Violence Risk Assessments and Management

Abstract

Risk assessment and management are central to much of contemporary psychiatric practice. Although many people with mental illness are not violent, mental health professionals are often called upon to perform violence risk assessments in a variety of situations and settings. Moreover, in general practice, assessing and mitigating patients' risk can be critical aspects of treatment. The task of applying the information gathered during risk assessments to manage risk clinically remains challenging. Knowing how to conduct skillful risk assessments can improve decision-making about violence and help treat patients well and safely. We review violence risk assessment research and the clinical application of risk assessments and risk management. [ Psychiatr Ann. 2018;48(2):109–114.]

The pathway to violence and public mass shooters in mental health treatment before attacks

“…Thus, it may be important for practitioners to be familiar with this model, especially the earlier stages, to potentially identify and intervene with individuals at risk of committing mass violence. Interventions in each of the Path to Intended Violence model (Calhoun and Weston, 2003) stages vary depending on the individual patient and are most effective when risk factors and warning behaviors are appropriately identified and targeted (Hagga ˚rd-Grann, 2007;Parke et al, 2018). Practitioners should focus on dynamic risk factors that can be modified or changed with evidence-based therapeutic interventions, such as acute stress, by providing psychoeducation and coping strategies or encouraging the patient to remove themselves from the stressful environment (Hagga ˚rd-Grann, 2007;Kivisto, 2016;Otto, 2000).…”

“…For example, the 2012 Aurora, CO movie theater shooter discussed his homicidal thoughts with a mental health clinician just one month before his attack (Associated Press, 2015) and the Seal Beach hair salon shooter disclosed his plans to a friend weeks before he attacked (Taxin, 2011). For this reason, when working with patients who show potential warning signs for violent intent, it is essential to try to consult with the individual's close family members and friends (Borum et al, 1999;Knoll and Annas, 2016;Lankford, 2018;Otto, 2000;Parke et al, 2018). Encouraging these collaterals to monitor the individual's social media accounts might be beneficial as well, as almost half of the perpetrators in our sample who had access to the internet engaged in social media use related to violence.…”

“…Therefore, asking about access to weapons and firearm proficiency is critical (Otto, 2000). Further, consulting with family and friends about what they are noticing at home can also assist (Borum et al, 1999;Knoll and Annas, 2016;Lankford, 2018;Otto, 2000;Parke et al, 2018;US Department of Justice, 2017). The majority of weapons used by the perpetrators in this current study were acquired more than one month before the shooting, substantiating the premeditated nature of their attacks.…”

“…An essential aspect of a mental health provider's role is engaging in risk assessment and mitigation when a patient presents with suicidal or homicidal ideation (Cowan and Cole, 2020;Lankford and Cowan, 2020;Borum and Reddy, 2001;Borum et al, 1999;Hagga ˚rd-Grann, 2007;Kivisto, 2016;Lankford, 2018;Parke et al, 2018). In most states, due to the Tarasoff v. Regents of the University of California, 17 Cal.3d 425 (1976) ruling, mental health professionals have a duty to warn and protect potential victims when a patient threatens violence (Adi and Mathbout, 2018;Borum and Reddy, 2001;Hagga ˚rd-Grann, 2007;Kivisto, 2016;National Conference of State Legislatures, 2018;Parke et al, 2018).…”

“…An essential aspect of a mental health provider's role is engaging in risk assessment and mitigation when a patient presents with suicidal or homicidal ideation (Cowan and Cole, 2020;Lankford and Cowan, 2020;Borum and Reddy, 2001;Borum et al, 1999;Hagga ˚rd-Grann, 2007;Kivisto, 2016;Lankford, 2018;Parke et al, 2018). In most states, due to the Tarasoff v. Regents of the University of California, 17 Cal.3d 425 (1976) ruling, mental health professionals have a duty to warn and protect potential victims when a patient threatens violence (Adi and Mathbout, 2018;Borum and Reddy, 2001;Hagga ˚rd-Grann, 2007;Kivisto, 2016;National Conference of State Legislatures, 2018;Parke et al, 2018). However, despite these laws and mandates at the core of the mental health profession, practitioners often lack the training, expertise and confidence needed to adequately assess for risk of violence (US Department of Justice, 2017) and frequently struggle with risk assessment due to its multifaceted and complicated nature (Fox and DeLateur, 2013;Kivisto, 2016).…”