Use of Violence Risk Assessments Tools a Growing Global Phenomenon

Jay P. Singh, Sarah L. Desmarais, Cristina Hurducas, Karin Arbach-Lucioni, Carolina Condemarin, Kimberlie Dean, Michael Doyle, Jorge O. Folino, Verónica Godoy-Cervera, Martin Grann, Robyn Mei Yee Ho, Matthew M. Large, Louise Hjort Nielsen, Thierry H. Pham, Maria Francisca Rebocho, Kim A. Reeves, Martin Rettenberger, Corine de Ruiter, Katharina Seewald, & Randy K. Otto

Mental health professionals are routinely called upon to assess the risk of violence presented by their patients. Prior surveys of risk assessment methods have been largely circumscribed to individual countries and have not compared the practices of different professional disciplines. Therefore, a Web-based survey was developed to examine methods of violence risk assessment across six continents, and to compare the perceived utility of these methods by psychologists, psychiatrists, and nurses. The survey was translated into nine languages and distributed to members of 59 national and international organizations. Surveys were completed by 2135 respondents from 44 countries. Respondents in all six continents reported using instruments to assess, manage, and monitor violence risk, with over half of risk assessments in the past 12 months conducted using such an instrument. Respondents in Asia and South America reported conducting fewer structured assessments, and psychologists reported using instruments more than psychiatrists or nurses. Feedback regarding outcomes was not common: respondents who conducted structured risk assessments reported receiving feedback on accuracy in under 40% of cases, and those who used instruments to develop management plans reported feedback on whether plans were implemented in under 50% of cases. When information on the latter was obtained, risk management plans were not implemented in over a third of cases. Results suggest that violence risk assessment is a global phenomenon, as is the use of instruments to assist in this task. Improved feedback following risk assessments and the development of risk management plans could improve the efficacy of health services.

Violence, risk assessment, survey, international, mental health

A total of 2135 mental health professionals around the world were surveyed with respect to their risk assessment practices. The majority of the respondents were women (60.3%) and the average age of respondents was 43.9 years (SD = 11.0), with an average of 15.9 years (SD = 10.7) spent in practice. “Approximately half of their time in the past 12 months was spent on clinical activities, most often in forensic psychiatric hospitals followed by private practice and correctional institutions. Additional professional responsibilities over the past 12 months included administrative duties and teaching, with comparatively less time spent on research activities” (p. 198). Mental health professionals were contacted through web-based surveying, in a variety of languages, to examine the similarities and differences in risk assessment practices. The majority of participants were psychologists given that one of the inclusion criteria was that participants have previous training and practice in assessment.

Assessment Instruments Being Used

Two primary approaches to risk assessment have been identified: the actuarial approach, which combines protective and risk factors for violence in a mechanical, statistically-based way within a particular population of interest, and the structured professional judgment (SJP) approach, which provides an evidence-based structure within which the evaluator may use clinical discretion. The three most commonly used instruments for violence risk assessments identified in this study were the Historical, Clinical, Risk Management-20 (HCR-20), the Psychopathy Checklist-Revised (PCL-R), and the Psychopathy Checklist: Screening Version (PCL:SV) over both a lifelong and twelve-month time period. More than any other instrument, the HCR-20 was used to conduct, develop, and monitor risk for violence assessments and risk management plans. Personality instruments, such as the PCL-R, do not accurately predict violence as well as tools specifically designed for violence risk assessment but may still be helpful in the overall evaluation of an individual;’s risk for violence. In Europe, the HKT-30 (an instrument that is based on the HCR-20 but adds an additional 10 factors to consider) and the FOTRES were used almost exclusively.

Overall, both actuarial methods and SJP approaches had success and popularity among professionals. This research underscores that the decision regarding which of the two approaches to use should be based on the particular characteristics of the individual being evaluated as well asthe specific environment in which the professional works. Participants using SJP methods rated them as very helpful for their assessments. SJP tools like the HCR-20 or the HKT-30 appear to be more useful in international settings as actuarial approaches are impacted more by local factors than are SJP instruments, causing greater variability in probabilities of violence risk.

Implementation of Assessment Tools

“In terms of professional discipline, psychologists reported using instruments to structure their violence risk assessments more often than did psychiatrists or nurses both over their lifetime and in the past 12 months. Nurses reported more often obtaining feedback on whether their risk management plans had been implemented and that their risk management plans were implemented more often than psychologists or psychiatrists. Finally, psychologists reported taking significantly longer to conduct both unstructured violence risk assessments and structured violence risk assessments” (p. 199)

These authors “found that respondents who used instruments to develop management plans frequently did not know whether their plans had been implemented (44.6%) and, amongst those who did, proposed plans were not implemented in over a third of cases (34.6%)” (p. 202-203). Execution of risk assessment and management plans is necessary to manage risks.

Global Trends and Practices in Risk Assessment

“Compared to North America, Europe, and Australasia, respondents in Asia and South America reported completing a smaller proportion of risk assessments with the aid of an instrument” (p. 199). This highlights the differences in professional practices and differences across different countries. In addition, the lack of representation of these countries in the development of risk assessment research and practice may contribute to the slower adoption of these clinical practices in these countries. Other cultural restrictions included unauthorized translation of foreign materials or lack of awareness for instruments that are commercially available.

As the need for quality violence risk assessment grows on a global scale, it will be important to identify appropriate tools for risk assessments in South America and Asia.

This survey has two primary implications for practice: (1) we need to Improve communication regarding the quality and follow up of violence risk assessment and management plans, and (2) we need more information regarding how cultural factors impact the usage and quality of violence risk assessments throughout different countries.

Risk assessments provide a primary means of communication for mental health professionals. As such, there must be a continuum of channels for communication to ensure the clinical assessment is used to its fullest potential. If a mental health professional is required to perform assessments with no direct follow up or no follow through, then assessments lose their utility. Only one-third of participants reported receiving feedback on the accuracy of their assessments. “Social psychology research demonstrates that judgment accuracy increases when decision-makers receive feedback about their performance” (p. 202). It is important to receive feedback on the accuracy of assessments to determine whether additional training, education, or experience is needed. On the other hand, identifying professionals with strong assessment skills could help train other professionals to improve their skills. The main goal is to strengthen assessment skills and become experienced using these tools which will help improve the predictive validity of risk assessments.

“Moving forward, clinical training programs in these areas may wish to incorporate modules on violence risk assessment tools, funding agencies may wish to issue grants to encourage the development of novel instruments in native languages or the authorized translations of available tools, and there needs to be increased discussion in the field about the strengths and limitations of the contemporary literature and best-practice recommendations in international settings” (p. 203). Cultural differences across countries can be controlled to an extent as more collective research is transformed into international, unified models of clinical practice.

Participants in this survey reported an average of 435.5 violence risk assessments in their lifetime with the use of a structured instrument for over half of those assessments. On average, about 35 violence risk assessments were performed within a twelve-month time frame. The time to conduct a structured assessment took an average of 7.8 hours while an unstructured assessment took an average of 2.8 hours. This 5-hours difference is significant but structured assessments offer more valid and reliable conclusions.

Younger participants and participants who had shorter careers were more likely to use structured violence risk assessments than older participants or participants with longer careers. This could be evidence towards a shifting philosophy in clinical practice that strives for the use of Structured Professional Judgment approaches.

As always, please join the discussion below if you have thoughts or comments to add!