September 17, 2020 - Assessing the potential for violent behavior by patients with psychiatric disorders is an essential but challenging responsibility for mental health professionals. A five-part series currently being published in the Journal of Psychiatric Practice summarizes an expert approach to screening, assessment, and management of the risk of "other-directed violence." The journal is published in the Lippincott portfolio by Wolters Kluwer.
Hal S. Wortzel, MD, of the University of Colorado and colleagues outline their experience-informed approach to therapeutic risk management of the potentially violent patient. While violence risk assessment is a legal and ethical requirement, it can also be "a crucial element of the comprehensive treatment plan to achieve therapeutic goals and optimize mental health," Dr. Wortzel and coauthors write.
Model for Therapeutic Risk Assessment of Other-Directed Violence
In several situations, mental health professionals are responsible for assessing the risk for violent behaviors in patients with psychiatric disorders. In many jurisdictions, they also have a duty to warn and protect others who may be at risk of violence. Many clinicians feel they lack the training and experience needed to conduct meaningful violence risk assessments.
In a previous series of "Law and Psychiatry" columns in Journal of Psychiatric Practice, Dr. Wortzel and colleagues shared their approach to assessing the risk of self-directed violence (SDV) in potentially suicidal patients. They emphasized the benefits of therapeutic risk assessment: a patient-centered model that supports the patient's overall treatment and the therapeutic alliance with mental health professionals.
The new series shifts the focus to therapeutic risk assessment for other-directed violence (ODV) - borrowing from the SDV risk assessment skills that many clinicians already have. The series focuses on five essential elements of the therapeutic risk assessment for ODV:
Clinical Risk Assessment - Assessment starts with a clinical interview, including questions about past violent thoughts or behaviors. The authors discuss the need to explore the patient's intent and plan to harm someone, the critical distinction between "risk factors" and "warning signs" for ODV, and approach to collecting collateral data from other sources, preferably with the patient's consent.
Structured Screening or Assessment Tools - Structured tools can provide and document additional information for the clinical risk assessment. While no questionnaire or rating scale can replace the clinical interview, adding various types of tools can provide "a more nuanced, multifaceted approach" to ODV risk assessment.
Risk stratification - Using all available sources of data, the clinician stratifies the individual's risk of ODV, focusing on the severity and temporality (acute versus chronic) of the risk.
Chain analysis - Assessment of pathways related to violent thoughts and behaviors allows the clinician to design effective therapeutic strategies targeting those pathways.
Safety planning - Mental health professionals work with patients toward developing a safety plan to recognize violent thoughts and other warning signs, engage in coping strategies to prevent violent behaviors, and get help when needed.
The first and second parts of the series appear in the July-August and September-October issues of Journal of Psychiatric Practice. The remaining columns are scheduled for upcoming issues.
Dr. Wortzel and colleagues hope their series will provide a "cogent process" for conducting violence risk assessments - in a way that fulfills legal and ethical responsibilities, protects the safety of patients and potential victims, and supports the patient's overall mental health care. The authors conclude: "Providers can collaborate with their patients to gain a better understanding of their risk for both SDV and ODV and develop plans to manage this risk."