You are on page 1of 10

Australian and New Zealand Journal of


Managing aggression and violence: The clinician's role in contemporary mental health care
Stephen H Allnutt, James R P Ogloff, Jonathon Adams, Colman O'Driscoll, Michael Daffern, Andrew Carroll, Vindya
Nanayakkara and David Chaplow
Aust N Z J Psychiatry 2013 47: 728 originally published online 21 May 2013
DOI: 10.1177/0004867413484368

The online version of this article can be found at:

Published by:

On behalf of:

The Royal Australian and New Zealand College of Psychiatrists

Additional services and information for Australian and New Zealand Journal of Psychiatry can be found at:

Email Alerts:




>> Version of Record - Jul 30, 2013

OnlineFirst Version of Record - May 21, 2013

What is This?

Downloaded from at UNIV FED DO RIO DE JANEIRO on May 16, 2014
ANP47810.1177/0004867413484368ANZJP ArticlesAllnutt et al.


Australian & New Zealand Journal of Psychiatry

Managing aggression and violence: The 47(8) 728736

DOI: 10.1177/0004867413484368

clinicians role in contemporary mental The Royal Australian and

New Zealand College of Psychiatrists 2013

health care Reprints and permissions:

Stephen H Allnutt1,2, James R P Ogloff 3,4, Jonathon Adams1,2,

Colman ODriscoll1,3, Michael Daffern3,4, Andrew Carroll3,4,
Vindya Nanayakkara1,2 and David Chaplow2

Objective: From time to time misconceptions about violence risk assessment raise debate about the role mental health
professionals play in managing aggression, with associated concerns about the utility of violence risk assessment. This
paper will address some of the misconceptions about risk assessment in those with serious mental illness.
Methods: The authors have expertise as clinicians and researchers in the field and based on their accumulated knowl-
edge and discussion they have reviewed the literature to form their opinions.
Results: This paper reflects the authors views.
Conclusion: There is a modest yet statistical and clinically significant association between certain types of mental illness
and violence. Debate about the appropriateness of clinician involvement in violence risk assessment is sometimes based
on a misunderstanding about the central issues and the degree to which this problem can be effectively managed. The
central purpose of risk assessment is the prevention rather than the prediction of violence. Violence risk assessment is
a process of identifying patients who are at greater risk of violence in order to facilitate the timing and prioritisation of
preventative interventions. Clinicians should base these risk assessments on empirical knowledge and consideration of
case-specific factors to inform appropriate management interventions to reduce the identified risk.

Violence, risk assessment, risk management, mental illness

Violence risk assessment is critical to contemporary gen- contextual imperatives. Experts have long accepted that
eral mental health. The primary goal of violence risk assess- prediction (that is, identifying which individuals will or
ment is the prevention rather than the prediction of violence. will not be violent) cannot be achieved (Cocozza and
To be effective, violence risk assessment must be linked to Steadman, 1976; Monahan, 1981; Ogloff and Davis 2005).
a process of better management of patients that raise con- This is not new knowledge. But to argue against violence
cern, by managing risk factors. The important issue here is risk assessment because prediction is not possible is to miss
that it is not the violence that is being managed, but the risk
factors for violence (which relate to propensity). While 1Universityof New South Wales, Sydney, Australia
related concepts, propensity refers to tendency, and predic- 2Justice
and Forensic Mental Health Network, NSW, Australia
tion to actual outcome. 3Monash University, Clayton, Australia

Some have suggested that psychiatrists and others 4Forensicare, Fairfield, Australia

should not engage in violence risk assessment (Large etal.,

Corresponding author:
2011; Ryan etal., 2010). This argument is based purely on Stephen Allnutt, Justice Health, 7 Fleet Street, Parramatta, Sydney, NSW
a statistical perspective, focuses on the limits of prediction, 2151, Australia.
and ignores clinical, legal, social, moral ethical and Email:

Australian & New Zealand Journal of Psychiatry, 47(8)

Downloaded from at UNIV FED DO RIO DE JANEIRO on May 16, 2014
Allnutt et al. 729

the point; and most worryingly, potentially leads to the clinicians opinions in dispositional decisions that result in
abandonment of violence risk management and thus the detention and supervision of people against their will,
prevention. or release.
This paper will examine the role of mental health clini- Patients with mental illness could at one time be locked
cians in violence risk assessment and management in the away for extended periods on the signature of a doctor.
context of contemporary mental health systems in devel- However legislation has curtailed clinicians powers.
oped countries. Modern notions of due process and natural justice have led
to increased human rights protections in mental health leg-
islation. Despite these safeguards, mental health clinicians
Methods are still perceived as broadening the traditional treating role
Due to the complexity of this topic, we did not conduct a to one of public protection. Clinicians should not lose sight
systematic review, which would have included using key of the possibility of arbitrary and capricious deprivation of
terms to identify relevant literature in recognised electronic liberties, which has occurred in the past.
databases. Instead, the arguments we present are a sum- The management of patients with mental health prob-
mary of accumulated knowledge gained by the authors, lems requires consideration of numerous outcomes includ-
keeping up date with the literature and discussing amongst ing: relapse, abuse of substances, self-harm/suicide and
each other and with colleagues nationally and internation- psychosocial disadvantage. While not all patients are at risk
ally over the years. The authors have expertise as clinicians of every one of these adverse outcomes, clinicians need to
and researchers in the field and based on their accumulated be aware of the possibility of such outcomes and when
knowledge and discussion have reviewed the literature to identified, take reasonable action to intervene by appropri-
form their opinions. ate management. Violence can be regarded as a behavioural
complication of serious mental illness in some sufferers
and an outcome that requires assessment and management
Results (Mullen, 2006). It is thus understandable that mental health
The following is an account of the authors views. professionals have an obligation to identify and manage
risk of this outcome as well. Without first conducting a
thorough assessment of the relevant risk factors, effective
Understanding the problem
management strategies to assist with wellness, recovery,
It is inevitable (as with all medical decision making) that adaptation and prevention cannot be identified. Taking
clinicians will from time to time be asked to form an opin- action only after an incident does a disservice to the patient
ion on the probability of an outcome. In this context they and the broader community.
might express their opinion as a percentage or rate and thus The ultimate expectation of any health service is the pre-
make predictive statements. There is clear evidence that in vention of premature mortality and amelioration of morbid-
doing so, using assessment approaches that are structured ity. Mental health services are no different. In mental health,
and have an empirical basis provides stronger predictive the most severe form being self-harm/aggression and sui-
validity and are more reliable than unstructured clinical cide/homicide. Mental health professionals must develop
judgement alone (gisdttir etal., 2006; Hanson and skills and methods to assertively manage that possibility
Morton-Bourgon, 2009; Mossman, 2000). (Mullen and Ogloff, 2009).
Mental health clinicians are regarded as experts in the Understanding the type of population the person falls
assessment and management of disturbing behaviours into enables awareness of the propensity for violence and
derived from mental illness. The community has a long his- the consequent management of the patient according to
tory of expecting mental health professionals to assist in their individual needs. Risk assessment is the process of
this process and in deciding who requires detention and identifying empirical and clinically derived risk factors.
treatment under restrictive conditions. For example, Section Risk management is a process of ameliorating this propen-
26(2)(b), Part IV, of the Mental Health Act, 1959 (Vic) [7 & sity through multidisciplinary intervention, addressing the
8 Eliz. 2, Ch. 72] provides that An application for [invol- identified risk factors that moderate the interaction between
untary] admission for a treatment may be made in respect mental illness and violent behaviour (Mullen, 2006).
of a patient on the grounds that is necessary in the inter- There is an empirically established relationship between
ests of the patients health or safety or for the protection of serious mental illness and violence based on studies of pris-
the other persons that the patient should be so detained oners, mentally ill offenders, mentally ill people who do not
(emphasis added). This is reflected in current Mental Health offend and the general population (Mullen etal., 2000;
Acts, which afford psychiatrists power to involuntarily Swanson etal., 1990, 2006a; Wallace etal., 2004). This
detain and treat people with serious mental illnesses. In relationship is mostly studied in those with schizophrenia
addition, the judiciary and adjudicators (e.g. parole boards, and psychosis not otherwise specified. Douglas etal. (2009)
mental health boards or tribunals) rely heavily on and Fazel etal. (2009) in comprehensive meta-analyses

Australian & New Zealand Journal of Psychiatry, 47(8)

Downloaded from at UNIV FED DO RIO DE JANEIRO on May 16, 2014
730 ANZJP Articles

investigated the relationship between psychosis and vio- found that 10% of patients involuntarily hospitalised in
lence. Results revealed a modest yet statistically significant general psychiatric hospitals discharged to the community
and clinically important relationship even when controlling were either arrested or convicted for a violent offence (seri-
for moderating variables. While psychosis alone is a statis- ous violence) during a follow-up period of approximately
tically significant risk factor for violence, the risk becomes 20 months (1999). On the other hand, base rates for any
greater when a patient has co-morbid substance misuse violence over a period of 1 year in the general community
(Douglas etal., 2009; Fazel etal., 2009; Wallace etal., has been reported to be between 25% and 30% for general
2004) and/or an antisocial personality disorder (Tengstrm psychiatric patients and higher for specific populations of
etal., 2004). Many other, less statistically significant, fac- people with mental illnesses and offence histories (Douglas
tors also have a moderating influence on the relationship etal., 1999; Hodgins etal., 2007; Nicholls etal., 2004;
between psychosis and violence (Douglas etal., 2009). Steadman etal., 1998; Swanson etal., 2006a; Walsh etal.,
Violence by those with mental illness has a significant 2001; Wootton etal., 2008). Steadman etal. (2000) found
impact on the victim, the victims family, the perpetrators that more than one-third (35.7%) of 10,000 involuntarily
family, carers, staff and the patient. Violence adds to the committed patients released to the community engaged in
stigma that those with mental illness are to be feared. The some form of violence within 20 months of discharge.
publicity that follows a violent offence committed by a In psychiatric hospitals the base rate of violence is much
patient with mental illness, in particular where there is a higher, with low severity aggressive behaviour being
coroners finding that psychiatric care was inadequate, does remarkably common (Daffern and Howells, 2002).
damage to the public image of patients with mental illness Assessing risk of aggression in this context is critical, and
and public confidence in mental health services (Hall, 2011). risk-related decision making is central to decisions about
Violence also causes significant difficulties for the patients leave, escorting requirements, the need for a patient to be
themselves. Most patients dislike acting in an aggressive moved to a high-dependency unit and even the need for
manner, often request assistance to refrain from such behav- medication (Ogloff and Daffern, 2006).
iour, and often suffer considerable guilt and shame after- Rates of violence increase, to a point, with the presence of
wards. Their aggression erodes relationships, and results in additional risk factors. For example, in the Wallace etal.
restrictions on liberty including confinement in restrictive, (2004) study, the rate of violent offending in those with
anti-therapeutic environments such as prison. schizophrenia alone was 8%, but rose to 26% in those with
In addition there are important clinical decisions that schizophrenia and a co-morbid substance use disorder. In a
require careful consideration of the potential of the risk study by Wootton etal. (2008), 22% of general psychiatric
posed. For example, there are circumstances where confi- patients discharged and followed up for 2 years committed
dentiality can be breached to protect third parties. Professional an assault but 37% of those who manifested other risk factors
codes of ethics allow (and when children are involved, (younger age and male, assault in the previous 2 years and
expect) clinicians to disclose confidential information under substance abuse in the previous 1 year) committed an assault
certain circumstances, such as serious concern about risk of within 2 years. In the MacArthur Foundation study (Steadman
violence (Kaempf etal., 2009) to a named person. etal., 1998) the 1-year aggregate prevalence of violence was
17.9% for patients with a major mental disorder discharged
from general psychiatric hospitals and 31.1% with a co-mor-
Dealing with uncommon events bid substance abuse diagnosis were violent; substance abuse
Commentary suggesting that violence risk assessment is contributed significantly to violence in this population.
inappropriate because the prevalence (base rate) of vio- To illustrate the above point, we consider the assessment
lence is too low (Large etal., 2011) requires explanation. of violence risk in a general psychiatric population using
The argument that one cannot accurately predict who will the Historical, Clinical Risk, Management-20 (HCR-20), a
or will not be violent is an old one, emphasised years ago tool to guide the structured professional judgement (SPJ)
by Monahan (1981), based on his review of studies using approach (discussed below) to violence risk assessment
unstructured clinical judgement, in the absence of adequate (Webster etal., 1997). The tool has been subject to more
research. Monahans findings led to the development of than 130 studies, finding good reliability (e.g. inter-rater
better assessment procedures. reliability = 0.800.85) and moderate to strong predictive
There is no one fixed rate of violence in the mentally ill. validity (e.g. area under the curve = 0.650.89) (Douglas
Reported rates of violence vary according to the severity and Reeves, 2010). A study in Canada examined the accu-
and nature of violence measured, how information on vio- racy of the HCR-20 in involuntary psychiatric patients dis-
lent behaviour is sourced, the population studied and the charged to the community from the hospital (Douglas etal.,
duration of follow-up. 1999; Nicholls etal., 2004). The rate of any violence
Swanson etal. (2006a) examined a wide spectrum of (any violence included acts of physical violence (any
patients with schizophrenia, and found a 6-month preva- attacks on persons), non-physical violence (serious threats to
lence of 3.6% for serious violence. Douglas etal. (1999) harm, verbal attacks), and criminal violence (criminal charges

Australian & New Zealand Journal of Psychiatry, 47(8)

Downloaded from at UNIV FED DO RIO DE JANEIRO on May 16, 2014
Allnutt et al. 731

or convictions for contact offences or robbery)) within 20 despite management of the patient. One can only be con-
months of discharge to the community from general psychiat- cerned what the empirical rates would be if mental health
ric inpatient services was approximately 38%. Patients who services did not actively manage violence in those deemed
scored above 25 (out of a potential 40) on the HCR-20 at dis- to be at risk. Most studies are of managed patients.
charge fell into a population of patients of whom about 75% Finally, lower base rates of serious violence (as
engaged in any violence within approximately 20 months. opposed to any violence) should not cause particular con-
Patients who scored below 15 fell into a population of patients cern to scholars and clinicians involved in violence risk
of whom about 10% engaged in any violence. assessment. While it has long been accepted that events
These prevalence rates are not insubstantial and on this with especially low base rates, such as homicide, will be
basis it would be fair to say that patients with schizophrenia nearly impossible to predict (Szmukler, 2001), most forms
(and to a lesser but not inconsequential extent patients with of violence have much higher base rates, but are also harm-
other serious mental illnesses) are at an increased risk of ful and low severity aggression often precedes serious vio-
aggression particularly within certain settings. Furthermore, lence. The base rates of any violence in specific
higher scores on some risk assessment instruments should populations (such as those involuntarily detained in civil
cause clinicians to pause, carefully consider their care plan- psychiatric hospitals, and more so in those with a high load-
ning and put in place risk management strategies to avert ing of risk factors) are significantly higher than the general
violence and other aggressive behaviours. population noted above.
While the HCR-20 is an SPJ tool it can, for research pur- The ultimate goal is to manage specific populations of
poses, produce numerical scores by totalling the 20 items, patients with an increased propensity for any violence
producing total scores in the range 040. This actuarial (those with risk factors). This approach is more likely to
approach is not advocated in clinical practice (nor do the capture those at risk for more serious and sometimes rare
authors of the HCR-20 advocate this approach), because it is violent events such as homicide. Not just serious violence,
a tick box approach and ignores other clinical factors. but any violence engaged in by patients requires the best
In practice, however, it is not researchers or commenta- clinical attention. This certainly does not mean that these
tors who determine what is or is not an acceptable threshold patients always require involuntary admission, as suggested
required for an intervention. Rather, it is the clinician, hav- in recent publications (Large etal., 2011; Ryan etal., 2010).
ing regard to clinical, personal and social context of the par- In most cases what they require is adequate psychiatric
ticular patient that defines the intervention. For example, if assessment, treatment and care to address clinical needs.
a patient was assessed (on an actuarial or SPJ assessment) to
cause concern for aggression and was incorporating their
Risk assessment in the mental health
mother, with whom they lived, into their delusional system
and making threats to harm her (that is, on clinical assess-
ment), the clinician might regard more frequent home visits The process of violence risk assessment is similar to other
and/or temporary placement in alternative accommodation diagnostic and prognostic processes in other fields of medi-
as appropriate. If, however, the same person was assessed to cine. That is, risk factors are identified through clinical
be of concern for aggression (on an actuarial or SPJ assess- enquiry. Consider the task of determining the risk of a per-
ment), was not living with their mother, or incorporating her son suffering a cardiac event; this is often based on the
into a delusional system or making threats (clinical assess- presence or absence of risk factors such as hypertension,
ment), the clinician might consider less restrictive alterna- smoking, prior cardiac events, family history and high cho-
tives. Arguments against risk assessment based on rates of lesterol. The clinician integrates objective information with
violence found in empirical studies always overlook indi- subjective perception about whether or not a patient falls
vidual contexts in which clinical decision making occurs into an at-risk population, and decides on the intervention
(Douglas and Skeem, 2005). and course of action/treatment. Risk assessment and man-
Further, empirically reported base rates of violence are agement is a fundamental medical process.
likely underestimates of the true base rate for a number of Simply allocating patients to a category of low, medium
reasons: family members are commonly victims and less or high risk, within the complexity of real-world risk man-
likely to report violence; people with mental illness are agement decisions is of course insufficient, as it would be
often diverted into mental health services rather than the in the assessment of a cardiac event. A more nuanced
criminal justice system; self-report is probably limited by a approach is now recognised in sophisticated critiques of the
need to avoid sanction or achieve social acceptability; there field of violence risk assessment (Mossman, 2006).
are problems with recollection; and clinical documentation Contemporary approaches to risk assessment and risk man-
is often inaccurate with regard to violent incidents. agement require clinicians to formulate and understand the
Empirically reported rates of violence are also concerned risk. Risk formulation is a description of the potential
with people released to the community and followed up by nature of violence, the patterns (escalation, de-escalation
mental health services, thus reflecting rates of violence and persistence), potential victims, underlying motives,

Australian & New Zealand Journal of Psychiatry, 47(8)

Downloaded from at UNIV FED DO RIO DE JANEIRO on May 16, 2014
732 ANZJP Articles

antecedents, and perpetuating and protective factors. Some requiring involuntary admission. It also improperly implies
suggest also reporting on the most likely scenarios to arise that involuntary admission is the only intervention in cases
if the behaviour is to recur (Mullen and Ogloff, 2009). This where risk of violence is identified. Obviously, this is not
provides others with a far better understanding of the prob- the case. Given that the purpose of assessment is to assess,
lem rather than a statement that the person is low, medium violence risk assessment is not and should not be consid-
or high risk. These categories are relatively meaningless in ered an intervention or treatment. The intervention or treat-
clinical situations (unless there is a shared understanding of ment is the risk management. It would be preferable to
the definition of these terms and they are attached to a par- consider the number of patients needed to assess (NNA) to
ticular intervention protocol). correctly identify one patient who goes on to be violent.
Such categorical statements are more relevant in legal Whether or not psychiatry should have a role in the
situations where experts are asked to provide an opinion on removal of a persons civil rights is a valid and worthy
risk of recidivism in categorical terms. In those circum- argument. While the practice of psychiatry occurs in the
stances the proportionality of the risk is legally determined context of a coercive backdrop of Mental Health Acts
and often complex. For example, the proportional level of (MHAs), the presence of a MHA is a legislative fact that
risk required to further detain a serious sex offender after psychiatrists are expected to have regard to. Until there is
expiry of a term of incarceration has been determined to be legislative change, if there is an expectation of psychiatrists
not higher than 50%. (The Court of Appeal in Tillman v to involuntarily detain, then decisions should be made uti-
Attorney General for New South Wales [2007] NSWA 327, lising the best available evidence, even if violence risk
referred to the term likely in s 17 (3) of the Crimes assessment has limitations. Utilising a non-empirical and
(Serious Sex Offenders) Act 2006 to mean a degree of unstructured clinical approach will result in even more peo-
probability at the upper end of the scale, but not necessarily ple being erroneously detained because these types of
exceeding 50 per cent.) judgements are the most inaccurate risk assessment method,
Nevertheless, it is worth noting that there is evidence that and unstructured risk assessments typically result in an
legal adjudicators who receive information in a descriptive overestimation of risk.
form that demonstrates an analysis of risk factors and pro- Some have regarded violence risk assessment in psy-
vides a risk management plan are more likely to release chiatry as a new process, becoming the focus of mental
patients found not guilty by reason of mental illness than if health practice, seeking to bring the present into the future
they received information that was only categorical or pre- and making it calculable, making clinicians agents of con-
dictive form (Dolores and Redding, 2009). This supports the trol and in the process contributing to social exclusion and
view that proper risk assessment reduces inappropriate discrimination of patients (Rose, 1998). As stated already,
detention rather than aggravating it. This also provides a risk assessment is not new to medicine; it is integral to
degree of reassurance to clinicians that the literature sup- daily medical practice in diagnosis and prognostication.
ports the assumption that management recommendations It is worth noting that to a large extent forensic mental
will be acknowledged and potentially incorporated into dis- health services are a repository for patients who have been
positional options by legal decision makers. failed by the mental health system, which sometimes does
The argument against violence risk assessment is some- not see the risk and so does not manage it, thus adding to
times based on the concern that an unacceptable number of the stigma that those with mental illness are to be feared.
people will have their rights impinged, because an unac- Nevertheless, it is important that strengths as well as risk
ceptable number of patients who would not have been vio- factors are elicited. Patients need to be seen as more than
lent will be involuntarily detained (Buchanan, 2008; the sum of risk factors.
Buchanan and Leese, 2006; Large etal., 2011). Arguing
against risk assessment based on the potential consequence
Approaches to assessment
of involuntary admission is to confound the issue. If the
option of involuntary admission based on risk was removed Violence is a complex and multiply determined behaviour.
from the statute, the need for the assessment of violence No risk assessment approach is perfect, and clinicians
risk in mentally ill patients would remain, and probably be should be aware of the limitations and benefits of the differ-
of even greater significance given that aggressive behav- ent approaches.
iour is a complication of severe mental illness and a poten- A common argument against violence risk assessment
tial mechanism to manage it in some cases, removed. that the authors experience in clinical practice is that it is
The predictive utility of risk assessment instruments is too rigorous and requires a specialist approach. A proper
sometimes (but rarely) measured by the number of people risk assessment requires little more than a comprehensive
needed to be detained to prevent one violent episode (NND) psychiatric assessment in most cases. The problem is not
(Buchanan, 2008; Buchanan and Leese, 2006). This is an that general clinicians are untrained in risk assessment or
unhelpful way of expressing utility if it is read as implying that it is too rigorous. The problem is that they are often
that the purpose of risk assessment is to identify those insufficiently focussed on the application of information

Australian & New Zealand Journal of Psychiatry, 47(8)

Downloaded from at UNIV FED DO RIO DE JANEIRO on May 16, 2014
Allnutt et al. 733

they have already obtained in a usual comprehensive inter- etal., 2006; Gardner etal., 1996; Hanson and Morton-
view, to the evaluation of violence risk. There is little in a Bourgon, 2009; Mossman, 1994; Olver etal., 2011). The
tool such as the HCR-20 that does not form part of such an amenability of actuarial tools to scrutiny provides grounds
evaluation. Almost all factors associated with violence risk for arguments about their limitations.
are embraced in a multidisciplinary approach to the treat- The third-generation structured professional judge-
ment of patients. ment (SPJ) approach relies on a combination of static risk
Beginning in the 1970s, systematic evaluations appeared factors, dynamic risk factors (addressing the fluctuating
of the predictive validity of mental health professionals nature of risk) and case-specific factors (individualised and
assessments of dangerousness (as it was then known). contextual), anchored by the items in the instrument. Rather
These were first-generation approaches. Cocozza and than providing mathematical probability estimates (as with
Steadman (1976) found that there were no differences in actuarial approaches), the SPJ approach enables a more in-
subsequent recidivism or violent recidivism among 257 depth and individualised understanding of the persons pro-
forensic patients assessed by psychiatrists and designated pensity for violence, and informs a more specific and
as dangerous (of whom 49% offended and 14% offended individualised formulation and treatment plan.
violently) or non-dangerous (of whom 54% offended and The SPJ approach goes beyond simply summing items
16% offended violently). They concluded there was clear to generate a total score, as with pure actuarial instruments.
and convincing evidence (p. 1084) of mental health profes- Structured means that the opinion is not statistical, but is
sionals inability to accurately predict violence. Studies still informed by empirical research, unlike unstructured
such as this have uniformly denounced unstructured clini- assessment. The SPJ approach allows for the consideration
cal judgement as an acceptable method of risk assessment of the personal circumstances of the patient, the nature of
(Heilbrun etal., 1999). the victims, underlying motivations, prior patterns of
Monahan (1981) identified errors with the unstructured aggression, context, prior experience of the patient and
clinical approach including lack of specificity in defining other case-specific risk factors relevant to the individual
the outcome, ignoring statistical base rates of violence, (de Vogel etal., 2004). An SPJ tool provides a structured
relying upon illusory correlations (i.e. variables misper- guide to enable clinical decision making and risk manage-
ceived to have a relationship with violence), and failing to ment anchored around empirically derived risk factors.
incorporate environmental or contextual information into There is evidence that a structured approach to clinical
assessments. decision making can be as accurate, and in some cases
The second-generation (actuarial) approach to vio- more accurate, than a purely actuarial approach. Guy
lence risk assessment focussed on the identification of (2008) found four studies that tested the predictive validity
empirically determined variables associated with violence. of the HCR-20 completed in two ways. The first approach
They provide objective, formal mathematical weighting of produced numeric scores totalling the 20 risk factors on
risk variables to arrive at a decision on risk level (Grove the HCR-20 (the actuarial approach), and the second, sum-
and Meehl, 1996). Actuarial tools are developed solely on mary scores where the HCR-20 was totalled and clinicians
the statistical relationship between a range of predictive were able to modify the overall level of risk using their
variables (risk factors) and the likelihood of violence. clinical judgement after considering all of the information
Aside from the clinical judgement needed to obtain the available (the SPJ approach), arriving at ratings of high,
information for each predictor, the final assessment of risk moderate or low risk. Guy found that in all of the studies
is purely mechanical (Quinsey etal., 2005). multivariate analyses demonstrated that the summary rat-
Actuarial methods provide a systematic, transparent, ings (the SPJ approach) added incrementally to the simple
objective approach. They are, however, limited by a range numeric use of the instrument (see also Douglas etal.,
of factors. They rely on static/historical factors, provide lit- 2003).
tle information pertaining to dynamic (changeable) current Using a structured instrument as a guide avoids many of
and circumstantial factors and thus neglect factors amena- the clinical biases identified by Monahan (1981). SPJ
ble to treatment. Actuarial methods are insensitive to schemes encourage specification of the criterion, minimise
change over time and have problems with generalisability the deleterious effects of making illusory correlations, and
(Davis and Ogloff, 2008; Mullen and Ogloff, 2009). They in some cases, encourage consideration of contextual fea-
do not allow for consideration of important aspects specific tures, thereby enabling flexible use.
to the individual case. They are largely comprised of risk
markers associated with but not necessarily causally
Managing risk in mental health
related to violence (Mullen and Ogloff, 2009).
Notwithstanding this, numerous studies show that even There is argument made that, because there is no evidence
simple actuarial methods consistently outperform unstruc- that violence risk assessment reduces harm, clinicians
tured clinical judgements in a variety of tasks (Dawes should probably abandon the practice (Large etal., 2011).
etal., 1989), including violence risk assessments (gisdttir In general medical practice, finding that mere observation

Australian & New Zealand Journal of Psychiatry, 47(8)

Downloaded from at UNIV FED DO RIO DE JANEIRO on May 16, 2014
734 ANZJP Articles

of a fever does not change the outcome of the infection, and without a history of conduct problems but less so in those
thus coming to the conclusion that clinicians should not with a history of conduct disorder (Swanson etal., 2008).
take a temperature would be regarded as incorrect. Taking a Antipsychotic medication is likely to be more effective
temperature is risk assessment for a fever, a fever is a risk in reducing violence in patients where there is a more direct
factor for infection, and an antibiotic is risk management of relationship between symptoms and aggression; but as
an adverse outcome (possibly mortality). Violence risk chronic illness exerts its effect on psychosocial functioning
assessment is not an intervention and conducting an assess- over time, psychosocial circumstances likely begin to
ment of violence risk does not change the outcome. Simply mediate and increase the risk of violence over and above
conducting a risk assessment without a plan to manage risk illness symptoms. Other factors such as personality and
factors would attract severe criticism in most other areas of conduct disorder, disadvantaged social circumstances, sub-
medicine. stance abuse, poor social and familial supports, and employ-
Structured risk assessment leads to risk management ment problems (Bonta etal., 1998) make a larger
strategies that mediate between the risk assessment and contribution to violence in the longer term than symptoms
aggression (Belfrage etal., 2012). The question therefore is of serious mental illness. Thus, risk management of pro-
not, Does violence risk assessment reduce harm? but pensity for violence requires consideration of a wide vari-
rather Does management of risk factors associated with ety of risk factors and the use of a range of interventions,
violence (identified by risk assessment) reduce harm? not just the prescription of medication.
There has been limited investigation into how services It is notable that many forensic patients, once discharged
use risk assessment to influence management of potentially from a forensic hospital and followed up by community
violent individuals. The research that does exist, however, forensic mental health services, commonly have a more
is promising. Abderhalden and colleagues (2008) con- stable lifestyle and less offending in the community than
ducted a cluster randomised controlled trial of the imple- before their acquisition of forensic status and involvement
mentation of structured risk assessment in acute psychiatric in more comprehensive management (Hodgins etal., 2007;
admission wards. Treatment units were those that intro- Ong etal., 2009). This is probably attributable to long-term
duced a standardised risk assessment following admission intensive care with a focus on risk factors that include but
with a mandatory implementation of prevention in high- extend beyond the management of mental illness symptoms
risk patients. The control units were business as usual. alone. Programmes that are multidisciplinary, have small
The results showed that the incidence of aggression patient to staff ratio, address criminogenic factors, incorpo-
decreased substantially in the treatment units, with little rate legal mechanisms to maintain adherence, as well as
change in the control units. Two other studies found that the residential programmes and substance abuse rehabilitation
risk factors from the HCR-20 validly predict risk level and have been shown to reduce violent behaviour (Cusack
that intense management of moderate- and high-risk etal., 2010; Gilbert etal., 2010; Swanson etal., 2001,
patients reduces violent outcome (Dernevik etal., 2002; 2006b).
Pedersen etal., 2012; see also Torrey etal., 2008).
There is evidence that antipsychotic medication reduces
aggression in some patients with serious mental illness
(Arango and Bernardo, 2005; Chengappa etal., 2002). In the face of the available evidence, violence is often a
Clozapine has superior effects on aggression in treatment- complication of mental illness that affects a disproportion-
resistant patients with schizophrenia (Dalal etal., 1999; ate number of mentally ill people. The community is
Krakowski etal., 2006; Volavka and Citrome, 2008). But unlikely to absolve clinicians of playing a role in managing
mere prescription of antipsychotics and a focus on symp- this public health problem, no matter what the statutes say
tom management is not enough to reduce violence in the (Maden, 2007). Reducing morbidity and mortality due to
longer term. However, increased frequency of clinical con- illness is the primary goal of most medical specialties, men-
tact reduces the occurrence of aggression (Monahan etal., tal health included. To better manage the propensity for
2001). While it is accepted that assertive community treat- violence by those suffering serious mental illness, clini-
ment (ACT) is clinically advantageous and cost effective in cians need to understand the problem and become better at
reducing re-hospitalisation and time in hospital (because it identifying that propensity. The primary purpose of risk
focuses on symptom reduction), neither standard care nor assessment is to identify risk and protective factors associ-
ACT has been shown to be effective in reducing violence in ated with violence in order to manage the risk factors and
the community over a period of 2 years (Walsh etal., 2001). build on the protective factors. Risk assessment should not
In the absence of longer-term treatments that focus on psy- be an exercise with the end goal of categorising the person,
chosocial factors associated with increased risk of violence, although this is often an unavoidable outcome, particularly
the effect of antipsychotics on violence diminishes with in some legal contexts (where the limits should be
time (Bobes etal., 2009; Swanson etal., 2006a, 2008). explained). Risk assessment is a precursor to treatment and
Antipsychotic medications reduce violence in those management aimed at preventing harm.

Australian & New Zealand Journal of Psychiatry, 47(8)

Downloaded from at UNIV FED DO RIO DE JANEIRO on May 16, 2014
Allnutt et al. 735

Violence risk assessment is also not a task that is in the Chengappa KN, Vasile J, Levine J, etal. (2002) Clozapine: its impact on
exclusive domain of forensic mental health professionals; aggressive behavior among patients in a state psychiatric hospital.
Schizophrenia Research 53: 16.
it is a clinical process with which all mental health profes- Cocozza JJ and Steadman HJ (1976) The failure of psychiatric predic-
sionals should gain familiarity. General mental health ser- tions of dangerousness: Clear and convincing evidence. Rutgers Law
vices are on the frontline and are regularly confronted Review 29: 10481101.
with patients who have a propensity for violence; and Cusack KJ, Morrissey JP, Cuddeback GS, etal. (2010) Criminal jus-
many carers who cannot manage them are frightened and tice involvement, behavioral health service use, and costs of foren-
sic assertive community treatment: a randomized trial. Community
worry those in their care will harm themselves or others. Mental Health Journal 46: 356363.
It is an unavoidable reality of daily general mental health Daffern M and Howells K (2002) Psychiatric inpatient aggression: A
practice that violence risk is an issue that needs to be review of structural and functional assessment approaches. Aggression
addressed. To do so, general mental health practitioners and Violent Behavior 7: 477497.
would benefit from developing expertise and employing a Dalal B, Larkin E, Leese M, etal. (1999) Clozapine treatment of long-
standing schizophrenia and serious violence: a two-year follow-up
structured, evidence-based approach to assessment, treat- study of the first 50 patients treated with clozapine in Rampton high
ment and management. To avoid utilising a structured security hospital. Criminal Behaviour and Mental Health 9: 168178.
approach or reverting to an unstructured approach because Davis MR and Ogloff JRP (2008) Key considerations and problems in
risk assessment is an inexact science is arguably assessing risk for violence. In: Canter DV and Zukauskiene R (eds)
unacceptable. Psychology and Law: Bridging the Gap. Aldershot: Ashgate.
Dawes R, Faust D and Meehl P (1989) Clinical versus actuarial judgment.
Science 243: 16681674.
Acknowledgements De Vogel V, De Ruiter C, Van Beek D, etal. (2004) Predictive validity of
the SVR-20 and Static-99 in a Dutch sample of treated sex offenders.
The authors are grateful to Professor Jay Singh who offered com-
Law and Human Behavior 28: 235251.
ments on an earlier version of the article, and Professor Dan
Dernevik M, Grann M and Johansson S (2002) Violent behaviour in foren-
Howard SC for the useful comments on the final draft. sic psychiatric patients: Risk assessment and different risk-manage-
ment levels using the HCR-20. Psychology, Crime & Law 8: 93111.
Funding Dolores JC and Redding RE (2009) The effects of different forms of risk
communication on judicial decision making. International Journal of
This research received no specific grant from any funding agency Forensic Mental Health 8: 142146.
in the public, commercial, or not-for-profit sectors. Douglas KS, Guy LS and Hart SD (2009) Psychosis as a risk factor
for violence to others: a meta-analysis. Psychological Bulletin 135:
Declaration of interest 679706.
Douglas KS, Ogloff JR and Hart SD (2003) Evaluation of a model of vio-
The authors report no conflict of interest. The authors alone are lence risk assessment among forensic psychiatric patients. Psychiatric
responsible for the content and writing of this paper. Services 54: 13721379.
Douglas KS, Ogloff JR, Nicholls TL, etal. (1999) Assessing risk for vio-
lence among psychiatric patients: the HCR-20 violence risk assess-
References ment scheme and the Psychopathy Checklist: Screening Version.
Abderhalden C, Needham I, Dassen T, etal. (2008) Structured risk assess- Journal of Consulting and Clinical Psychology 67: 917930.
ment and violence in acute psychiatric wards: randomised controlled Douglas KS and Reeves KA (2010) Historical-Clinical-Risk
trial. British Journal of Psychiatry 193: 4450. Management-20 (HCR-20) Violence Risk Assessment Scheme:
gisdttir S, White MJ, Spengler PM, etal. (2006) The meta-analysis Rationale, application, and empirical overview. In: Otto RK and
of clinical judgment project: Fifty-six years of accumulated research Douglas KS (eds) Handbook of Violence Risk Assessment. New York:
on clinical versus statistical prediction. The Counseling Psychologist Routledge.
34: 341382. Douglas KS and Skeem JL (2005) Violence risk assessment: Getting spe-
Arango C and Bernardo M (2005) The effect of quetiapine on aggres- cific about being dynamic. Psychology, Public Policy, and Law 11:
sion and hostility in patients with schizophrenia. Human 347383.
Psychopharmacology: Clinical and Experimental 20: 237241. Fazel S, Gulati G, Linsell L, etal. (2009) Schizophrenia and violence:
Belfrage H, Strand S, Storey JE, etal. (2012) Assessment and management systematic review and meta-analysis. PLoS Med 6: e1000120.
of risk for intimate partner violence by police officers using the Spousal Gardner W, Lidz CW, Mulvey EP, etal. (1996) Clinical versus actuarial
Assault Risk Assessment Guide. Law and Human Behavior 36: 6067. predictions of violence in patients with mental illness. Journal of
Bobes J, Fillat O and Arango C (2009) Violence among schizophrenia Consulting and Clinical Psychology 64: 602609.
out-patients compliant with medication: prevalence and associated Gilbert AR, Moser LL, Van Dorn RA, etal. (2010) Reductions in arrest
factors. Acta Psychiatrica Scandinavica 119: 218225. under assisted outpatient treatment in New York. Psychiatric Services
Bonta J, Law M and Hanson K (1998) The prediction of criminal and 61: 996999.
violent recidivism among mentally disordered offenders: a meta-anal- Grove WM and Meehl PE (1996) Comparative efficiency of informal (sub-
ysis. Psychological Bulletin 123: 123142. jective, impressionistic) and formal (mechanical, algorithmic) pre-
Buchanan A (2008) Risk of violence by psychiatric patients: Beyond the diction procedures: The clinicalstatistical controversy. Psychology,
actuarial versus clinical assessment debate. Psychiatric Services 59: Public Policy, and Law 2: 293323.
184190. Guy LS (2008) Performance Indicators of the Structured Professional
Buchanan A and Leese M (2006) Quantifying the contributions of three Judgment Approach for Assessing Risk for Violence to Others: A
types of information to the prediction of criminal conviction using the Meta-analytic Survey. Simon Fraser University, Burnaby BC, Canada.
receiver operating characteristic. British Journal of Psychiatry 188: Hall L (2011) Waterlow found not guilty of murdering father and sis-
472478. ter. Sydney Morning Herald. Available at:

Australian & New Zealand Journal of Psychiatry, 47(8)

Downloaded from at UNIV FED DO RIO DE JANEIRO on May 16, 2014
736 ANZJP Articles

au/nsw/waterlow-found-not-guilty-of-murdering-father-and-sister- Pedersen L, Ramussen K and Elsass P (2012) HCR-20 violence risk

20110419-1dmfd.html (accessed 1 August 2012). assessments as a guide for treating and managing violence risk in a
Hanson RK and Morton-Bourgon KE (2009) The accuracy of recidivism forensic psychiatric setting. Psychology, Crime and Law 18: 733743.
risk assessments for sexual offenders: a meta-analysis of 118 predic- Quinsey VL, Harris GT, Rice ME, etal. (2005) Violent Offenders:
tion studies. Psychological Assessment 21: 121. Appraising and Managing Risk (2nd edn). Washington, DC: American
Heilbrun K, Ogloff JR and Picarello K (1999) Dangerous offender statutes Psychological Association.
in the United States and Canada. Implications for risk assessment. Rose N (1998) Governing risky individuals: The role of psychiatry in the
International Journal of Law and Psychiatry 22: 393415. new regimes of control. Psychiatry, Psychology and Law 5: 177195.
Hodgins S, Mller-Isberner R, Freese R, etal. (2007) A comparison of gen- Ryan C, Nielssen O, Paton M, etal. (2010) Clinical decisions in psychiatry
eral adult and forensic patients with schizophrenia living in the com- should not be based on risk assessment. Australasian Psychiatry 18:
munity. International Journal of Forensic Mental Health 6: 6375. 398403.
Kaempf A, McSherry B, Rothschild A, etal. (2009) Confidentiality Steadman HJ, Mulvey EP, Monahan J, etal. (1998) Violence by people
for Mental Health Professionals: A Guide to Ethical and Legal discharged from acute psychiatric inpatient facilities and by oth-
Principles. Sydney: Australian Academic Press. ers in the same neighborhoods. Archives of General Psychiatry 55:
Krakowski MI, Czobor P, Citrome L, etal. (2006) Atypical antipsychotic 393401.
agents in the treatment of patients with schizophrenia and schizoaf- Steadman HJ, Silver E, Monahan J, etal. (2000) A classification tree
fective disorder. Archives of General Psychiatry 63: 622629. approach to the development of actuarial violence risk assessment
Large MM, Ryan CJ, Singh SP, etal. (2011) The predictive value of risk tools. Law and Human Behavior 24: 83100.
categorization in schizophrenia. Harvard Review of Psychiatry 19: Swanson JW, Borum R, Swartz MS, etal. (2001) Can involuntary outpa-
2533. tient commitment reduce arrests among persons with severe mental
Maden A (2007) Treating Violence: A Guide to Risk Management in illness? Criminal Justice and Behavior 28: 156189.
Mental Health. Oxford: Oxford University Press. Swanson JW, Holzer CE, 3rd, Ganju VK, etal. (1990) Violence and psy-
Monahan J (1981) Predicting Violent Behavior: An Assessment of Clinical chiatric disorder in the community: evidence from the Epidemiologic
Techniques. London: Sage Publications. Catchment Area surveys. Hospital & Community Psychiatry 41:
Monahan J, Steadman HJ, Silver E, etal. (2001) Rethinking Risk 761770.
Assessment: The MacArthur Study of Mental Disorder and Violence. Swanson JW, Swartz MS, Van Dorn RA, etal. (2006a) A national study of
Oxford: Oxford University Press. violent behavior in persons with schizophrenia. Archives of General
Mossman D (1994) Assessing predictions of violence: Being accurate about Psychiatry 63: 490499.
accuracy. Journal of Consulting and Clinical Psychology 62: 783792. Swanson JW, Swartz MS, Van Dorn RA, etal. (2008) Comparison of
Mossman D (2000) Evaluating violence risk by the book: a review of antipsychotic medication effects on reducing violence in people with
HCR-20: Assessing Risk for Violence, version 2 and The Manual for schizophrenia. The British Journal of Psychiatry 193: 3743.
the Sexual Violence Risk-20. Behavioral Sciences and the Law 18: Swanson JW, Van Dorn R, Monahan J, etal. (2006b) Violence and lev-
781789. eraged community treatment for persons with mental disorders. The
Mossman D (2006) Critique of pure risk assessment or, Kant meets American Journal of Psychiatry 163: 14041411.
Tarasoff. University of Cincinnati Law Review 75: 523609. Szmukler G (2001) Violence risk prediction in practice. The British
Mullen PE (2006) Schizophrenia and violence: from correlations to pre- Journal of Psychiatry 178: 8485.
ventive strategies. Advances in Psychiatric Treatment 12: 239248. Tengstrm A, Hodgins S, Grann M, etal. (2004) Schizophrenia and crimi-
Mullen PE, Burgess P, Wallace C, etal. (2000) Community care and crimi- nal offending. Criminal Justice and Behavior 31: 367391.
nal offending in schizophrenia. Lancet 355: 614617. Torrey EF, Stanley J, Monahan J, etal. (2008) The MacArthur Violence
Mullen PE and Ogloff JRP (2009) Assessing and managing the risk of Risk Assessment Study revisited: two views ten years after its initial
violence towards others. In: Gelder M, Andreasen N, Lopez-Ibor J, publication. Psychiatric Services 59: 147152.
etal. (eds) New Oxford Textbook of Psychiatry (2nd edn). Oxford: Volavka J and Citrome L (2008) Heterogeneity of violence in schizophre-
Oxford University Press. nia and implications for long-term treatment. International Journal of
Nicholls TL, Ogloff JR and Douglas KS (2004) Assessing risk for vio- Clinical Practice 62: 12371245.
lence among male and female civil psychiatric patients: the HCR-20, Wallace C, Mullen PE and Burgess P (2004) Criminal offending in schizo-
PCL:SV, and VSC. Behavioral Sciences & the Law 22: 127158. phrenia over a 25-year period marked by deinstitutionalization and
Ogloff JR and Daffern M (2006) The dynamic appraisal of situational increasing prevalence of comorbid substance use disorders. The
aggression: an instrument to assess risk for imminent aggression in American Journal of Psychiatry 161: 716727.
psychiatric inpatients. Behavioral Sciences & the Law 24: 799813. Walsh E, Gilvarry C, Samele C, etal. (2001) Reducing violence in severe
Ogloff JRP and Davis MR (2005) Assessing risk for violence in the mental illness: randomised controlled trial of intensive case manage-
Australian context. In: Chappell D and Wilson P (eds) Issues in ment compared with standard care. British Medical Journal 323:
Australian Crime and Criminal Justice. Chatswood: Lexis Nexis 10931096.
Butterworths, pp.301338. Webster CD, Douglas KS, Eaves D, etal. (1997) HCR-20: Assessing Risk
Olver ME, Stockdale KC and Wormith JS (2011) A meta-analysis of pre- for Violence (2nd edn). Vancouver: Mental Health, Law and Policy
dictors of offender treatment attrition and its relationship to recidi- Institute, Simon Fraser University.
vism. Journal of Consulting and Clinical Psychology 79: 621. Wootton L, Buchanan A, Leese M, etal. (2008) Violence in psycho-
Ong K, Carroll A, Reid S, etal. (2009) Community outcomes of men- sis: estimating the predictive validity of readily accessible clinical
tally disordered homicide offenders in Victoria. Australian and New information in a community sample. Schizophrenia Research 101:
Zealand Journal of Psychiatry 43: 775780. 176184.

Australian & New Zealand Journal of Psychiatry, 47(8)

Downloaded from at UNIV FED DO RIO DE JANEIRO on May 16, 2014