Day # 82: Violence Risk Assessment

Today we will discuss the violence risk assessment. This discussion will include an introduction, risk factors, and an approach to the assessment.


Today's Content Level: All Levels (Beginner, Intermediate, Advanced)



INTRODUCTION


•Psychiatrists and other mental health providers are often asked to assess the probability that a patient may commit a violent act as well as formulate a plan to mitigate that risk.


•Keep in mind there is no evidence showing that asking patients about violent/homicidal ideation will increase their risk of violence.


There are two main subtypes of violence:

  • Affective violence = defensive. It is a response to a real or imagined threat and is accompanied by high levels of autonomic arousal, anger, or fear.

  • Predatory violence = offensive. It is planned, purposeful, and emotionless, with minimal levels of autonomic arousal. It is generally marked by a lack of remorse unless the perpetrator was unsuccessful in the violent act or the act resulted in negative consequences for the perpetrator.


•Assessing risk of violence may be a routine screening done for all of our patients, but a more thorough assessment is required in a number of circumstances. These include patients with violent/homicidal ideations and in a variety of forensic/criminal settings such as pre-trial proceedings, sentencing, and determining suitability for parole and probation.


•It is important to note that we, as a field, are not very good at predicting the risk of violent acts. There really is no accurate way to precisely predict whether or not someone will become violent in the future. In one systematic review, the most commonly used violence risk assessment tools were found to have positive predictive values between 0.18-0.76. That is, they correctly predict those likely to offend with an accuracy between 18% and 76% depending on the baseline risk of those studied 1. In general adult psychiatry, where violence is a rare event, predictive power is extremely low.


What is the relationship of mental illness and violence? Overall it plays a small role in total violence across the general population. Only 4% of violence in the United States is attributed to serious mental illness 2. In fact, those with serious mental illness are more likely to be victims of violence. Other factors such as a history of violence, misuse of alcohol or drugs, or prior convictions for violent misdemeanors are greater predictors of violence. Also, risk factors associated with convicted criminals that reoffend are similar for those with and without mental disorders.



RISK FACTORS


•Risk factors for violence are commonly broken down into static factors (not easily modified) and dynamic factors (possible area for intervention). Factors can be identified through the clinical interview, observable behaviors, collateral, record review, and formal assessment tools. The following list of risk factors is compiled from data drawn from the CDC, NIH (National Institutes of Health), VA/DOD (Veteran Affairs / Department of Defense), and other relevant research.


Static Risk Factors:

  • History of violent behavior (*best predictor of future violence*)

  • Age of first violent act (before adolescence increases risk)

  • History of violent victimization / witnessing / experiencing abuse as child/teen

  • Male gender

  • Age (15-24 at highest risk)

  • Low socioeconomic status

  • Antisocial personality disorder (particularly with traits associated with psychopathy-> lacking empathy and close relationships, behaving impulsively, superficially charming, primarily interested in self-gratification)

  • Low IQ / Poor behavioral control / Social cognitive deficits

  • Prior arrest

  • History of head injury

  • Teens -> low parental education/income; parental substance abuse; parental criminality


Modifiable Risk Factors

  • Untreated, active psychiatric symptoms (stronger link related to specific symptoms rather than diagnosis. For example -> command hallucinations, grandiosity, suspiciousness, hostility, and certain delusions with anger/disorganization. Patients who see the need for treatment and are adherent to treatment are at lower risk.

  • Those with mental illness are more likely to have other modifiable risk factors.

  • Substance use (increases risk 12-16x) 3

  • Stressful life events / triggers

  • Access to weapons, particularly firearms

  • Unemployment

  • Low interest/commitment to work/school

  • Anger / impulsivity / social rejection / bullying

  • Involvement in gangs

  • Similar circumstances to prior violence (for example-> if prior violent acts have occurred primarily in the setting of new homelessness and substance relapse, presence of those features again should raise concern)

  • Recent threatening statements

  • Current homicidal ideation

  • Identified target or specific plan

  • Teens -> authoritarian parenting; low parental involvement/attachment



VIOLENCE RISK ASSESSMENT


There are three potential approaches in assessing risk of violence / homicide:

  • Unaided clinical judgement

  • Actuarial assessment tools

  • Structured professional judgement (SPJ)


Unaided clinical judgement

  • Estimates risk of violence based on their own clinical experience and judgement.

  • Utilizes knowledge of risk factors but does not use a structured tool.

  • Incorporates information from the clinical interview, observable behaviors, collateral, and record review.

  • Common method but shown to be the least accurate.


Actuarial assessment tools

  • Structured instruments based on statistical models composed of risk/protective and static/dynamic factors. They are designed to show the relationship between these factors and an outcome of violence.

  • The benefit of using an actuarial assessment is that human biases are removed from the clinical decision-making process, giving them higher perceived usefulness in legal settings.

  • Some of the drawbacks of using these tools include the limited set of risk factors included, some patient-specific factors may not be taken into account, and can sometimes be difficult to translate to a specific situation/context of the potential violent act. 4

  • Commonly used tools include: Violence Risk Appraisal Guide (VRAG) (available free online); Level of Service Inventory (LSI); and Static-99.


Structured professional judgement (SPJ)

  • You can think of SPJs as a hybrid between the actuarial tools and clinical judgement.

  • They provide guidelines for making decisions but they do no impose strict cutoffs or algorithms for determining violence risk.

  • They can assist in the development of risk management plans based on an understanding of the causes of past violence.

  • Commonly used SPJ tools include: Historical-Clinical-Risk-20 (HCR-20) (available free online); Structured Assessment of Protective Factors for Violence (SAPROF) (available free online).


•REMEMBER. Patients with homicidal ideation and intent for violence are also at increased risk for suicide. Violence risk assessment should also include suicide risk assessment.



MANAGEMENT


•Just a few words on management.


•According to the Tarasoff reporting laws we have a "duty to protect" all known or suspected potential and readily identifiable victims. The specific implementation of this law varies by state (always verify with your local guidance), but in general includes ethical permission to breach confidentiality in order to protect the patient or the identified victim(s).


If you assess a patient and deem them to be dangerous to others then consider the following possible interventions:

  • Consider hospitalization, particularly if the danger is related to serious mental illness.

  • Consider notification of law enforcement authorities.

  • Consider notification of the identifiable victim(s) via telephone, in-person, mailed letter, etc.

  • Consider notification of other individuals who could reasonably prevent the tragedy (example: boss of a company identified as a target).

  • Consider verifying removal of firearm or other weapons.

  • DOCUMENT all attempts to contact the above individuals including all efforts to mitigate risk.

  • Other interventions aimed at treating/mitigating dynamic risk factors: psychotherapy, medication changes, substance use treatment, etc.



CONCLUSION


I understand that this topic can be intimidating. I hope this post was helpful and provided a framework for these assessments. Please comment below if you have anything else to add.


Resources for today's post include Pocket Psychiatry and the articles referenced in the lesson.


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