What Are the Odds on Predicting Violent Behavior? by Joel A. Dvoskin, Ph.D., A.B.P.P.

What are the Odds on Predicting Violent Behavior?

by Joel A. Dvoskin, Ph.D., A.B.P.P.

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Predicting violent behavior among persons with mental illness has always
been an important part of the mental health professions, but especially
so since the 1960s, when commitment laws began to specifically require
such prediction in order to involuntarily hospitalize people in
psychiatric crisis. Unfortunately, these predictions were made with a
confidence that turned out to be largely unfounded.

In the 1970s, researchers such as Henry Steadman began to systematically
test psychiatric predictions of dangerousness. By the late seventies,
these studies and others had led to a general belief that mental health
professionals were no more accurate at predicting dangerousness than the
general public. This dramatic turnabout from clinical overconfidence to
clinical nihilism when it came to predicting violent behavior had an
unfortunate side-effect: a long and disappointing dearth of research
interest in the topic. “We can predict anything” had sadly become “we
can predict nothing.”

Yet practitioners continued to make predictions. Indeed they were forced
to by laws which continued to require dangerousness (or predictable
violence) for a variety of legal purposes. At the same time, it was
intuitively clear to many practitioners that we could indeed accurately
predict a great many things, such as response to various treatment
modalities or medications. As is often the case when science and
intuition conflict, a second generation of prediction researchers paid
closer attention to what the earlier researchers had really said. Our
failures had been around the “long-term prediction” of violent behavior.
What about short-term predictions?

During the second half of the eighties, researchers such as Binder and
McNiel, Mulvey, Klassen, and others began to look toward violence
predictions in a whole new light. “We can predict nothing” became a
question: “What can we predict, when, and for whom?” They began to look
at the interactions between certain types of people with mental illness
and the situations in which they were likely to find themselves.
In short, it is clear that mental illness by itself does not
necessarily increase the probability of violent behavior. But for
some people in some circumstances, it may. While most people with mental
illness are not violent most of the time, it is also true that some
people with mental illness will indeed behave violently some of the
time. The challenge for practitioners and researchers alike is to try to
identify the treatments and life situations which raise or lower the
odds for individuals. Judgments about groups of people can only
lead to stigma and discrimination, while judgments about individuals, if
based on reason and information, can lead to better treatment outcomes
and increased safety for the individuals and their communities.

Those of us who work in forensic mental health systems are repeatedly
faced with the need to recommend continued hospitalization or release to
the community for people who may have committed serious acts of violence
in the past. According to actuarial data, these historical acts indeed
raise the likelihood that the person will again behave violently. Yet
our inability to make accurate long-term predictions has left us with a
difficult dilemma. Suppose that each of ten people had a one-in-ten
chance of committing a violent crime if released. We would be forced to
choose between retaining all ten, thus unnecessarily taking liberty away
from nine people, or letting them all go and thus guaranteeing an injury
to an innocent member of the public. While such odds are of course
impossible to ascertain, the example is nevertheless instructive. We are
often torn between the wish to maximize the liberty of each citizen and
the need to protect the public—truly a rock and a hard place. How have
we managed?

The answer, for me at least, has been to reject the dilemma. I do not
believe that the odds are stagnant. For example, there are mentally ill
people who have only behaved violently when drunk. For these people,
release without alcohol treatment raises their own risk of violence.
Others have never behaved violently when taking their prescribed
medication. Obviously, their attitude and knowledge about medication
will have an effect on their odds of success. The absolute odds are
impossible to determine, but the relative odds are not. Our challenge is
to continue to develop responsive community supports and treatments so
that each person who is returned to freedom after an involuntary
hospitalization has the highest possible likelihood of a successful,
non-violent life.

The other principle which governs our management of the risk of violence
among our patients is to provide small increments of increased freedom
and reduced control. This graduated path to freedom not only allows the
patient to demonstrate trustworthiness and an ability to adapt to new
situations, but allows a sometimes retributive public to adapt to them
as well.

In a number of studies, including our own recent study in New York,
persons found “not guilty by reason of insanity” have shown
recidivism rates for violent crime which were dramatically lower than
those of convicted felons. Generally these patients receive treatment
and supervision in the community following release, while other parolees
are often placed on ridiculously large caseloads where help is virtually
impossible to find. Thus, a societal response of support and
treatment seems to yield better results than one of punishment and
scrutiny. Yet there remain a number of mentally ill citizens who,
because of their criminal-justice status, may be receiving less support
and treatment than they need to maximize their chances of success. An
investment in these mentally ill probationers, parolees, detainees and
inmates would seem to appeal not only to our generous hearts, but to our
selfish minds as well.

IF YOU FEAR VIOLENCE FROM A MENTALLY ILL FAMILY MEMBER

1. Trust your instincts. They are born of years of valid experience. If
   you feel afraid, you probably have a good reason.

2. Be honest about your own feelings, but don’t judge those of your
   mentally ill family member.

3. Violence is often the product of anger and fear. Try not to make it
   worse.

4. It is okay to ask your family member if you are in danger, and what
   they would like for you to do.

5. If you become frightened during an argument, back off. It’s not a
   good time to negotiate, anyway.

6. Persons with mental illness are often more afraid of their violent
   feelings than we are. Pretending that everything is fine when it clearly
   isn’t will only further confuse and frighten both of you.

7. Don’t feel compelled to either confirm or challenge delusions or
   hallucinations. If pressed try: “I believe these things are real to
   you.” Be kind but honest. Lying is disrespectful and humiliating.

8. What has worked for you in the past? Things that defused past
   situations are likely to work again.

9. Know your local support systems. If your community has a mobile
   crisis team or a supportive police force, know how to contact them and
   what to expect.

And, for heaven’s sake, don’t be afraid to ask for help.

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For more information about Dr. Joel A. Dvoskin, or to read more articles by this leading leading forensic psychologist, click here.