Preventing the Unpredicted: Managing Violence Risk in Mental Health Care

Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, DUMC 3071, Durham, NC 27710, USA.
Psychiatric Services (Impact Factor: 2.41). 03/2008; 59(2):191-3. DOI: 10.1176/
Source: PubMed


Using clinical judgment alone, mental health professionals cannot predict individual patient violence much more accurately than chance. Clinicians could improve their prediction of violence if they routinely used structured risk assessment instruments, but they don't; the use of such tools for screening is not currently the standard of care in the United States and is not commonly reimbursed by insurance. The author argues, however, that clinicians actually can predict and prevent violence if they consider their patients as a group from the perspective of public-health epidemiology. Optimizing treatment for all patients will help prevent violence by the few who pose a risk of violence, even when such patients are not identified in advance.

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    • "Significant efforts continue to add knowledge to the practice of risk assessment with a great deal of the focus placed on developing actuarial and hence supposedly more scientific mechanisms for identifying and predicting future risk behaviours (Boardman and Roberts 2014, DoH 2007, Gray et al, 2011). Swanson (2008) however has noted that the predictive accuracy of risk assessment in mental health care is fraught with problems such that even the best actuarial tools perform substantially below that which is commonly acceptable in other branches of medicine. "

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    • "Workers show that while they are aware of the intrusive nature of their monitoring they remained convinced that this was the best way of managing potential risk behaviours and avoiding blame. The belief that this intensive supervision provides sufficient leverage over individuals to reduce risk behaviours in the absence of attention to social and structural factors may however prove unfounded (Swanson, 2008). "
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    ABSTRACT: Patients leaving forensic psychiatric settings on conditional discharge face the challenge of achieving successful community integration, which involves not re-offending, adjusting to the local community and building support networks. Aftercare and monitoring of patients by workers ostensibly assists with integration, but is often dominated by concerns about risks to the public. Risk is seen to emanate from individuals, with steps taken to ensure intensive monitoring and, if necessary, swift return to hospital. This article shows that workers and conditionally discharged patients have distinct views about risk in community living which are driven by contrasting values and priorities; and that some of these differences are associated with the provision of care itself. A discursive analysis of accounts, drawn from 59 interviews with patients and workers, demonstrates that fears about deviant status weigh most heavily for the individual leaving hospital. Aftercare, with its focus on intensive regular visits by nurses, social workers, police and voluntary agencies, works to ‘unmask’ the person to the wider community, setting them apart as needing supervision. Discharged patients express unease that this unmasking undermines their attempts to begin new lives. Their concern suggests that significant iatrogenic risk arises from aftercare. Workers are not indifferent to this issue, but are themselves subject to public safety imperatives which require surveillance and control of individuals deemed risky. Community integration has the potential to be an important mediator in future risk behaviours. However, managing intensive aftercare without allowing for its wider visibility may jeopardise its achievement.
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    • "This has led to much discussion about the best approach for assessing the risks posed by individuals with mental health problems; this includes the risks to both themselves and others. Within the research literature, the nature of assessment and management is often framed in terms of prediction, particularly the strengths and weaknesses of actuarial and clinical judgment approaches (Dolan & Doyle, 2000; Petrila & Douglas, 2002; Swanson, 2008). The centrality of a risk management approach to the provision of health care has raised a number of tensions for service providers. "
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    ABSTRACT: Risk assessment and management is a major component of contemporary mental health practice. Risk assessment in health care exists within contemporary perspectives of management and risk aversive practices in health care. This has led to much discussion about the best approach to assessing possible risks posed by people with mental health problems. In addition, researchers and commentators have expressed concern that clinical practice is being dominated by managerial models of risk management at the expense of meeting the patient's health and social care needs. The purpose of the present study is to investigate the risk assessment practices of a multidisciplinary mental health service. Findings indicate that mental health professionals draw on both managerial and therapeutic approaches to risk management, integrating these approaches into their clinical practice. Rather than being dominated by managerial concerns regarding risk, the participants demonstrate professional autonomy and concern for the needs of their clients.
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