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).

Clinicians need to look carefully for clues to a change in a patient’s psychological or emotional status that could herald a decline potentially associated with danger. A penetrating and informed inquiry in patients deemed to be at risk is needed instead of relying on immediate situational threat appraisals used by police officers, personnel who work in emergency settings, and others.⁵ How to deal with such “hands-on” crises is a topic in itself.

Principle 3.Risk assessments should be carried out under circumstances that are comfortable to both client and assessor (who must ensure the safety and security of all involved in the process).

Evaluations that are conducted in busy hallways or holding cells are handicapped from the start. There needs to be some realistic chance of establishing rapport.⁶ Securing some measure of rapport between the examiner and evaluee and conducting the evaluation in an environment that is conducive to the discussion will greatly enhance the sharpness and overall effectiveness of the inquiry.

Principle 4.Assessors should have a working familiarity with the literature on violence risk assessment and management as well as its limitations.

Much of the scientific and professional literature on violence risk assessment and management has been summarized in recent books, and there is an easy-to-find compilation of recent key articles.^7-9 Although perhaps a little technical, Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence¹⁰ describes the largest North American study of released civil patients. It also provides the underpinnings for the Classification of Violence Risk,¹¹ which was an attempt by the authors to create a computer analysis model for assessing an individual’s risk for violence. It is also useful for clinicians to acquaint themselves with the time-honored work of Hervey Cleckley,¹² especially as formulated by Robert Hare (Psychopathy Checklist–Revised [PCL-R])13 and Stephen Hart and colleagues (Psychopathy Checklist: Screening Version [PCL:SV]).¹⁴

Principle 5.A thorough history is essential for the completion of risk assessments. The best predictor of future violence is past violence.

While Principle 5 is true, in recent years the Hare Psychopathy Checklist (which places strong weighting on violence history) has outperformed sheer violence history as a predictor.¹⁵ However, statistically based studies have emphasized repeatedly that active risk factors during childhood and adolescence tend to continue into late adolescence and adulthood.¹⁶ A cue to remember before conducting a thorough risk assessment is depth prevents death.

Principle 6. Although actuarial information is not often available to psychiatrists who practice outside mental hospitals and prisons, it should not be ignored if it has been properly consolidated.

One scale with an appreciable correlation between predictions and violent outcomes is the Violence Risk Appraisal Guide.¹⁷ Because of the established correlation, it is unwise to discount such statistically based risk appraisals if they have been or can be compiled-provided that the case corresponds with the essential characteristics of the standardization sample (ie, age, sex, previous violence, psychiatric history, etc). Evaluators will be interested to see whether their own analyses accord with the results of actuarial assessments. More generally, if the results do not match up, clinicians should be at pains to make sense of the discrepancy. Bear in mind that risk assessments are invariably about individuals. Incidents based on the performance of groups can inform the individual assessment, but they also have the capacity to obfuscate a decision when the consequences for the evaluee are or can be dire.¹⁸

Principle 7.Structured professional judgment (SPJ) scales may assist in the assessment task.

In 1995, the Historical/Clinical/ Risk Management–20 (HCR-20, V1)¹⁹ scale was published after extensive consultation with psychiatrists, social workers, correctional officers, psychologists, emergency department staff, and other colleagues. The HCR-20 uses a 0 (not present, or “no”), 1 (possibly present, or “maybe”), or 2 (definitely present, or “yes”) scoring scheme. What sets this scale apart from others is the division of items into past (10 items), present (5 items), and future (5 items).

The HCR-20 was reviewed positively for its potential by Borum.²⁰ The review excited colleagues abroad who wanted to translate the HCR-20. However, Version 1 had some pretty obvious faults. One such failing was a too-strong reliance on some DSM-diagnostic categories for a few items. Version 2 was developed and the reworked scale was published in 1997.²¹

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