Tonia L. Nicholls

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.

Forensic psychiatric inpatients and aggression: an exploration of incidence, prevalence, severity, and interventions by gender.

BACKGROUNDnPrevious investigations suggest that women judged to be not criminally responsible on account of mental disorder (NCR-MD) differ markedly from their male counterparts in important ways, underscoring the necessity of subsequent study.nnnOBJECTIVEnThe goal of the present study was to inform our understanding of the presenting profile of female forensic psychiatric patients and contrast their risk of inpatient aggression with their male counterparts.nnnMETHODnThe population of patients assessed and/or treated at a secure Canadian forensic psychiatric hospital were available for study. In total, 527 patients had complete data and were part of intensive retrospective file reviews; inpatient aggression was evaluated using the Overt Aggression Scale.nnnRESULTSnWomen were no less likely than men to have a violent index offence and to perpetrate inpatient aggression. Examining the range of aggressive behaviours and severity levels did little to increase the relevance of gender to inpatient risk.nnnDISCUSSIONnFemale forensic patients represent a highly selected subgroup of women with exceptional clinical and behavioural challenges and associated treatment needs.

Protective Factors in Forensic Mental Health: A New Frontier

The field of violence risk assessment has made substantial strides in the past four decades. In large part, these advances reflect the addition of purpose-designed risk assessment measures such as the HCR-20 and COVR as well as the contributions of prolific scholars and state of the art studies (Hodgins’ Aftercare Project; Monahan, Steadman et al.s MacArthur Violence Risk Assessment study). However, important areas of inquiry have been left largely unexplored. The potential incremental value to be added by dynamic risk factors to historical and static factors is relatively unexamined. Yet, changeable factors offer the capacity to identify new opportunities for the prevention and management of violence risk. Similarly, the added value to be offered by a consideration of protective factors in addition to risk factors is only now emerging as a field of inquiry in adult forensic mental health. This special section is dedicated to addressing some of these limitations and provides papers describing two new measures (SAPROF and START) and empirical evidence supporting the role of protective factors in risk assessment and risk management research.

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.

Female Perpetrators of Intimate Abuse.

Abstract A review is made of female intimate abuse. It is concluded that females are as abusive as males in intimate relationships according to survey and epidemiological studies. This is especially so for younger “cohort” community samples followed longitudinally. Predictors of intimate violence with women appear to be similar to those of men; including antisocial criminal records, alcohol abuse, and personality disorders.

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.

Criminal Behavior and Victimization Among Homeless Individuals With Severe Mental Illness: A Systematic Review

OBJECTIVESnThe objectives of the systematic review were to estimate the prevalence and correlates of criminal behavior, contacts with the criminal justice system, and victimization among homeless adults with severe mental illness.nnnMETHODSnMEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Web of Science were searched for published empirical investigations of prevalence and correlates of criminal behavior, contacts with the justice system, and episodes of victimization in the target population.nnnRESULTSnThe search yielded 21 studies. Fifteen examined prevalence of contacts with the criminal justice system; lifetime arrest rates ranged between 62.9% and 90.0%, lifetime conviction rates ranged between 28.1% and 80.0%, and lifetime incarceration rates ranged between 48.0% and 67.0%. Four studies examined self-reported criminal behavior, with 12-month rates ranging from 17.0% to 32.0%. Six studies examined the prevalence of victimization, with lifetime rates ranging between 73.7% and 87.0%. Significant correlates of criminal behavior and contacts with the justice system included criminal history, high perceived need for medical services, high intensity of mental health service use, young age, male gender, substance use, protracted homelessness, type of homelessness (street or shelter), and history of conduct disorder. Significant correlates of victimization included female gender, history of child abuse, and depression.nnnCONCLUSIONSnRates of criminal behavior, contacts with the criminal justice system, and victimization among homeless adults with severe mental illness are higher than among housed adults with severe mental illness.

Predictive validity of risk assessments in juvenile offenders: Comparing the SAVRY, PCL:YV, and YLS/CMI with unstructured clinical assessments.

This study examined the validity and reliability of the Structured Assessment of Violence Risk in Youth (SAVRY), the Youth Level of Service/Case Management Inventory (YLS/CMI), and the Psychopathy Checklist: Youth Version (PCL:YV) in a sample of Spanish adolescents with a community sanction (N = 105). Self-reported delinquency with a follow-up period of 1 year was used as the outcome measure. The predictive validity of the three measures was compared with the unstructured judgment of the juvenile’s probation officer and the self-appraisal of the juvenile. The three measures showed moderate effect sizes, ranging from area under the curve (AUC) = .75 (SAVRY) to AUC = .72 (PCL:YV), in predicting juvenile reoffending. The two unstructured judgments had no significant predictive validity whereas the SAVRY had significantly higher predictive validity compared with both unstructured judgments. Finally, SAVRY protective factor total scores and SAVRY summary risk ratings did not add incremental validity over SAVRY risk total scores. The high base rates of both violent (65.4%) and general reoffending (81.9%) underline the need for further risk assessment and management research with this population.

Mentally ill individuals in limbo: obstacles and opportunities for providing psychiatric services to corrections inmates with mental illness.

For more than two millennia, prison reformers and inmate advocates have lamented the ethical and humanitarian injustices experienced by persons with mental illness in correctional settings; yet, we continue to see mentally ill individuals stuck in limbo between health care and custody. Using a case study that exemplifies the challenges that can prevent the provision of efficient mental health care in correctional settings, we identify the gaps and failures in service delivery, and provide specific strategies for streamlining inmates access to psychiatric assessment and treatment. As a backdrop, we present a brief overview of the reasons why correctional centres experience difficulties in ensuring expedient care (e.g., competence, mental health legislation, waitlists) as well as reviewing the prevalence of mental health needs in correctional settings. Using the partnership and strategic alignment that have been developed for several years between our forensic psychiatric system and our provincial correctional system, we provide a roadmap to successfully reducing wait times and enhancing service delivery to mentally ill inmates. In our view, custody admissions provide a rare opportunity to provide mental health (and other services) to marginalized individuals who often slip through the cracks. imPROVE and related programs and strategies have been found to be effective means of preventing these opportunities from being lost.