Medicolegal Issues

Violence risk: Is clinical judgment enough?

Current Psychiatry. 2008 June;7(6):66-72

References

1. Tarasoff vs Regents of the University of California, 551 P. 2d 334 (Cal. 1976).

2. McNiel DE, Chamberlain JR, Weaver CM, et al. Impact of clinical training on violence risk assessment. Am J Psychiatry 2008;165:195-200.

3. Monahan J. The clinical prediction of violent behavior. Washington, DC: National Institute of Mental Health; 1981.

4. Mossman D. Assessing predictions of violence: being accurate about accuracy. J Consult Clin Psychol 1994;62:783-92.

5. Rice ME, Harris GT. Violent recidivism: assessing predictive validity. J Consult Clin Psychol 1995;63:737-48.

6. Gardner W, Lidz CW, Mulvey EP, Shaw EC. Clinical versus actuarial predictions of violence in patients with mental illness. J Consult Clin Psychol 1996;64:602-9.

7. Dawes RM, Faust D, Meehl PE. Clinical versus actuarial judgment. Science 1989;243:1668-74.

8. Hart SD, Michie C, Cooke DJ. Precision of actuarial risk assessment instruments: evaluating the ‘margins of error’ of group v. individual predictions of violence. Brit J Psychiatry 2007;190:60-5.

9. Webster CD, Douglas KS, Eaves D, Hart SD. HCR-20: assessing risk for violence, version 2. Burnaby, British Columbia: Simon Fraser University, Mental Health, Law, and Policy Institute; 1997.

10. Quinsey VL, Harris GT, Rice ME, Cormier CA. Violent offenders: appraising and managing risk. 2nd ed. Washington, DC: American Psychological Association; 2006.

11. Hanson RK, Morton-Bourgon KE. The accuracy of recidivism risk assessments for sexual offenders: a meta-analysis. Ottawa, Canada: Public Safety Canada; 2007. Available at: http://www.publicsafety.gc.ca/res/cor/rep/_fl/crp2007-01-en.pdf. Accessed April 21, 2008.

12. Swanson JW. Preventing the unpredicted: managing violence risk in mental health care. Psychiatr Serv 2008;59:191-3.

13. Lamberg L. New tools aid violence risk assessment. JAMA 2007;298(5):499-501.

14. Mossman D. Commentary: assessing the risk of violence—are “accurate” predictions useful? J Am Acad Psychiatry Law 2000;28:272-81.

15. Monahan J, Steadman HJ, Robbins PC, et al. An actuarial model of violence risk assessment for persons with mental disorders. Psychiatr Serv 2005;56:810-15.

16. Simon RI. The myth of “imminent” violence in psychiatry and the law. Univ Cincinnati L Rev 2006;75:631-43.

17. Dobbs DB. The law of torts. St. Paul, MN: West Group; 2000:269.

Table 2

Items from the Historical, Clinical, and Risk Management (HCR-20)

Historical items	Clinical items	Risk management items
H1 Previous violence	C1 Lack of insight	R1 Plans lack feasibility
H2 Young age at first incident	C2 Negative attitudes	R2 Exposure to destabilizers
H3 Relationship instability	C3 Active symptoms of major mental illness	R3 Lack of personal support
H4 Employment problems	C4 Impulsivity	R4 Noncompliance with remediation attempts
H5 Substance use problems	C5 Unresponsive to treatment	R5 Stress
H6 Major mental illness
H7 Psychopathy
H8 Early maladjustment
H9 Personality disorder
H10 Prior supervision failure
Score each item 0, 1, or 2, depending on how closely the patient matches the described characteristic. For example, when scoring item C3 (active symptoms of major mental illness), a patient gets 0 for “no active symptoms,” 1 for “possible/less serious active symptoms,” or 2 for “definite/serious active symptoms.” An individual can receive a total HCR-20 score of 0 to 40. The higher the score, the higher likelihood of violence in the coming months.
Source: Reprinted with permission from Webster CD, Douglas KS, Eaves D, Hart SD. HCR-20: assessing risk for violence, version 2. Burnaby, British Columbia, Canada: Simon Fraser University, Mental Health, Law, and Policy Institute; 1997

Is not using ARAIs negligent?

Some writers believe that using ARAIs should¹² or may soon¹³ become the standard of care. Why, then, do psychiatrists seldom use ARAIs in their clinical work? Partly it is because clinicians rarely receive adequate training in assessing violence risk or the science supporting it. After a 5-hour training module featuring the HCR-20, psychiatry residents could better identify factors that affect violence risk, organize their reasoning, and come up with risk management strategies.²

Psychiatrists may have other reasons for not using ARAIs that make clinical sense. Although ARAIs can rank individuals’ violence risk, the probabilities of violence associated with each rank aren’t substantial enough to justify differences in management.¹⁴ Scientifically, it’s interesting to know that we can separate patients into groups with “low” (9%) and “high” (49%) risks of violence.¹⁵ But would you want to manage these patients differently? Most psychiatrists probably would not feel comfortable ignoring a 9% risk of violence.

Clinical Point

Psychiatrists seldom employ ARAIs to assess violence risk, so failing to use them cannot constitute malpractice

Also, ARAIs typically focus on factors that influence violence risk over weeks, months, or years. But as Simon¹⁶ notes, clinicians often are asked to address “imminent” violence. No agreed-upon definition of imminence exists, but even if the meaning were clear, ARAIs “are insensitive to patients’ clinical changes that guide treatment interventions or gauge the impact of treatment.”¹⁶

To avoid negligence, psychiatrists need only “exercise the skill, knowledge, and care normally possessed and exercised by other members of their profession.”¹⁷ Psychiatrists seldom use ARAIs,¹² so failing to use them cannot constitute malpractice. As Simon points out, a practicing psychiatrist’s role is to treat patients, not predict violence. He concludes, “at this time, the standard of care does not require the average or reasonable psychiatrist to use actuarial assessment instruments in the evaluation and treatment of potentially violent patients.”¹⁶

Violence risk: Is clinical judgment enough?

References

Pages

Recommended Reading