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Therapeutic intervention – an option in the case management
AETAP Conference (Association of European Threat Assessment Professionals)
April 20-23, 2009, Berlin, Germany
Werner Tschan, M.D.
http.// AbstractTherapeutic intervention – an option in case management Therapeutic interventions in violent and/or threatening behavior are based on a comprehensive assessment. Thetreatment of ers an option for the (potential) of ender and helps to overcome the “tunnel vision”, that violence is theonly solution. As a more long term consequence individual conflict resolving strategies and social skil s are improved,which then contribute to non-violent behavior. In general, the earlier the intervention, the bet er the result. Based oncase examples the speaker discusses possible strategies, limits and common problems.
Using the cops to crack crime is like taking aspirin for a brain tumor. Philip Marlowe, quoted in Gil igan,2001.
This paper is an exploration of possible approaches in dealing with threatening of enders. The presentedapproach is not yet ful y approved, rather it is a vision on how to handle a dif icult subject, based onpractical experiences (see Tschan 2009).
In most cases, a person on the path to violence is blinded by tunnel vision, that violence is the only optionto solve their problems and/or to overcome their grievances. In these cases therapeutic interventions maycontribute in expanding this tunnel vision by providing other options. However, therapeutic interventionsshould not be regarded as a last resort; e.g. when nothing else works, then final y one could try thisapproach; rather it should be used as early as possible and may then contribute in avoiding violentoutbursts. The therapeutic approach should provide conflict solutions before violent incidents take place.
A man in his forties was left by his wife. He found it difficult to cope with this situation. He felt that his onlyoption was to kil his wife, his two children, and then himself. The same evening he talked with his brotherand let slip his intentions. The brother insisted that he immediately goes to see a therapist.
Confronted with this issue the therapist should first reassure this man that he has made the right decisionin coming to seek help. The next step is to negociate a contract between the therapist and the client onhow to prevent a lethal outcome; e.g. by asking: “what do you expect from coming to see me?” This helpsin establishing a cooperative approach. Often the biggest step in overcoming the tunnel vision by thesimple decision to seek help.
The main dilemma for the therapist is how to weigh up the potential danger of the client and securityconcerns of potential victims. The most straightforward way to tackle this problem is to receive thepermission of the client to inform his potential targets (which is simultaneously a sign of how cooperativethe client is).
Part of this first meeting is to establish the whereabouts of possible weapons and their removal to a secureplace. The focus of this intervention is put on suicidal intentions rather than their potential to harm others,as this makes it easier to negociate a positive outcome. Another important issue at this stage is to provide avision of the future based on the therapeutic al iance: it is possible to overcome these grievances and toregain a good quality of life.
One of the first tasks during the therapeutic intervention is to decide whether someone is on the path toviolence (see il ustration below); and if so; at which stage that person is. It makes a huge difference, ifsomeone has already purchased a gun or not. The path to violence is il ustrated in the fol owing figure.
The acting out process: the path to violence The assessment is not primarily a finding of facts; rather it is carried out in a col aborative way to decidewhether someone is cooperative or not in preventing violent acts. Therapists should keep in mind the limitsof any therapeutic approach. Line number one indicates the area up to where therapeutic interventions areappropriate; as long as the person is within the “grievance” zone. The closer someone is on the path to“action”, the more essential it becomes for law enforcement and security divisions to be involved. Linenumber two indicates, when someone crosses from “planning” to “ preparation” the situation becomes verycritical, where therapeutic interventions are no longer possible.
An involuntary hospitalization due to threat to oneself or to others may be indicated; but in any case lawenforcement should be involved at this stage. The information of potential victims is also critical at this point– if the of ender does not give permission to contact potential targets confidentiality should be overruled bycontacting health care regulating authorities, which can give permission to health care professionals toinform third parties under such conditions.
Various tools are available for the practical risk assessment. Gold standard today is based on a structuredinterview using methods such as DyRiAS or WAVR-21.
Treatment approach
Healthcare professionals offering treatment in violent cases require two different approaches – one is thetraditional therapeutic intervention, the other is ongoing risk assessment (Tschan 2009). The treatmentapproach is goal oriented. The first and most immediate intervention is the de-escalation of the currentsituation. The more professionals can achieve in establishing the therapeutic al iance the better the chanceof a positive outcome.
The clinical needs for intervention in violent cases are primarily defined by the fact that the goal of theclinical work is always directed towards the clients. Clinical interventions should help contribute to stoppingany form of violence (primary prevention). They should also help prevent violent outbursts and minimizecol ateral effect of the violence experienced on health conditions and quality of life (secondary prevention)(Tschan 2009). However, threat management is often difficult to define, both in terms of the magnitude ofviolence that is to be expected and how individuals wil be affected by this (Tschan 2009).
Any therapeutic intervention leads to the “intervention dilemma”, which outlines the possibility that theintervention can increase the risk of violent outbursts dramatical y (Tschan 2009). Defensive interventionstrategies focus on the victim’s side; whereas offensive strategies focus on the offender’s side.
Limits and common problems
The main limits are il ustrated in the previous il ustration – when the line between fantasy and reality iscrossed the involvement of law enforcement is imperative. In case of threatening behavior therapeuticinterventions are only possible as long as the client is cooperative. It must be clear, that therapeuticinterventions cannot prevent al acts of violence. The cooperation between law enforcement, justicesystem, and therapeutic professionals is crucial; a common training is essential to overcome the singledisciplinary view. It helps to clarify the various approaches and limits of each of the involved disciplines.
The goal is, that al involved professionals are trained in using the same language: violence is not acceptedas a conflict solution strategy.
The goal is, that al involved professionals use the same language: violence is not accepted an acceptedoutcome in personal conflicts. Treatment offers new strategies to potential offenders and helps to overcometunnel vision. Treatment should be carried out “with” the client, not against him, to be effective. Humanattachment always plays an important role in al forms of interpersonal violence. Any commitment to closesocial bonding is considered as an important protective factor against violence. Therapeutic interventionand risk assessment go hand in hand in violent cases. The short term accuracy of clinical risk prediction isgeneral y high and decreases over time. Therefore the risk assessment is more a process and not just asingle event.
Case management always faces the intervention dilemma, where any form of intervention may lead to adramatic escalation of violence. Defensive strategies are directed towards the victims, whereas offensivestrategies are directed towards offenders. A path to violence always exists where interventions arepossible. When you consider therapeutic intervention as an option in case management of violent andthreatening behavior, you should compare this approach with avalanche prevention. You wil then clearlyrealise that the earlier you intervene, the better the outcome wil be. Then, therapeutic intervention aretruely an option! References
Dutton D.G.: Rethinking domestic violence. Vancouver, UBC Press, 2006.
Gavaghan C.: A Tarasoff for Europe? A European Human Rights perspective on the duty to protect. International Journal of Law andPsychiatry, 2007;30:255-267.
Gil igan J.: Preventing Violence. New York, Thames and Hudson, 2001.
Mil er W.R., Rol nick S.: Motivational Interviewing. Preparing People to Change Addictive Behavior. New York, Guilford, 1991.
Tschan W.: Assessing the clinical needs for stalking and domestic violence. In: J.L. Ireland, C.A. Ireland, Ph. Birch (eds.): Violent andSexual of enders. Assessment, treatment and management. Cul ompton, Wil an, 2009, pp. 132-149.
Van der Hart O., Nijenhuis E., Steele K.: The Haunted Self. Structural Dissociation and the Treatment of Chronic Traumatization. NewYork, W.W. Norton, 2006.
I appreciate the work of native English speaking Clare Kenny who improved the style of this handout considerably.



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