Violence Risk Assessment in Everyday Psychiatric Practice

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).