Clinicians need to look carefully for clues to a change in a patient’s psychological or emotional status that could herald a decline potentially associated with danger. A penetrating and informed inquiry in patients deemed to be at risk is needed instead of relying on immediate situational threat appraisals used by police officers, personnel who work in emergency settings, and others.5 How to deal with such “hands-on” crises is a topic in itself.
Principle 3. Risk assessments should be carried out under circumstances that are comfortable to both client and assessor (who must ensure the safety and security of all involved in the process).
Evaluations that are conducted in busy hallways or holding cells are handicapped from the start. There needs to be some realistic chance of establishing rapport.6 Securing some measure of rapport between the examiner and evaluee and conducting the evaluation in an environment that is conducive to the discussion will greatly enhance the sharpness and overall effectiveness of the inquiry.
Principle 4. Assessors should have a working familiarity with the literature on violence risk assessment and management as well as its limitations.
Much of the scientific and professional literature on violence risk assessment and management has been summarized in recent books, and there is an easy-to-find compilation of recent key articles.7-9 Although perhaps a little technical, Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence10 describes the largest North American study of released civil patients. It also provides the underpinnings for the Classification of Violence Risk,11 which was an attempt by the authors to create a computer analysis model for assessing an individual’s risk for violence. It is also useful for clinicians to acquaint themselves with the time-honored work of Hervey Cleckley,12 especially as formulated by Robert Hare (Psychopathy Checklist–Revised [PCL-R])13 and Stephen Hart and colleagues (Psychopathy Checklist: Screening Version [PCL:SV]).14
Principle 5. A thorough history is essential for the completion of risk assessments. The best predictor of future violence is past violence.
While Principle 5 is true, in recent years the Hare Psychopathy Checklist (which places strong weighting on violence history) has outperformed sheer violence history as a predictor.15 However, statistically based studies have emphasized repeatedly that active risk factors during childhood and adolescence tend to continue into late adolescence and adulthood.16 A cue to remember before conducting a thorough risk assessment is depth prevents death.
Principle 6. Although actuarial information is not often available to psychiatrists who practice outside mental hospitals and prisons, it should not be ignored if it has been properly consolidated.
One scale with an appreciable correlation between predictions and violent outcomes is the Violence Risk Appraisal Guide.17 Because of the established correlation, it is unwise to discount such statistically based risk appraisals if they have been or can be compiled—provided that the case corresponds with the essential characteristics of the standardization sample (ie, age, sex, previous violence, psychiatric history, etc). Evaluators will be interested to see whether their own analyses accord with the results of actuarial assessments. More generally, if the results do not match up, clinicians should be at pains to make sense of the discrepancy. Bear in mind that risk assessments are invariably about individuals. Incidents based on the performance of groups can inform the individual assessment, but they also have the capacity to obfuscate a decision when the consequences for the evaluee are or can be dire.18
Principle 7. Structured professional judgment (SPJ) scales may assist in the assessment task.
In 1995, the Historical/Clinical/ Risk Management–20 (HCR-20, V1)19 scale was published after extensive consultation with psychiatrists, social workers, correctional officers, psychologists, emergency department staff, and other colleagues. The HCR-20 uses a 0 (not present, or “no”), 1 (possibly present, or “maybe”), or 2 (definitely present, or “yes”) scoring scheme. What sets this scale apart from others is the division of items into past (10 items), present (5 items), and future (5 items).
The HCR-20 was reviewed positively for its potential by Borum.20 The review excited colleagues abroad who wanted to translate the HCR-20. However, Version 1 had some pretty obvious faults. One such failing was a too-strong reliance on some DSM-diagnostic categories for a few items. Version 2 was developed and the reworked scale was published in 1997.21
The Table includes items from the current scheme. Note, however, that this is not a substitute for reading the entire manual carefully before attempting to use the guide. An up-to-date summary of the evidence for HCR-20 and its progeny can be located at http://kdouglas.wordpress.com/hcr-20. This topic was addressed in detail in 2 recent books and in a review article.7,8,22 The HCR-20 outperforms the PCL-R (or the 12-item PCL:SV) in prediction-outcome correlations. Although predictive power is never as high as might be wished, the HCR-20 improves substantially against chance.15
There are other important items about the HCR-20 and similar scales. After the assessment, evaluators are asked to judge whether the potential for future violence risk against others is low, moderate, or high. The HCR-20 manual stresses that occasionally an individual will achieve a very low total numerical score, yet the assessor may still decide that the patient’s case is a high risk. Similarly, a case with a high score may not necessarily warrant a high-risk designation (eg, because the eventual untoward outcome is not expected to be particularly serious or because the risk is easily managed). In other words, unlike strict actuarial approaches, the clinician is left with the final say (presuming that the HCR-20 has been administered as intended).23
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.
14. Hart SD, Cox DN, Hare RD. The Hare Psychopathy Checklist: Screening Version (PCL:SV). Toronto: Multi-Health Systems; 1995.
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.
16. Hodgins S, Janson CG. Criminality and Violence Among the Mentally Disordered: The Stockholm Metropolitan Project. New York: Cambridge University Press; 2002.
17. Quinsey VL, Harris GT, Rice ME, Cormier AC. Violent Offenders: Appraising and Managing Risk. 2nd ed. Washington, DC: American Psychological Association; 2006.
18. Hart SD, Mitchie C, Cooke DJ. The precision of actuarial risk assessment instruments: evaluating the “margins of error” of group versus individual predictions of violence. Br J Psychiatry. 2007;190:S60-S65.
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.
21. Webster CD, Douglas KS, Eaves D, Hart SD. HCR-20: Assessing Risk for Violence (Version 2). Vancouver, BC: Mental Health, Law & Policy Institute, Simon Fraser University; 1997.
22. Bloom H, Webster C, Hucker S, De Freitas K. The Canadian contribution to violence risk assessment: history and implications for current psychiatric practice. Can J Psychiatry. 2005;50:3-11.
23. Webster CD, Müller-Isberner R, Fransson G. Violence risk assessment: using structured clinical guides professionally. Int J Forensic Ment Health. 2002;1:185-193.
24. Kropp PR, Hart SD, Webster CD, Eaves D. Manual for the Spousal Assault Risk Assessment Guide. 3rd ed. Toronto: Multi-Health Systems; 1999.
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.
29. Borum R, Bartel P, Forth A. Manual for the Structured Assessment of Violence Risk in Youth (SAVRY). Tampa, FL: University of Florida; 2002.
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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.