Psychiatrists have expended considerable effort over the last few decades to disabuse the legal system and the public of the notion that they can predict who will be violent in the future. Using modern assessment tools, however, there is a growing body of data to suggest that psychiatrists can, in fact, predict violence more accurately than many believe—at least in the short term.
This was the message hammered home by several speakers at an APA annual meeting session in New Orleans in May sponsored by the APA Task Force on Psychiatric Aspects of Violence.
"Psychiatrists have come a long way in assessing violence risk," said forensic psychiatrist Bradley Johnson, M.D., an assistant professor at the University of Arizona. "We can now predict short-term violence with moderate accuracy, which is substantially better than being wrong two-thirds of the time," he said, as was the case not too many years ago.
Psychiatrists can’t, however, take shortcuts if they want to produce a comprehensive violence assessment, noted Johnson, who is also chief of psychiatry at the Arizona Community Protection and Treatment Center, which treats civilly committed sex offenders. This means "it is important to obtain information about the person from every possible source. This is a serious undertaking and cannot be rushed," he emphasized, cautioning that such an evaluation could take at least several hours. "This is not the time to do a brief, managed-care intake on a person," he stressed.
Among the key factors that should cause psychiatrists to sit up and take notice, he said, is a history of violence, "which is the single best predictor of future violence." Having a major mental illness, substance abuse disorder, or a combination of both is also associated with increased violence risk, Johnson said. He stressed, however, that most people with these disorders are not a danger to themselves or others.
Violence is "often underpredicted" in women, he noted, urging his audience not to ignore or minimize the possibility that a woman could become violent just because women do so less frequently than men.
Key factors to assess during a clinical evaluation of violence risk include criminal history, possession of a gun, history of multiple psychiatric admissions, the presence of violence fantasies, and sexually aggressive behavior or fantasies about such behavior, Johnson pointed out. He noted as well that violent acts attributed to "homosexual panic" can also signal a violence risk.
Binder, who is chair of APA’s Council on Judicial Action, said that additional risk factors for violence are a first criminal arrest occurring at a young age; being a male under age 40; a history of cruelty to animals, firesetting, or reckless driving; viewing oneself as a "victim"; being very resentful of authority; and a lack of compassion and empathy for others.
From the perspective of psychiatric diagnosis, Johnson suggested that violence risk rises among individuals who have acute mania, ADHD along with interim explosive disorder, antisocial personality disorder, or paranoid schizophrenia with acute decompensation. Binder also suggested that evaluators should be alert to a history of noncompliance with psychiatric treatment.
Johnson also pointed out that it is crucial that psychiatrists weigh mitigating factors before reaching a conclusion about a person’s violence risk. Among such factors are the capacity to bond and the presence of mentors in the person’s life.
Binder emphasized several elements that psychiatrists should include in a comprehensive violence-risk assessment, particularly when it is conducted in the emergency room, a common venue for these evaluations.
The basis of such an evaluation is, of course, a clinical interview during which the person is asked specifically about intent; possible victims; and history of violence, violent thoughts, and criminal behavior, Binder said. This information is, she warned, "highly unreliable" if a psychiatrist stops at this point without gathering additional data.
The additional data should come from interviewing the person’s therapist, family members, and police, Binder suggested. And remember, she cautioned, that while the evaluator can ask these individuals any relevant questions, he or she cannot give information about the patient without written consent, despite the likelihood that the psychiatrist will be asked to provide such information in the course of these interviews.
It is also critical to review medical records, though these may be unavailable in the emergency room setting. If the medical records of the person being evaluated turn out to be easily available and the psychiatrist does not review them, the evaluator opens himself or herself up to later accusations of "laziness or sloppiness" if their prediction is wrong, she noted.
Johnson pointed out that there are now "helpful tools" such as checklists, scales, and interview protocols that can aid in arriving at a violence-risk prediction.
Judith Becker, Ph.D., a professor of psychology and psychiatry at the University of Arizona and editor of the journal Sexual Abuse, cited several such assessment tools that are now on the market, such as the Psychopathy Checklist, Revised; Static-99; Violence Risk Appraisal Guide (VRAG); and Sexual Offender Risk Assessment Guide (SORAG).
"There has been tremendous progress in developing actuarial tools" to help psychiatrists conduct a violence-risk evaluation, Becker said, "but there is still a long way to go."
If a psychiatrist believes that a person being evaluated does present a high risk of becoming violent, Binder urged taking several "essential actions" to support that determination and minimize liability risks.
These begin with a clinical interview with the patient that results in a hospital admission, followed by the psychiatrist’s visiting the patient more often than might be necessary with other types of patients, obtaining appropriate consultations and referrals, and prescribing medication.
The psychiatrist should also back up the assessment with interviews of victims or potential victims, even in states that do not mandate a legal duty to warn, Binder stressed. In addition to alerting these individuals to potential danger, the psychiatrist should advise them on steps that could decrease their risk, she added.
Session chair Paul J. Fink, M.D., who chairs the APA Task Force on Psychiatric Aspects of Violence, emphasized that "psychiatrists have been too modest about their ability to predict violence and afraid to take that risk." But when they do offer their knowledge and expertise in evaluating risk, they take a step that helps the community and goes a long way to "undoing the notion that all mentally ill people are violent." ▪