The prediction of interpersonal violence demands the use of psychometrically
sound measurements and an understanding of such tools' limitations. Research in
clinical decision making (Benner, 1984; Harbison, 1991; Schon, 1983a) identifies
three major models for prediction: (a) the linear, rationalist model, (b) the
hypothetico-deductive model, and (c) the risk assessment model (Gottfredson &
Gottfredson, 1988). Depending on the goal of the assessment, the clinician may
use aspects of one or more of these models.
LINEAR
MODEL
Because prediction has such significant forensic implications,
clinicians may use a linear model, including a decision tree or critical pathway,
to guide them when making decisions that have legal ramifications. For example,
Gross, Southard, Lamb, and Weinberger (1987) propose seven steps to follow when
a client makes suggestive threats (see Figure 1.1).
Step
1 is to clarify the threat. Many clients make vague comments that may
or may not indicate a real danger. Thus the clinician must take the time to fully
explore intent. For example, after an acute beating, a battered woman may state
that she wishes someone would "blow his [the abuser's] brains out."
In this case the clinician needs to ask the client directly whether she intends
to kill her abuser. This client simply may be expressing her anger. Further inquiry
might reveal that she does not own or have access to a firearm. In the above case
the risk factor for retaliatory violence is low, especially when compared with
the client who tells the clinician that she would like to kill her abuser and
has borrowed her brother's loaded handgun.
Thus,
if there is a clear threat, Step 2 is to assess its lethality, as well
as the likelihood of the person acting on the threat. As with suicidal thoughts,
not all "threats" pose a true danger or can be enacted. The incarcerated
client may verbalize specific threats of violence against someone outside of prison
but have no means to carry through on the threats.
If
there is evidence of danger, Step 3 is to identify a specific, intended victim. in family violence and family sexual assault cases, it is easy to identify intended
victims. The violence is seldom random, even within homes in which multiple members
reside. The clinician working with a client who is verbalizing concerns about
physically and/or sexually assaulting a stranger may find it more difficult to
identify a specific victim (by name). However, the clinician can ask the client
to indicate the intended victim's gender and any specific victim characteristics.
If
the client can name the intended victim or specifics about the type of victim
who will be sought, the threat of harm is imminent (Step 4). At this
point the clinician needs to consider his or her duty to warn the specified victim.
For more detail the reader is referred to material on the Tarasoff decisions (Tarasoff
v. Regents of the University of California, 1974, 1976).
The
clinician also must take into account the client's relationship to the intended
victim (Step 5). If the intended victim is a family member, rather than
a political figure, the clinician may employ different preventive and treatment
strategies.
Step 6 requires the clinician to decide
whether a family therapy intervention would be suitable. For example,
if the family violence is ongoing, family therapy may impose greater danger to
the potential victim or victims.
Finally, Step 7 requires
the clinician to consider whether civil commitment or involuntary hospitalization
would provide the greatest good to the client and potential victim or victims. At the completion of Step 7, the clinician needs to follow up on the
results of the decisions made and may need to recycle through the decision tree
at a later date.
The strength of the linear model is that it
provides relatively clear direction for the clinician, as well as a "logical"
argument for the decision. Using the linear model, the clinician approaches problem
solving with some notion of probability. He or she weighs outcomes according to
objective standards or theory. The weakness of this model is also its objectivity;
contextually relevant information is given little consideration. In other words,
factors such as treatment outcomes, social support, and stabilization of stress
are not considered in making the prediction. The decision is driven by formula,
more than by the specifics of the actual situation.
- Campbell, Jacquelyn,
Assessing Dangerousness, Sage Publications: London, 1995.
Self-Injurious Behavior in Adolescents
- Whitlock J. (2010). Self-injurious behavior in adolescents. PLoS medicine, 7(5), e1000240. doi:10.1371/journal.pmed.1000240
================================= Personal
Reflection Exercise #8
The preceding section contained information
about clinically based prediction models in assessing dangerousness. Write three
case study examples regarding how you might use the content of this section in
your practice.
QUESTION
22 What is the strength in utilizing the linear model for assessing interpersonal
violence? Record the letter of the correct answer the Answer
Booklet.
