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Risk Assessment


is necessarily based upon an assessment that may take one of a number of forms; it will also likely have been conducted without benefitting from all the possible information that might be available.


Te purpose of this chapter is therefore to offer guidance concerning ways of extracting good quality information potentially relevant to the risk of future violence by an individual, so as to provide a (not ‘the only possible’) risk assessment.


An overview of risk assessment


In medical practice, assessment of an individual patient is based upon a combination of: clinical assessment of the individual, originating in known symptoms and signs of particular diseases; and, if fortunate, in known pathological mechanisms, on the background of knowledge about the occurrence of particular conditions in members of the population carrying particular characteristics (the ‘epidemiology’ of any given condition).


Different approaches are applicable to prediction of violent behaviour in an individual with a known psychiatric diagnosis. Epidemiological data about the characteristics of populations of individuals with, for example, schizophrenia, is relevant, but is in no way sufficient for valid and reliable prediction concerning an individual. Ultimately, the best basis of prediction lies in knowledge of that individual, and his past pattern of violence, and associated variables, rather than in knowledge of ‘people like him’.


Hence, although risk assessment does utilise epidemiological data (often referred to as ‘actuarial data’) concerning the association of particular diagnoses or mental symptoms with violence, the focus of risk assessment for violence is the individual and their own ‘biography of violence’, expressed both in terms of factors intrinsic to them, and of what circumstances, within them and within their environment, have been associated with violence they have previously exhibited. It is also expressed in terms of ‘narratives’ of their past violent episodes, plus ‘formulation’ (with the aim of achieving an ‘understanding’ of such past episodes).


Knowing what you are doing


In order to arrive at a ‘good’ risk assessment, the clinician must be clear and confident about what they ‘should’ be doing, in the same way that a clinical assessment, such as a mental state examination or an IQ assessment, has a clear set of parameters that guide the clinician. It is therefore important for there to be clear guidance and boundaries concerning the assessment of risk.


Everything is possible, but what is the probability of an outcome?


At its core, any risk assessment is a comment on a likely outcome. It is the probability, not the possibility, of a given event occurring that is described. It is possible for anyone to act violently, but it is more probable, for example, in someone who has a history of violence (past behaviour), is impulsive (by personality), is interested in/rewarded by violence (by personality), has a history of gross interpersonal problems (past behaviour), and who often becomes intoxicated with alcohol or drugs (affecting concurrent mental state).


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