Biopsychosocial Model of Violence Risk Assessment

Introduction

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.

Individual/Psychological Domain

• Male
• Age
• Past History of Violence
• Paranoia
• Intelligence Below Average
• Anger/Fear Problems
• Psychopathy / Other Attachment Difficulties

Social/Environmental Domain

• Family of Origin Violence
• Adolescent Peer Group Violence
• Economic Instability
• Weapons History/Skill/Interest and Approach Behaviour
• Victim Pool
• Alcohol/Psychostimulant Use
• Popular Culture

Biological Domain

• 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.

• Structured Assessment of Violence Risk in Youth (SAVRY)
• Spousal Assault Risk Assessment (SAVRY)

Other Resources

• Threat Assessment in Education
• Violence Risk & Threat Assessment: A Practical Guide for Mental Health & Criminal Justice Professionals

References

Bureau of Justice Statistics. (2011) “Homicide Trends in the United States, 1980-2008” Retrieved on October 28, 2016 from https://www.bjs.gov/content/pub/pdf/htus8008.pdf