Sarah L. Desmarais

Prevalence of physical violence in intimate relationships, part 2: Rates of male and female perpetration.

Physical violence perpetrated by men against their female partners is widely recognized as a serious social problem. Whether women’s use of physical violence against their male partners represents a serious social problem remains a question under debate. We examined research published in the last 10 years to summarize the current state of knowledge regarding the prevalence of physical IPV perpetrated by men and women in heterosexual relationships. Our specific aims were to (a) describe the prevalence of physical IPV perpetration in industrialized, English-speaking nations, and (b) explore study and sample characteristics that affect prevalence. Literature searches undertaken in 3 databases (PubMed, PsycINFO, and Web of Science) identified 750 articles published between 2000 and 2010. We included 111 articles that reported 272 rates of physical IPV perpetration in our review: 25 articles reported 34 rates for men, 14 articles reported 24 rates for women, and 72 articles reported 214 rates for both men and women. The vast majority of studies were conducted in the United States (k = 95, 85.6%) and most (k = 81, 73.0%) measured IPV using a Conflict Tactics Scale-based approach. We calculated unweighted, pooled prevalence estimates for female and male perpetration overall and by sample type, country, measurement time frame, and measurement approach. Across studies, the overall pooled prevalence estimate was 24.8%. Consistent with prior reviews, pooled prevalence was slightly greater for female- compared to male-perpetrated physical IPV: more than 1 in 4 women (28.3%) and 1 in 5 men (21.6%) reported perpetrating physical violence in an intimate relationship. This pattern of results remained when we calculated pooled prevalence estimates by sample and study characteristics, with few exceptions. Findings underscore the need for interventions that acknowledge the use of violence by women in intimate relationships.

The Short-Term Assessment of Risk and Treatability (START): a prospective validation study in a forensic psychiatric sample

A new assessment scheme-the Short-Term Assessment of Risk and Treatability (START)- presents a workable method for assessing risks to self and others encountered in mentally and personality disordered clients. This study aimed to demonstrate (a) prevalence and severity of risk behaviors measured by the START, (b) psychometric properties of START, (c) similarities and differences in START scores across different mental health professionals, and (d) concurrent validity of START with diverse negative outcomes. Treatment team members completed the 20-item, dynamically focused START for 137 forensic psychiatric inpatients. Prevalence and severity of START risk domains were measured for 51 patients detained in the hospital for 1 year. Results revealed high rates of generally low-level adverse events. With some exceptions, START scores were meaningfully associated with outcomes measured by a modified Overt Aggression Scale.

International Perspectives on the Practical Application of Violence Risk Assessment: A Global Survey of 44 Countries

Mental health professionals are routinely called upon to assess the risk of violence presented by their patients. Prior surveys of risk assessment methods have been largely circumscribed to individual countries and have not compared the practices of different professional disciplines. Therefore, a Web-based survey was developed to examine methods of violence risk assessment across six continents, and to compare the perceived utility of these methods by psychologists, psychiatrists, and nurses. The survey was translated into nine languages and distributed to members of 59 national and international organizations. Surveys were completed by 2135 respondents from 44 countries. Respondents in all six continents reported using instruments to assess, manage, and monitor violence risk, with over half of risk assessments in the past 12 months conducted using such an instrument. Respondents in Asia and South America reported conducting fewer structured assessments, and psychologists reported using instruments more than psychiatrists or nurses. Feedback regarding outcomes was not common: respondents who conducted structured risk assessments reported receiving feedback on accuracy in under 40% of cases, and those who used instruments to develop management plans reported feedback on whether plans were implemented in under 50% of cases. When information on the latter was obtained, risk management plans were not implemented in over a third of cases. Results suggest that violence risk assessment is a global phenomenon, as is the use of instruments to assist in this task. Improved feedback following risk assessments and the development of risk management plans could improve the efficacy of health services.

Using Dynamic Risk and Protective Factors to Predict Inpatient Aggression: Reliability and Validity of START Assessments.

The Short-Term Assessment of Risk and Treatability (START; C. D. Webster, M. L. Martin, J. Brink, T. L. Nicholls, & S. L. Desmarais, 2009; C. D. Webster, M. L. Martin, J. Brink, T. L. Nicholls, & C. Middleton, 2004) is a relatively new structured professional judgment guide for the assessment and management of short-term risks associated with mental, substance use, and personality disorders. The scheme may be distinguished from other violence risk assessment instruments because of its inclusion of 20 dynamic factors that are rated in terms of both vulnerability and strength. This study examined the reliability and validity of START assessments in predicting inpatient aggression. Research assistants completed START assessments for 120 male forensic psychiatric patients through review of hospital files. They also completed Historical-Clinical-Risk Management-20 (HCR-20; C. D. Webster, K. S. Douglas, D. Eaves, & S. D. Hart, 1997) and Hare Psychopathy Checklist: Screening Version (PCL:SV; S. D. Hart, D. N. Cox, & R. D. Hare, 1995) assessments. Outcome data were coded from hospital files for a 12-month follow-up period using the Overt Aggression Scale (OAS; S. C. Yudofsky, J. M. Silver, W. Jackson, J. Endicott, & D. W. Williams, 1986). START assessments evidenced excellent interrater reliability and demonstrated both predictive and incremental validity over the HCR-20 Historical subscale scores and PCL:SV total scores. Overall, results support the reliability and validity of START assessments and use of the structured professional judgment approach more broadly, as well as the value of using dynamic risk and protective factors to assess violence risk.

The Role of Client Strengths in Assessments of Violence Risk Using the Short-Term Assessment of Risk and Treatability (START)

Despite significant advances in the field of violence risk assessment, we are limited in our understanding regarding the utility of existing measures for predicting violence risk over brief time frames (i.e., weeks to months) as well as by our focus on factors that increase risk to the neglect of those which may reduce risk or protect against future violence. To address these knowledge gaps, this study evaluated the use of a structured professional guide, the Short-Term Assessment of Risk and Treatability (START; Webster, Martin, Brink, Nicholls, & Middleton, 2004), in assessing short-term violence risk (i.e., up to one year) and, specifically, the role of client strengths in this process. Research assistants completed file-based START assessments for four 3-month intervals for 30 male forensic psychiatric inpatients. Information pertaining to aggressive incidents was obtained from files. Overall, results supported the usefulness of the START in assessing short-term violence risk. Assessments evidenced validity in predicting future violence, particularly over the short-term (i.e., up to 9 months). Although ratings of client strengths did not contribute uniquely to the prediction of violence risk, results support their clinical utility in risk management.

Predictive validity of dynamic factors: assessing violence risk in forensic psychiatric inpatients

There is general consensus that dynamic factors ought to be considered in the assessment of violence risk, but little direct evidence exists to demonstrate that within-individual fluctuations in putative dynamic factors are associated with changes in risk. We examined these issues in a sample of 30 male forensic psychiatric inpatients using a pseudoprospective design. Static and dynamic factors were coded on the basis of chart review using 2 structured measures of violence risk: Version 2 of the Historical-Clinical-Risk Management-20 (HCR-20; C. D. Webster, K. S. Douglas, D. Eaves, & S. D. Hart, 1997, HCR-20: Assessing risk for violence, Version 2, Vancouver, BC, Canada: Mental Health, Law, and Policy Institute, Simon Fraser University) and the Short-Term Assessment of Risk and Treatability (START; C. D. Webster, M. L. Martin, J. Brink, T. L. Nicholls, & S. L. Desmarais, 2009, Short-Term Assessment of Risk and Treatability [START], Version 1.1, Coquitlam, BC, Canada: British Columbia Mental Health and Addiction Services). HCR-20 and START assessments were repeated every 3 months for a period of 1 year. Institutional violence in the 3 months following each assessment was coded using a modified version of the Overt Aggression Scale (S. C. Yudofsky, J. M. Silver, W. Jackson, J. Endicott, & D. W. Williams, 1986, The Overt Aggression Scale for the objective rating of verbal and physical aggression, The American Journal of Psychiatry, Vol. 143, pp. 35-39). Dynamic risk and strength factors showed predictive validity for institutional aggression. Results of event history analyses demonstrated that changes in dynamic risk factors significantly predicted institutional violence, even after controlling for static risk factors. This is one of the first studies to provide clear and direct support for the utility of dynamic factors in the assessment of violence risk.

Measurement of Predictive Validity in Violence Risk Assessment Studies: A Second-Order Systematic Review

The objective of the present review was to examine how predictive validity is analyzed and reported in studies of instruments used to assess violence risk. We reviewed 47 predictive validity studies published between 1990 and 2011 of 25 instruments that were included in two recent systematic reviews. Although all studies reported receiver operating characteristic curve analyses and the area under the curve (AUC) performance indicator, this methodology was defined inconsistently and findings often were misinterpreted. In addition, there was between-study variation in benchmarks used to determine whether AUCs were small, moderate, or large in magnitude. Though virtually all of the included instruments were designed to produce categorical estimates of risk - through the use of either actuarial risk bins or structured professional judgments - only a minority of studies calculated performance indicators for these categorical estimates. In addition to AUCs, other performance indicators, such as correlation coefficients, were reported in 60% of studies, but were infrequently defined or interpreted. An investigation of sources of heterogeneity did not reveal significant variation in reporting practices as a function of risk assessment approach (actuarial vs. structured professional judgment), study authorship, geographic location, type of journal (general vs. specialized audience), sample size, or year of publication. Findings suggest a need for standardization of predictive validity reporting to improve comparison across studies and instruments.

After 30 Years, What Do We Know about What Jurors Know? A Meta-Analytic Review of Lay Knowledge Regarding Eyewitness Factors

Surveys typically characterize lay knowledge of eyewitness factors as low and highly variable. However, there are notable differences across methodologies, samples, and individual factors. To examine these differences systematically, we took a meta-analytic approach to reviewing the findings of 23 surveys assessing lay knowledge of eyewitness issues. Our analyses examined the beliefs of 4,669 respondents. Overall, respondents correctly agreed with survey items approximately two-thirds of the time. Results revealed significant differences in performance as a function of variable type, question format, and over time. We found few differences as a function of sample type, publication status, or jurisdiction. Although performance varied, a majority of lay respondents achieved “correct” consensus for as many as 11 of the 16 items included in this review.

Community Violence Perpetration and Victimization Among Adults With Mental Illnesses

OBJECTIVES In a large heterogeneous sample of adults with mental illnesses, we examined the 6-month prevalence and nature of community violence perpetration and victimization, as well as associations between these outcomes. METHODS Baseline data were pooled from 5 studies of adults with mental illnesses from across the United States (n = 4480); the studies took place from 1992 to 2007. The MacArthur Community Violence Screening Instrument was administered to all participants. RESULTS Prevalence of perpetration ranged from 11.0% to 43.4% across studies, with approximately one quarter (23.9%) of participants reporting violence. Prevalence of victimization was higher overall (30.9%), ranging from 17.0% to 56.6% across studies. Most violence (63.5%) was perpetrated in residential settings. The prevalence of violence-related physical injury was approximately 1 in 10 overall and 1 in 3 for those involved in violent incidents. There were strong associations between perpetration and victimization. CONCLUSIONS Results provided further evidence that adults with mental illnesses experienced violent outcomes at high rates, and that they were more likely to be victims than perpetrators of community violence. There is a critical need for public health interventions designed to reduce violence in this vulnerable population.

Effects of Outpatient Treatment on Risk of Arrest of Adults With Serious Mental Illness and Associated Costs

OBJECTIVE This study examined whether possession of psychotropic medication and receipt of outpatient services reduce the likelihood of posthospitalization arrest among adults with serious mental illness. A secondary aim was to compare service system costs for individuals who were involved with the justice system and those who were not. METHODS Claims data for prescriptions and treatments were used to describe patterns and costs of outpatient services between 2005 and 2012 for 4,056 adult Florida Medicaid enrollees with schizophrenia or bipolar disorder after discharge from an index hospitalization. Multivariable time-series analysis tested the effects of medication and outpatient services on arrest (any, felony, or misdemeanor) in subsequent 30-day periods. RESULTS A total of 1,263 participants (31%) were arrested at least once during follow-up. Monthly medication possession and receipt of outpatient services reduced the likelihood of any arrests (misdemeanor or felony) and of misdemeanor arrests. Possession of medications for 90 days after hospital discharge also reduced the likelihood of arrest. Prior justice involvement, minority racial-ethnic status, and male sex increased the risk of arrest, whereas older age decreased it. Criminal justice and behavioral health system costs were significantly higher for the justice-involved group than for the group with no justice involvement. CONCLUSIONS Routine outpatient treatment, including medication and outpatient services, may reduce the likelihood of arrest among adults with serious mental illness. Medication possession over a 90-day period after hospitalization appears to confer additional protection. Overall, costs were lower for those who were not arrested, even when they used more outpatient services.