Risk assessment of the potential of violence to self or others has been accepted as a core element of clinical practice in psychiatric forensic community and private clinical environmental settings (Stedman et al., (2000). Risk assessment increases the ability to understand an individuals potential for violent behaviour, assists the individual to change and for organisations to better allocate limited resources to more effective treatment programs (Snowden et al., 2009).
There is a significant correlation between substance abuse, psychiatric disorders, non-compliance with medication and the likelihood of aggressive behaviour amongst those with significant mental illness (Daffern et al., 2002). The link between medication noncompliance, violence and the effect medication noncompliance has on the over use of alcohol and other substances needs to be taken into account in conducting a risk assessment (Swartz et al., 1998). Daffern (2002), highlights the need for clinicians to be aware of the link between aggressive behaviours, the influence other environments and personal interactions outside of the hospital situation have on the patient and the need to take this into account when developing any risk assessment plan. There needs to be considerable care taken in developing a risk management plan to ensure that the plan does not focus on “control” and moves away from the primary goal of management (Heilbrun, 1997).
Case Study Risk Assessment Plan
James presents with three main issues that need to be focused on in the risk assessment plan. James has ongoing symptoms that would appear to indicate schizophrenia, but a more detailed assessment will need to be conducted. James has issues related to his aggressive behaviour towards others when he feels overwhelmed by his delusion schizophrenia symptoms. The first indicator of these symptoms was when he was 21 and believed he was being watched by cameras at his place of work. James reports that this delusional belief resulted in James assaulting a co worker and that police were involved and he was subsequent hospitalised. James reports twice assaulting his father when he believed his father was “in his head”. The James also reports a history of using illicit drugs since his early teens at high school. James reports that his marijuana use has been regular since early teens and he has on occasions misused prescription drug Valium. In adulthood, James reports use of beer and vodka has gone from weekend “binge drinking” to regular four to five days a week of heavy use of beer and spirits. James also reports his tobacco use has been regular since early teens and has increased to heavy use of 30 cigarettes a day over the last 12 months. This last 12-month period also is reported by James as a period where he has increased significantly his abuse of alcohol and marijuana. From James’ presentation during the interview, it would be reasonable to assume that he is minimising he level of substance use. Another issue that influences James’ symptoms and behaviours is the noncompliance with prescribed medication, which needs to be addressed in the overall risk assessment plan (Swartz et al., 1998).
Antonius et al. (2010), highlights the value of risk assessment as a valuable tool to assist the clinician to predict and prevent future violence and to improve current treatment and management protocols. Howells (1996), postulates that it is not possible to eliminate all risks of violence by forensic mental health patients, but therapeutic programs can be effective in changing violent behaviours. Although James’ level of violence would appear, from his self-report, to be on the lower level of violence, there appears to be in recent time a sense within James that he is becoming overwhelmed in the last 12months. This is indicated by not only what he says but also his use of substances, alcohol and tobacco usage has increased significantly in the last 12 months.. The potential for committing acts that are more violent can also be assumed to be increasing. Snowden et al. (2009), found that the testing with the Classification of Violence Risk (COVR) showed good validity when attempting to assess the risk of violence amongst patients with a history of violence and mental health issues. However, Snowden (2009), also warns that the COVR test requires information from patient files as well as patient self-report, and test results may be affected by the patient who minimises their history or violence, and the lack of access to the patient’s file. In this case, James presents as guarded in his answers to many questions and clearly only wanted to be out of the hospital, hence there would be a high probability of James minimising his level of violent behaviour. The mention that the police were still outside would give an indicator that they may have more knowledge of James’ past level of violence. Doing a clinical interview to assess the level of risk without the patients file, as was occurring in this instance, would appear unwise and places the interview into a clinical interview format with low predictor validity (Steadman et al., 2000). The quality of the information that the person conducting the risk assessment has access to, will determine the effectiveness of the risk assessment process (Heilbrun, 1997).
Actuarial risk assessments have been found to be significantly more valid in predicting violence than unstructured clinical interviews (Steadman et al.,2000). Hilton et al., (2001), argues that risk assessment of disordered offenders with a history of violence requires the use of actuarial assessment tools to enable a valid indicator in relation to danger to self or others. Howells (1996), argues the benefits of ensure risk management plans requires the individual to attend some form of anger management program, to assist the individual to learn more functional strategies for dealing with their current frustrations.
Buchanan (2008), highlights the need for those conducting a risk assessment to be aware of the casual connection between mental disorder and violence. There needs to be more information obtained other than the basic demographic information of age, race, gender and relationship status, which should include family environment, history of victimisation of client, how a client spends their day all of which have been found to correlate with mental illness and violence (Buchanan, 2008).
Substance Abuse and Non-compliance with Medication
Swartz et al., (1998), found in their study that a combination of substance abuse history and a history of non-compliance with medication, either recent or long term, was found to have a significant association with violent behaviour. Swartz et al. (1998), also made the observation of a correlation between an individual with limited personal insight combined with poor understanding of their illness and role of medication. This non-compliance with medication may not be deliberate behaviour by the individual as non-compliance and substance abuse may be mutually reinforcing which results in self-medicating with alcohol and substances. James would appear to have been self-medicating for many years with a self-reported significant increase in approximately the last 12 months. James reports the misuse of prescription medication Valium at various times. James would appear to view medication as only effective if it gives an immediate reaction and would need to have medication education as part of formulating an effective risk assessment/risk management plan. Any risk management plan for James would also need to incorporate a community based specialised out patient program focused on treating dually diagnosed mental illness clients (Swartz et al., 1988). Research shows a high level of co morbidity between those suffering from a mental illness such as schizophrenia and substance abuse and violent behaviour (Daffern et al., 2002).
Although James has admitted to no serious violent acts, his history of symptoms of schizophrenia with delusions elements would have to taken as a warning of potential risk to self or others. James reports that, in the last 12 months he has been finding it increasing difficult to cope. James presents as not having insight into his mental illness, and not wanting to be compliant in any medical treatment. Taylor (1998), found in her research that “of the 309 people with psychosis who had killed, the large majority (75%) were deluded at the time of their offence” (p49). Patient presentation must be observed carefully when assessing risk of violence apart from the obvivious features of psychosis that may be present, but also delusions may produce symptoms of anxiety or depression and delusions can indicate the patient’s inability to make or maintain relationships and history of violence (Taylor, 1998). James states during his interview that his illness had caused a break up of a past relationship and as a result had not been in a relationship for 3 years when he had to move back to live with his parents.
Rogers (2000), makes mention of the need to take into account when conducting a risk assessment not only the risk factors but the protective factors, which are factors that may reduce maladaptive behaviours on the individual. In the case of James, he appears to have a closer connection to his mother than he does with his father. However, his mother would seem to be very passive and his fathers more dominate. James’ mother may well have a significant impact on James being more complaint with medication, if her assistance was incorporated into a risk management plan. Her participation in the management plan may well assist James to remain compliant with medication and assist in harm minimisation strategies in relation to alcohol and tobacco use by James. Swartz et al., (1988), also advised to be aware when doing a risk assessment on a patient exhibiting non compliance with medication and substance abuse that the patient may have some underlying personality traits that may need testing for.
James does not present as a threat to himself and reports no past history of self-harming behaviours and denies any current thought of self-harming ideation. However, James’ current file is not available to the interviewer and it would be unwise to accept James’ own statement as to his current mental state. James presents as depressed, agitated, reactive and extremely frustrated which would require the potential of self-harm to be incorporated for monitoring in any risk assessment, especially if he is kept in hospital for further psychiatric assessment. Douglas et al., (2009), reports that suicide/self-harm is a risk factor when the patient has a history of schizophrenia, violence and substance abuse. Close observation of James during the interview shows that he would go into a rocking motion on numerous occasions, did not maintain good eye contact with the interviewer and indicated a number of times his level of frustration about the time he had waited and not liking hospitals. The probability would be that James would be kept in the psychiatric ward of the hospital for 72 hours to allow for a complete psychiatric assessment to ascertain his level of threat to himself or his father. Often people with the current presentation, clinical history and violence of James have a higher potential to assault others especially family members, which further tends to alienate them from their remaining family support (Douglas et al., 2009).
Rogers (2000) warns that “risk only evaluations are inherently inaccurate” (p598), which may have consequences on the client by labelling the client as violent. We must also work towards a standardised definition of “risk assessment”. The New Zealand Mental Health Commission (1998) defines risk assessment as a risk to the progression of symptoms of the illness, risk of the individual intentionally self-harming, the risk of self-harm that was not done intentionally and the risk of causing harm to others either by intent or as a result of risk taking behaviours. Crowe (2003), raises the issue of the need for a more specific defining of “risk” in the context of “risk assessment” and “risk management”.
The debate in between health professionals as to whether clinical or actuarial assessment provides a higher level or risk assessment and hence reduces the risk of harm to others as well as the patient continues to be debated. Doyle et al., (2002), reports that although actuarial assessments is shown as statistically superior to unstructured risk assessment techniques, actuarial assessment focuses on static factors and misses dynamic factors such as treatment non-compliance, family dynamics, poor impulse control and substance abuse. Rogers (2000), reports that parents’ who are more accepting and hence understanding of the patients mental illness has been found to be a strong protective factor to assist the patient.
There appears to be a need for further research to develop a more integrated approach to risk assessment to ensure a more standardised process is implemented. The risk management of violent behaviours is a complex process and requires a multidisciplinary approach that needs to focus on social, psychological and medical aspects of the individual (Howells, 1996). In the case of James, any risk management program must be approached from the broader perspective to achieve beneficial for James in the long term. Hilton et al., (2001), suggests that as demand for more valid risk assessment outcomes increase in relation to forensic mental health patients that actuarial assessment will be incorporated as an important part of the risk assessment process.