Dr. Anthony Ng

    Risk Assessment

    9/24/2013 12:00:00 AM

    Risk Assessment
    Healthy Living - September 24, 2013
    Anthony Ng, MD, DFAPA

    With the recent news of shooting and violence in the news, such as nationally of the young child shot in Chicago, and the mass shooting in Washington, DC, as well as local acts of violence within our local Maine communities, many have been wondering if there is a way that we can tell or predict who will be such likely perpetrator of violence. The hope is that we can prevent such violence from happening, short of the ongoing debate on gun control. The answer is both yes and no.

    For mental health professionals, this is probably the crux of what they do, sorting out who is at risk and how severe is that risk. In the field of risk assessment, there are risks factors that are defined as static. These are risk factors that don’t change easily, such as age, violence history, social isolation, history of mental health issues associated with some sort of violence and violent criminal history for example. Then there are dynamic risk factors that are more situation dependent, such as alcohol and drug use, sudden stressors in life that may be traumatic, overwhelming, poor social support and access to weapons. Risk assessment is not a simple yes or no. It is more defined as low, moderate and high risk. Most individuals are at very low risk of violence, despite them having factors such as specific age and gender for example. And even those with mental health diagnosis, a majority of them do not present any significantly higher risk. Risk assessment is not about one identifiable factor, but it involves a combination of factors. These factors help determine how severe and how imminent those risks are. Violence risk can also be determined to be acute (very near term) or chronic (longer term).

    With the current evidence in the field of risk assessment, violence can be most effectively predicted within a 48 hour window. Beyond that time frame, risk assessment becomes more challenging. Of course, we can identify individuals who may be at long term risk but that does not equate to imminent risk. Risk factors can also increase over time. In many cases in hindsight, individuals who commit violence are likely to have an escalation in such risks, including increased anger, voicing more thoughts of violence, more erratic behaviors and thinking, increased mood disturbances for example. Often times, such changes are not noticed by people close to them, as these changes are often subtle and progressive over time. They may be dismissed or minimized by those around them. And perhaps more often, many people are noticing slight individual changes but collectively if such observations were shared, the changes will be more remarkable.

    Many worry that not more individuals with violence risk are identified but more often, violence risks are over-identified. This create unique sets of issues. This can for example lead to stigmatization of individuals, such as saying everyone with a mental health issues are at high risk of violence, which is inaccurate. One also noticed some backlash for example after 9/11 where folks of Middle Eastern culture were overly identified as risk individuals. There may be such over concerns for violence that any children at school with any difficulties get referred for violence assessment. There may be backlashes to misidentified individuals including alienating them at a minimal to potentially referring such individuals forcibly to the mental health system and law enforcement.

    When someone is identified at high risk of violence, law enforcement may be involved. For those individuals with possible mental health issues affecting their risk, the mental health system is involved. Individuals are brought for assessment and if deemed an acute risk, they may be held further by court order petition. This is known as “Blue Paper” in Maine, as the petition form is blue in color. Providers tend to be very careful on when to initiate such a process as it involves essentially holding someone against their will. This is the reason that jurisdictions around the country mandates that the provider should only use this option if the risk is acute and imminent and for psychiatric reasons only.
    Predicting violence is not a sure thing, based on current evidence. While there may be some identifiable associated factors, the best way to mitigate violence are through vigilance and screening, balanced with support, collaboration between people. It also involves sensible discussion to discuss the best ways to help folks at risk once they are identified.
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