Structured Professional Judgment (SPJ) Violence Risk Case Formulation and Psychopathic Personality Disorder | International Journal of Forensic Mental Health | 2022, Vol. 21, No. 1, 20-36
Dylan T. Gatner; Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada; Forensic Psychiatric Services, BC Mental Health and Substance Use Services, Vancouver, British Columbia, Canada
Kevin S. Douglas; Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada; Helse Bergen Sikkerhet Kompetansesenter, Bergen, Norway; University of Oslo, Oslo, Norway
Stephen D. Hart; Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada; Department of Psychology, University of Bergen, Bergen, Norway
P. Randall Kropp; Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada; Forensic Psychiatric Services, BC Mental Health and Substance Use Services, Vancouver, British Columbia, Canada
The bivariate, empirical association between psychopathic personality disorder (PPD) and violence has been well established. Yet, questions remain about how to explain why this association occurs. To address this conceptual gap, we presented a review of theories of violence related to PPD. Next a conceptual analysis of how psychopathic traits may influence violent decisions was conducted. Specifically, we systematically analyzed how Comprehensive Assessment of Psychopathic Personality (CAPP; Cooke et al., International Journal of Forensic Mental Health, 11(4), 242–252, 2012) traits influence violence from a structured professional judgment (SPJ) theory of violence known as SPJ decision theory. This conceptual analysis clarifies how various CAPP traits may motivate, disinhibit, or destabilize violence. Implications include the role of causality and clinical applications of violence risk case formulations.
Violence; risk assessment; psychopathy; case formulation; personality disorder
Summary of the Research
“…PDD [psychopathic personality disorder; psychopathy] broadly includes emotional, behavioral, and interpersonal deficits…including, but not limited to, callousness, low empathy and emotionality, poor behavioral controls, rule violations, disruptiveness, and irresponsibility…As such, it is not unreasonable to assume that violence and psychopathy co-occur, and the empirical literature would support this claim…Although psychopathy may hold only moderate statistical weight from a violence prediction perspective, the disorder remains a central consideration in violence risk management and certain forensic evaluations…Beyond violence prediction, assessing psychopathy can inform case formulations and the intensity of risk management recommendations…But how precisely does the putative psychopathy-violence mechanism function? We attempted to address this important question by conducting a conceptual analysis using a theory of violence to explain how people with PDD act violently. We aimed to inform mental health professionals’ violence risk case formulations when PPD traits are clinically relevant…” (p. 20).
“…In the current review, the model of psychopathy was operationalized using the Comprehensive Assessment of Psychopathic Personality (CAPP; Cooke et al., 2012). Each of its enumerated PPD traits were analyzed as to whether they might influence violence through the case formulation approach known as SPJ [structured professional judgment] decision theory…It was our aim that this conceptual analysis would address calls for clarifying a logical connection between mental disorder and violence…all 33 CAPP traits were analyzed to determine if each trait could be conceptually identified as a motivator, disinhibitor, and/or destabilizer of violence based on the SPJ decision theory…” (p. 22-24).
“…The analysis revealed frequent and diverse functional pathways between CAPP and violence, suggesting that psychopathic traits motivate, disinhibit, and destabilize decisions to act violently…31 of 33 CAPP traits had a plausible causal link to violence…CAPP traits were equally motivating and disinhibiting (14 traits each), whereas CAPP traits were most frequently identified as destabilizing violent decisions (16 traits). Despite the large number of destabilizing traits, these deficits seem conceptually less extreme than the influence of prototypic destabilizers like psychotic symptoms…At the domain level, the strongest motivators of violence were captured by the CAPP Dominance and Self domains…the Dominance and Self domains include explicit interpersonal exchanges – such exchanges have been identified as strongly contributing to violence…where something can be won or obtained…the central destabilizing traits from this conceptual analysis were captured by the CAPP Cognitive and Self domains…a pattern emerged from our analysis suggesting that the Self domain was the common thread between motivators, disinhibitors, and destabilizers of violence” (p. 27-28).
“At a trait-level, the conceptual analysis revealed that individual CAPP traits influence violence decisions in various ways by motivating, disinhibiting, or destabilizing these decisions. In reviewing this analysis, relevant CAPP traits varied in their theoretical closeness to these violent decisions…A clear pattern emerged that certain CAPP traits have strong conceptual overlap with disinhibiting mechanisms, suggesting these traits may have a strong causal role in violent decisions. Although motivators seem to be a generally necessary component for violence, strong motivators for those with PPD may be less salient with a relevant disinhibitor is directly and causally related to violence (e.g., Unempathic). This might help explain why criminal versatility, which includes versatility in violence, is associated with PPD…because diminished inhibition may augment indiscriminate violence…Aggressive and Garrulous were the only two CAPP traits that did not exhibit any clear or possible causal relation to violence…Conceptually, these [traits] may reflect general patterns of dysfunction rather than personality traits or proclivities….Although CAPP Garrulous was not identified as directly causing violence, it may still be pathological...psychopathic traits (e.g., Garrulous) can also be important features of the disorder without being associated with or causing violence…” (p. 28-29).
Translating Research into Practice
“…Interventions might target any of three areas: (a) the CAPP trait, (b) dysfunction (i.e., violence), or (c) the functional link between the two. With this premise in mind, these identified traits may be higher priority intervention targets given that the trait-mechanism-dysfunction association has strong overlap. It is possible that a single intervention might be able to influence more than one PPD-violence area…For clinicians in high-risk correctional and forensic settings, this analysis has clear application to improving violence case formulations...Clinicians need to specify psychopathic traits or symptoms-the current analysis provides a framework for such specification. Formulating violence risk at a granular or symptom level of PPD can improve clinical utility by specifying relevant management targets and mechanisms for future violence. This approach may also benefit clinicians who do not comment on diagnosis during their violence risk or threat assessments or for those forensic mental health professionals working in settings…where PPD prevalence is lower…mental health professionals may improve their violence risk assessment opinions by considering the role of CAPP Self and Dominance traits in violent behavior” (p. 28-30).
“…the findings from this CAPP-violence decision theory framework may serve as a map to help clinicians identify relevant and idiographic risk management targets…Nomethetically, the current findings suggest that motivators may have most direct causal role on violent decisions, and so professionals might emphasize CAPP traits serving as motivators in their specific formulations…All mechanisms of violence require management, but motivators may be the first priority. Professionals might also prioritize treatment targets around those psychopathic traits and decision theory mechanisms that are conceptually overlapping. For instance, Lacks Concentration is both a CAPP trait and mechanisms that destabilizes violent thinking. Treating and managing this specific mechanisms may influence two areas of concern: the trait and the mechanism of dysfunction that converts the trait into a symptom vis-à-vis violence…” (p. 30).
“Future research should include surveying subject matter experts for consensus ratings of CAPP-violence functional links. This alternative approach to the present conceptual analysis could provide empirical data on the reliability and validity of CAPP-violence causal links via an SPJ framework. Such expert ratings may clarify the relative strength of causal links – a topic not explored in the present analysis” (p. 32).
Other Interesting Tidbits for Researchers and Clinicians
“…One particular theory underpinning violence risk case formulation is known as action or decision theory…Broadly, action theory asserts that all human action is, to some degree, intentional and is influenced by mental states…Action theory has been applied to psychological perspectives…and criminological theories of violence and crime. One such criminological theory is situational action theory of crime (SAT)…which is an attempt to address causal explanations of moral behavior. SAT defines crime as one of many actions that occurs because of action-relevant moral rules…self-control, and emotions…SAT assumes that (a) people make choices to act violently or criminally; (b) these choices can only be enacted when it is perceived as viable; and (c) these choices vary from deliberate to habitual. Bounded rational choice (BRC; Felson, 2009) is another criminological variant of action theory. BRC assumes that all violence is a product of instrumental (i.e., goal-directed) and rational choices. This form of rationality…is defined by the capacity to reason-irrespective of accuracy…” (p. 21).