Violence risk: Is clinical judgment enough?
Table 2
Items from the Historical, Clinical, and Risk Management (HCR-20)
| Historical items | Clinical items | Risk management items |
|---|---|---|
| H1 Previous violence | C1 Lack of insight | R1 Plans lack feasibility |
| H2 Young age at first incident | C2 Negative attitudes | R2 Exposure to destabilizers |
| H3 Relationship instability | C3 Active symptoms of major mental illness | R3 Lack of personal support |
| H4 Employment problems | C4 Impulsivity | R4 Noncompliance with remediation attempts |
| H5 Substance use problems | C5 Unresponsive to treatment | R5 Stress |
| H6 Major mental illness | ||
| H7 Psychopathy | ||
| H8 Early maladjustment | ||
| H9 Personality disorder | ||
| H10 Prior supervision failure | ||
| Score each item 0, 1, or 2, depending on how closely the patient matches the described characteristic. For example, when scoring item C3 (active symptoms of major mental illness), a patient gets 0 for “no active symptoms,” 1 for “possible/less serious active symptoms,” or 2 for “definite/serious active symptoms.” An individual can receive a total HCR-20 score of 0 to 40. The higher the score, the higher likelihood of violence in the coming months. | ||
| Source: Reprinted with permission from Webster CD, Douglas KS, Eaves D, Hart SD. HCR-20: assessing risk for violence, version 2. Burnaby, British Columbia, Canada: Simon Fraser University, Mental Health, Law, and Policy Institute; 1997 | ||
Is not using ARAIs negligent?
Some writers believe that using ARAIs should12 or may soon13 become the standard of care. Why, then, do psychiatrists seldom use ARAIs in their clinical work? Partly it is because clinicians rarely receive adequate training in assessing violence risk or the science supporting it. After a 5-hour training module featuring the HCR-20, psychiatry residents could better identify factors that affect violence risk, organize their reasoning, and come up with risk management strategies.2
Psychiatrists may have other reasons for not using ARAIs that make clinical sense. Although ARAIs can rank individuals’ violence risk, the probabilities of violence associated with each rank aren’t substantial enough to justify differences in management.14 Scientifically, it’s interesting to know that we can separate patients into groups with “low” (9%) and “high” (49%) risks of violence.15 But would you want to manage these patients differently? Most psychiatrists probably would not feel comfortable ignoring a 9% risk of violence.
To avoid negligence, psychiatrists need only “exercise the skill, knowledge, and care normally possessed and exercised by other members of their profession.”17 Psychiatrists seldom use ARAIs,12 so failing to use them cannot constitute malpractice. As Simon points out, a practicing psychiatrist’s role is to treat patients, not predict violence. He concludes, “at this time, the standard of care does not require the average or reasonable psychiatrist to use actuarial assessment instruments in the evaluation and treatment of potentially violent patients.”16
