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Violence risk assessment: The question is not whether but how

  • Anthony Maden (a1)
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Abstract
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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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Fallon, P., Bluglass, R., Edwards, B., et al(1999) Report of the Committee of Inquiry into the Personality Disorder Unit, Ashworth Special Hospital (Cm 4194-ii). London: Stationery Office.
Hart, S. D., Cox, D. N. & Hare, R. D. (1995) The Hare Psychopathy Checklist – Revised. Screening Version. Toronto: Multi Health Systems.
Higgins, N., Watts, D., Bindman, J., et al (2005) Assessing violence risk in general adult psychiatry. Psychiatric Bulletin, 29, 131133.
Monahan, J., Steadman, H. J., Silver, E., et al (2001) Rethinking Risk Assessment. The MacArthur Study of Mental Disorder and Violence. Oxford: Oxford University Press.
Swanson, J.W., Holzer, C. E., Ganju, V. K., et al (1990) Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area surveys. Hospital and Community Psychiatry, 41, 761770.
Webster, C. D., Douglas, K. S., Eaves, D., et al (1997) HCR–20: Assessing Risk for Violence (Version 2). Toronto: Psychological Assessment Resources.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Violence risk assessment: The question is not whether but how

  • Anthony Maden (a1)
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eLetters

Violence Risk Assessment in General Adult Psychiatry

Daniel M Beales, Specialist Registrar in Forensic Psychotherapy
05 July 2005

Maden’s editorial (Psychiatric Bulletin, April 2005, 29, 131-133) in response to the article by Higgins et al (Psychiatric Bulletin, April 2005, 29, 121-122) neglects a fundamental aspect of risk assessment and his recommendations therefore need to be treated with caution. Higgins et al refer to the different contexts in which risk assessment forms were being used but Maden doesn’t appear to have taken this fully into account in advocating the routine use of the HCR-20 in adult general psychiatry.

There is no doubt that the HCR-20 is a useful tool in forensic settings, where it is already widely used. However there would be significant time and cost implications to introducing it routinely into general adult settings and it could be argued that it this would not be a sensible or cost-effective thing to do. Although Maden starts by advocating “a more systemic approach in marginal cases”, which it is hard to disagree with, his advocacy of the routine use of the “ideal” HCR-20 doesn’t appear to address whether this is a feasible option with non-marginal cases. The HCR-20 can be very effective in supporting teams in assessing and reviewing ongoing risks but it is not clear that it is a practical solution to supporting, for example, the risk assessment and management decisions of a junior psychiatrist doing an assessment of a newpatient in an accident and emergency department in the middle of the night.

Maden notes that Higgins et al reported many consultants did not attend the (presumably free) half-day training on violence risk assessmentalready on offer within their services. To suggest three day external fee-based training specifically for violence risk assessment seems a disproportionate response when other priorities in mental health (for example assessing the risk of deliberate self-harm) are not identified as requiring such expensive formalised training.

It is a pity that neither Higgins et al nor Maden were able to expandon the possible utility of the CARDS project (Watts et al 2004) that the Higgins et al study was part of. This appears to be a worthwhile collaborative attempt at developing a more standardised approach to risk assessment in general adult psychiatry. It is also free and potentially more easily integrated into routine clinical practice than the wholesale use of the HCR-20.

References

WATTS, D., BINDMAN, J., SLADE, M., HOLLOWAY, F., ROSEN, A., THORNICROFT, G., (2004) Clinical assessment of risk decision support (CARDS): The development and evaluation of a feasible violence risk assessment for routine psychiatric practice. Journal of Mental Health, 13,569-581.
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