David A. Crighton

Risk assessment with offenders

In the 1990s there has been renewed interest in risk assessment with offenders. It is important to distinguish between terms such as dangerousness, prediction and risk assessment. It is particularly difficult to estimate the probability of occurrence for behaviours with low base rates, such as homicide and suicide. A generic framework for risk assessment is outlined. Risk factors associated with suicide amongst offenders are examined. Homicide is used as an exemplar for the risk assessment framework. The need for theory led risk assessments to inform risk management and review strategies are emphasized.

Risk assessment: predicting violence

Violence in its many and varied forms represents a major public health problem. Home Office figures for England & Wales, based on the British Crime Survey, suggest that there were just over two million incidents of violence between January and December 2010.1 It is therefore not surprising that significant efforts have been made to predict the risk of future violence in at risk groups. At a fundamental level, the challenges of assessing risk in this area are similar to those in other areas of public health, where uncertainty can be divided into two types: aleatory and epistemological. Aleatory uncertainty refers to what might also be termed true chance or randomness, as in the throw of a dice, the toss of a coin or the similar types of events which fill statistics textbooks. Epistemological uncertainty refers to our lack of knowledge about potentially verifiable events. In areas such as screening for a disease, it has been noted that the uncertainty is all epistemological, with the disease either being present or absent.2 In making predictions about violence though, there is a mix of the epistemological and aleatory uncertainty. Future events are unknown and chance events will have unknown impacts on these. Gathering more information may change our predictions, but we will always be faced with a remaining level of uncertainty which cannot be eliminated in predicting violence. In common with other areas of prediction, future violence therefore presents very significant challenges. In addressing these challenges there has, in recent years, been a dramatic growth in the use of structured assessments to try to predict future risk. Most of these assessments have been based on actuarial models of risk and have come to be termed Actuarial Risk Assessment Instruments ( ARAIs ) or, less formally, risk assessment ‘tools’. These ARAIs have sought to …

Experimental interventions with sex offenders: a brief review of their efficacy

Sexual offending is an area which generates considerable public concern and which has received much attention, with a marked growth in a range of experimental interventions designed to reduce the risk of re-offending among participants. A number of significant challenges arise from this including the polythetic nature of the category “sex offender”. Any two people identified as sex offenders may have different and non-overlapping patterns of behaviour. Additionally most research and practice has focussed on those detected and convicted of sexual offences. Rates of reporting, detection and conviction in this area are generally very low, which suggests the existence of a large pool of undetected offenders. The extent to which this group differs from convicted groups is rarely acknowledged, yet an understanding of this is likely to be fundamental to efforts to prevent such offending and improve public protection.1,2 There have been two Cochrane Collaboration reviews of interventions with known sex offenders.3,4 Strikingly both reviews found no high quality randomised studies. The great majority of the research was excluded from review and was characterised as small scale and non-randomised, having high exclusion rates and being of relatively poor standard. Both reviews found only a small number of randomised studies, all of which had important weaknesses in terms of the description of randomisation and efforts to ensure blinding in assessment. Currently, cognitive behavioural group work is fashionable in the treatment of convicted sex offenders. The use of this approach, based on relapse prevention principles, was compared with a no treatment group by Marques et al .5 The mean duration of follow-up for this study was three years. No difference was found between the two groups in terms of rates of sexual offending (OR 0.76, 95% CI 0.26 to 2.28). The treatment group showed lower rates for …

Policing and mental health

The way in which the Police deal with those experiencing mental health problems has a long and fraught history, in terms of deaths in custody. It can also be argued that the, always difficult, interface between mental health and criminal justice services has become more difficult still due to two trends. First, the closure of many hospital places and second, the tendency for mainstream mental health services to increasingly withdraw from working with those in contact with the police. There has been a significant loss of skills in dealing with such patients, in favour of specialist ‘forensic’ services, leaving the police to cope as best they …

Uses and abuses of the Hare Psychopathy Checklist

Notions of psychopathic personality and personality disorder have a lengthy history within criminal justice and mental health settings. Issues of how to assess and intervene with this group of individuals also continue to present significant challenges for both services. Those categorised as psychopathic or personality disordered may behave in ways that are seriously damaging both to themselves and to others. There has also been frequent criticism and, at times, castigation of services for failing to engage with these groups and protect the public effectively.1 Such pressures have provided impetus to the search for reliable and valid assessments of psychopathy with prognostic value. The Psychopathy Checklists (PCL) is a family of structured assessments developed in the USA by Robert Hare2 ,3 (see box 1). They are based loosely on the criteria for psychopathy set out by Cleckley,4 although it should be noted that significant differences exist. The most commonly used version in practice is the full length Psychopathy Checklist in its revised form (PCL-R). This is a structured checklist that yields an overall score, which is generally divided into two factors. Factor 1 (F1) relates to the selfish, callous and remorseless use of others, factor 2 (F2) relates to a chronically unstable and antisocial lifestyle. Each of the factors can be further divided into facets, with F1 comprising interpersonal and affective facets and F2 comprising lifestyle and antisocial facets.5 ,6 #### Box 1 The Psychopathy Checklist The PCL-R is a 20 item clinical rating scale completed by an appropriately trained practitioner. Items are rated on a 3 point scale: 0 if the item does not apply at all, 1 if the item applies somewhat, 2 if the item fully applies. These ratings are generally used to produce ratings on two factors. Factor1: “Aggressive narcissism”

The politics of mental health

At the time of writing a number of issues dominate the headlines and seem set to impact on future practice. The role and funding of social care has moved in and out of the public eye but the question of how we care for growing number of elderly people with mental health problems does not go away. Nor indeed does the question of how to ensure humane and compassionate care, be it in hospitals or nursing homes. The issue of sexual offenders is also again in the news, with both high-profile and low-profile cases and media calls to address this serious issue. The artificial divisions between health and social care bedevil many mental health systems to a greater or lesser degree. The UK for …

Limited evidence that bullying behaviour in children may be linked to later suicidal behaviour

ED FROM Klomek AB, Sourander A, Niemela S, et al. Childhood bullying behaviours as a risk for suicide attempts and completed suicides: a population-based birth cohort study. J Am Acad Child Adolesc Psychiatry 2009;48:254–61. Correspondence to: Anat Brunstein Klomek, Department of Psychiatry, Division of Child and Adolescent Psychiatry, Columbia University, NYSPI, 1051 Riverside Drive, Unit 72, New York, NY 10032; klomek@childpsych.columbia.edu Source of funding: Sigrid Juselius Foundation and Paediatric Research Foundation, Finland. C O M M EN TA R Y T his study by Klomek and colleagues addresses childhood bullying as a risk factor in relation to later suicide. A population based birth cohort is used with a sample of 5302 children born in Finland in 1981. The authors note that bullying has a relatively high frequency among children, with individuals often being both victims and perpetrators of such behaviour. Despite the distress which follows such aggression there have been few efforts to make links between bullying and later self-injury and suicide. The present study addresses this gap in the literature by looking at associations between these behaviours and suicide, as well as controlling for identified confounding factors of conduct problems and childhood depression. The study identifies higher rates of bullying than in many previous studies, with 47% of boys and 23% of girls being identified as sometimes bullying others, and 48% of boys and 36% of girls reporting being victimised sometimes. The study identified a total of 24 deaths among men, 13 of which were recorded as suicides; for women, 16 deaths were recorded of which two were recorded as suicides. The main finding of the study is reported to be a gender based difference in the association between bullying and later suicidal behaviour. The authors note an association between frequent victimisation in girls at 8 years and subsequent suicide. The study helpfully builds on previous studies of the same data set in drawing attention to developmental characteristics and later suicide. It also adds to earlier studies of the association between anger, aggression and suicide. 2 In this respect the study supports the observation that aggression in childhood is often associated with later suicide. The key point of the paper though is the suggestion of a gender difference in the association between childhood bullying and suicide. Here the authors face the perennial problem of prospective studies of low frequency events such as suicide and their conclusions are, necessarily, based on very small numbers. Given that the study involved only two suicides by women, it is unclear how robust the findings are or the extent to which they might, at this stage, inform clinical practice. David A Crighton, PhD Roehampton University London and Ministry of Justice, London, UK Competing interests: None. 1. Apter A, Plutchik R, Sevy S, et al. Defense mechanisms in risk of suicide and risk of violence. Am J Psychiatry 1989;146:1027–31. 2. Towl GJ, Crighton DA. Suicide in Prisons in England and Wales from 1988 to 1995. Crim Behav Ment Health 1998;8:184–92. 3. Conner KR, Duberstein PR, Conwell Y, et al. Reactive aggression and suicide: Theory and evidence. Aggress Violent Behav 2003;8:413–32. Aetiology 124 EBMH November 2009 Vol 12 No 4

Dictionary of Forensic Psychology

List of entries. List of contributors. Table of cases. Acknowledgements. Introduction and overview. Dictionary of Forensic Psychology. Appendix I: Abbreviations. List of references