Violence risk assessment and

management for health care

providers.

Darrin Cowan.

Clinical Nurse Consultant

Overview

• Defining violence and aggression.

• Assessing violence risk.

• Structured professional judgment.

• HCR 20 V3

• John, an 18 year old male with a lengthy

history of assault and robbery, confronted an

elderly woman after entering through an

unlocked back door. In the course of robbing

the woman, John threw her to the ground

where she struck her head on a coffee table

and later died.

John

• Kim is 35 years old. She has a complex mental illness with ongoing psychotic features. She lives with her mother, father and one sister. Kim sometimes uses alcohol to excess. She is often argumentative at such times. On the last such occasion she began to verbally abuse her mother and scratched her father when he tried to intervene.

Kim

• Sam is visited by home care services on a

weekly basis. He has an acquired brain injury

from an accident some 10 years previously.

Sam has impulse control problems as a result

and has assaulted people in the past. On the

last visit he became angry and shouted at the

worker because they didn’t bring him

cigarettes. As the worker left he yelled ‘You

come back here again and I’ll fucking kill you.’

Sam

• Dave recently broke up with Lara, his girlfriend

of 6 months. Since then he has continually

called her and waited outside her home and

work. He left a note on Lara’s car saying ‘You

can’t escape your past!!!’

Dave

• Ali and Jimmy have no prior relationship. They

are on tonight’s bill for the boxing

championship. Ali knocks Jimmy out and

breaks his jaw in the 2nd round.

Ali and Jimmy

• Violence: Actual, attempted, or

threatened physical harm of another

person that is deliberate and non

consensual.

(Steven Hart)

Assessment approaches

• Unstructured clinical judgment.

• Actuarial measures.

• Structured professional judgment.

Problems with Risk Assessment

Professional Criterion

• Overt focus on dynamic factors: pays

limited attention to less vivid but potentially

important factors

• Predictive accuracy is of limited value:

theory, conventional wisdom and personal

experience may be of unknown or low

validity

Non-discretionary, actuarial measures:

• Information weighted and combined using

fixed and explicit rules

• Actuarial, algorithmic and mechanical

Approaches to Violence Risk

Assessment

• The prediction debate!

Some Risk-Related Principles

• Risk assessment should begin with the application of empirically-based factors.

• Risk fluctuates.

• A risk statement has a finite life and must be reviewed.

• Risk assessment and management is a recurrent process, not a single time event.

• Risk can never be eliminated. It may be

minimized.

• The process is never complete without a risk

management plan.

Goal of Risk Assessment

• Prevention: Guide and coordinate activities

• Accountability: improve transparency and

consistency of decisions

• Protection: infringement of rights, exposure

to liability

Synthesis

• Risk assessment: process of speculating about violence risk posed by a client

• Risk management: Process of mitigating the

violence risk posed by a client

• Risk assessment informs risk management

decisions

Guides

prevention via

planning

Reflects best

practice

Specifies basic

risk factors

Doesn’t restrict

scope

No scoring

rules

Good for

monitoring

change

Structured Professional Judgment

• Relies on guidelines to structure the process of

professional discretion

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Process

1. Identify and gather relevant information

2. Determine presence of risk factors

3. Determine relevance of risk factors

4. Develop primary scenarios of violence

5. Develop case management plans

6. Communicate findings

HCR-20

Past (Static)

Documented

(10 Items)

Historical

Present (Dynamic)

Observed

(5 Items)

Clinical

Future (Dynamic)

Projected

(5 Items)

Risk Management

Violence Risk

HCR-20

HISTORICAL

PAST / STATICI.e. History of

problems with:

H1 Violence

H2 Other antisocial

behaviorH3 Relationships

H4 EmploymentH5 Substance UseH6 Major Mental

DisorderH7 Personality disorderH8 Traumatic

experiencesH9 Violent attitudesH10 Treatment or

supervision response

CLINICAL

PRESENT / DYNAMICI.e. Recent problems with:

C1 Insight

C2 Violent ideation or intent

C3 Symptoms of

major mental disorder

C4 Instability

C5 Treatment or supervision response

RISK MANAGEMENT

FUTURE / DYNAMICI.e. Future problems with:

R1 Professional services and plans

R2 Living situation

R3 Personal support

R4 Treatment or supervision response

R5 Stress or coping

(Webster, Douglas, Eaves, & Hart, 1997)

Synthesis

• Risk assessment: process of speculating about violence risk posed by a client

• Risk management: Process of mitigating the

violence risk posed by a client

• Risk assessment informs risk management

decisions