The authors are affiliated with the Integrated Behavioral Healthcare System of the Ohio Department of Mental Health. Mr. Ignelzi is the chief executive officer, Dr. Stinson is a clinical and forensic psychologist, and Dr. Raia is the psychology director of Twin Valley Behavioral Healthcare, Columbus. Dr. Osinowo is the chief clinical officer at Northcoast Behavioral Healthcare, Toledo. Dr. Ostrowski is the chief clinical officer at Summit Behavioral Healthcare, Cincinnati. Ms. Schwirian is the clinical program director at Appalachian Behavioral Healthcare, Athens. Send correspondence to Mr. Ignelzi, Twin Valley Behavioral Healthcare, 2200 W. Broad St., Columbus, OH 43223 (e-mail: firstname.lastname@example.org). William M. Glazer, M.D., is editor of this column.
This column provides best-practice recommendations for the assessment of the risk of violence and the utilization of those findings in communication among care providers to manage risk of violence and assist in planning mental health treatment as clients are transferred or referred.
We are members of the Forensic Risk Assessment Work Group of the Ohio Department of Mental Health's statewide Forensic Product Line Leadership Team (ODMH-FPLT). ODMH-FPLT consists of an interdisciplinary group of 23 mental health and forensic professionals (for example, from psychiatry, psychology, nursing, social work, quality and legal assurance, and clinical and forensic administration), with participants from each of ODMH's five statewide behavioral health care organizations. The best-practice recommendations expressed in this column were developed in the course of our leadership over the past five years in addressing ODMH-FPLT's forensic mission and goals. The statewide FPLT is charged with implementing ODMH's forensic plan and working collaboratively with the department's Office of Forensic Services on statewide issues. Each year, FPLT develops major goals and objectives as a way of reviewing and renewing its service planning efforts.
The best practices that we recommend emphasize that the risk of violence be scientifically assessed and consistently used for the evaluation of clients' treatment needs at each level of care, because management of the risk of violence is typically central to the therapeutic process. These guidelines also emphasize that risk assessments of violence include static and dynamic risk factors because these factors are predictive of future violence. Finally, best practices call for treatment providers to effectively communicate findings on risk of violence, related data, and recommended interventions among all providers, within and across treatment settings, in order to effectively manage risk.
For years, clinicians relied on the clinical interview, mental status examination, observations, and resulting "clinical judgment" when identifying potential risk factors for dangerous behaviors among people with mental illness, despite early devastating critiques of clinical judgment (1). As Quinsey and associates (2) pointed out, a reliance on this clinical judgment started to change in the 1970s when a series of studies by various authors further cast doubt on the utility of clinical judgment alone to assess and predict dangerous behaviors (3,4).
Research moved past the focus on unstructured clinical assessment and began to systematically study the process by which clinicians estimated risk of dangerousness (5). An emphasis was placed on evidenced-based actuarial tools that would inform judgment (6), with subsequent development of risk assessment tools based on science and statistics rather than solely intuition and clinical judgment (2). More recently, classification trees have been proposed, which allow one to consider mental disorders with a combination of various risk-of-violence factors (7).
Despite the ongoing scientific development of tools for assessing risk of violence, the research literature provides limited specific guidelines for the utilization of risk-of-violence findings in communication among treatment providers and management of potential violence for continuity of care among all treatment providers and settings.
The literature on violence risk assessment clearly indicates that a number of static (historical and unchangeable) and dynamic (changeable and treatable) factors are predictive of violence. Examples of static risk factors include the seriousness of the offense for which an offender with mental illness was arrested, a history of paternal alcoholism, and a history of parental fighting (7). Dynamic risk factors include, among others, the client's noncompliance with mental health treatment or the discontinuation of medication (with the emergence of severe symptoms that medications attenuate), the use of alcohol and illegal substances, social isolation, neighborhood conditions, recent violent behaviors, and violent fantasies (7). The need for the effective communication and management of all violence-related risk factors to ensure continuity of care across all treatment providers and care settings cannot be overstated.
The ultimate goals of violence risk assessment and communication and management of that risk are effective treatment and prevention of violence. However, the assessment and identification of risk of violence are not enough to prevent violence. Clinicians must communicate and manage risk in ways that respect the rights of clients, protect the public, are unobtrusive, and foster the principles of recovery. The effective communication about potential violence and management of the risk of violence are an institutional responsibility, an individual clinician's responsibility, and the responsibility of the clients themselves. After reviewing clients' care and violence risk-management plans, we identified that it is this shared responsibility in the assessment, communication, and management of risk factors that underlines best clinical practices for managing risk of dangerous behaviors and promoting clients' early and safe recovery.
For treatment planning purposes, the identification, communication, and management of dynamic risk-of-violence factors should be a priority in planning care. The individual's identified dynamic and changeable risk factors should drive the treatment planning process, including the implementation of existing evidence-based risk-management practices. Care providers need to attend to the dynamic risk-of-violence factors that are germane to the individual client.
Each client's individual treatment and risk-of-violence management plan should address factors identified during the assessment and reassessments of the individual's risk, with special attention to several areas.
Risk factors may have multiple causes and may involve a complex interaction of variables. The treatment and interventions from a risk-of-violence management plan must be sensitive to the causes of the client's high-risk behaviors. Understanding antecedent events and behavioral consequences in assessing dynamic risk factors is crucial and should be reflected in the plan.
The management of risk of violence is not fixed or static; therefore, all plans should be updated as soon as new information becomes available and identifiable progress is made.
The mental health consumer's plan should clearly define the roles and responsibilities of all treating staff, as well as time frames for reassessment of risk of violence, depending on the level of risk as identified by the treating sources during prior risk assessments.
Dynamic risk factors vary over time and in response to specific situations, contexts, and interventions. The treatment and risk-management plan must be sensitive to these changing risk factors over time so that it can guide clinicians in making treatment and care decisions with the client. The prudent clinician should comprehend the client's history of response to specific treatment and medication interventions in order to know what works best in managing behaviors that can lead to violence.
Some dynamic risk factors change quickly in response to treatment and the environment, whereas others change gradually. Change over time is an element in planning care and assessing risk of violence and should be explained in the treatment and risk plans.
The mental health consumer's treatment plan should include explicit strategies for responding to issues related to a high risk of violence, such as the client's noncompliance with treatment, missed contacts with clinicians, access to weapons, and abuse of substances. These strategies should be commensurate with the level of risk identified.
The degree and level of interventions and the monitoring of the client's risk of violence are largely dependent on such variables as past levels of risk and previous dangerous behaviors, the severity of mental illness and types of symptoms present, the degree of impulsivity and level of insight (at time of treatment and by history), the extent of treatment adherence and level of progress, real and perceived safety (to the client, victims, family, staff, and so on), and the history of violence.
Effective management of risk of violence includes supporting a safe environment for the client and anyone who may be affected by the client's potential violent behavior. Safety management is an ongoing, continuous process as a client moves from provider to provider and across different treatment settings. (Contact the first author for information on additional risk-of-violence references and resources.)
The accurate assessment and effective communication of a client's risk of violence are essential for the management and reduction of future risk as a client moves from one treatment provider to another and from one setting to another. Clinical judgment alone is not a satisfactory risk-assessment technique. Evidence-based tools for assessing the risk of violence should be used to assess static and dynamic risk factors. The failure to secure accurate risk-of-violence assessments and to communicate this risk information among providers can contribute to ineffective client outcomes in mental health care and may compromise client and public safety. As new or additional risk-of-violence information becomes available, the sharing and discussion of the latest risk findings are essential to the management of risk, especially during shift changes among treating staff, across clinical service departments, and among treatment settings.
When clients are transferred or referred, previous risk-of-violence treatment information from past care needs to be obtained, carefully reviewed, and communicated to all current treatment providers on a timely basis. It is recommended that all referring and receiving clinicians have an opportunity to personally discuss the client when making a clinical handoff so that each clinician has the opportunity to ask and respond to questions about the client's mental health treatment and any matters related to risk of violence.