In their article, Doyle and Logan (2012) suggest a system, Short-Term Assessment of Risk and Treatability (START), for assessing violence risk that addresses shortcomings of current methods. Studies have estimated between one in 10 and one in three admissions are preceded by violence toward others. Although assessing violence risk has been widely studied, there are far fewer studies related to managing and reducing risk once identified.
Risk judgments made based on total scores of risk factors is only loosely related to risk management. The structured professional judgment (SPJ) approach to risk assessment considers not only the presence or absence of specific risk factors, but also specific individual and contextual factors. There are six stages of SPJ:
- Gather information from a variety of sources.
- Consider the presence and relevance of risk factors – historical, current, contextual, protective.
- Develop a risk formulation – motivators (drivers), (dis)inhibitors, destabilizers. Here the clinician discusses whether or not these risk factors are relevant to the individual’s potential to be violent in the future.
- Consider risk scenarios, e.g. repeat, escalation, twist. This step directly links risk assessment to risk management by formulating a judgment about risk and protective factors, and how these factors impact potential for violence in the future.
- Develop risk management strategies derived from the most relevant risk and
protective factors. - Summary of judgment including judgments of the urgency of action, risk in other areas, any immediate action required, and when the next review should occur.
Several risk assessment tools have been validated to assist in short-term risk assessment, stage two in SPJ. These include:
- Violence Screening Checklist (VSC):
- Assesses risk for aggression upon admission
- Consists of four items: history of physical attacks and/or fear-inducing behavior during the two weeks prior to admission, absence of recent suicidal behavior, diagnosis of schizophrenia or mania, and male gender
- Brøset Violence Checklist (BVC):
- Developed to help nurses assess risk of imminent violence upon admission and during hospital stay
- Consists of six items: confusion, irritability, boisterousness, verbal threats, physical threats, and attacks on objects
- Dynamic Appraisal of Situational Aggression (DASA):
- Developed to help clinical decision-making on admission units
- Consists of the six items from the BVC, as well as negative attitudes and impulsivity
- Classification of Violence Risk (COVR):
- Developed to predict violence in the community after discharge
- Violence Risk – 10 items (V-Risk 10):
- Assesses risk for inpatient violence
The START is a brief guide for assessing risks, strengths, and treatability. It was developed based on forensic mental health services, but can be applied in a variety of mental health settings. Preliminary evidence suggests the START has the potential to be a useful tool in informing clinical judgment. Studies have also indicated adequate reliability and validity in a variety of settings and different countries. The START assesses risk across the following domains: risk to others, suicide, self-harm, self-neglect, substance misuse, unauthorized leave, and victimization. It consists of 20 dynamic items that may change across days or weeks. Changes in the items could result in an elevation or reduction of risk. All items can be considered as both risk factors and protective factors. The 20 items include:
1. Social skills
2. Relationships
3. Occupational
4. Recreational
5. Self-care
6. Mental state
7. Emotional state
8. Substance use
9. Impulse control
10. External triggers
11. Social support
12. Material resources
13. Attitudes
14. Medication adherence
15. Rule adherence
16. Conduct
17. Insight
18. Plans
19. Coping
20. Treatability
The next step is to address the fourth and fifth stages of SPJ by considering risk formulation and developing risk management strategies. When developing a risk formulation, it is important to first address the question “risk of what” because risks can have different antecedents. One should consider different scenarios an individual may decide to be harmful in the future, called scenario planning. Scenario planning is not prediction, but rather it is based on identifying why an individual has acted in a violent way in the past.
The final stage includes risk management, or taking action to prevent the identified future scenarios from happening in the future. Risk management strategies include treatment, supervision, and victim safety planning.
Doyle, M., & Logan, C. (2012). Operationalizing the assessment and management of violence risk in the short-term. Behavioral Sciences and the Law, 30, 406-419.
Danielle McNeill, M.S., M.A.
WKPIC Doctoral Intern