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THOUGHTS ABOUT THE ASSESSMENT OF
VIOLENCE DIRECTED AT SELF AND OTHERS

PROBLEM

Violence, directed at self or others is a complex, multi-causal phenomenon that concerns the psychiatrist primarily when it occurs as an outcome of mental illness. The same process is used in assessing the risk of suicide and homicide. The demographics are also very similar. Major depression is primarily responsible for successful suicides and 80 percent of completed suicides carry a diagnosis of alcoholism, major depression, or both. More than 90 percent of suicide completers suffer from psychiatric illness; primarily affective disease, alcoholism, schizophrenia, or borderline personality disorder. Violence against others is highest in substance abusers and substance abuse and schizophrenia is even higher.

SUCCESSFUL SUICIDES

• Major depression is responsible for most suicides
• Major depression combined with alcoholism leads to 80% of suicides

PSYCHIATRIC ILLNESS

The following diagnosis accounts for 90% of suicides:

• affective disease
• alcoholism         
• schizophrenia             
• borderline personality disorder.

VIOLENCE AGAINST OTHERS

• substance abusers highest
• substance abuse and schizophrenia is highest

INTERVENTION

Psychiatrists cannot predict when or if a patient will actually commit suicide or homicide. Psychiatrists cannot PREDICT future harmful acts. Psychiatrists can only ASSESS dangerousness or the potential for harm in the here-and-now.

LEGAL CONSIDERATION

The psychiatrist can and will be expected to make a reasonable risk assessment. The psychiatrist cannot predict violence very accurately but they can assess the risk of violence. The legal standard of reasonableness in assessing and treating violence prone patients preempts the dilemma of "violence prediction" because psychiatrists are judged not on the absolute accuracy of their determinations but on whether their risk assessment process was clinically reasonable.

QUESTION: WAS THE PROFESSIONAL STANDARD OF CARE MET?

WHEN PATIENTS SHOULD BE EVALUATED

Assessment and documentation of suicidality and homicidality are integral components of any psychiatric evaluation and become primary concerns in this evaluation at the following times:

• INITIAL PATIENT CONTACT
  • initial interview (all patients)
  • admission to a facility or program (all patients)
• OCCURRENCE OF ANY SUICIDAL/SELF-DESTRUCTIVE BEHAVIOR OR IDEATION
• ONGOING THERAPY IN AN OUT-PATIENT
  • Noteworthy Clinical Change
    • Significant new symptoms
    • Mental status changes
    • Stressors
    • Depression
• HOSPITALIZED PATIENTS
  • For inpatients who have been assessed to be suicidal, the following situations may prompt an additional assessment (any boundary situation):
    • When a significant procedural decision is made
    • Progression to a less restrictive level of precautions/ increased privileges
    • Therapeutic passes
    • At time of discharge from hospital
  • The presence of violent thoughts, feelings, or impulses MUST be weighed against an assessment of the patient's ability
    • to control these impulses and the
    • sufficiency of the environment to support the patient’s control of these impulses.

DOCUMENT DISCHARGE PLANNING TO INCLUDE:

• Living arrangements, work, communication with significant others
• Follow-up appointments or contact with outpatient provider
  • likely compliance with follow-up care
• The availability of family or other support
• The presence of substance abuse or other comorbid condition
• The need for safety
• The importance of resumption of life outside the hospital
• Medications (include prescriptions)
• Current suicide &/ or homicide assessment
• Severity of illness

THIS IS A "HERE AND NOW" DETERMINATION

Patients who are no longer at acute risk of violence toward self or others may nevertheless remain at long-term, chronic risk of manifesting destructive behaviors. All the psychiatrist can do is carefully note that the patient is not at acute risk at the time of discharge. Once the patient is discharged, the potential for violence will depend on the patient's mental condition at any given time in addition to concurrent situational factors. Violent behavior is the result of dynamic, complex interaction among a variety of clinical, personality, social, and environmental factors whose relative importance varies across time and situations.