Therapeutic Risk Management for Violence: Stratifying Risk and Characterizing Violence

Abstract

Violence risk assessment is a requisite component of mental health treatment. Adhering to standards of care and ethical and legal requirements necessitates a cogent process for conducting, and then documenting, other-directed violence risk screening, assessment, and management. In this 5-part series, we describe a model for achieving therapeutic risk management of the potentially violent patient, with essential elements involving: clinical interview augmented by structured screening or assessment tools; risk stratification in terms of temporality and severity; chain analysis to intervene on the functions of violent ideation and behavior; and personalized safety plans to mitigate/manage risk. This third column in the series describes other-directed violence risk stratification in terms of both severity and temporality, as well an approach for characterizing (ie, predatory/planned or impulsive/reactive) the violence risk posed by an individual.

Therapeutic Risk Management and Firearm-related Lethal Means Safety

“…Generally, medical professional societies and clinical practice guidelines concerning suicide prevention recommend promoting LMS among individuals with elevated suicide risk 17,18. Previous Law and Psychiatry columns in this journal have described methods for assessing and stratifying risk for suicide and ODV,19,20 and have recommended that persons identified as having elevated (moderate or high) acute or chronic risk receive LMSC. Some have advocated for transitioning from a selective suicide prevention strategy, whereby resources are focused on those already identified as at-risk, to a more universal one in which LMSC is delivered to patients without identified elevated suicide risk.…”

Therapeutic Risk Management for Violence: Chain Analysis of Other-directed Violent Ideation and Behavior

“…This case example was first introduced in the third column of this series in the context of the risk stratification of ODV. 4 The case example details a Veteran's engagement in ODV when he makes threats to his girlfriend after an argument with her. For a full description of the case example, see Table 2.…”

“…The chain should be interpreted as part of a comprehensive assessment of the Veteran's ODV ideation and behavior, including the elements described in the earlier columns in this series. [2][3][4] Such assessment is facilitated by functional assessment like chain analysis, further informing risk stratification and appropriate next steps with regard to management and intervention. Considerations of symptom validity may be important in interpreting the chain with a client engaging in ODV ideation and behavior, particularly if the chain of events does not tell a story that makes sense to the clinician.…”

“…Using a case example, we describe how to determine the function of ODV thoughts and behavior to select the most efficient and effective intervention strategies. In addition to the structural assessment approaches described in the first 3 columns of this series, [2][3][4] a functional approach that employs a behavioral chain to determine the factors maintaining ODV ideation and behavior is essential to comprehensive assessment, management (ie, safety planning), and treatment.…”

Practical Steps Towards Identifying and Assisting Victims of Domestic Violence

“…To close out our series addressing therapeutic risk management for violence, [1][2][3][4][5] it seems appropriate to present a guest column reflecting on the needs of victims of violence. To this end, guest columnists Chien and colleagues offer an excellent overview on the subject of domestic violence, with concrete guidance about screening, risk assessment, and safety planning for domestic violence.…”