Violence Risk Assessment Overview

• Author: Hy Bloom, Richard D Schneider
• Pages: 253-297

253

chapter eight

Violence Risk Assessment Overview

A. INTRODUCTION

Evaluating an individua l’s risk for violence has always been an importa nt task

in the f‌ield of psychiatr y, and has recently been described as a “core skill of

mental hea lth” cli nician s.1 As Mossman puts it, psychiat rists “make predic-

tions all the time, but usua lly without realizing it.”2 Mossman goes on to de-

scribe how predictions of one form or another of self-injurious or dangerous

behaviour are unavoidable in psychiatr y “because dozens of common clinical

actions require implicit judgments about the violence potential of a patient

or evaluee.”3 Beyond the domain of a general psychiatrist, assessin g risk for

future v iolence is a core component of forensic a nd correctional ps ychiatry.

1) What Is “Violence”

For the purpose of this ch apter, violence may be def‌ined as behaviour that caus-

es physical or psychological harm to people and/or damages or destroys inan i-

mate objects, while aggression character izes the emotional and psychological

state of a person who, through verbal or physical displays, signa ls that violence

may occur as a manifestat ion of what that person is thinki ng and feeling.4

1 Jennifer L Piel & Ronald S chouten, “Violence Risk Assessment ” in Ronald Schouten,

ed, Mental Heal th Practice and the L aw (New York: Oxford University Press, 2017) [ Piel

& Schouten].

2 Douglas Mossman, “Understand ing Prediction Instr uments” [Mossman] in Robert I

Simon & Liza H Gold, eds, Textbook of Forensic Psychiatry ( Washington, DC: American

Psychiatric P ublishing, Inc, 2004) at 501.

3 Ibid.

4 See Hy Bloom & Christopher D Webster, “Assessing Imm inent Risk for Violence and

Threats” in Hy Bloom & Ric hard D Schneider, eds, Law and Men tal Disorder: A Compre-

hensive and Pra ctical Approach ( Toronto, ON: Irwin Law 2013) 485 [LMD ].

254 MENTAL DISORDER AND THE LAW

2) Types of Violence/Aggression

Aggression and violence come in different f‌lavours and are used in dif ferent

circumstances to effect various results. Writers5 and clin icians in the f‌ield

have identif‌ied three broad subtypes:

1) Emotionally based

◆arousal based

◆emotional state is anger

◆may be induced by insult or shame

◆high affect ive state and irritability

◆correlates to personality disorders (e.g., narcissistic, borderline, and

antiso cial)

◆may be ego-dystonic

2) Aggression in defense

◆induced by actual or perceived threat

◆central emotional state is fear

◆may ref‌lect more serious mental disorder, e.g. psychosis (fear-induced

by misperce ption of threat)

◆may be more amenable to treatment

3) Predator y (proactive)

◆utilitarian — violence in the service of crime

◆planned

◆no signif‌icant emotional state (cold-blooded and lack of car ing and

empathy)

◆aggression i s ego-syntonic

◆aggression concludes when other purposes completed (e.g., aggres-

sion by felon)

3) What Is Violence Risk Assessment

Violence risk assessment is by its very nature a prospective inquir y. It consid-

ers the potential for an adverse aggressive event to occur w ithin a wide tem-

poral range that includes the im mediate (seconds, minutes, a few hours), the

foreseeable (days, a few weeks, perhaps up to a year), and the distant (several

years) fut ure.6 Assessing imminent risk for violence, in particu lar, is precise-

5 David Nussbaum, J Saint- Cyr, & Erica Bell, “A Biologically Der ived, Psychometric Model

for understandin g, Predicting and Treati ng Tendencies Toward Future Violence” (1997)

18:4 Ameri can Journal of Forensic Ps ychiatry 35.

6 See Bloom & Webster, above note 4.

Chapter Eight: Violence Risk Assessment Overview 255

ly within the domain of t he general psychiatrist, esp ecially when the poten-

tial actor is either intoxicated or suffer ing from a severe mental disorder, or

both (as opposed to being from the cr iminal realm). Clinic ians working in

psychiatric hospitals, par ticularly those who assess patients in the emergency

room, must make moment-to-moment clinical judgments about a patient’s

risk for harm to himself or to others, if not for the benef‌it of t hose potentially

in harm’s way, then to ensure that the clinician is meet ing her statutory obli-

gations (for example, provincial and territorial c ivil commitment legislation)

and common law obligations (for example, the duty to warn7).

Risk assessment/violence prediction is essentially a f‌ledgl ing (though

rapidly and incrementally progressing) f‌ield. Over t he forty or so years that

the subject of risk assessment and violence prediction has been a focu s of

formal clinica l interest and scientif‌ic research, there have been marked osc il-

lations in the perspect ive mental health exper ts have held, and in their level

of optimism about the extent to which an i ndividual’s future risk for violence

can be def‌ined. T he expanding need for violence risk assessment in var ious

legal, administrative, and c linical situations (see Sect ion C below) speaks to

the need for a focused approach to many situations where risk must be iden-

tif‌ied and quantif‌ie d, and then eliminated or reduced (to the extent possible).

Risk assessments answer which perp etrator will commit which act ions

by which means towards whom and within what time f rame. Although the

evaluee is clearly the focus of the assessment, e xpert assessors appreciate

that violence does not generally occur in a vacuu m. It is interactional and al-

most always depends on the presence of/friction between t wo or more vari-

ables, including susceptible perpet rators and victims, environmental factors,

and an event or stressor that serves as the accelerant for the conf‌lag ration of

violence. In any violence risk assessment, examiners should develop a theory

about from where and whence the violence derives.

Hart provides an eminently usef ul def‌inition of risk assessment, and de-

scribes it as “a contingency-based action plan for what should be done in the

future, not a quantitative statement of fact of what wil l occur in the future.”8

The declaration that an i ndividual represents a risk for dangerous conduct

in the community does not necessarily say any thing about the precise na-

ture of the risk, when it wil l manifest, the degree to whic h it will manifest,

7 Smith v Jon es, [1999] 1 SCR 455 [Smith].

8 SD Hart, “Complex ity, Uncertainty, and the Reconcept ualization of Violence Risk As -

sessment” (Key note address at the Annual Meet ing of the European Associ ation of Psy-

chology and the L aw, Lisbon, Portugal, 8 June 2001), in R Abr unhosa, ed, Victims a nd

Offend ers: Chapters on Ps ychology and the L aw (Brussels: Pliteia, 2004) 57.