Risk Appraisal Guide (VRAG) and the Sex Offender Risk Appraisal Guide (SORAG). Although the Psychopathy Checklist-Revised (PCL-R; Hare, 1991) can be used to assess psychopathy, there are many situations where a Psychologist or other individual trained in the administration of this tool is not available. In this situation, the CATS tool can be used to assess psychopathy instead.

Quinsey et. al. (2006) determined that the CATS tool is an appropriate replacement for the PCL-R assessment when determining psychopathy on the VRAG and SORAG assessments. Lister (2010) examined the CATS and found that there were no differences in rates of psychopathy as determined by the PCL-R and the CATS with Caucasian and African-American individuals.

Conduct Disorder Symptoms

In order to answer question 4 below, it’s necessary to identify how many conduct disorder symptoms are present.

Count those present those that occurred before age 16 except for items 13 and 15 which are before aged 16:

  1. Often bullied, threatened or intimidated others
  2. Often initiated physical fights
  3. Used a weapon that could cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
  4. Was physically cruel to people
  5. Was physically cruel to animals
  6. Stolen while confronting a victim (e.g., mugging, purse snatching, extortion, robbery)
  7. Forced someone into sexual activity
  8. Deliberately engaged in fire setting with the intention of causing serious damage
  9. Deliberately destroyed others’ property (other than by fire setting)
  10. Broken into someone else’s house, car, or building
  11. Often lied to obtain goods or favors or to avoid obligations (i.e., “cons” others)
  12. Stolen items of nontrivial value without confronting a victim (like shoplifting, theft, or forgery)
  13. Before [age] 13, stayed out late at night, despite parental prohibitions
  14. Ran away from home overnight (or longer) at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
  15. Before [age] 13, was often truant from school

Childhood & Adolescent Taxon Scale (CATS) Items

The CATS scale has 8 items that are reviewed below, along with supplementary scoring guidelines.

Elementary School Maladjustment

This refers to the first 8 years of formal schooling after kindgarten. A couple of incidents of truancy, smoking on school property or other minor incidents like this would be classified as Mild or Moderate. Severe incidents include repeated truancy or violent actions like assault. Also included in Severe is actions that result in criminal convictions like selling drugs at school.

  • 0 – No Problems
  • 0 – Slight (Minor discipline or attendance) or Moderate Problems
  • 1 – Severe Problems (Frequent disruptive behavior and/or attendance or behavior resulting in expulsion or serious suspensions)

Teenage Alcohol Problem

The National Institute on Alcohol Abuse and Alcoholism produces a guide to screening and intervening with youth (NIAAA, 2015) who consume alcohol. Their screening and assessment rubric can be used to determine if there is a teenage alcohol problem.

Based on the empirically determined risk guidelines, someone who is 12-15 and drinks more than 6 days in the past year would indicate a 1 below, someone who is 16 and drinks more than 12 days in the last year, someone who is 17 would need to drink more than 24 days while an individual who is 18 or higher would need to drink more than 52 days a year.

  • 0 – No
  • 1 – Yes

Childhood Aggression Rating

  • 0 – No Evidence of Aggression
  • 0 – Occasional Moderate Aggression
  • 1 – Occasional or Frequent Extreme Aggression

More Than 3 DSM Conduct Disorder Symptoms

These are the conduct disorder symptoms filled out below.

  • 0 – No
  • 1 – Yes

Ever suspended or expelled from school

  • 0 – No
  • 1 – Yes

Arrested under the age of 16

  • 0 – No
  • 1 – Yes

Lived with both biological parents to age 16 (except for death of parents)

Separation for more than one month is required for coding a “no” on this item. This could be because of institutionalization, divorce, or other separations but does not include death of one or both parents.

  • 0 – Yes
  • 1 – No

Scoring the CATS

Each of these items will result in a 0 or 1 score. All items are summed and the value can then be used to complete Item 12.b on the VRAG or item 14b on the SORAG.

References

American Psychological Association. (2006) Quinsey, V.L., Harris, G.T., Rice, M.E. & Cormier, C.A. (2006) 2nd Ed. Violent Offenders: Appraising and Managing Risk. Washington D.C: American Psychological Association.

Hare, R.D. (1991) The Hare Psychopathy Checklist-Revised (Hare PCL-R). Toronto: Multi-Health Systems.

Lister, M.B. (2010) A Comparison of the Violence Risk Appraisal Guide, Psychopathy Checklist, and child and Adolescent Taxon Scale: Predictive Utility And Cross Cultural Generalizable. Dissertation.

National Institute on Alcohol Abuse and Alcoholism (NIAAA). (2015). Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide. Retrieved on January 28, 2017 from https://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuide.pdf

Cite this article as: MacDonald, D.K., (2017), "Childhood and Adolescent Taxon Scale (CATS)," retrieved on November 17, 2017 from http://dustinkmacdonald.com/childhood-adolescent-taxon-scale-cats/.
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Using the Sex Offender Risk Appraisal Guide (SORAG)

Introduction

Following up on my article about how to use the Violence Risk Appraisal Guide (VRAG), this article reviews how to use a tool that is bundled with that tool, the Sex Offender Risk Appraisal Guide (SORAG). Like the VRAG, this is an actuarial tool that can be used to predict the risk of re-offending among sex offenders.

Before reading about the SORAG, it is helpful to review the VRAG post as many of the elements that are covered in that post are required before proceeding to the SORAG items. It is recommended that any completion of the SORAG be preceded by a completion of the VRAG as this will save you a significant amount of time.

Completing the SORAG

Like the VRAG, the first step is to complete the Childhood & Adolescent Taxon Scale (CATS) worksheet and the list of Conduct Disorder Symptoms.

Cormier-Lang Criminal History Scores

In order to answer item 5 on the SORAG, Criminal History Score for Non-Violent Offenses Prior to the Index Offense, it’s necessary to complete the Cormier-Lang Criminal History worksheet also provided on the SORAG. This worksheet is completed by filling out the number of non-violent offenses and applying the weight to them noted on the sheet.

Sex Offender Risk Appraisal Guide (SORAG) Items

The SORAG itself has 14 items that are similar to those found on the VRAG.

  1. Lived with both biological parents to age 16 (except for death of parent)
  2. Elementary School Maladjustment
  3. History of alcohol problems
  4. Marital status (at the time of or prior to index offense)
  5. Criminal history score for nonviolent offenses (from Cormier-Lang system)
  6. Criminal history score for violent offenses (from Cormier-Lang system)
  7. Number of previous convictions for sexual offenses (pertains to convictions known from all available documentation to be sexual offenses prior to the index offense)
  8. History of sex offenses only against girls under 14 (including index offenses; if offender was less than 5 years older than victim, always score +4)
  9. Failure on prior conditional release (includes parole or probation violation or revocation, failure to comply, bail violation, and any new arrest while on conditional release)
  10. Age at index
  11. 11. Meets DSM criteria for any personality disorder (must be made by appropriately licensed or certified professional)
  12. Meets DSM criteria for schizophrenia (must be made by appropriately licensed or certified professional)
  13. Phallometric test results
  14. 14. a. Psychopathy Checklist score (if available, otherwise use item 12.b. CATS score)
    14. b. CATS score (from the CATS worksheet)
    14. WEIGHT (Use the highest circled weight from 12 a. or 12 b.)

You’ll note that many of these items are available from the VRAG. The tool indicates where there are overlaps in order to save you time filling out the worksheets and tools.

Determining Risk Level of Sex Offenders

After completing the tool, you must take the total score of the SORAG and compare it to the below levels.

  • A score of -17 to +2 indicates an individual is at Low risk for re-offending
  • A score of +3 to +19 indicates an individual is at Medium risk for re-offending
  • A score of +20 to +34 indicates an individual is at High risk for re-offending

An individual who is on the border between these two levels should have that indicated. For instance, someone who scores at +1 or +2 should be noted as “Low-Medium Risk” to highlight that they are at the edge of the established risk level.

Recidivism Rates using the SORAG

Rather than grouping an individual into low, medium or high risk categories, it is often more illuminating to examine the recidivism rates. These come from Violent Offenders as well.

Probability of Recidivism
SORAG score 7 years 10 years
< − 9 0.07 0.09
−9 to -4 0.15 0.12
-3 to +2 0.23 0.39
+3 to +8 0.39 0.59
+9 to +14 0.45 0.59
+15 to +19 0.58 0.76
+20 to +24 0.58 0.80
+25 to +30 0.75 0.89
> +31 1.00 1.00

References

American Psychological Association. (2006) Quinsey, V.L., Harris, G.T., Rice, M.E. & Cormier, C.A. (2006) 2nd Ed. Violent Offenders: Appraising and Managing Risk. Washington D.C: American Psychological Association.

Cite this article as: MacDonald, D.K., (2017), "Using the Sex Offender Risk Appraisal Guide (SORAG)," retrieved on November 17, 2017 from http://dustinkmacdonald.com/using-sex-offender-risk-appraisal-guide-sorag/.
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Using the Violence Risk Appraisal Guide (VRAG)

Introduction

The Violence Risk Appraisal Guide (VRAG; Quinsey, Harris, Rice, & Cormier, 2006) is a tool that can be used to estimate statistically the risk of recidivism. It is comprised of 12 items that are associated with a risk of re-offending and is completed with all available information. You can download the full VRAG in PDF format. The Sexual Offender Risk Appraisal Guide (SORAG) is reviewed in another article.

The VRAG is an actuarial risk assessment, involving a mathematical technique applied to determines what factors were present in offenders who later went on to commit violent crimes. (Brown & Singh, 2014) This approach eliminates the bias found in unstructured judgement.

The VRAG has been examined in over 40 studies, and has been found effective even with individuals who have a lower IQ. (Camilleri & Quinsey, 2011)

Completing the VRAG

The first step to completing the VRAG is to complete the Childhood & Adolescent Taxon Scale. Below, where a request for information relates to an “index offense” that is the one that led to the individual entering the Criminal Justice system

Childhood & Adolescent Taxon Scale (CATS) Worksheet

This scale includes 8 items that are scored from 0 to 1, based on the coding guidelines provided. These items are:

  1. Elementary School Maladjustment
  2. Teenage Alcohol Problem
  3. Childhood Aggression Rating
  4. More Than 3 DSM Conduct Disorder Symptoms
  5. Ever suspended or expelled from school
  6. Arrested under the age of 16
  7. Lived with both biological parents to age 16 (except for death of parents)

Conduct Disorder Symptoms

Next, the assessor will complete the list of Conduct Disorder symptoms, circling those that occurred before age 16 except for items 13 and 15 which are before aged 16:

  • 1. Often bullied, threatened or intimidated others
  • 2. Often initiated physical fights
  • 3. Used a weapon that could cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
  • 4. Was physically cruel to people
  • 5. Was physically cruel to animals
  • 6. Stolen while confronting a victim (e.g., mugging, purse snatching, extortion, robbery)
  • 7. Forced someone into sexual activity
  • 8. Deliberately engaged in fire setting with the intention of causing serious damage
  • 9. Deliberately destroyed others’ property (other than by fire setting)
  • 10. Broken into someone else’s house, car, or building
  • 11. Often lied to obtain goods or favors or to avoid obligations (i.e., “cons” others)
  • 12. Stolen items of nontrivial value without confronting a victim (like shoplifting, theft, or forgery)
  • 13. Before [age] 13, stayed out late at night, despite parental prohibitions
  • 14. Ran away from home overnight (or longer) at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
  • 15. Before [age] 13, was often truant from school

Cormier-Lang Criminal History Scores for Non-Violent Offenses

This scoring form allows you to answer item number 5 below, the Criminal History Score for Non-Violent Offenses Prior to the Index Offense. This score is developed by counting the number of non-violent offenses and applying a weight to them. For instance, bank robbery is counted x7 while Indecent Exposure is counted x2. So an individual who has two instances of Indecent Exposure and 1 instance of Bank Robbery would have (2×2 = 4) + (1×7 = 7) = 4+7 = 11.

Violence Risk Appraisal Guide (VRAG) Items

Next are the 12 VRAG items. The tool provides detailed coding instructions for each of these:

  1. Lived with both biological parents to age 16 (except for death of parent):
  2. Elementary School Maladjustment:
  3. History of alcohol problems
  4. Marital status (at the time of or prior to index offense):
  5. Criminal history score for nonviolent offenses prior to the index offense
  6. Failure on prior conditional release (includes parole or probation violation or revocation, failure to comply, bail violation, and any new arrest while on conditional release):
  7. Age at index offense
  8. Victim Injury (for index offense; the most serious is scored):
  9. Any female victim (for index offense)
  10. Meets DSM criteria for any personality disorder (must be made by appropriately licensed or certified professional)
  11. Meets DSM criteria for schizophrenia (must be made by appropriately licensed or certified professional)
  12. a. Psychopathy Checklist score (if available, otherwise use item 12.b. CATS score)
  13. (Technically 12b) bCATS score (from the CATS worksheet)

Scoring the VRAG

Determining Risk

Risk categories are provided in the VRAG manual. They are approximated here although more detail is available in the complete manual. For each score, if an individual is close to the next score you should list them as a combination of the two. For instance an individual whose score is -10, -9 or -8 would be listed as Low-Medium rather than just Low.

  • -24 to -8 is Low Risk
  • -7 to +13 is Medium Risk
  • +14 to +32 is High Risk

Determining Rate of Recidivism

The risk of recidivism is presented below, from the same manual (pages 283-286):

Probability of Recidivism
VRAG score 7 years 10 years
< −22 0.00 0.08
−21 to −15 0.08 0.10
−14 to −8 0.12 0.24
−7 to −1 0.17 0.31
0 to +6 0.35 0.48
+7 to +13 0.44 0.58
+14 to +20 0.55 0.64
+21 to +27 0.76 0.82
> +28 1.00 1.00

This is to be interpreted as a percentage. For instance a score of -10 is in the -14 to -8 category; therefore an individual would have a 7 year recidivism rate of 12% and a 10 year recidivism rate of 24%.

References

American Psychological Association. (2006) Quinsey, V.L., Harris, G.T., Rice, M.E. & Cormier, C.A. (2006) 2nd Ed. Violent Offenders: Appraising and Managing Risk. Washington D.C: American Psychological Association.

Brown, J. & Singh, J.P. (2014) Forensic Risk Assessment: A Beginner’s Guide. Archives of Forensic Psychology. 1(1). 49-59. Retrieved on January 20, 2017 from http://www.archivesofforensicpsychology.com/web/wp-content/uploads/2015/01/Brown-and-Singh1.pdf

Camilleri, J.A. & Quinsey, V.L. (2011) Appraising the risk of sexual and violent recidivism among intellectually disabled offenders. Psychology, Crime & Law. 17(1) 59-74

Cite this article as: MacDonald, D.K., (2017), "Using the Violence Risk Appraisal Guide (VRAG)," retrieved on November 17, 2017 from http://dustinkmacdonald.com/using-violence-risk-appraisal-guide-vrag/.
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Dynamic Appraisal of Situational Aggression (DASA)

Introduction

The Dynamic Appraisal of Situational Aggression (DASA) is a tool developed by Ogloff & Daffern (2006) to assess the likelihood that a patient or client will become aggressive within a psychiatric inpatient environment. The DASA is based on the Norwegian Brøset-Violence-Checklist (BVC).

DASA Items

  1. Irritability
  2. Impulsivity
  3. Unwillingness to follow instructions
  4. Sensitive to perceived provocation
  5. Easily angered when requests are denied
  6. Negative attitudes
  7. Verbal threats.

Scoring the DASA

Each of the items are scored 0 if absent or 1 if is present now or has been present in the last 24 hours. This means that if someone is not currently displaying easy anger upon denied requests, but was earlier, that item should be scored 1.

There is no typical cut-off score for the DASA, although Barry-Walsh et. al. (2009) note in their research that “for each increase in DASA total score, there was a 1.77 times increased likelihood that the patient would behave aggressively in the following 24 hours.”

In Ogloff & Daffern’s original 2006 study

  • 18% of aggressive patients scored 1 to 3
  • 15% of aggressive patients scored 4 or 5
  • 55% of aggressive patients scored 6 or 7

Kaunomäki (2013) used a cut-off score of 4 to identify high-risk individuals.

DASA Research

A study of the DASA by Griffith, Daffern & Godber (2013) the DASA allowed nurses to predict aggressive behaviour significantly better than unaided judgements. Lantta et. al. (2016) confirmed the same on mental health inpatient units.

Taylor & Large (2013) question the predictive validity of the DASA, noting that of 200+ patients identified as potentially becoming aggressive, only one actually will. (This “low base rate” problem is the same issue affecting violence risk assessment and suicide risk assessment.)

Daffern & Howells (2007) compared the DASA with the HCR-20 and noted moderate predictive validity.

Current Use

The DASA is currently used by a variety of mental hospitals around the world. Some DASA write-ups include:

Reference

Barry-Walsh, J., Daffern, M., Duncan, S., & Ogloff, J. (2009). The prediction of imminent aggression in patients with mental illness and/or intellectual disability using the Dynamic Appraisal of Situational Aggression instrument. Australasian Psychiatry, 17(6), 493-496. doi:10.1080/10398560903289975

Chan, O. (2014) The Assessment of Imminent Aggression in Forensic Setting A Validation Study of the Dynamic Appraisal of Situational Aggression (DASA) in Hong Kong. Non-Peer Reviewed. Retrieved on November 13, 2016 from http://www.hkcpsych.org.hk/index.php?option=com_docman&task=doc_view&gid=1338&Itemid=354&lang=en

Daffern, M., & Howells, K. (2007). The Prediction of Imminent Aggression and Self-Harm in Personality Disordered Patients of a High Security Hospital Using the HCR-20 Clinical Scale and the Dynamic Appraisal of Situational Aggression. International Journal Of Forensic Mental Health, 6(2), 137.

Griffith, J. J., Daffern, M., & Godber, T. (2013). Examination of the predictive validity of the Dynamic Appraisal of Situational Aggression in two mental health units. International Journal Of Mental Health Nursing, 22(6), 485-492. doi:10.1111/inm.12011

Kaunomäki, J. (2015) Patient interventions after the assessment of violence risk: Observational study in a Finnish psychiatric admission ward. Institute of Behavioral Sciences. Thesis. Retrieved on November 13, 2016 from https://helda.helsinki.fi/bitstream/handle/10138/156453/Pro%20Gradu%20Kaunomäki%202015.pdf?sequence=3

Lantta, T., Kontio, R., Daffern, M., Adams, C. E., & Välimäki, M. (2016). Using the Dynamic Appraisal of Situational Aggression with mental health inpatients: a feasibility study. Patient Preference & Adherence, 10691-701. doi:10.2147/PPA.S103840

Ogloff, J. P., & Daffern, M. (2006). The dynamic appraisal of situational aggression: an instrument to assess risk for imminent aggression in psychiatric inpatients. Behavioral Sciences & The Law, 24(6), 799-813. doi:10.1002/bsl.741

Taylor, L., & Large, M. (2013). Dynamic Appraisal of Situational Aggression lacks utility. International Journal Of Mental Health Nursing, 22(6), 579. doi:10.1111/inm.12019

Cite this article as: MacDonald, D.K., (2016), "Dynamic Appraisal of Situational Aggression (DASA)," retrieved on November 17, 2017 from http://dustinkmacdonald.com/dynamic-appraisal-situational-aggression-dasa/.

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