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Hey everyone. Welcome back. Glad to be here and excited to have my guest here today.
Dr. Alex Rodrigues is a licensed psychologist who completes various high-stakes and forensic evaluations throughout the U.S. He regularly consults with legal and community stakeholders on matters [00:01:00] related to mental illness, violence prevention, and online safety. Alex regularly provides expert testimony in court and presents to a variety of audiences, including non-clinicians, attorneys, and community members.
We are talking all about threat assessment today. We’ve discussed threat assessment on the podcast before but I would say more on a micro-level in terms of what’s involved in the assessment process. Today, we take a little bit more of a macro perspective where we zoom out, we look at some of the societal and cultural factors around threat assessment, and the value of multidisciplinary teams. We talk about the distinction between different types of threats and risk factors for violence among many other things.
This is a relevant episode and one that you will take a lot of information from.[00:02:00] Another cool thing about Alex is that he has a project called Digital Birds & Bees that he teaches about online safety and so forth for adolescents and kids. So I will provide a link to that in the show notes and encourage you to go check it out. It’s a really cool thing that I think is super helpful for kids these days as they say.
All right, before we jump to the conversation, I of course, invite any of you who would like some support with your practices to check out The Testing Psychologist mastermind groups. You can get more information and schedule a pre-group call at thetestingpsychologist.com/consulting.
All right, let’s get to my conversation with Dr. Alex Rodrigues.[00:03:00] Alex, hey, welcome to the podcast.
Dr. Rodrigues: Thanks so much for having me. Delighted to be here.
Dr. Sharp: Glad to be chatting with you for a number of reasons. One, just nice to talk to another Colorado person. We’re mostly a stone’s throw apart, down the interstate.
Dr. Rodrigues: In my defense, I was grandfathered in via my wife. She’s a native.
Dr. Sharp: Okay. That’s fair. Whatever it takes to get here. It’s a nice place to be. So that’s one reason. Another reason, of course, is that the topic is super important and not something that we’ve discussed a lot on the podcast. I’m excited for the direction we’re going to take here with the conversation. So thanks for being here.
Dr. Rodrigues: Absolutely.
Dr. Sharp: I’ll start the way that I always start, which is, of all the [00:04:00] things you could spend your time doing in your life or your practice, why this?
Dr. Rodrigues: Well, as you already hinted at, unfortunately, it’s a very timely discussion, specifically here in the US, it’s often described as an epidemic in terms of targeted violence, more colloquially referred to as school attacks or workplace shootings. What I hope to convey in our conversations today is the vital role that clinicians can actually play in preventing targeted violence.
I think out of all the work I do and I do a lot of forensic evaluations and such, this to me feels like where I can have likely the greatest impact, where I can perhaps do some measurable good.
Dr. Sharp: That’s important. I think that’s why a lot of us do what we do. Sometimes it’s hard to know if we are changing anything or not, but [00:05:00] you’re right. This is really important and impactful.
I would love to start with some background definitions, terms, so we’re going to be talking about a lot of different things. I will absolutely use the wrong terms just from not living in this world. I’m curious, threat assessment, workplace violence, anything you feel would be helpful to define at the beginning, let’s do that.
Dr. Rodrigues: Yes, absolutely. I think your confusion is totally justifiable because in preventing threats and preventing school and workplace violence, we’re often coming at it from a multidisciplinary approach and we see each field has its own language to relate or describe the same experience or phenomenon. Some of the language that gets used interchangeably while it overlaps, they are discrete constructs. They are discrete [00:06:00] ideas.
For instance, violence can be the intent to harm someone. That could be manifested in a series of ways that could obviously be a verbal threat but it could also be physical aggression, gun violence- violence that could be facilitated or perpetrated via a firearm. That can include both suicide, which would maybe colloquially refer to as harm to self, but also using a gun to facilitate violence and attack others.
Also, sometimes thrown into that larger conversation is mass attacks. Mass attacks would be an event in which three or four individuals aside from the perpetrator, are either injured or killed. If we were to already highlight some of these discrepancies, we could have a mass attack that could be perpetrated by gun violence but alternatively, we could also have a mass attack which is carried out via blades, meaning knives, machetes, things of the such or weapons, IEDs.
And then finally, [00:07:00] targeted violence, which is probably where we’re going to spend a bulk of our conversation today talking about, is violence that’s carried out against specific individuals, groups, institutions, organizations with elements of premeditation. Usually, the motivations are perceived grievance by the way, the perpetrator or to affect some type of change.
So this could also incorporate some elements of terrorism as well but I think as long as people keep within their mind, the construct of the idea of instrumental or planned violence, that’s what we’re really talking about. We’re talking about targeted violence.
Dr. Sharp: Mm, that’s fair. I think there are a lot of misconceptions in the media and even among our profession as to how some of these things come about. I’m looking forward to digging into some of these details. [00:08:00] It’s such a big topic to wrap our arms around but I would love to start with this idea of premeditation or planning because that to me lends itself to the assumption rightfully or wrongfully that they might be more preventable. What would you do with that statement or idea?
Dr. Rodrigues: Absolutely, I would say, definitely key to get this out in the early part of the conversation, and I would say you’ve already touched upon one of the key elements that we try to communicate within the threat assessment community to fellow practitioners or lay people. Contrary to popular misconception, attackers, shooters if you will, in some instances, they don’t suddenly snap.
I know for a lot of us, we know the colloquial crude analogy from the 90s of someone going postal [00:09:00] to capture this spontaneous destabilization, but that’s not the case. Additionally, as you indicated, with that planning, more often than not, when we do a post-event analysis, so looking back retrospectively, deconstructing these events, these tragedies, we see that many people had concerns about the would-be attacker beforehand.
Ultimately, if these attacks weren’t premeditated, we would be substantially ill-equipped to prevent them. If they truly were these organic sudden events, we would be in a really poor position to prevent or stop them. Alternatively, because, and this is supported by the research that’s been going on for over 25 years, these attacks do include some element of planning.
And so sometimes the forensic clinician in me, to help paint a picture and draw that distinction, you can think of reactive or [00:10:00] emotional violence would be that sudden response. Imagine you’re somewhere and all of a sudden or maybe not you because you’re a professional and you’re well-conditioned and a pro-social individual, but imagine someone else someone insulting another person’s family, making some crude gesture, and then simultaneously violence erupting.
That’s that reactive sometimes referred to as hot-headed. Conversely, what we’re discussing, the landscape that we’re surveying today is that targeted, premeditated. I imagine some of the audience who’s familiar with violence or forensic work are also familiar with the phrase; instrumental violence. So that’s violence to carry out or facilitate a specific purpose.
Dr. Sharp: I just want to highlight, you said that the research is pretty clear that the majority of the attacks that we hear about involve some element of planning and premeditation, is that right?
Dr. Rodrigues: Yeah, absolutely. Maybe a [00:11:00] good point to provide the empirical findings here is that this is not necessarily me making this up intuitively, the early prevention, early examination, and early study of U.S. school and workplace attacks is carried out primarily and still to a greater degree by the U.S. Secret Service. I imagine some people are probably seeing that as somewhat incongruent. How does the purview of protecting schools fall under the Secret Service?
Dr. Sharp: Sure. That’s surprising.
Dr. Rodrigues: But if you take a second and you dive into what essentially one is doing in the realm of threat assessment, which is, identifying, assessing risks, and then responding appropriately, you start to realize that they’re excellently resourced, excellently trained and skilled to provide such insights.
When we think about their long-term mission of protecting politicians, legislatures, officials, they have to readily distinguish, is someone just [00:12:00] exercising their First Amendment right when they say something that maybe is unhealthy but simultaneously constitutionally provided, or is this someone who’s going to elevate and graduate to some type of physical attack?
I think if you apply that lens, that paradigm of thinking, all of a sudden we start to understand, oh, they probably have a lot of lessons and insights that we can extrapolate and take from.
Dr. Sharp: Yeah, that makes sense. That makes me think of… We’ve already touched on this concept of multidisciplinary approaches to all of this. It seems like there are lots of folks that get involved in these situations, whether it’s like psychologists like yourself, school personnel, if there’s a school issue, or if it’s a student at a school who might be at risk, Secret Service in some cases, or other governmental entities, I’m trying to [00:13:00] formulate the question here.
I think the feeling I’m getting at is that feels hard, like anytime you bring more entities or assessors into a situation, communication is hard. Consistency is hard. How does all that work together as far as you understand in bringing teams together and communicating effectively to assess these threats?
Dr. Rodrigues: Absolutely. I think it is complicated. On the flip side, what I would offer as a reframe is that the problem is so complex that we need those diverse skill sets and that…
Dr. Sharp: It’s a good reframe.
Dr. Rodrigues: Especially because we’re not talking about individuals who necessarily have, for those listeners who are familiar with violence risk assessment, that within a correctional setting, we’re not talking about individuals who have committed violence already. We have them in a controlled environment to some [00:14:00] extent, and we’re extrapolating what their future risk is. We’re talking about a host of people who haven’t acted violently yet, and we have to come up with some really creative ways to manage and intervene.
To go back to the original part of your question, it really emphasizes the piece of a threat assessment management team. We want to be able to have some type of system in which citizens, and concerned parties, can offer referrals, call perhaps a hotline anonymously or not, and provide insights. Then we need some type of standardized system to collect those referrals, to collect those infield requests, assess them, and then act accordingly.
And so if we were to use, for instance, the scenario you offered about perhaps a school. That multidisciplinary threat assessment team is going to call in individuals from a variety of fields. So we’re probably going to have upper-level school administration, [00:15:00] maybe not necessarily attending all the meetings, but ready for consult with the legal professionals just in terms of duty to warn, how to respect students’ privacy versus public safety.
We’re going to also have school counselors. The school counselor or school therapist may not have the additional insight to assess violence but they can speak very intelligently, very coherently about what they’re seeing in the students’ dynamics.
We also want to see law enforcement. I would like to share with that is that law enforcement can provide insight but admittingly, the bar for them to formally intervene and perhaps arrest or charge someone is quite high. And so one thing that we’ve gleaned from the years of study on this phenomenon specifically in schools, is that we should not be waiting for students to break the law to intervene.
If you’ll allow me, the adage that I think about is, it’s much easier to stop a runaway train at 5 miles per hour versus 60. So we want to catch it earlier in the trajectory, [00:16:00] when there’s less harm, less eminence, and we have more tools available to assist. Maybe also sprinkling because we’re talking about school, perhaps just a teacher familiar with the student. And then also trusted community members, stakeholders. Again, it’s this idea that we really want to bring in a multitude of individuals.
Dr. Sharp: Of course. I wonder if we could talk just for a second about what that multidisciplinary approach looks like in the community. I think schools are top of mind for obvious reasons and it’s easy for me to conceptualize what a team approach looks like. Do you have an idea of what that looks like in the community when the individual, I’m not sure what to call this person, the suspected individual?
Dr. Rodrigues: Concerned individual, concerned party, subject, we don’t necessarily have to use things like suspect or would be [00:17:00] attackers. I think just anyone that would raise concern from a community standpoint.
Dr. Sharp: Sure. What’s the process there where there may not be a central entity like a school to serve as the hub for this process?
Dr. Rodrigues: So the school, as you very eloquently pointed out, provides a kind of organic structure, if you will, for a team and implementation. However, if we were talking about concerned citizens, for instance, here in Colorado, we have the Safe2Tell program in which people can make anonymous reporting.
While they may not see it on the front end, looking at it from a civilian perspective, there is a whole back-end back shop of partnerships going on between different government agencies, nonprofits, and mental health providers. They are, I don’t want to say quietly convenient because I don’t want to make it seem covert or nefarious, but kind of working in the back to fill these [00:18:00] reports and develop partnerships and liaisons.
For instance, I want to say, perhaps two weeks ago, I was asked to attend as part of a panel community meeting in Aurora. And we were talking about this topic. Aurora, unfortunately, like many places in the U.S. has this shared tragic history. There were individuals from all sorts of organizations represented there, and much of the conversation was about facilitating partnerships, getting information to the necessary parties, and then even earlier, what we be doing with respect to primary invention.
Dr. Sharp: That’s great. I assume that there was some infrastructure in place. There has to be, I’m just curious what that looks like without the glue, I suppose, of a school. Thanks for diving into that.
We’ve talked a little bit actually already about the predictability or this [00:19:00] pattern or stopping a train early. There’ve been lots of hints at this. Could we dive into the research a little bit around risk factors for attackers, what that looks like, what are we looking for, who are these individuals, et cetera?
Dr. Rodrigues: Absolutely. What have we been talking about but not explicitly saying just yet?
Dr. Sharp: Sure.
Dr. Rodrigues: And I think this is another excellent example about different fields, different professionals using slightly different language. So, for some, they would use language like concerning behaviors or indicators. Maybe a little bit more in the traditional clinical realm, we’re talking risk and protective factors.
What I would offer to the audience is if they would imagine their mind almost like the scales of justice, imagine the scales. What we’re really thinking about are situations where the one side of the scale regarding risky concerning, indicating [00:20:00] is starting to weigh heavy and becoming much more pronounced. Generally, from a qualitative fashion, as we start to see those elements accumulate, for an analogy purpose, think suicide risk assessment, as we start to see more risk factors present in a case, then we’re going to be more concerned. We might elevate or triage that matter.
In terms of the behaviors, in terms of some of the details and the insights that we’ve gleaned over research and I mentioned earlier the U.S. Secret Service, for those listeners who wanted to learn more, the National Threat Assessment Center, which falls under the purview of the Secret Service, they produce pretty regularly reports on school attacks, school safety, workplace, averted school attacks; so those in which someone was perhaps mobilizing or moving towards facilitating attack but something prevented them and some really accessible white papers, not stuff that’s going to be weighed down with a ton of jargon or statistical analysis. [00:21:00] They’re designed for multiple audiences to read.
So there’s no such thing as a school attacker profile. What we’re thinking about is maybe themes, patterns that we’ve seen across attacks, and a lot of this overlaps where they’re talking about school or workplace with just a few distinctions that I don’t honestly think we need to necessarily interject because it will confound.
Most often as we’ve already highlighted is that there was some form of leakage prior to the attack. It has to come from law enforcement because they always have such a cool tactical twist on the things they say, but basically, it’s where someone outside of the attacker becomes aware of an imminent attack, that someone is planning to do something.
In many scenarios, it’s actually leaked by the attackers themselves. So it’s often heard by a friend, a family member, a classmate. In many instances, that individual who receives [00:22:00] that information at first will try to talk the individual out of it, try to provide them direction and guidance.
However, there’s also, unfortunately, a great number of situations where no one does anything with that information.
I’m not by any means projecting blame onto the recipient or the audience to that information. I think that’s actually a challenge where we in the community can do a better job of making sure that the communication lines are open and they know or anyone for that matter, knows where to go with this Intel.
Dr. Sharp: Can I jump in real quick?
Dr. Rodrigues: Yeah, sure. Absolutely.
Dr. Sharp: Because I feel like that’s a story that you hear a lot. There’s always this retrospective look, and it seems like more often than not, that’s the case. Somebody knew something. Somebody heard something. Somebody heard a lot of things, but folks don’t necessarily share that or act on it.
I’m curious, do we know much either from the research or clinical experience around what keeps the recipients of that information from [00:23:00] sharing when they are concerned?
Dr. Rodrigues: Absolutely. I do want to offer a silver lining. We’re getting better at it but there still a tremendous room to grow. From a clinical standpoint, imagine if the audience or a therapist was meeting with a potential attacker and they disclosed something, what I most often hear, in terms of a barrier, is born out of anecdotally with my own experience and some of the work groups I’m involved in, is concerns about privileged communication, confidentiality, violating privacy.
On the school level, that could look like something like PHIPA, questions about HIPAA. I don’t want to be offering any kind of legal advice, here’s my official disclaimer, but in most instances where someone utters an attack against the workplace or school, the receiving audience will be empowered and have sufficient grounds to make the necessary disclosures.
I think also from a student standpoint, I’m also wondering, and this is more a [00:24:00] hypothesis. I don’t want to portray this as part of empirical findings, but I’m also wondering if some students are hesitant because it gets misinterpreted or rolled into this phenomenon of snitching on your classmates. And so I think that brings up, when institutions, organizations, communities are implementing these kinds of hotlines, the importance of maybe having a de-identified system where people can do anonymous reporting.
I think in terms of the barriers; those are some of the chief challenges. And as we’re doing right now in this moment, getting the information, getting if you’ll allow me to red flag knowledge out there, we’ll then empower and position individuals in the community to be able to act accordingly.
Dr. Sharp: Yeah. I think that’s a nice segue, actually, I was going to ask what sort of information, what does this leakage looks like just based on past experience and information.
Dr. Rodrigues: [00:25:00] It usually comes in a variety of ways. If we were to use the Columbine attack as just an example of this. This was a very early attack. I think for much of modern society, this crystallizes the onset of this. And maybe also too, for your listeners, I didn’t say this, but I should offer this caveat.
When speaking about targeted violence, I do my best, sometimes I do make an error where I don’t name attackers. I don’t identify them by names. And the reason being, to go back and highlight some of the research, is that notoriety and infamy are motivations that have been cited by attackers, whether in post-analysis interviews or in their manifestos.
The FBI has long hypothesized that attacks were a vehicle for people who felt that they were unheard to all of a sudden elevate their voice and their identity. And so there’s a host of different organizations, different movements, one that comes to mind is the No [00:26:00] Notoriety Pledge which was started by family members of Aurora victims.
And so I try to do a decent job of not perpetuating the names. Just wanted to put that out there right now, someone was perhaps wondering why is he not saying just the names of the attackers. That’s the reason.
Dr. Sharp: Yeah, that’s fair. Thanks for the explanation.
Dr. Rodrigues: To go back momentarily, we will use the Columbine attack as just a model, and it was very early on. I was not there and I’m still not in a position by any means to Monday quarterback. But that was actually one in which up into about a year before the attack, people had demonstrated concerns. Third parties had brought information about concerning behaviors to district attorney at the time.
There had been early online presence of problematic inflammatory language. In that instance, the attackers originally tried to purchase a firearm [00:27:00] from, I believe a gun shop, but they were turned around because they didn’t have someone older than 18. They said they did return later on. One of the proprietors pointed out, oh, you got someone who’s 18 this time.
More often, I think lots today, we probably see a lot leakage with respect to social media messages, things being sent in emails, that probably capture the majority of what we encounter in terms of leakage or information about a potential attack being disclosed beforehand.
Dr. Sharp: Yeah, that makes sense. It seems like there’s a lot of social media presence in many of these cases.
Dr. Rodrigues: Absolutely, and then it’s added another element particularly kind of morbid element. For instance, we were to use the New Zealand attack where we also are seeing live streaming of violence. And that’s just another element.
But I will say, there’s partnerships that have already been crafted or in the [00:28:00] midst of being constructed to see, hey, what can the tech companies, what can we in the community collaboratively do to prevent that because I think it feeds into this idea or this theory that it perpetuates.
The attackers of Columbine via their act have lived on. I have been far more following their debt, Columbine is frequently cited as inspiration or preoccupation or focus of attackers. That some of the other elements we hear are Neo-Nazis, Adolf Hitler, and things of the such. So again, some of these themes, what we can do to quash them and prevent them from living on in infamy could help in lessening these events.
Dr. Sharp: Yeah, that’s fair. I definitely want to talk about anything we can do on the prevention side. Maybe we can put a pin on that for a second and go back to, I don’t know if we closed the loop on the risk factor discussion, or [00:29:00] I know you said there is a profile, but I wonder if there are any other factors that…
Dr. Rodrigues: Yeah, maybe I’ll just highlight a handful of them and you tell me which ones that maybe double back and do a deeper dive on. So access to firearms, emphasis on access, not exclusively ownership or access to weapons as well. The most often cited reason is a perceived grievance on the would-be attacker’s side.
That doesn’t necessarily mean that a grievance was real. It also doesn’t mean that any subsequent action you carry out is justified, but that is something that’s frequently cited. Individuals or attackers, perpetrators reporting that they were bullied.
We also see a history of adverse childhood events in the homes. Psychiatric illness, if you’ll allow me to put a pin in something, why don’t we put a pin in that one and we come back because that can be very confusing and there’s a lot of misconceptions about that. [00:30:00] Additionally, past mental health contacts, past contacts with law enforcement but not necessarily formal criminal charges.
Those are some other elements that that I would say that as we look at to an individual and also, as I mentioned a few moments ago, this construct of a violent preoccupation, those are a nice grab bag, if you will, of some things to look at.
Dr. Sharp: Yeah, those are good factors. Again, the disclaimer is that none of these are causative or anything like that but items to pay attention to, and characteristics to be aware of.
Dr. Rodrigues: Absolutely. For those audience members who are familiar with forensic risk assessment or risk assessment in general, there’s been no behavior of targeted concern that we’ve been able to identify that we can attribute to one behavior. Human behavior is complex and that rings true for violence and targeted violence.
Dr. Sharp: Yeah. You know, Alex, I was curious, is severe mental illness [00:31:00] related to targeted violence?
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Dr. Rodrigues: I’m so happy you brought that up because I was thinking about that. By and large, and this is large epidemiological research, mental illness in a broad construct, and so I’m going to be talking about symptoms and features, not necessarily diagnosis. I think your participants will appreciate that one can, of course, exhibit features, symptoms or elements, traits related to a disorder but that doesn’t mean that they meet the diagnostic criteria.
We don’t often see formalized diagnoses in attackers. We do see themes of depression. We do see things like suicidality. There are some who have a history of neurodevelopmental disorders. But again, I don’t want to draw a straight line. My suspicion is that if a child has ADHD, it [00:33:00] may make them susceptible to other life setbacks that then further complicate and sends them down a poor trajectory. I don’t want to make it seem like a straight shot.
With respect to targeted violence, we don’t actually often see much of what I refer to as the Tier 1 conditions. So that would be, for me or Tier 1, the way I describe it or the way that I think about it are those disorders that a layperson could look at, and they would see that individual and then immediately recognize something was askew. For me, that’s active psychosis, schizophrenia, bipolar disorder, bipolar 1, the midst of a manic spell.
More broadly speaking, there is a significant but albeit small relationship between severe mental illness and general violence. Okay, so not targeted violence, just in case if people are encountering things or they’re maybe questioning at home right now going well, that doesn’t seem to align with what I know. Again, this comes back to how we define these things. Because without [00:34:00] good definitions, it’s hard to articulate, educate and explore.
The one symptom constellation, which I would say holds a unique potential to be involved in targeted violence is what’s colloquially referred to as a threat/control-override symptoms and psychosis. I don’t know if you’ve necessarily ever heard that.
Dr. Sharp: Mm-mm, no, explain.
Dr. Rodrigues: Sometimes referred to as TCO in shorthand. Most individuals with schizophrenia are not violent. They’re definitely not at risk of committing targeted violence. They’re more often terrified of the public than the public is of them.
The threat/control override, though, has been found to be associated with an increased risk. And what that is, is a sense that experiencing command, auditory hallucinations and feeling compelled to follow them through fear or paranoia about something tragic would happen to them if they don’t, or alternatively, carrying out actions to test their [00:35:00] influence, that’s the threat/control.
And then additionally, if someone believes that their thoughts are being extracted or their behavior is being controlled, those more symptoms, more than a specific diagnosis that holds a unique relationship. For people who are maybe on the front lines or they’re conducting their professional work and they work with people with SMI, that would just be something I would particularly be clued into, doesn’t mean, obviously, that I’m going to flag someone as a risk or an imminent risk, but probably opens up the door for some more inquiry.
Dr. Sharp: Yeah, that makes sense. I just want to honor that this is a complex topic to talk about. There are so many misconceptions and ideas out there about characteristics that may influence the propensity for violence and things like that. And so just a moment to reflect and appreciate your willingness to talk around some of these things [00:36:00] and talk in detail because it can be tricky.
Dr. Rodrigues: I appreciate that. For those audience members who are interested in this subject or interested in this type of work, I would not present myself as, I can readily rattle off names of more prominent, better competent but the gateway for entrance and accessing this material and refining what knowledge set, it’s not a terribly high bar.
I’m not dismissing the importance of being thorough and doing competent work, but clinicians who want to get involved in this work, there are organizations out there. There are resources and I’m going to willing to extrapolate from my experience, we are very much welcomed into the fold. We are valued for what we can bring to the table. I always feel, when I’m meeting with multidisciplinary teams, different stakeholders, that they really are listening to the things that clinicians are sharing.
Dr. Sharp: That’s great. I do want to talk about the actual process, the threat assessment process. [00:37:00] Before we do that though, I’m going to wade into some potentially murky territory and continue this discussion around risk factors, so to speak or characteristics. We do hear a fair amount, especially in recent years, about certain political groups or organizations or internet areas, chat room, things like that. Does that have any influence? Does that play any kind of role here? I’m trying to be tactful.
Dr. Rodrigues: Well, I feel like I’m going to submarine your tackle effort by just being blunt.
Dr. Sharp: Let’s just do it.
Dr. Rodrigues: Feel free to cut your tandem parachute from mine. No, I think exactly what you’re having difficulty articulating is what we, as a society, are having a [00:38:00] really difficult time grasping with. Especially here in the U.S., we put understandably tremendous weight on the First Amendment and protecting government infringement on free speech.
And so we may have individuals that belong, espouse, emphasize messages of certain groups, and they could be on either end. They can be the far right. We could be talking about Nazi Christian Patriot movements, not Christianity, but Christian Patriot movements that espouse a white identity. We can also be talking about the far left, and we can be talking about black bloc, Antifa, or what was previously, was it Weather Underground? I think they were more in the 70s and 80s.
And so I think it’s more, if one is inclined where they’re going to dive into that, they’re going to ask questions about it, which I think is relevant. Also recognizing that the vast number of these keyboard warriors are not going to facilitate violence. [00:39:00] Sometimes like howlers versus attackers, there’s this different language.
I think it’s more important to, on a case-by-case basis, think about what this individual, what this ideology means for them, whether there’s other risk factors as we talked about that are present. I didn’t say this earlier, but this is embarrassing, a history of violence. When you have no, I think that the general rule as first uttered by Thorndike in 1918, if you have no other information and you’re just given a case, past behavior is usually the best indicator by itself of future behavior.
And so more about that, there are cases where people have obviously attacked to carry out some type of grievance along with a political ideology. There was that spree killing in 2014, that was conducted by a man out of San Diego, while he wasn’t particularly identifying as an involuntary celibate, I can define that idea [00:40:00] in a second, it was a lot of those themes about hatred towards women, about being deprived the romantic and sexual interests that he wanted.
What I would say is if you’re looking, if you are presented, if you’re on the receiving end of this information, perhaps of a professional and you’re trying to find out more about an organization, Southern Poverty Law Center, Hate Watch does an excellent job. The FBI, they release annual gang reports. And so there is data out there from a white paper-neutral perspective if you needed to learn.
Dr. Sharp: Great. It seems like the takeaway with a lot of this is hey, these are factors to consider. We can’t draw a straight line from necessarily any one of these personal characteristics to, hey, this is an absolute relationship.
Dr. Rodrigues: Yeah, I would agree. If you allow me to use access to firearms or interest in guns [00:41:00] as an example, it’s really about context. If a young person has been raised in a family where hunting has been a tradition for generations, it’s a seen as a rite of passage practices, say firearms. Their access to firearms is relevant but it has to be contextualized versus someone who is fascinated not only with firearms but with massacres, they’ve taken an interest in Hitler. Maybe they’ve adopted Neo-Nazi attire. Again, it’s the totality and as those risk factors start to develop and accumulate, as should our concern.
Dr. Sharp: Makes sense. Well said. Let’s talk about the actual process. I’d love to dig into this process. So when we say threat assessment, that’s a big umbrella. From a psychologist’s perspective, what is actually happening?
Dr. Rodrigues: They’re probably twofold [00:42:00] One, if you’ll allow me, I’ll talk broadly about the threat assessment process and then maybe talking about clinically how a clinician involved in a threat assessment evaluation would conduct themselves.
We mentioned earlier this idea of threat assessment management. We want to be able to assess but then subsequently, we need to manage. We need to monitor cases as they develop a risk. In a similar vein to let’s say clinical pathology, it’s not a static phenomenon. It can ebb and flow. It can fluctuate.
An individual could be potentially relatively safe and sustained and then all of a sudden experience life triggers that would elevate their risk. So as that information is fielded, we usually have an identified threat assessment team. That would be individuals that are representative of these different disciplines, bringing together the tools, and talking about specific cases as they populate.
Again, we’re triaging cases. So someone who maybe has been on the radar for a [00:43:00] while but we are moving them towards safety. They’re doing well. It may not require the same degree of monitoring or discussion.
Alternatively, you get a brand new case, and when you first get that case, it’s like opening up a book in the middle and trying to read. You don’t have a lot of information. You’re trying to make a lot of sense out of things. You’re trying to see, okay, I’m just receiving this information, but this doesn’t mean that it’s early in the would-be attackers’ plot. They could be preparing to attack soon enough. You don’t know that when you’re on the receiving end.
And so usually at that point, there should be some form of standardized process. So that could be, common language is like a structured professional judgment tool, some type of method so there’s transparency about the evaluation process in terms globally, in terms that there’s consistency and then acting responsibly.
So perhaps if you allow me, someone who’s low risk, maybe we just do further community outreach. We try to set them up with a trusted caregiver or adult. [00:44:00] We build partnerships. Alternatively, maybe more moderate risk. We’re reaching out to the family to see if there’s things that we can do from a collective standpoint to stabilize the family, which will then indirectly stabilize the child, perhaps a referral to mental health. Just outpatient counseling.
Alternatively, the higher risk, we might need to be operating faster. There’s certain states that have now enacted red flag laws determining access to someone’s firearms if they’re perhaps presenting an imminent threat. So that would kind of be the global perspective.
As a clinician conducting this work, I would say a lot of the original evaluation pieces are just born out of good forensic practice. And that, for me, a professional degree of skepticism, when someone tells me something, I’m always looking if I can confirm or corroborate what they’re saying by third-party information.
I’m trying to collect data for multiple pieces. [00:45:00] We’ll jump a little bit ahead, but depending on the report that I draft, it’s probably not going to be as lengthy as a full-blown diagnostic evaluation because just because someone may presenting a threat, I legally but also ethically, my own ethics, I’m trying to protect their privacy.
And if you operate from perspective, like need to know, what does it really need to know? In a current day risk assessment or threat assessment of someone who’s 17 years old, do we really need me to wax on about their annual recess in 3rd grade to the degree that it’s helpful?
There are various instruments, one could just be talking about some of the factors that we’ve already outlined. People could be thinking intelligently about that. There’s other instruments like the HCR-20, which I’ve seen used in this fashion, even if it wasn’t necessarily originally designed. Another one is the WAVR-21. Those are some different ways to collect the information, to gather it, and then integrate it.
Dr. Sharp: I would [00:46:00] imagine in this process that the individual is not super forthcoming about their intent or ideas. Maybe that’s a misconception. I’m curious if we know much about that.
Dr. Rodrigues: Most often, I would say that the referrals that I get are not necessarily, they’re not presenting from my end as particularly high. They’ve said something that’s concerning in a school workplace, and so I don’t want to minimize that, but they fall more under the realm of spontaneous utterance, poor emotional control, poor behavioral control, and impulsivity.
And so sometimes with those cases, once they come in, the actual assessment can be very therapeutic. Obviously, that’s not my design. I try to be as clear and transparent as I can in terms of purposes of it. But for many of the individuals I meet with, they’ve been struggling quietly for a long time, and this is their first contact with mental health.
I still think that, still within ones [00:47:00] professional bounds, that you can build fantastic rapport. You can be empathic without necessarily compromising your objectivity. I would say that there are circumstances where someone’s telling me a tale and giving their account and it just doesn’t read all that logical. It doesn’t read coherent.
An anecdotal rule for me is that everyone gets one leap of faith in their story. So basically there’s one bridge where I don’t have to understand it. You just get that. Alternatively, if I feel like in order to tether and pull your story together to integrate it, I have to take multiple leaps of faith, over time, that’s when my spidey sense goes off.
That’s when I’m asking more specific detailed questions because I think there’s information lacking. Like someone says, well, I just stopped going to school. Okay, well, what happened? Well, there was something happened. I was expelled. Okay. So then I’m clearly going to keep inquiring more and more. Just because [00:48:00] they were expelled doesn’t necessarily mean one thing or the other but I’m more curious if maybe that expulsion had something to do with violent or aggressive behavior.
Dr. Sharp: Sure. I like the leap of faith premise. That’s a good one for general clinical interviewing.
Dr. Rodrigues: Everyone gets one for me. You get one where I am totally confused and we’re going to put the owners on me for not getting it. But again, and this is born out of my forensic work, if I’m repeatedly doing that to tether the story together, most often actually, it’s because I’m meeting with someone with severe SMI and some of that psychosis is starting to bleed through.
Alternatively, is because someone is consciously withholding information from me. And that becomes the importance of corroborating it. And then ultimately my report, talking about the response style that someone put forth and then the limitations of it. If I can’t confirm when they say exit, that is in fact, accurate or true, and that might be important work for someone else on the investigative team to do.
Dr. Sharp: [00:49:00] Yeah. In my very limited experience primarily with kids in school, various ages, usually middle and high school, there’s always some dynamic of, I didn’t mean it that way, or so and so took this out of context, or I was just saying that. But it is nonetheless, comes across as pretty serious.
And so I’m wondering if there are, some of the measures you mentioned help tease that out or is the onus on us really to do good interviewing and good collateral to work through that or alternatively, I’ll just keep throwing ideas out there, does the research somehow guide us in that direction in terms of what threats, basically, I’m asking, what do we take seriously and what do we chalk up to teenage impulsivity?
Dr. Rodrigues: Absolutely. So let’s talk a little bit about ages. These are rough [00:50:00] metrics for people to orientate how they think about the cases. I don’t want them to necessarily use dichotomous age intervals as threat versus not threat.
The research suggests that generally your younger kids, your elementary school kids, they’re more awfully more often going to express a verbal threat but lack intention to carry out. And if we were just thinking about developmental lens, it makes sense. We know the younger we get, greater impulse control issues, inability to perceive long-term consequences, the actions, difficulties with mind blindness, recognizing the motivations and feelings of others.
As we get into the later parts of high school, we see less spontaneous utterances and we see more, not a tremendous more but an increased risk that someone’s going to carry out. What’s a little different from the general violence literature, and again, for maybe all these members who don’t know, usually, you’ll see on a lot of risk instruments or when we’re talking about research, 18 to 30 as being a [00:51:00] heightened risks for violence or criminal offending.
Again, I think we’re looking at it from a developmental lens, that the prefrontal cortex is not fully online yet. However, in the targeted violence world, we’ve had a fair number of attackers beyond the age of 35. I think all that to say is, it’s a mishmash and the importance of contextualizing it. To bring it back to the original question that prompted this monologue for me is the idea of thorough investigations, clinical questions, and corroborating the data.
If someone does make an utterance, they make a threat and they don’t have any other history, there’s nothing else. They seem to relatively perhaps be doing well academically. They get paper/favor reports from both home and the classroom. I think, hey, look, that seems like not necessarily a threat issue here, not a clinical issue. I’m sure the school will have means of implementing an appropriate kind of discipline.
Also, [00:52:00] there are systems; one that was fastened by Dr. Dewey out of Virginia, who’s done tremendous work in the school safety movement, standardized approaches and models for helping schools think through and discriminating between verbal threats, lacking any intention versus more serious ones.
If you’ll just allow me to add one more is that when we implement these transparent, consistent standardized systems in school, we see less discipline based on discrimination, let’s say African American compared to Caucasian students. We see the discrepancies of suspension diminish. The students themselves report safer schools. They talk about the overall climate of the school being improved. And people generally just feel grounded.
I recognize an age of progress and talking about issues of DIE. Actually, these instruments can help move us towards that. These [00:53:00] processes that are outlined can help move us towards that.
Dr. Sharp: I’m glad you brought that up. I was going to ask about, again, just cursory interaction with rubrics, I’ve seen two rubrics or models out there for school threat assessment. Maybe that’s what you’re talking about like this process that we’re moving through or where seems to be, there’s a lot of work to standardize this whole process. Is that accurate?
Dr. Rodrigues: Yeah. While unfortunately, we are experiencing an increased number of attacks with greater lethality, they still are rare events. That doesn’t make it any less tragic. I’m not suggesting that but I offer that because some of the instruments that we use in typical forensic risk assessment, the actuarials, they give these deep probability estimates.
I got to bore the listeners and put them asleep, especially if they’re listening to this while they’re driving, [00:54:00] but we’re not going to be able to get that data because it’s such a low base rate event, targeted violence. What you often see are these structured professional judgment tools where we are, and this is extremely simplified, but we’re kind of weighing the protective factors. Are they connected to school? Do they have social supports? Relatively stable life versus some of the other elements that we talked about, and then allowing individuals to make an assessment as a low, medium, high risk. And you see all types of different qualitative descriptors.
Dr. Sharp: Great. I wanted to ask, so we move through this process and at some point make a determination, I suppose. I’m curious about whether we have any research for those who, I would love to hear about two things; attacks that have been prevented and… let’s just start there. I won’t even cloud [00:55:00] the rest of our discussion or the rest of the question. So let’s start with that. What do we know about attacks that have been prevented?
Dr. Rodrigues: Yes, again, a silver lining. We have demonstrated across time, in the last 20 years that we can prevent, we can avert school attacks.
These are not inevitable, which unfortunately, I think some people in a position of power have, I think are well intended, but they’ve perpetuated this false message that we are in this place where we can’t do anything about it. And that’s not true.
Most often it’s because of this leakage. The more robust of a detection system that we can develop in a community, in a school, the better we are. There’s law enforcement security specials you can talk to the importance of hardened measures. How do we make the school actually physically safer? And it would be after the attack.
The challenge with that is, outside of recent memory, the Covenant [00:56:00] School attack, most attacks overwhelmingly, the attack studied are over in 5 minutes, most around 2 minutes. So that puts a really difficult response time on law enforcement. The ones in which they were subsequently ended, it was because a teacher, a student intervened, or there was a school resource officer on campus.
If we’re thinking about what triggered the forwarding of attack, if you’ll, is that praise, is someone other than the attacker receiving knowledge about this, and then relaying it to necessary parties? For the listeners, not only in their professional work but in terms of families and communities, I think it’s reasonable to bring up to your school, your workplace, hey, what is our process? How do we go about doing this?
I don’t mean to turn school board meetings into further combative situations but this is collaborative and I think it works really well. It offers a nice opportunity to either introduce [00:57:00] what the school is doing or remind people what they’re doing and how to go about getting necessary information to the needed parties.
Dr. Sharp: Absolutely. I am curious, the second part of that question that I held off on was, say that we go through this process and we identify someone as actually being a legitimate threat. What actually happens at that point? Where does this individual and let’s pretend, this is a teenager in high school, let’s say.
Dr. Rodrigues: Sure. I’m going to unpack potential and we’re going to say that even potential can be a broad construct. I totally appreciate, you’re using normal language and I’m having to get into the weeds but it’s reasonable. Everyone has the potential, it’s the degree and how much we’re talking about.
I’m sure from a clinical standpoint, we can’t say that someone zero risk of suicide, that risk varies. That by the very nature of risk, there’s [00:58:00] always a potential, no matter how infinitesimal. What we do know is that we don’t want to necessarily be using just disciplinary measures in school. First and foremost, simply suspending a kid doesn’t do anything to improve that kid’s situation.
I think probably I appreciate that it probably sends some sense of relief in the immediate future because said individual is not on campus. However, doesn’t mean that said individual couldn’t return to campus while on leave. So that creates challenges. We want to bring people into the fold.
There’s always the potential for emergency hospitalization, but even that standard is pretty high, in terms of moving someone from a 72-hour hold to inpatient. Really it’s about how can we put the most appropriate interventions, according to the specific case. We want to move away from a one-size-fits-all model.
This is based a lot on my criminal forensic work is, [00:59:00] and I say, a one size fits all doesn’t fit anyone. It winds up getting stretched to such extremes that it doesn’t really help much of anyone. And so what can we do? And some of the things I talked about is, in a school, do we have some type of bully prevention program? Do we have these various anonymous reporting systems? Are we looking for referral to therapy?
Potentially, a lot of these kids, if we’re talking about from the school perspective, school violence, they weren’t performing well in school. So there might even be issues where a classic psychodiagnostic with a cognitive piece could be particularly helpful because there might be elements that would trigger an IEP.
The way that I think about it is I want to move someone’s life safety. Safety can be accomplished by moving someone’s life to as much normalcy and stability as we can. And so I want to try to do that. I want to try to create that to the best of my ability or best our ability.
Dr. Sharp: [01:00:00] That’s fair. This discussion, I think of it as intervention, like what intervention options do we have right up until the point that we don’t, I suppose. It makes me think of this question that, my understanding anyway, is those individuals who have survived suicide attempts, it seems like pretty overwhelmingly have a sense of, I wish I didn’t do that or I wish I didn’t try.
We hear about that a lot but the ambivalence, I suppose, the ambivalence around the act. I wonder if that is also true for individuals, do we know anything about individuals who’ve perpetrated violence and how they follow that continuum?
Dr. Rodrigues: Yeah, I think we see many individuals that after they become stabilized, granted, some of them are incarcerated, they did carry out attacks. For listeners looking for more details and interviews with [01:01:00] such parties, I want to say the name of the book is The Violence Project. It talks about the school shooting epidemic and what can be done.
Obviously, it’s very dense with respect to emotional material but it is very lay person accessible. So it weaves in hardened data with these narratives in a very fluid fashion. I brought it recently on a vacation. I don’t necessarily know if that was the best thing to do for self-care, but it did keep me very engaged.
Dr. Sharp: If I had a list of all the “vacation reading” that I’ve done, it would be ridiculous, as a psychologist.
Dr. Rodrigues: If I may just add to something you said, because the other thing I’m thinking about in terms of suicidality that I’m actually now just openly wondering myself about workplace and school taxes, that decision that the actual window where someone is prepared to act is relatively short.
Yes, we’re talking about targeted violence and we’re talking about premeditated [01:02:00] but I’m also similarly thinking as they’re moving up along this trajectory about the specific window in which they are active to attack, could there be a similar phenomenon?
I can’t think of any literature off the top of my head about intervening and another, I apologize, one more point that I think, and I know you’re very much of the psychology assessment culture, the importance of an assessment really being the precursor and the blueprint for the interventions. I’m sure even if we’re talking about psychodiagnostic cognitive evaluations, personal aside, it’s infuriating when you spend all that time constructing this really important report and no one’s implementing the recommendations, the interventions they’re following up.
Dr. Sharp: Yeah. I think a lot of people probably resonate with that. It is. We do a lot of work on these assessments and it’s tough when folks don’t pay attention. I would [01:03:00] imagine there’s a little more weight in the scenarios, though. Hopefully, folks actually do read the reports and try to implement some of the recommendations.
Dr. Rodrigues: Well, I think actually too, in reading the report, the importance, actually for the first time, writing in a layperson language. Typically, this is more of minute but for those who really get into details of assessment report writing, writing in a language that human resources can understand.
Look, there’s a place to talk about unconscious projections and all that, what I would say is the utility of the audience, the report’s only going to be so, it’s only as good as it is interpretable and that the recommendations could be implemented. So any word that I had to go to school to learn the meaning of, I usually try to wordsmith that a little bit.
Dr. Sharp: Yes. I’m glad that you are jumping on this train of writing readable reports. I am pretty passionate [01:04:00] about that. And so are many other folks and good to get another vote.
I want to maybe start to close with a question about liability; two aspects of this. I’m curious how folks in your position who do a fair number of these assessments handle liability from like a legal perspective and just managing such high-stakes cases, but I’m also curious about the emotional perspective, the emotional liability, so to speak, of making recommendations or decisions that have pretty profound impacts on people’s lives in either direction, either the person being assessed or the potential location of violence.
Dr. Rodrigues: If you will, let me take the latter question or the latter portion first, and then I’ll touch upon the liability piece because for yourself and for [01:05:00] myself, I don’t see the questions very timely because just to bring it back this idea of self-care and managing and thinking about this work. I previously worked with law enforcement pretty intimately and that was very challenging because, great, but in terms of when officers were feeling dejected and depressed, there were so many risk factors that were just part of their lives. I remember just chronically feeling exhausted by it.
By the nature of the profession, they have access to a firearm. By the nature of the profession, they could be isolated that they have third tour, their sleep is deprived. And so it can weigh very heavily. Maybe I just emphasize a theme that seems to really be resonating and catching on broadly in the field is the importance of self-care. The importance of having a support team, a consultation team.
I’m constantly bouncing ideas off people. I’m constantly working with others, whether for supervision or consultation. [01:06:00] Essentially, as I mentioned, many of your listeners, I pitch them the case and my conceptualization of it, my thoughts about it. I asked them what I’m missing because they go this work alone I think is, it’s just impossible.
There’s the black swan phenomenon. You don’t know what you don’t know. It can be exhausting. The other thing is, too, is that you’re not the fail stopgap. This doesn’t hinge on you. There are other parties that are involved. They’re helping out by making sure that people take time off and away from this because even the best of cases can be stressful. That would be in terms of the emotional weight or emotional liability, which you were referencing.
And then in terms of legal liability, with the caveat of be obviously knowledgeable, be consulting with your local licensing board, your state, because some states don’t have the explicit tariffs off. [01:07:00] Warning, there are a number of states that don’t have that. By and large, though, let me hang a big caveat asterisk on this, because this is me just speaking outside of any professional. Well, I have found that most entities and parties are well receiving when you make a good faith disclosure.
There is even exemptions in the Patriot Act for this type of disclosure. I’ve noticed, interestingly for myself, as I’ve gotten older and farther away from graduate school, where they just beat into your head that if you violate any confidentiality, your career is done. I’ve actually gotten much more comfortable in terms of initiating welfare checks on individuals.
In terms of like, somebody will leave my office, I’m very concerned. Sometimes I know I’m going to make the welfare check. I know where they’re headed, but I think it’s actually unsafe to initiate and call the [01:08:00] police to my office because that could be more distressing.
I guess I just, I don’t know and I’m not, this has been my own recipe, I just feel like I would much rather be wanting to explain to the licensing board why I made a disclosure as opposed to being confronted by the news on my doorstep because some tragic outcome came to be.
And that’s not a project on anyone else. I do think if you document appropriately, even in a progress note, just some of the factors that we talked about and you’re conveying, hey, I communicated to XX organization. I called police. I left an anonymous message. Here’s the ID reference for that message, I do think people by and large are going to understand and give leeway.
Dr. Sharp: I appreciate you talking through that. We all, to some degree, have to do our own personal calculus around these decisions. It is nice just to hear someone in your position approach it.
Dr. Rodrigues: Yeah, I think the phenomenon for [01:09:00] me is that probably one part with experience, I feel more confident and competent in my work. I am much more sensitive to it, could also be the larger climate and kind of what is going on this whole topic today.
Dr. Sharp: Sure. Well, I know we’ve talked about a lot of things that we could talk about plenty more, but just to start to pull these threads together, I would love to hear from you like, of all the things we’ve talked about, what do you hope people might walk away with from this discussion if we could boil it down to three, four fine points.
Dr. Rodrigues: Yeah, absolutely. Back to the envelope key takeaways:
1) As we mentioned earlier, attackers don’t suddenly snap. We have unfortunately, seen time and time again, and after action reports, multiple parties know.
2) Because they don’t suddenly just snap and because information can be relayed, they are preventable [01:10:00] and we have been increasingly more successful in preventing attacks.
3) Because so many would-be attackers as well as those who carried out “successful attacks” had mental health contacts, mental health professionals are very likely to come into contact with some of these concerning people upstream because they, in a sense, none of these attackers are really coming from well-to-do nuclear families structure in their life. So some of the same things that are bringing people into therapy, are also going to catch some of them.
And so for those professionals who are just as maybe concerned citizens going, what can I do there? You can play a very relevant point. You can just take the information that was shared today and think about, hey, how do I assess for this type of violence? It been a lead for myself and, this is kind of embarrassing, but I will say, outside of graduate school, I didn’t really have a very robust way of assessing for violence. I had basically very roundabout [01:11:00] explicit, kind of like, do you feel like hurting anyone else, which everyone always says no.
I think that would be it. And then if people were inclined to want to learn more about this, I would direct them to the National Threat Assessment Center. Here in Colorado, we have the targeted violence prevention. There’s also the prevention providers network out of McCain Institute. And then lastly, in terms of a professional organization, ATAP, the Association for Threat Assessment Professionals, and that’s a multidisciplinary organization.
Dr. Sharp: Fantastic. There’s a lot of notes in the show notes today and a lot of resources. I appreciate you providing all those. This is a topic that is touching a lot of our lives, both personally and professionally. I think a lot of folks; we can only do our best to learn as much as we can. So these resources are important.
I know that we didn’t really dive into the true nuts and [01:12:00] bolts of interviewing and what you’re asking and the assessment process but I think this more macro perspective is pretty crucial in helping us understand.
Dr. Rodrigues: Maybe if I could offer, for listeners who are maybe wanting to do a deeper dive into that, I would recommend a book, International Handbook of Threat Assessment. Just make sure that they get the most recent edition. It’s great. It’s chapter by chapter. You don’t have to read it in a linear fashion. And so you can jump in if you were looking at threat assessment for primary school versus college or workplace or even a chapter dedicated to legal issues around threat assessment. That would be an excellent resource.
Dr. Sharp: Fantastic. Well, I will say, thank you again for coming on and having this conversation. It’s really important. Unfortunately, it’s really important. We need to know as much as we can. So thanks for being here, Alex.
Dr. Rodrigues: Thanks so much and [01:13:00] thanks for allowing me to come onto your platform and reach your ever-expanding audience. Thank you.
Dr. Sharp: All right, y’all. Thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes, so make sure to check those out.
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