The Assessment of Danger in Everyday Practice

(The first part of this two-part article will discuss assessment and diagnosis of potential violence and danger in clinical psychiatric practice. The second part will discuss treatment and legal issues of dealing with potentially violent patients--Ed.)

In presenting the subject of dangerousness assessments at my hospital, I told a story about my grandchildren that illustrated the fact that we all make such assessments and act on them regularly in various contexts. Our back patio is a favorite gathering place for family members. My 4-year-old grandson and my 3-year-old granddaughter usually play well together. One day, the boy approached the girl while vigorously waving around a large stick. We relieved him of the stick and redirected their play toward other toys. We had made a dangerousness assessment, followed by preventive and remedial action.

In our offices, we perform consultations and do therapy. Sources of our information concerning dangerousness include all the elements of the interview with the patient: what they say, how they say it and how we feel about it. We need to be skillful in our inquiries--to consider actual danger. Often the right questions are overlooked. I encourage the folks who interview patients in our emergency room to ask questions about history of conflict with the law. I simply ask: "Have you had any trouble with the law?"

This is open-ended and nonjudgmental. It does not imply fault. If a patient has had trouble with the law, it might just as easily be the law's fault as their own. One can easily think of historical examples of this. The clinician is more likely to gain information in a morally neutral style of inquiry and can very easily get off track by projecting judgmental feeling tones.

While this reminder might seem insultingly superfluous, it is commonplace for judgmental tones to enter this area of inquiry. If there is a history of one or more arrests, follow-up questions should be asked about stays in jail, the charges and the outcomes. The skilled clinician can elicit a good picture of past dangerous behavior. Past violent conduct is the single best predictor of future dangerousness. Collateral information from relatives or friends, as well as past written records, is often readily available with the patient's permission.

We should deeply respect our own feelings as we interview. When the dynamic therapist is frightened, the affect is most important. Of course, affective memories of events in our own lives intervene as readily as reaction to what the patient presents. Such wide-angled examination of the transference-countertransference combination has become a central interest for today's psychoanalysts--tremendous progress from the days when much discussion of the intense erotic and aggressive emotions of the analyst was avoided.

If a clinician is frightened, it may be because the patient is truly frightening and about to do dreadful acts. This is true whether or not there is gross mental disorder present. Assessment reveals the presence or absence of hallucinations, command or otherwise, and/or delusions. Substance abuse is very important, since, while most mentally ill people are not dangerous, the combination of mental illness with substance abuse dramatically increases the risk.