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.
(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.
What To Look For
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.
Alcohol is involved in many acts of violence. Cocaine can produce mood swings that look just like bipolar disorder, paranoid anxieties and reduced control over aggressive impulses. The drug PCP produces a disorganizing psychotic process with particularly nasty and often extremely violent, mutilating, murderous behavior. Hallucinogens such as LSD can lead to abiding or recurrent hallucinations and delusions; I have two young women in my current practice for whom it is questionable whether or not they would ever have developed their current chronic psychotic illnesses had they not used LSD. Heroin and other opioids rarely cause violence except when, during withdrawal, users feel impelled to violence to gain the wherewithal for their next fix.
Sometimes it is not the patient who is dangerous, but the dyadic relationship between the patient and the therapist. For example, a patient who acts seductively, combined with a therapist whose ability to set boundaries is diminished can result in doctor-patient sexual misconduct that can be ruinous to the two of them.
Active mental illness, especially with a strong affective component, raises the risk for danger. People who are quietly depressed or delusional are less likely candidates for violent acting-out. The Table outlines various clinical presentations that should raise a warning flag for clinicians.
We should also look for issues of revenge in people with personality disorders with antisocial features or a history of solving problems by resorting to physical assault or violence. Some families, as well as some social subgroups, habitually turn to violence as a way of problem-solving. Certainly, people who commit notorious acts of public violence have often consulted a mental health care professional at some point in their trajectory.
Not too long ago, the Washington, D.C., area was under assault as two serial snipers roamed the community killing 10 people with single rifle shots from long distance. What will prove to be their history of attempted mental health interventions, if any?
When our patients express intent to injure or kill others, we should ask about access to weapons--especially guns: Do they own guns or have access to them? Have they moved them lately? A gun collection, neatly disarmed or locked in a cabinet, with the bullets secured safely in a difference place, is one set of facts. A shotgun or pistol kept under the bed is another. As Scott and Resnick (2002) wrote:
Subjects should be asked whether they own or have ever owned a weapon. The recent movement of a weapon, such as transferring a gun from a closet to a nightstand, is particularly ominous in a paranoid person.
Knives can do terrible damage to human flesh, and anyone who has used a knife as a weapon in the past and is now under similar psychosocial stressors or circumstances is a candidate to commit violence. Again, past violent conduct is the single best predictor of future violence.
Just as the question, "Have you ever had trouble with the law," can be quite useful in obtaining important personal history, it is also useful to ask, "What is the most violent thing you have ever done?" This can be contrasted with "What is the most violent fantasy you have ever had?"
The personal interview can be supplemented by collateral interviews with a close relative or friend of the patient and can produce invaluable information. The forensic psychiatrist regularly obtains all kinds of records with collateral information from prior hospitalizations, jobs, mental health treatment, the military or school. The office clinician may not find it appropriate to ask for most of these, but, with the patient's permission, can almost always request and receive information from other doctors and mental health care professionals who have seen the patient in the past.
Clinicians who are asked to assess the risk of violence or dangerous behavior are increasingly supplementing their clinical assessments with the use of standardized risk assessment instruments. There are a number of these, including:
The Hare Psychopathy Checklist-Revised (PCL-R), and its Screening Version (PCL-SV). This test is a clinical construct rating scale that measures attributes of people considered at high risk for crime or violence.
The Violence Risk Appraisal Guide (VRAG), an actuarial risk assessment instrument that includes 12 variables covering childhood history, adult criminal history, demographics and psychiatric diagnosis. The most weight is given to the psychopathology variable, as defined by the PCL-R.
HCR-20 (Historical, Clinical and Risk Management). This risk assessment tool combines historical risk factors with clinical judgment regarding dangerousness. Its 20 items cover historical, clinical and risk management issues.
Experts in this field emphasize that use of these standardized tests is not a substitute for clinical expert assessment. As Scott and Resnick (2002) wrote: "The clinician should balance information gathered from these risk assessment instruments with clinical judgment when making recommendations regarding risk for future violence."
The authors of the landmark MacArthur Violence Risk Assessment Study (Monohan et al., 2001) won the Guttmacher Award--the prize for best writing in psychiatry and the law awarded jointly by the American Psychiatric Association and the American Academy of Psychiatry and the Law--for their book titled Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence. They found that there is no "magic bullet," no "unitary causes of and solutions to violence." They also stated:
Our data are more consistent with the view that the propensity for violence is the result of the accumulation of risk factors, no one of which is either necessary or sufficient for a person to behave aggressively toward others. People will be violent by virtue of the presence of different sets or risk factors There is no single path in a person's life that leads to violence.
These authors go on to suggest the standard of practice for today's clinician who wishes to practice risk assessment:
This reliance on clinical judgment--aided by an empirical understanding of risk factors for violence and their interaction--reflects, and in our view should reflect, the standard of care at this juncture in the field's development.
In ongoing treatment, the nature and quality of the therapeutic alliance is key in managing destructive impulses and their potential. The psychoanalyst and dynamic psychiatrist, in recognizing transference, countertranference and the other vicissitudes of the therapeutic relationship, will be aware of this central fact.
References 1.Monohan J, Steadman HJ, Silver E et al. (2001), Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence. New York: Oxford University Press.
2.Scott CL, Resnick PJ (2002), Assessing risk of violence in psychiatric patients. Psychiatric Times 19(4):40-43.