Hy Bloom provided an expert psychiatric report in a multiple murder case in which the accused, who had schizophrenia and depression, had killed his wife and 2 children. Before the murders, the accused had been seeing a psychiatrist and family physician for treatment of the mental disorders.
The extensive media attention that the case received questioned, among other things, the care the accused had received from his family physician and psychiatrist. The press reported that shortly before the murders, the patient’s sister had informed the psychiatrist that her brother’s mental health had deteriorated, that he was psychotically preoccupied, and that he was behaving in a bizarre fashion. The accused’s sister specifically requested that her brother be hospitalized.
The court documents and expert reports, which became a matter of public record, stated that although the patient had been under a psychiatrist’s care for several years, the psychiatrist never spent any appreciable time with him.1 The evidence strongly suggested that the psychiatrist seemed to have had only a limited understanding (as reflected by his notes) of the seriousness of the patient’s psychotic symptoms and his potential to act out because of them. Whatever understanding he did have was never disclosed to the patient’s primary physician who, as it turned out, shared an office with the psychiatrist. The psychiatrist who assessed the accused after the arrest questioned whether the prescribed dosage of medication could possibly have been expected to yield a therapeutic effect, especially after extended administration. Finally, there was considerable concern about the adequacy of charting in the patient’s file.
The court ruled that the accused was not criminally responsible (ie, not guilty by reason of insanity) for the murder of his family because of his mental disorders.
This case raises some questions that are important to all psychiatrists and other mental health professionals. Given the paucity of the psychiatrist’s meetings with the patient, it would seem unlikely that he could have probed for peculiarities in his patient’s thinking. However, the psychiatrist should have noted enough red flags to spark a thorough risk assessment. As the late eminent British psychiatrist Peter Scott2 pointed out, it takes time, persistence, and clinical acumen to gain the sort of information that is so essential to the complexities of a violence risk assessment. Scott believed that clinicians need an “elementary practical guide” to complete evaluations at levels of detail that are acceptable to professional bodies.3,4
As is almost always the case with retrospective analysis of tragic outcomes, this case offers many lessons, which are encapsulated in the following 12 principles about risk and risk appraisal.
Principle 1. Clinicians must be aware of the possibility of risks at multiple junctures in their patient’s life.
Clinicians need to have an index of suspicion and, in some areas of psychiatric subspecialization, a high index of suspicion, about potential areas of risk. A critical eye needs to be applied to clinical work.
Principle 2. Critical appraisal of essential information plays an important role in influencing clinical (and legal) decision making about a patient’s “dangerousness.”
Assuming that a fuller, timely, “front-end” evaluation had disclosed that the threat was real or credible and that it could be enacted, the psychiatrist in this case failed to take steps to constrain his patient (eg, through voluntary admission to a psychiatric hospital, civil certification, or arranging for intense temporary supervision in the community).
1. Makin K. Grisly killings expose system’s failure. globeandmail.com. September 23, 2008. http://v1.theglobeandmail.com/servlet/story/RTGAM.20080923.wbreakdown2309/BNStory/mentalhealth. Accessed June 2, 2009.
2. Scott PD. Assessing dangerousness in criminals. Br J Psychiatry. 1997;131:127-142.
3. American Psychiatric Association. Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors. Washington, DC: American Psychiatric Association; 2003.
4. National Institute for Clinical Excellence. Violence: The Short-Term Management of Disturbed/Violent Behaviour in Psychiatric In-Patient Settings and Emergency Departments. Quick Reference Guide. Clinical Guidelines 25. UK: National Collaborating Centre for Nursing and Supportive Care; February 2005.
5. Webster CD, Martin ML, Brink J, et al. Short-Term Assessment of Risk and Treatability (START): An evaluation and planning guide Version 1.1. St Joseph’s Healthcare, Hamilton and Forensic Psychiatric Services Commission, BC; 2009.
6. Webster CD. A guide for conducting risk assessments. In: Webster CD, Jackson MA, eds. Impulsivity: Theory Assessment and Treatment. New York: Guilford Press; 1997:343-357.
7. Maden A. Treating Violence: A Guide to Risk Management in Mental Health. Oxford, UK: Oxford University Press; 2007.
8. Webster CD, Hucker SH. Violence Risk Assessment and Management. Chichester, UK: Wiley; 2007.
9. Bloom H, Webster CD. Essential Writings in Violence Risk Assessment. Toronto: Centre for Addiction and Mental Health; 2007.
10. Monahan J, Steadman H, Silver E, et al. Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence. New York: Oxford University Press; 2001.
11. Monahan J, Steadman HJ, Robbins PC, et al. An actuarial model of violence risk assessment for persons with mental disorders. Psychiatr Serv. 2005;56: 810-815.
12. Cleckley H. The Mask of Sanity. 5th ed. St Louis: Mosby; 1976.
13. Hare RD. Hare Psychopathy Checklist–Revised. 2nd ed. Toronto: Multi-Health Systems; 2003.
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15. Gray NS, Hill C, McGleish A, et al. Prediction of violence and self-harm in mentally disordered offenders: a prospective study of the efficacy of HCR-20, PCL-R, and psychiatric symptomatology. J Consult Clin Psychol. 2003;71:443-451.
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19. Webster CD, Eaves D, Douglas KS, Wintrup A. The HCR-20 Scheme: The Assessment of Dangerousness and Risk—Version 1. Burnaby, BC: Mental Health, Law and Policy Institute, Simon Fraser University; 1995.
20. Borum R. Improving the clinical practice of violence risk assessment: technology, guidelines, and training. Am Psychol. 1996;51:945-956.
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25. Boer DP, Hart SD, Kropp R, Webster CD. Manual for the Sexual Violence Risk–20: Professional Guidelines for Assessing Risk of Sexual Violence. Vancouver, BC: British Columbia Institute Against Family Violence; 1997.
26. Bouch J, Marshall JJ. Suicide Risk Assessment and Management Manual (S-RAMM) Research Edition. Dinas Powys, UK: Cognitive Centre Foundation; 2003.
27. Augimeri LK, Koegel CJ, Webster DD, Levin KS. Early Assessment Risk List for Boys (EARL-20B) Version 2. Toronto: Earlscourt Child Family Centre; 2001.
28. Levene KS, Augimeri LK, Pepler DJ, et al. Early Assessment Risk List for Girls (EARL-21G), Version 1 Consultation Edition. Toronto: Earlscourt Child Family Centre; 2001.
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31. Bloom H, Webster CD, Eisen R. ERA-20. Employment Risk Assessment. A Guide for Evaluating Potential Workplace Violence Perpetrators. Toronto: workplace.calm, inc; 2002.
32. Stouthamer-Loeber M, Loeber R, Wei E, et al. Risk and promotive effects in the explanations of persistent serious delinquency in boys. J Consult Clin Psychol. 2002;70:111-123.
33. Loeber R, Pardini DA, Stouthamer-Loeber, Raine A. Do cognitive, physiological, and psychosocial risk and promotive factors predict desistance from delinquency in males? Dev Psychopathol. 2007;19:867-887.
34. Fluttert F, Van Meijel B, Webster C, et al. Risk management by early recognition of warning signs in patients in forensic psychiatric care. Arch Psychiatr Nurs. 2008;22:208-216.
35. Monahan J. Predicting Violent Behavior: An Assessment of Clinical Techniques. Beverly Hills, CA: Sage; 1981.
36. Johnstone L, Cooke DJ. PRISM: Promoting Risk Intervention by Situational Management. Structured Professional Guidelines for Assessing Risk Factors for Violence in Institutions. Burnaby, BC: Mental Health, Law, and Policy Institute, Simon Fraser University; 2008.
37. Bloom H, Eisen R, Pollock N, Webster CD. WRA-20. Workplace Risk Assessment. A Guide for Evaluating Systemic Violence Risk in the Workplace. Toronto: workplace.calm, inc; 2002.
38. Reid WH. Risk assessment, prediction, and foreseeability. J Psychiatr Pract. 2003;9:82-86.