Forensic-ethical

Question 1

Principles of risk assessment for future violence

Answer 1

· Violence risk prediction is an inexact science, which has led to the development of systematic structured
protocols to assist in the assessment of the risk of violent behaviours.
· Violence prediction will never be entirely accurate; given violence is a complex concept.
· Risk assessment is necessary when considering involuntary commitment of those diagnosed with
mental illness.
· In forensic psychiatry risk assessment is important when considering an accused person of offending
or re-offending.
· Obtaining all the available information, including information from various collateral sources, enhances
the validity of assessment and improves management.
· Both ethics and law hold that confidentiality is relative not absolute.

Question 2

Assessment of risk of violence is done using the conventional classification of ‘static’ and ‘dynamic’ factors,
including:

Answer 2

Static factors (pre-existing vulnerabilities) are enduring unchangeable characteristics linked to the
offending behaviour.
Male gender.
Single, never married.
Young age / under 25 years of age at first violent incident.
Conduct disorder / antisocial personality disorder / traits.
Major mental illness.
History of previous violence / sexual offence – best predictor of future violence is past violence.
Criminal history; history of imprisonment.
History of substance abuse.
Childhood abuse, neglect, or harsh inconsistent parenting.
Lifestyle instability.
Employment problems.
Relationship instability.

Dynamic factors (tend to change and moderate static risk factors) are acute rapidly changing
changeable characteristics; may indicate that a re-offense will occur within a short period of time
Negative attitudes such as anger and hostility.
Suspiciousness, irritability, impulsivity.
Lack of insight.
Intoxication / withdrawal – exposure to substances.
Cognitions supporting violence.
Carries weapon / access to firearm.
Recent threats or other aggressive actions / thoughts.
Victim availability.
Intimacy deficits.
Collapse of social supports.
At risk of sexually abusing others.
Unresponsive to treatment.
Noncompliance with remediation attempts.
Stress.
Symptoms of mental illness related to risk include active symptoms, poor compliance with medication
and treatment, poor engagement with treatment services.
Elevated mood state.
Psychotic symptoms - command hallucinations, threat-control-override and misidentification
symptoms, morbid jealousy

Question 3

Structured risk assessment instruments:

Answer 3

A combination of clinical and actuarial (historical risk factors) approaches increasingly used in settings where
there is the possibility of serious violence or offending behaviours. There is good evidence that these
instruments have reasonable predictive validity when assessing the risk of violent behaviours.
Some of the commonly used instruments to assess risk of violent behaviours are:
1. Hare Psychopathy Checklist Revised (PCL-R) is a 20-item rating scale with semi-structured interview and
collateral information. It has shown to be a relatively good predictor of violence across diverse populations.
2. Historical Clinical Risk (HCR-20) is a 20-item rating scale with 10 historical variables (static-past
documented), 5 clinical variables (dynamic-present observed), and 5 risk management factors (speculativefuture
projected).
3. Violent Risk Appraisal Guide (VRAG) is a 12-item actuarial scale used to predict risk of violence within a
specific time frame following release in violent, mentally disordered offenders.

Question 4

HCR-20

Answer 4

The HCR-20 has 20 items: (History, Clinical and Risk parameters)
· 10 items concerning the patient’s history.
· 5 items related to clinical factors.
· 5 items that deal with risk management.
· Total score range from 0 – 40.

a) Historical items
History of problems with…
b) Clinical items
Recent problems with…
c) Risk Management items
Future problems with…

H1 Violence
Previous violence
H2 Other antisocial behaviour
Young age at first incident
H3 Relationships
Relationship instability
H4 Employment
Employment problems
H5 Substance use
Substance use problems
H6 Major mental disorder
H7 Personality disorder
Psychopathy
H8 Traumatic experiences
Early maladjustment
H9 Violent Attitudes
H10 Treatment or supervision
response
Prior supervision failure

C1 Insight
 Mental Disorder
Lack of insight
 Violence risk
 Need for treatment
C2 Violent ideation or intent
Negative attitudes
C3 Symptoms of major mental disorder 
C4 Instability
Impulsivity
C5 Treatment or supervision response
Unresponsive to treatment

R2 Living situation
Exposure to destabilisers
R1 Professional services and plans
Plans lack feasibility
R3 Personal support
Lack of personal support
R4 Treatment or supervision response
 Compliance
Noncompliance with remediation attempts
 Responsiveness
R5 Stress or coping

Question 5

Formulate a management plan that reduces the risk of future violence:

Answer 5

· Attempt to modify “dynamic risk factors’ by:
o Thorough clinical assessment – presents high risk of harm to others.
o Assertive management of mental illness – treating and monitoring active symptoms of mental illness.
o Use of Mental Health Act or other appropriate legislation
o Decide on the best setting for treatment – inpatient, secure facility / high dependence unit.
o Request input from local Forensic services, including Forensic Risk Assessment.
o Professional service plans – consider types of “leave” processes to monitor adjustment, and
compliance. Reduction in intensity of monitoring to commence only after adequate clinical response.
o Ensure adequate supervision in the community.
o Consider legislated restrictions in the community, if appropriate – liaising with other agencies
effectively.
o Aim to improve insight – motivational interviewing, therapeutic alliance, stages of change model;
compliance with treatment.
o Identify stressors, aim to reduce occurrence of likely stressors and improve coping.
o Management of substance abuse, including motivational counselling, prophylactic medications.
o Enhance compliance through compliance therapy / adherence therapy.
o Treatment of symptom resistance and responsiveness - consider clozapine in treatment resistant
psychosis, mood stabilisers, ECT, etc.
o Change negative / antisocial attitudes through cognitive behavioural approaches.
o Manage emotions / behavioural instability such as use of dialectical behaviour therapy.
o Collaborate with family, friends and other associates. Encourage personal support and limit /
discourage antisocial support and influences.
o Increase opportunities for prosocial support – vocational, recreational.
o Social skills training.
o Living situation – consider optimising environment to reduce violence and improve opportunities for
monitoring; limit exposure to destabilisers and monitor for exposure such as substances, explore and
restrict access to weapons, victims.
o Notify the intended victim about the statement made by the patient, as soon as possible.
o Notify the police about the patient’s statements.
o Consult the Medical Director and Hospital Lawyers prior to these actions.

Question 6

Ethical aspects duty to warn, relevant codes in RANZCP

Answer 6

It is now generally accepted that psychiatrists have a duty to warn an identifiable victim of a patient’s serious
threat of harm. The legal precedent was the Tarasoff v. Regents of the University of California decision of the
Supreme Court of California in 1976.
The ethical dimension of psychiatry provides a system of moral principles, rules and standards governing the
practice of psychiatry and professional conduct. The Code of Ethics includes the principle of confidentiality –
psychiatrists shall strive to maintain confidentiality of patients and their families. Confidentiality is at the core
of the doctor-patient relationship, involving a ‘holding in trust’ process and shall not be undermined.
Principle 4.3 of the RANZCP Code of Ethics states that a breach of confidentiality may be justified on rare
occasions in order to promote the best interests and safety of the patient or of other people. Psychiatrists may
have a duty to inform the intended victim(s) and / or relevant authorities. Principle 4.4 states the clinical
information may need to be shared with colleagues in order to provide best possible care (annotation 3.9 being
mindful of the constraints of confidentiality, psychiatrists shall provide relevant clinical information when the
care of a patient is transferred to a colleague or institution).
The patient should be informed of the general limits of confidentiality. Where the patient is unable to understand
the concept of confidentiality and its limits, substitute consent may be required. The Code of Ethics serves to
guide ethical conduct and is a benchmark of satisfactory ethical behaviour in the practice of psychiatry as this
is interpreted in Australia and New Zealand. Since the Code is a public document, it may be referred to in a
court of law or in other statutory contexts.

Question 7

Do psychiatrists have a duty to protect potential victims of their patients’ violence?

Answer 7

The general policy is to promote public safety over privacy concerns in certain circumstances. It involves issues
of predicting violence, breaching confidentiality, defensive practices and insurance implications that can be
overcome by this duty of care. There is a risk that the actions of a third party can be imposed on a psychiatrist
if there is a failure to prevent harm caused by someone else. In psychiatric patients they at times are not
deemed morally responsible for their actions due to insanity. Psychiatrists must be seen to have appropriately
used medication, therapy and compulsory detention to reduce the risk of violence.
The psychiatrist or mental health professional must, pursuant to the standards of their profession determine,
if the patient presents a serious danger of violence to another, thereby incurs an obligation to use reasonable
care to protect the intended victim against such danger. The discharge of the duty to protect and the duty to
warn may require the therapist to take one or more various steps, depending on the nature of the case. It holds
that the obligation is to use reasonable care to protect the intended victim against danger. It may call the
psychiatrist to warn the intended victim or others likely to apprise the victims of that danger, to notify the police
or take whatever steps are reasonably necessary under the circumstances, including determining if there is a
past history of violence, any thoughts about seriously harming another person / group, symptom management,
deteriorating mental illness, and patients’ ability to control their violent impulses. Further steps can be warning
the potential victim(s), informing mental health services of the threat, notifying police, use of Mental Health
Act, professional supervision and so on. Code of Ethics for psychiatrists entails the duty to warn and protect.

Question 8

Stalking definition

Answer 8

when a person intentionally directs their attention towards another person and this
pattern of behaviour / attention is seen as repeated, unwanted pursuit that the victim considers as harassing
or threatening and possibly harmful. For stalking to be classified as such, it either needs to be of more than
one type or of the same type of behaviour repeated on more than one occasion

Meloy and Gothard’s definition: “Stalking is typically defined as the wilful, malicious, and repeated following
or harassing of another person that threatens his or her safety’’ (Meloy & Gothard, 1995, p.258)

including loitering,
watching, contacting, phoning, messaging or leaving material for another person which causes that other
person to become fearful or causes detriment to them or others. Stalking behaviour ranges from acts that
would appear benign and nonthreatening if they occurred in a different context (e.g., sending gifts or letters)
to acts that are overtly threatening (e.g., verbal threats to harm the victim) or violent (e.g., assault, rape,
murder). One would expect that there is no single profile of a “stalker” and stalkers do exhibit a broad
spectrum of behaviours and psychodiagnostic traits

Question 9

Contextual factors important in stalking behaviour

Answer 9

unemployment, business failure, relationship breakdown,

personal failure and social isolation all play important roles in the onset and maintenance of stalking.

Question 10

Statistics of stalking victims

Answer 10

Victims of stalking can be anyone, from family, (ex)-partner, to an acquaintance or even a stranger. The
Australian Bureau of Statistics Personal Safety Survey 2012, released in 2013, identified that women and
men who had experienced violence during the last 12 months were more likely that those who had not
experienced violence, to have also experienced stalking or harassment during this time. During their lifetime
women are more likely to have experienced an episode of stalking (19% vs 7.8%). Women are also much
more likely to be stalked by a man than by another female (94%), whereas there is no real difference for men
being stalked by either a man or a woman (approximately 4% each). 12-month prevalence is again higher in
women with a similar pattern to the lifetime prevalence.

Question 11

Duration of stalking behaviour

Answer 11

Research from the United States shows that in slightly over half the cases, stalking ceases within one year;
while in one-quarter of the cases it lasts for 2±5 years (Tjaden & Thoenness, 1997). In some cases, the
violence may escalate until the stalker actually murders the victim and/or his/her children. In the United
States, it is estimated that between 21% and 25% of forensic stalking cases culminate in significant violence
(Harmon et al, 1995: Meloy & Gothard, 1995). Stalking may indicate increased risk for future domestic
violence. The incidence of murder or manslaughter in stalking cases in the United States is estimated at 2%
(Meloy, 1996: Fritz, 1995) showed that 90% of women killed by their ex-husband had previously been
stalked.

Question 12

What police want to know about a stalker/behaviour

Answer 12

may wish to know whether an actual threat has been
made by the stalker to any particular person, whether the person has kept any messages/photos, etc. from
the stalker, whether police protection notices have been put in place, whether there are others involved
particularly children, whether the stalker possesses any weapons/firearms, is substance use involved, and
what is the extent of any medical or psychiatric history that could be influencing stalking behaviour. Legal
definition of stalking is based on State and Territory (National legislation in NZ) and incorporates the
intention to harm or frighten someone.

Question 13

Stalking behaviour and mental illness

Answer 13

Many stalkers do not suffer from a mental illness however up to 50% of stalkers entering the US criminal
justice system have been found to have a mental disorder; most commonly personality disorders,
schizophrenia/related psychoses, depression and substance use (McEwan TE et al; 2009: Mohandie K et al;
2006). Stalkers can be more likely to have a history of disrupted childhood attachment but little else is found
as diagnostic factors contributing specifically to stalking behaviour

In the context of mental illness, Kienlen et al. (1997) found that nearly one-third had a psychotic disorder and
were delusional. Non-psychotic mentally ill stalkers tended to have a range of diagnoses (depression,
adjustment and substance use) including Axis II disorders. While various psychological drivers including
anger, hostility, jealousy, blame, obsession, dependency, minimization and denial were identified, of interest
was the fact that the psychotic subjects in the cohort visited the victims’ homes more often, although nonpsychotic
stalkers tended to make more verbal threats and act more violently. Psychosis stalkers can often
have ‘intimacy seeking’ or ‘resentful’ motivations; while those with personality disorders, depression and
substance misuse are more commonly ‘rejected’, ‘resentful’ and ‘predatory’ stalkers.

In a significant minority of stalkers the behaviour is directly related to psychotic symptoms (usually paranoid
or erotomanic) and should resolve once the psychosis is adequately treated both psychologically and
pharmacologically, with some limited legislative/criminal intervention. For a bigger proportion of stalkers, the
mental illness may have contributed to the onset and maintenance but is indirect or complicated by other
factors and may require more than just health related interventions

Question 14

Important history/examination to consider for stalking-> admissioin to hospital

Answer 14

relevant details of stalking behaviour,
including longitudinal aspects (onset and how it has developed over time) and current psychotic symptom
presentation, impact on his functioning (both psychosocial and physical functioning), history of psychosis (30% psychosis),
substance abuse (worsening, +risk), personal history especially on signs of conduct disorder, forensic history-> antisocial PD
stressors leading to presentation and
this review, the patient’s goals for the admission, recent threats of harm to magistrate, its triggers and the
intent behind it, impulsivity, history of aggression and offending behaviour, history of substance misuse but
recognises minimal use as important to current level of risk; demonstrating awareness of legal aspects of the
situation and any associated statutory obligations
broader risk assessment with issues such as long term impulsivity, risk to
others, triggers and protective factors.