Are Violence Risk Assessment Tools Clinically Useful?

Abstract

Despite increasing concerns regarding the prevalence of violent behaviour in mainstream mental health settings, the impressive body of forensic research on violence risk assessment has thus far had only limited impact on front-line general mental health practice. The common objection raised by clinicians that risk assessment tools lack utility for clinical practice may contribute to this. The present paper argues that this objection, although understandable, is misplaced. Usage of appropriate, validated risk assessment tools can augment standard clinical approaches in a number of ways. Some of their advantages derive simply from having a well-structured approach, others from consideration of specific kinds of risk factors: 'static' and 'dynamic'. The inappropriate use of tools without a firm evidence base, however, is unlikely to enhance clinical practice significantly.

Risk Assessment: A Reflection on the Principles of Tools to Help Manage Risk of Violence in Mental Health

“…By contrast to actuarial approaches, a purely clinical approach can encompass an unstructured and impressionistic risk assessment for violence; sometimes inclusive of rating scales or "checklist" approaches with no scientific basis (Allnutt & O'Driscoll, 2008). Such scales or checklists are highly questionable in communicating clinical information of value to risk assessment (Carroll, 2007).…”

“…A substantial volume of literature focused on mental disorder and violence, risk assessment and risk management has suggested the inclusion of appropriate risk assessment tools in clinically assessing risk for violence (Allnutt & O'Driscoll, 2008;Carroll, 2007Carroll, , 2008; Monahan et al, 2001) Incorporation of such tools into routine clinical practice in community and lower security hospital settings has been seen as problematic; in particular, the more longitudinal approach to assessing risk for future violence invited by risk assessment tools might deter clinicians due to time constraints. Such views and practicalities have contributed to significantly variable approaches to risk assessment for future violence with persons presenting to public mental health services (Allnutt & O'Driscoll, 2008).…”

“…It has also been noted that events such as stranger homicide by persons with a psychotic illness are extremely rare and by inference "unpredictable" (Nielssen et al, 2009). Such criticisms can fuel anxiety about making errors in risk assessment, in part due to the noted emphasis in most published studies on prediction rather than prevention (Carroll, 2007). However, such anxiety would arguably only exist if prediction rather than management of risk is the goal of risk assessment.…”

“…In concurrently seeking to minimize the likelihood of harm and acknowledge the limitation of being unable to prevent all harm, mental health care need not be viewed as significantly different to any other medical specialty. Rather than being used as a way of simply estimating risk, tools assist mental health management by identifying areas for intervention and subsequent evaluation (Carroll, 2007). Thus, the real value of a risk assessment tool is whether effective risk management is the consequence of identifying a person in a "high-risk group", rather than the capacity to accurately identify the smaller group who kill and seriously harm others (Wallace et al, 1998).…”

Interventions to Address Violence Associated with Mental Illness

“…27 There is a growing evidence base for the use of validated risk assessment tools to not only estimate the likelihood of future violence but also to actively inform assertive management and appropriate resource allocation for patients at increased risk of violence. 28 …”