Threat Assessments

[BuckeyeLove]

Anyone on here completed any of these? We've recently gotten an influx of referrals for them through a few school districts looking to contract. Looks like the work done out of UVA represents best practice, but the literature base still seems somewhat thin. I put a message out the other day on the psylaw listserv looking for anyone that has done them, so figured I'd throw one out here too.

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[Therapist4Chnge]

I get requests here and there for them (there is typically a brain injury on top of whatever else is going on legally). I decline them bc the literature seems limited at best, though hopefully a forensic person can speak to it more completely.

 

[PsyDr]

I did a few on fellowship. Not happy my name was on them.

My general opinion is that the setting and population really defines how willing I am to opine. In a court setting, I am fine with giving a strict opinion based upon available evidence. I don't deviate, extend, or otherwise compromise my opinion. Something like, "based upon the literature, and this person's responses to X instruments, they would be classified under the category of Y according to Z.". Worst case scenario, the person does something and I have confined my opinions to things that can be readily reproduced.

For a different setting, I am not willing to do this. Even if I pull the nerdy professor who only presents data, a skilled litigator would have no problem putting damages on me for either side: person gets expelled/fired and sues for damages, person is not identified and many sue for damages.

 

[Justanothergrad]

Behavioral prediction is not an arena of assessment I want to be in personally because of the crappy lit on it. PsyDr sums up how I would approach it, if I were to do them. Still wouldn't want to do it.

 

[BuckeyeLove]

a skilled litigator would have no problem putting damages on me for either side: person gets expelled/fired and sues for damages, person is not identified and many sue for damages.

Could you expand on this a little, because it has also been my main (catastraphizing) concern. The little that I have looked at into it (of which was circumscribed to school stuff), it looks like the onus isn't on the psychologist in making a prediction on how likely this person is to engage in the act [in fact, the authors as I mentioned out of UVA really seem to stress that this is not a violence risk assessment at all], but rather, a multi-systems approach to mitigation and prevention subsequent to a made threat. So in terms of the psychologist's role, psychiatric assessment of any present symptomatology, as well as finding out what happened that led to the threat and addressing those areas through recs for treatment, potential mediation or non-mediation, etc. It seems like you would be able to do a good amount of qualitative hedging (i.e., consistently falling back and framing opinions based on the available evidence, always being transparent with one's limitations, etc), in order to make sure that if something were to happen, the finger couldn't be pointed back your way with merit. Based on the one's I've looked at, it doesn't look like at any point in the eval one would be proffering opinions such as, "This person is at a high risk, moderate risk, low risk for engaging in the threat behaviors." But at the same time, part of me thinks if an attorney is going to find something, they are going to find something, regardless of how much one qualifies their opinions, especially if people get hurt.

 

[Fan_of_Meehl]

In general (outside of specialty practice contexts), I think that people/agencies trying to get you to do a 'threat assessment' or 'write a note' to 'clear' a person to engage in x, y, or z activity appears to be a primitive attempt to pass along responsibility/liability of the decision to you as a third party. You'd be amazed (or maybe you wouldn't) to witness the number of such requests that spontaneously arise out of a VA outpatient psychotherapy practice (with everyone wanting you to 'write letters' to certify this or that).

As a non-forensic person, I'll pass on that one every time--if necessary, citing conflict between treatment and forensic roles (if they are a client of mine) and/or citing the lack of empirical support for the practice, generally.

 

[DrTisMe]

In general (outside of specialty practice contexts), I think that people/agencies trying to get you to do a 'threat assessment' or 'write a note' to 'clear' a person to engage in x, y, or z activity appears to be a primitive attempt to pass along responsibility/liability of the decision to you as a third party. You'd be amazed (or maybe you wouldn't) to witness the number of such requests that spontaneously arise out of a VA outpatient psychotherapy practice (with everyone wanting you to 'write letters' to certify this or that).

As a non-forensic person, I'll pass on that one every time--if necessary, citing conflict between treatment and forensic roles (if they are a client of mine) and/or citing the lack of empirical support for the practice, generally.

Here's my take on this - having worked for a large community agency where they were constantly trying to get me to do things that were way above my paygrade (custody evals, threat assessments etc). The reason they want you to do this is because that signature - Dr. BuckeyeLove, Ph.D. (or Psy.D.) means something. It means that you have attained sufficient knowledge and training to be considered an "expert." That knowledge and training cost you a lot of money, time, effort, and opportunity costs. That signature of yours is therefore quite valuable. In order to retain its value, you want to make sure you never do anything that will jeopardize it (like getting involved in a high-profile case where you were the idiot that said this kid is not a threat, before he blew up half of Texas or wherever.) So you want to make really, really, really sure that you are being paid so much to do a threat assessment that you will be able to consult a lawyer as necessary, buy yourself top-notch supervision, and make sure you have the time and headspace to follow all best-practices, so you can't be held liable.

Your training is in forensics, so presumably you already know how to do all of this. I had a supervisor who was a forensic psychologist and he used to charge in increments of 1,000.00 for his custody evals - as in - this 1,000.00 is to cover the fact that I have to have a lawyer on retainer, this 1,000.00 is to cover the fact that I have to practice in a building that has extremely expensive security, this 1,000.00 to cover the eval, this 1,000.00 to cover the fact that most custody evals end up giving the people involved heartburn, this 1,000.00 to cover the time it's going to take me to respond to the inevitable Board complaint from whichever party didn't like my assessment, etc.

At the time, I thought he was being so callous. I have learned better. Mostly, what I have learned is that forensics is not for me. I also have learned that I don't want to work for large community agencies that don't have my back and try to pressure me into doing things that are above my paygrade!

 

[smalltownpsych]

In general (outside of specialty practice contexts), I think that people/agencies trying to get you to do a 'threat assessment' or 'write a note' to 'clear' a person to engage in x, y, or z activity appears to be a primitive attempt to pass along responsibility/liability of the decision to you as a third party. You'd be amazed (or maybe you wouldn't) to witness the number of such requests that spontaneously arise out of a VA outpatient psychotherapy practice (with everyone wanting you to 'write letters' to certify this or that).

As a non-forensic person, I'll pass on that one every time--if necessary, citing conflict between treatment and forensic roles (if they are a client of mine) and/or citing the lack of empirical support for the practice, generally.

Yes, they are passing the buck to you, but how is this different from a physician clearing a patient for involvement in sports? In our rural setting, we don't really have the option to refer for a forensic expert, although we will for child custody cases. Meanwhile a kid can't go to school because he wrote a note that said he wants to kill everybody. I actually am seeing one kid who neither I nor the child psychiatrist (who is about two hours away and is the closest psychiatrist) will clear and he is thus being sort of home-schooled. Nevertheless, I have cleared kids in the past even going back to early on in my training and with approval from my clinical supervisor who was quite experienced and clear about liability and legality. I also clear suicidal people to return to their lives on a very frequent basis. Final point to make is that if we don't clear people who make threats, don't you think that the LPCs will and is that a good idea or not?

 

[Fan_of_Meehl]

Yes, they are passing the buck to you, but how is this different from a physician clearing a patient for involvement in sports? In our rural setting, we don't really have the option to refer for a forensic expert, although we will for child custody cases. Meanwhile a kid can't go to school because he wrote a note that said he wants to kill everybody. I actually am seeing one kid who neither I nor the child psychiatrist (who is about two hours away and is the closest psychiatrist) will clear and he is thus being sort of home-schooled. Nevertheless, I have cleared kids in the past even going back to early on in my training and with approval from my clinical supervisor who was quite experienced and clear about liability and legality. I also clear suicidal people to return to their lives on a very frequent basis. Final point to make is that if we don't clear people who make threats, don't you think that the LPCs will and is that a good idea or not?

Good topic for discussion and I see your points. However, one recent anecdote involves (hypothetically) a client who, for example, wants a 'letter' to 'clear' them to get employment as a firearms instructor despite being service-connected for PTSD (at a high percentage). This was apparently a request from an 'supported employment' type person who decided, on their own initiative, that they needed a letter from 'their doc' 'clearing' them to pursue this career path. I do want to help my patients when I can but I am not comfortable 'firing off a letter' basically saying 'they'll be fine' or 'they ain't a threat.' I spent a little time doing due diligence and looking up the 'threat assessment' literature (what there is out there) and the most comprehensive account I found was from a forensic psychology textbook and--in addition to the usual legal/ethical hedging and caveats--it was notable that the procedure and example they outlined in there involved a bunch of structured interviews, psychological inventory (e.g., MMPI-2-RF) assessment (with validity scales), interview of collaterals, etc...basically, a procedure that (including all the interviewing, testing, and write-ups) would take more than an entire 8 hour day (maybe a day and a half to two days) to complete. Having hit the literature, I consulted with colleagues (who also do not write such letters (for reasons we discussed)), and awaited further clarification from the 'employment services' person regarding what issues, in particular, they were wanting 'cleared' with a 'letter.' In the meantime the client was involved in a domestic violence situation, the cops were involved, he was arrested and charged with a domestic violence related charge. I felt like I dodged a bullet on that one, so to speak. After reading the literature on threat assessments, I simply don't feel that I have the time, experience, or expertise (and it's also a role conflict that can harm the therapeutic relationship) to properly conduct such assessments in a scientifically reliable or valid fashion. Simple as that. I am sure there is a diversity of opinions on this issue and I have no doubt that the area one practices in (rural vs. urban) where alternative professionals who specialize in forensic assessments are more (or less) available factors into the decision-making.

 

[erg923]

Good topic for discussion and I see your points. However, one recent anecdote involves (hypothetically) a client who, for example, wants a 'letter' to 'clear' them to get employment as a firearms instructor despite being service-connected for PTSD (at a high percentage). This was apparently a request from an 'supported employment' type person who decided, on their own initiative, that they needed a letter from 'their doc' 'clearing' them to pursue this career path. I do want to help my patients when I can but I am not comfortable 'firing off a letter' basically saying 'they'll be fine' or 'they ain't a threat.' I spent a little time doing due diligence and looking up the 'threat assessment' literature (what there is out there) and the most comprehensive account I found was from a forensic psychology textbook and--in addition to the usual legal/ethical hedging and caveats--it was notable that the procedure and example they outlined in there involved a bunch of structured interviews, psychological inventory (e.g., MMPI-2-RF) assessment (with validity scales), interview of collaterals, etc...basically, a procedure that (including all the interviewing, testing, and write-ups) would take more than an entire 8 hour day (maybe a day and a half to two days) to complete. Having hit the literature, I consulted with colleagues (who also do not write such letters (for reasons we discussed)), and awaited further clarification from the 'employment services' person regarding what issues, in particular, they were wanting 'cleared' with a 'letter.' In the meantime the client was involved in a domestic violence situation, the cops were involved, he was arrested and charged with a domestic violence related charge. I felt like I dodged a bullet on that one, so to speak. After reading the literature on threat assessments, I simply don't feel that I have the time, experience, or expertise (and it's also a role conflict that can harm the therapeutic relationship) to properly conduct such assessments in a scientifically reliable or valid fashion. Simple as that. I am sure there is a diversity of opinions on this issue and I have no doubt that the area one practices in (rural vs. urban) where alternative professionals who specialize in forensic assessments are more (or less) available factors into the decision-making.

I am also in the VA, as I think you know. I am in primary care, which gets just as hard if not harder by similar requests.

My approach is simple, and I hope both appealing and ethical. I will write brief, factual testaments. No opinion. Only documented facts (presenting issues, number of sessions attended, etc).

 

[Fan_of_Meehl]

I am also in the VA, as I think you know. I am in primary care, which gets just as hard if not harder by similar requests.

My approach is simple, and I hope both appealing and ethical. I will write brief, factual testaments. No opinion. Only documented facts (presenting issues, number of sessions attended, etc).

Thanks, erg...this is a useful approach, I think. Sticking to the facts. I know that there's some policy somewhere (at VA) stipulating that we, as providers, must (upon request) put certain bits of information in the chart in writing such as diagnosis, symptoms, treatment plan, expected future course of illness, etc. I suppose I would be concerned about what the expectations/understanding of the requesting client and/or the third party recipient would be in terms of receiving such a factual letter in the context of a request to 'clear' a person to engage, say, in a return to duty as a police officer, for example. From a certain point of view I suppose it could be said that their expectations/understanding of what the letter means is beyond my control, but I'm not up on any case law concerning this practice. By the way, has anyone had any experience conducting 'fitness for duty' evaluations for a police officer post-employment (e.g., after being placed in off duty status subsequent to an acute inpatient hospitalization for mental illness and/or homicidal or suicidal ideation?). If anyone does engage in such assessments, what are some of the things that you look at? Measures used and principles followed? Good discussion, so far.

 

[smalltownpsych]

Thanks, erg...this is a useful approach, I think. Sticking to the facts. I know that there's some policy somewhere (at VA) stipulating that we, as providers, must (upon request) put certain bits of information in the chart in writing such as diagnosis, symptoms, treatment plan, expected future course of illness, etc. I suppose I would be concerned about what the expectations/understanding of the requesting client and/or the third party recipient would be in terms of receiving such a factual letter in the context of a request to 'clear' a person to engage, say, in a return to duty as a police officer, for example. From a certain point of view I suppose it could be said that their expectations/understanding of what the letter means is beyond my control, but I'm not up on any case law concerning this practice. By the way, has anyone had any experience conducting 'fitness for duty' evaluations for a police officer post-employment (e.g., after being placed in off duty status subsequent to an acute inpatient hospitalization for mental illness and/or homicidal or suicidal ideation?). If anyone does engage in such assessments, what are some of the things that you look at? Measures used and principles followed? Good discussion, so far.

My colleague here does fitness for duty for law enforcement, but I have declined those. He generally just uses an interview and an MMPI is my understanding. Haven't actually seen one of the reports so can't elaborate further.

I also follow erg's strategy of just reporting facts and observations of behavior. I tend to stick with that philosophy for any of my documentation and discussions with patients and others whether family members or treatment team members who tend to be the worst at jumping to erroneous conclusions. "So did the patients actually say that?" is one of my favorite lines to used those situations.

At a conference I attended, Dr. Linehan conducted a great exercise to illustrate this point, and had a whole room full of clinicians making ass-umptions of themselves. She stood in front of us making various faces for about ten seconds with instructions to observe and describe what we saw. I was surprised at how many people saw her being angry or feeling bored or thinking this or that. It made me wonder what setting and populations they were working with as I have learned that making assumptions or inferences can get you into a lot of trouble.

As far as what verbiage I will put in reports, I tend to stick to something along the lines of there is not sufficient evidence to take away basic civil rights as there is no clear evidence that they present an imminent danger; however, due to unforeseen stressors or patient needing to present in a positive light it is impossible to predict with a reasonable degree of certainty future behavior. Here are the risk factors and here are the protective factors. The final decision is ultimately yours (school or employer) and responsibility for monitoring if situation changes yours too. In other words, I try to kick the can back to them a bit.

 

[AcronymAllergy]

I regularly have requests for capacity evaluations, which is of course a bit different than a risk assessment. These I don't mind, as I have experience with them and there's a generally accepted framework for abilities necessary to demonstrate decisional capacity. Relatedly, I've had a handful of requests from prior patients asking if I could write a letter stating that they have the ability to manage X, Y, or Z (e.g., their finances). If my evaluation with them has been recent and supports such a letter, I'm happy to provide it. If not, I'll let them know and tell them why. If I had a request for a risk assessment or to "clear" someone, my reply would likely be akin to erg's; anything more than that would be outside my competency.

 

[WisNeuro]

I regularly have requests for capacity evaluations, which is of course a bit different than a risk assessment. These I don't mind, as I have experience with them and there's a generally accepted framework for abilities necessary to demonstrate decisional capacity. Relatedly, I've had a handful of requests from prior patients asking if I could write a letter stating that they have the ability to manage X, Y, or Z (e.g., their finances). If my evaluation with them has been recent and supports such a letter, I'm happy to provide it. If not, I'll let them know and tell them why. If I had a request for a risk assessment or to "clear" someone, my reply would likely be akin to erg's; anything more than that would be outside my competency.

I recently had a younger guy who bombed validity testing and was bottomed out ask for a letter that they could manage their own finances. As you said, had to have a conversation stating that based off the test data, it would actually suggest that he probably could not manage his finances. He went elsewhere for his letter.

 

[BuckeyeLove]

In other words, I try to kick the can back to them a bit.

This. Absolutely this. I never ever ever phrase anything as an absolute in my evaluations, and always qualify my opinions on the available evidence. Recently I've met a few evaluators that have got into the habit of saying "defendant has a 95% chance to reoffend" and I shutter at what a paid attorney would do on cross to these people. What I've found with the few referrals I've had for these, in conjunction with many other capacity assessments (most recently I've had an influx of firearms restorability referrals) is that just as with a competency to stand trial or sanity eval, I'm never being asked to proffer ultimate issue opinions, nor do I ever ever proffer opinions regarding the ultimate issue being addressed in any of my evals anyway (i.e., Dude WILL or WILL not be violent, Kid WILL or WILL not blow up school, Dude WAS sane at the time, Dude IS competent to stand trial, etc.). Consequently, with regards to that can being in my court, if it was ever in my court, it is clearly stated multiple times throughout my evaluation that it never really was, and I was never specifically asked to look at the can to begin with, and also that it is outside the scope of psychological science to opine on absolutes in relation to the can; but rather, what we can offer, based on the available evidence about the can, are opinions on issues that may be important in regards to having an understanding of the can's identifiable risk factors, capacities, etc..., always offered to a reasonable degree of psychological certainty. Sorry for the overload on the can analogy.

 

[BuckeyeLove]

I can't thank you all enough for your thoughts and input on this subject!