Clinical and actuarial violence risk assessment has been analogized to weather forecasting.1,2 The weather forecast model can be applied to both violence and suicide risk assessment. Neither violence nor weather can be predicted with 100% accuracy as can be done with eclipses and other astronomical events. Actuarial predictions, similar to weather forecasts, are made within certain probabilities. Both short-term and long-term weather predictions are probability determinations beyond the immediate present (eg, 24 to 48 hours, 7 to 10 days). In contrast, clinical risk assessments are here and now determinations, much like sticking one’s head out the window to check current weather conditions. However, time erodes clinical assessments.
Both clinicians and weather forecasters employ the same general process of information gathering, analysis, and reaching a conclusion. Clinicians can assess level of risk but cannot predict reliably who will or will not become violent or attempt or complete suicide. Weather forecasters make probability predictions, using sophisticated weather instruments and computer models. Meteorology has achieved a high level of predictive accuracy. However, weather often changes rapidly, undermining prediction.
Some psychiatrists opine that clinical assessments can predict violence in the short term. For example, Tardiff,3 in discussing clinical violence assessment, defines short-term as “within days or a week.” Fawcett and colleagues,4 in a 10-year prospective study of 954 patients with major affective disorders, identified acute, short-term indicators of suicide risk that were statistically significant within 1 year of assessment.
There are, however, no evidence-based short-term, or “imminent,” risk factors for the assessment of violence or suicide.5 The frequently used and misused term “imminent violence,” often found in clinical usage and in legal or statutory language, is a prediction of violence that masquerades as a real-time assessment. Clinical assessment, similar to weather forecasting, is a process that requires frequent updating.
The difference between clinical and actuarial assessment is illustrated by a seemingly trivial event. I was waiting in a hotel lobby with other speakers for transportation to a symposium on violence assessment and prediction. One of the speakers, a nationally and internationally recognized expert on the actuarial assessment of violence, decided to step outside to see whether he should wear a coat. After walking around in a circle a few times, he came back into the lobby and announced that a coat was unnecessary. I was immediately struck by the similarity of the actuarial expert’s here and now assessment of the current weather to the clinical approach of the assessment of violence.
Other similarities exist between clinical assessment and weather forecasting. Microclimates exist that are analogous to the assessment of uniquely individual violence risk factors that must be considered. Geographical weather predictions, for example, in oceanic or mountain climates, are analogous to cultural differences that need to be factored into violence assessments. Then there is the analogy between clinical crises and storms that must be assessed to guide appropriate actions. Both weather forecasters and clinicians must stay tuned to their respective instruments.
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