Violence Risk Assessment in Everyday Psychiatric Practice
Twelve Principles Help Guide Clinicians
By Christopher D. Webster, PhD, Hy Bloom, MD, and Leena Augimeri, PhD |
December 14, 2009
Dr Webster is professor emeritus of psychiatry at the University of Toronto and professor emeritus of psychology at Simon Fraser University in Burnaby, British Columbia. He is senior research associate at workplace.calm, inc. Dr Bloom is a forensic psychiatrist and lawyer. He is assistant professor of psychiatry at the University of Toronto and McMaster University in Ontario, and adjunct professor at the University of Toronto’s Faculty of Law. He conducts both criminal and civil forensic psychiatric assessments and has a special interest in workplace behavior and violence. He is CEO of workplace.calm, inc. Dr Augimeri is director of research at the Child Development Institute in Toronto and assistant professor in the faculty of social work at the University of Toronto. The authors report no conflicts of interest regarding the subject matter of this article.
Since 1995, roughly a dozen other SPJ scales have been published. There are scales that measure risk for spousal assault, sex offenses, and suicide. There are also scales that measure violence risk in boys and in girls younger than 12 years, in adolescents, and in persons remanded to jails.24-30 One scale measures a person’s potential for workplace violence.31 In this article, we have emphasized the Hare PCL-R and the HCR-20, but this is mainly for illustration purposes. Other scales are available.
Principle 8. Client strengths are important in creating plans for risk management.
There is increasing recognition of the importance of an evaluee’s strengths and other protective and promotive factors. First, consideration of these factors provides a more global and fair appraisal of risk. Second, doing so allows for potentially greater liberty and derestriction.32,33 The Structured Assessment of Violence Risk in Youth departs from tradition by including a small number of “protective factors” (eg, prosocial involvement, strong social support, resilient personality).27
Recently, this recognition was carried a step further in the Short-Term Assessment of Risk and Treatability (START).5 All 20 dynamic factors are rated for strength (on a scale of 0, 1, or 2) and risk (again, on a 0, 1, or 2 scale). In one jurisdiction, staff members invite clients to rate themselves on the START items. These opinions help mold a plan that is agreeable to all concerned.
Principle 9. Risk of violence against others usually provides a focus for assessment, but there are other interrelated issues that may need to be taken into account.
It might be necessary to assess risk for suicide, self-harm, self-neglect, the taking of unauthorized leave, the tendency to become victims of others, relapse into substance abuse, and so on. The START assesses all of these topics.
Principle 10. Signature risk signs should be documented.
Some patients consistently show signs that violence or other violence-related risks may be inevitable. For example, a patient might have his hair cut a certain way, put on particular items of clothing, begin to talk about religion excessively, and so on. These early warning signs, which are unique to each patient, can be crucially important in averting violence if they are understood and documented by staff.34 Evocative and volatile environments and the presence of a particular potential victim can incite a patient to express injurious behavior that he was managing before the catalytic agents entered the equation.
Principle 11. All propensity for violence is not entirely inherent within the individual; rather, circumstances and situational effects also exert powerful influences.
This older idea of violence propensity coming from within revolved around “dangerousness,” as if the person carried around a certain static quantum of this assumed entity. John Monahan’s Predicting Violent Behavior: An Assessment of Clinical Techniques35 helped change our thinking toward the idea that risk can vary with the person and the situation. It is probably true that scales such as the HCR-20 could place greater weight on situational variables than they presently do (item R2, destabilizers, catches some of it).
Scales are now being created around the situational measurement.36 This is a necessary development because it helps us determine whether we could be doing more to eliminate orattenuate violence and other related risks—by paying attention to policy, procedures, building design, organizational issues, staff training, and the like. Specific schemes exist that focus exclusively on systemic risk factors for workplace violence.37
Principle 12. It is often vital and reassuring to obtain a second opinion from a trusted and experienced colleague.
Busy practitioners, even those who are able to spend adequate amounts of time with their patients, may need to avail themselves in some instances of that old, tried-and-true medical practice of seeking a second opinion. Transference issues remain very much alive. In therapeutic relationships, dangers can be overlooked, which later in the harsh lights cast by court hearings and inquests may well be noticed and dealt with.
It is not possible to make invariably correct assessments about violence and related risks. Some error is inevitable.35 Certainly, accurate evaluations cannot be completed in a few minutes or, in complex cases, a few hours.38 Yet by paying attention to these 12 principles, evaluators can reduce risks to society without imposing undue restriction on individual patients. Risk assessments require detailed, in-depth analyses of all factors—individual and systemic— relevant to the inquiry by informed, well-read, experienced, and committed evaluators.
Physicians appraise risks of all types in everyday clinical practice. We hope that these 12 principles will help guide and focus evaluations so that the most meaningful considerations concerning risk are brought to bear.
Also in this Special Report
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