edited by Robert Simon, M.D., and Kenneth Tardiff, M.D., M.P.H.; Washington, D.C., American Psychiatric Publishing, Inc., 2008, 614 pages, $84
Dr. Buchanan is associate professor in law and psychiatry at Yale University, New Haven, Connecticut.
This is a large and comprehensive book. The first chapter is written by one of the editors and proceeds from two premises: first, that actuarial methods predict violence better in the long term while clinical approaches are better over days or weeks, and second, that short-term predictions are more accurate. The second chapter, written by John Monahan, denies the first of these premises in the course of an authoritative and stimulating description of three degrees of structure in risk assessment instruments. Both chapters of the Textbook of Violence Assessment and Management make their arguments well.
How should clinicians assess risk over the ensuing days or weeks? The first chapter identifies ten areas of interest: the appearance of the patient, thoughts of acting violently (specific threats being more serious than vague ones), intent to act violently, availability of a victim, the means to harm someone, a history of violence or impulsivity, current alcohol and drug use, personality disorder (not limited to antisocial personality disorder), treatment noncompliance, and demographic characteristics (youth, male gender, and family disruption). The chapter recommends combining the information by using clinical judgment. There are no points for particular replies, no total score, and, hence, no cutoff for "risky." The approach seems to correspond to the first of Monahan's "three degrees."
The ten areas of risk assessment are well reviewed in this book and elsewhere. However, I was left wondering about the crucial question of thresholds. The authors note that an assessment of risk of violence is expected of all treating clinicians and that this should include interviewing police and family members, contacting present and past therapists, and seeking out police and arrest reports in old charts. Even strong advocates of collateral information gathering will find it difficult to imagine all clinicians doing all of this in all cases. But where is the line drawn? Some form of screening, or staged, approach seems a necessary concomitant of structured risk assessment. In a chapter by James Beck two screening questions are identified: "Are you angry at anyone?" and "Have you ever hurt anyone?" If the answer to both of these is no, Beck suggests, the risk of violence is low. There is an important empirical question here: we don't yet know how successful screening could be in picking out the cases that matter.
I enjoyed the willingness of the editors to include many viewpoints, although I would have preferred the points of disagreement to have been referenced and developed. Chapters 1 and 9, for instance, offer tantalizingly different perspectives on the genesis of violence among individuals with narcissistic personality disorder. However, I was uncomfortable with repeated references to "treating violence," which implies that violence is a medical condition. I find it easier to think of violence as one symptom of some of the illnesses that we treat. The distinction has important ethical consequences for clinicians, particularly in these days of sexual predator statutes.
But these are quibbles. This collection of essays is comprehensive and written by a number of leaders in the field. Many of the analyses, such as Lim and Bell's "Cultural Competence in Risk Assessment," are not widely known. The book deserves its place on the shelf, even in this crowded field.