Risk appraisal and management of violent behavior

OBJECTIVE: To help clinicians enhance the safety of the public, hospital staff, and patients and improve patient management, this article briefly reviews recent empirical work on appraisal of the risk of violence and the management of violent individuals. METHODS: Research on the prediction, management, and treatment of violent persons published in the last decade was reviewed. RESULTS: Risk appraisal research indicates that violence is predictable in some populations. The factors most highly and consistently related to risk are historical, including age, sex, past antisocial and violent conduct, psychopathy, aggressive childhood behavior, and substance abuse. Major mental disorder and psychiatric disturbance are poor predictors of violence. Actuarial methods are more accurate in predicting risk than unaided clinical judgment, which is a poor index. The Violence Risk Appraisal Guide has been shown to be a reliable and accurate actuarial instrument. Well-controlled studies have shown the effectiveness of behavior therapy and of behavioral staff training programs to reduce violence by persons in institutions, chronic psychiatric patients, and other populations. Otherwise, little is known about what psychotherapeutic or pharmacological treatments reduce violent recidivism by which clients under what circumstances. Recent work on the neurophysiology of aggression holds exciting promise but does not yet provide a scientific basis for prescriptive treatment. CONCLUSIONS: The most exciting and promising avenues for research on the management of violence lie in the joining of two scientific paths to understanding violence--biology and psychology.