Randy Borum

Violence and severe mental disorder in clinical and community populations: the effects of psychotic symptoms, comorbidity, and lack of treatment

This paper examines links between violent behavior, type and severity of psychopathology, substance abuse comorbidity, and community mental health treatment, using matched data from two surveys: the National Institute of Mental Health Epidemiologic Catchment Area project and the Triangle Mental Health Survey (a North Carolina study of adults with severe and persistent mental illness). Multivariate logistic regression analysis was used to model the risk of violent acts attributable to three domains of independent variables: sociodemographic characteristics, clinical diagnoses and symptomatology, and mental health services utilization. Findings include: (1) Symptom severity was significantly greater in the clinically-selected sample than in the community survey of respondents with comparable diagnoses who self-reported using mental health services; (2) Violence risk was related to psychoticism/agitation in a curvilinear form; (3) In a multivariable model, violence was significantly associated with substance abuse comorbidity, particular psychotic symptoms (perceived threat and loss of internal cognitive controls), and absence of recent contact with a community mental health provider; (4) The relationship between lack of treatment and higher odds of violence was less pronounced among respondents with substance abuse comorbidity; (5) When clinical and services-use variables were taken into account, sociodemographic predictors were not significantly related to violence.

Police perspectives on responding to mentally ill people in crisis: perceptions of program effectiveness

In this study, we sampled sworn police officers from three law enforcement agencies (n = 452), each of which had different system responses to mentally ill people in crisis. One department relies on field assistance from a mobile mental health crisis team, a second has a team of officers specially trained in crisis intervention and management of mentally ill people in crisis, and a third has a team of in-house social workers to assist in responding to calls. Calls involving mentally ill people in crisis appear to be frequent and are perceived by most of the officers to pose a significant problem for the department; however, most officers reported feeling well prepared to handle these calls. Generally, officers from the jurisdiction with a specialized team of officers rated their program as being highly effective in meeting the needs of mentally ill people in crisis, keeping mentally ill people out of jail, minimizing the amount of time officers spend on these calls, and maintaining community safety. Officers from departments relying on a mobile crisis unit (MCU) and on police-based social workers both rated their programs as being moderately effective on each of these dimensions except for minimizing officer time on these calls where the MCU had significantly lower ratings.

Threat assessment: defining an approach for evaluating risk of targeted violence.

Although the field of risk assessment has made tremendous advances in the past 20 years, assessments of targeted violence continue to pose a significant challenge to law enforcement, mental health, and other professionals. These specific and critical assessments require an innovative approach. The threat assessment model, developed and refined by the U.S. Secret Service, provides a useful framework for thinking about assessments of potential for targeted violence. In this paper, we attempt to define this approach as it has been developed by the Secret Service, and apply it within the existing professional/scientific literature on risk assessment. We begin with a brief review of existing models and approaches in risk assessment, and identification of some gaps in our existing knowledge as it relates to assessments of targeted violence. We then proceed with an outline of the threat assessment approach, including a review of principles and guiding operational questions, and discussion of its use in assessment of targeted violence.

What Can Be Done About School Shootings? A Review of the Evidence

School shootings have generated great public concern and fostered a widespread impression that schools are unsafe for many students; this article counters those misapprehensions by examining empirical evidence of school and community violence trends and reviewing evidence on best practices for preventing school shootings. Many of the school safety and security measures deployed in response to school shootings have little research support, and strategies such as zero-tolerance discipline and student profiling have been widely criticized as unsound practices. Threat assessment is identified as a promising strategy for violence prevention that merits further study. The article concludes with an overview of the need for schools to develop crisis response plans to prepare for and mitigate such rare events.

Taking the wrong drugs: the role of substance abuse and medication noncompliance in violence among severely mentally ill individuals

Abstract Increasing numbers of severely mentally ill individuals are being treated in nonhospital, community-based settings and public concern about potential violence by these individuals has increased, often as a result of tragic, albeit uncommon events. The present study examines potential predictors of serious violence among persons with severe mental illness (SMI), with a specific focus on the joint effect of substance abuse and medication noncompliance. Subjects in the study are involuntarily admitted inpatients with SMI awaiting a period of court-ordered outpatient treatment, termed “involuntary outpatient commitment”. During enrollment in a longitudinal outcome study of the effectiveness of OPC, 331 subjects and, whenever feasible, family members or other informants were interviewed. In addition, complementary data were gathered by review of involuntary commitment records and hospital records. Data collection included sociodemographic characteristics, illness history, clinical status, medication adherence, substance abuse and violent behavior during the 4 months preceding hospitalization. Descriptive and multivariable logistic regression procedures were used to examine the association between serious violent acts and a number of personal, social, and clinical characteristics. The combination of medication noncompliance and substance abuse was a significant predictor of serious violent acts in the community. Individuals who had problems with both alcohol and illicit drug abuse appear to be at greatest risk for violence. These results suggest that reducing violence risk among persons with SMI requires an aggressive approach to improving medication adherence in the context of integrated mental health and substance abuse treatment.

Improving clinical judgment and decision making in forensic evaluation

Psychologists, psychiatrists and other mental health professionals are frequently involved as expert witnesses in legal proceedings. However, clinical judgment and decision making, which play a role in almost all clinical evaluations, have problems and limitations. Mental health professionals who conduct forensic examinations should be aware of these problems and take steps to address them. This article details the limitations of clinical judgment and decision making, and suggests ways to minimize associated problems, thereby improving the validity and utility of forensic evaluations.

Predictive validity of the Structured Assessment of Violence Risk in Youth (SAVRY) during residential treatment

This prospective study examines the predictive validity of the Dutch version of the Structured Assessment of Violence Risk in Youth (SAVRY) by examining relationships between SAVRY scores and various types of disruptive behavior during residential treatment. The SAVRY, a risk assessment instrument, was coded for 66 male adolescents on the basis of file information and interviews. The adolescents were referred to Rentray, a juvenile correctional and treatment facility, by the Dutch juvenile courts because of severe behavioral problems or serious offenses. Institutional infractions were retrieved from incident registration files, which included acts of physical violence, verbal threat, verbal abuse, and violation of institutional rules. The interrater reliability of the SAVRY scores was good. The predictive validity of the SAVRY for physical violence against persons was excellent (Risk Total: AUC=.80, r =.33; Summery Risk Rating: AUC =.86, r =.48). The SAVRY also had good predictive validity for violence against objects, verbal threats and violations of rules, but not for verbal abuse. Implications for assessment and management of violent behavior among adolescents in residential treatment are discussed.

Can involuntary outpatient commitment reduce arrests among persons with severe mental illness

Involuntary outpatient commitment (OPC) is a promising but controversial legal intervention that may reduce criminal justice contact in persons with severe mental illness (SMI). This article examines arrest outcomes in a 1-year randomized study of OPC in 262 participants with SMI in North Carolina. Extended OPC was found to be significantly associated with reduced arrest probability (12% vs. 45%) in a subgroup with a prior history of multiple hospitalizations combined with prior arrests and/or violent behavior. Reduction in risk of violent behavior was a significant mediating factor in the association between OPC and arrest. In persons with SMI whose history of arrests is related directly to illness relapse, OPC may reduce criminal justice contact by increasing participation in mental health services.

Psychiatric impairment, social contact, and violent behavior : evidence from a study of outpatient-committed persons with severe mental disorder

Abstract The need to better understand and manage risk of violent behavior among people with severe mental illness in community care settings is increasingly being recognized, as public-sector mental health systems face mandates to provide more cost-effective services in less restrictive environments. The potential for serious violence in a small proportion of severely mentally ill (SMI) individuals has emerged as a key factor that increases cost and limits continuity and normalization of community-based services for populations with psychiatric disabilities. A major challenge to developing better strategies for risk assessment and management in community care settings involves specifying complex interactions between psychiatric impairment and the conditions of social life – including the quality and frequency of contact with others at close quarters. This is a study of the determinants of violent behavior in a sample of 331 adults with severe mental disorders in community-based treatment. An interaction between severity of functional impairment and frequency of social contact was found to be significantly associated with risk of violence. Among respondents with Global Assessment of Functioning (GAF) scores in the lowest 20%, more frequent contact with family and friends was linked to a higher probability of violent events. However, among better functioning respondents, frequent social contact was associated with lower risk of violence and greater satisfaction with relationships. These findings suggest that, where violence risk is concerned, the most salient feature of psychiatric impairment is the impairment of social relationships –the ways in which disorders of thought and mood not only distort ones subjective appraisal of experience and threat, but impair the ability to relate meaningfully to others, to resolve conflict and derive necessary support from family and friends. Thus, social contact may be a mixed blessing for SMI individuals. For some, it signals a positive quality of life, but for others – particularly those with extreme psychiatric impairment – frequent contact may add to conflict, stress, and increased potential and opportunity for physical violence. The impact of psychiatric impairment on violent behavior cannot be known in isolation, but must be considered in a social context. Effective community-based strategies to anticipate and prevent violence in the lives of persons with severe mental illness must take into account such interactions between social and clinical variables.

Male-female differences in the setting and construction of violence among people with severe mental illness

Abstract Data from a sample of severely and persistently mentally ill involuntary patients indicated that differences in violence between males and females in the 4 months prior to hospital admission depended on the measure. In the bivariate analysis, males had a greater prevalence of violence on the two indicators which separated more serious violence from lesser and no violence; but there was no gender difference on the more inclusive measure which incorporated threats and fights not involving weapons or injuries. In multivariate analysis when other relevant predictors were controlled, gender was significant in predicting only the most inclusive indicator of violence and only in interaction with substance abuse problems.