Australian and New Zealand Journal of

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Managing aggression and violence: The clinician's role in contemporary mental health care
Stephen H Allnutt, James R P Ogloff, Jonathon Adams, Colman O'Driscoll, Michael Daffern, Andrew Carroll, Vindya
Nanayakkara and David Chaplow
Aust N Z J Psychiatry 2013 47: 728 originally published online 21 May 2013
DOI: 10.1177/0004867413484368

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484368
2013
ANP47810.1177/0004867413484368ANZJP ArticlesAllnutt et al.

Review

Australian & New Zealand Journal of Psychiatry

Managing aggression and violence: The 47(8) 728736

DOI: 10.1177/0004867413484368

clinicians role in contemporary mental The Royal Australian and

New Zealand College of Psychiatrists 2013

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Stephen H Allnutt1,2, James R P Ogloff 3,4, Jonathon Adams1,2,

Colman ODriscoll1,3, Michael Daffern3,4, Andrew Carroll3,4,
Vindya Nanayakkara1,2 and David Chaplow2

Abstract
Objective: From time to time misconceptions about violence risk assessment raise debate about the role mental health
professionals play in managing aggression, with associated concerns about the utility of violence risk assessment. This
paper will address some of the misconceptions about risk assessment in those with serious mental illness.
Methods: The authors have expertise as clinicians and researchers in the field and based on their accumulated knowl-
edge and discussion they have reviewed the literature to form their opinions.
Results: This paper reflects the authors views.
Conclusion: There is a modest yet statistical and clinically significant association between certain types of mental illness
and violence. Debate about the appropriateness of clinician involvement in violence risk assessment is sometimes based
on a misunderstanding about the central issues and the degree to which this problem can be effectively managed. The
central purpose of risk assessment is the prevention rather than the prediction of violence. Violence risk assessment is
a process of identifying patients who are at greater risk of violence in order to facilitate the timing and prioritisation of
preventative interventions. Clinicians should base these risk assessments on empirical knowledge and consideration of
case-specific factors to inform appropriate management interventions to reduce the identified risk.

Keywords
Violence, risk assessment, risk management, mental illness

Introduction
Violence risk assessment is critical to contemporary gen-
eral mental health. The primary goal of violence risk assess-
ment is the prevention rather than the prediction of violence.
To be effective, violence risk assessment must be linked to
a process of better management of patients that raise con-
cern, by managing risk factors. The important issue here is
that it is not the violence that is being managed, but the risk
factors for violence (which relate to propensity). While
related concepts, propensity refers to tendency, and predic-
tion to actual outcome.
contextual imperatives. Experts have long accepted that
prediction (that is, identifying which individuals will or
will not be violent) cannot be achieved (Cocozza and
Steadman, 1976; Monahan, 1981; Ogloff and Davis 2005).
This is not new knowledge. But to argue against violence
risk assessment because prediction is not possible is to miss
1Universityof New South Wales, Sydney, Australia
2Justice
and Forensic Mental Health Network, NSW, Australia
3Monash University, Clayton, Australia

Some have suggested that psychiatrists and others 4Forensicare, Fairfield, Australia

should not engage in violence risk assessment (Large etal.,

Corresponding author:
2011; Ryan etal., 2010). This argument is based purely on Stephen Allnutt, Justice Health, 7 Fleet Street, Parramatta, Sydney, NSW
a statistical perspective, focuses on the limits of prediction, 2151, Australia.
and ignores clinical, legal, social, moral ethical and Email: stephenallnutt@me.com

Australian & New Zealand Journal of Psychiatry, 47(8)

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Allnutt et al. 729
the point; and most worryingly, potentially leads to the
abandonment of violence risk management and thus
prevention.
This paper will examine the role of mental health clini-
cians in violence risk assessment and management in the
context of contemporary mental health systems in devel-
oped countries.
Methods
Due to the complexity of this topic, we did not conduct a
systematic review, which would have included using key
terms to identify relevant literature in recognised electronic
databases. Instead, the arguments we present are a sum-
mary of accumulated knowledge gained by the authors,
keeping up date with the literature and discussing amongst
each other and with colleagues nationally and internation-
ally over the years. The authors have expertise as clinicians
and researchers in the field and based on their accumulated
knowledge and discussion have reviewed the literature to
form their opinions.
Results
The following is an account of the authors views.
Understanding the problem
It is inevitable (as with all medical decision making) that
clinicians will from time to time be asked to form an opin-
ion on the probability of an outcome. In this context they
might express their opinion as a percentage or rate and thus
make predictive statements. There is clear evidence that in
doing so, using assessment approaches that are structured
and have an empirical basis provides stronger predictive
validity and are more reliable than unstructured clinical
judgement alone (gisdttir etal., 2006; Hanson and
Morton-Bourgon, 2009; Mossman, 2000).
Mental health clinicians are regarded as experts in the
assessment and management of disturbing behaviours
derived from mental illness. The community has a long his-
tory of expecting mental health professionals to assist in
this process and in deciding who requires detention and
treatment under restrictive conditions. For example, Section
26(2)(b), Part IV, of the Mental Health Act, 1959 (Vic) [7 &
8 Eliz. 2, Ch. 72] provides that An application for [invol-
untary] admission for a treatment may be made in respect
of a patient on the grounds that is necessary in the inter-
ests of the patients health or safety or for the protection of
the other persons that the patient should be so detained
(emphasis added). This is reflected in current Mental Health
Acts, which afford psychiatrists power to involuntarily
detain and treat people with serious mental illnesses. In
addition, the judiciary and adjudicators (e.g. parole boards,
mental health boards or tribunals) rely heavily on
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clinicians opinions in dispositional decisions that result in
the detention and supervision of people against their will,
or release.
Patients with mental illness could at one time be locked
away for extended periods on the signature of a doctor.
However legislation has curtailed clinicians powers.
Modern notions of due process and natural justice have led
to increased human rights protections in mental health leg-
islation. Despite these safeguards, mental health clinicians
are still perceived as broadening the traditional treating role
to one of public protection. Clinicians should not lose sight
of the possibility of arbitrary and capricious deprivation of
liberties, which has occurred in the past.
The management of patients with mental health prob-
lems requires consideration of numerous outcomes includ-
ing: relapse, abuse of substances, self-harm/suicide and
psychosocial disadvantage. While not all patients are at risk
of every one of these adverse outcomes, clinicians need to
be aware of the possibility of such outcomes and when
identified, take reasonable action to intervene by appropri-
ate management. Violence can be regarded as a behavioural
complication of serious mental illness in some sufferers
and an outcome that requires assessment and management
(Mullen, 2006). It is thus understandable that mental health
professionals have an obligation to identify and manage
risk of this outcome as well. Without first conducting a
thorough assessment of the relevant risk factors, effective
management strategies to assist with wellness, recovery,
adaptation and prevention cannot be identified. Taking
action only after an incident does a disservice to the patient
and the broader community.
The ultimate expectation of any health service is the pre-
vention of premature mortality and amelioration of morbid-
ity. Mental health services are no different. In mental health,
the most severe form being self-harm/aggression and sui-
cide/homicide. Mental health professionals must develop
skills and methods to assertively manage that possibility
(Mullen and Ogloff, 2009).
Understanding the type of population the person falls
into enables awareness of the propensity for violence and
the consequent management of the patient according to
their individual needs. Risk assessment is the process of
identifying empirical and clinically derived risk factors.
Risk management is a process of ameliorating this propen-
sity through multidisciplinary intervention, addressing the
identified risk factors that moderate the interaction between
mental illness and violent behaviour (Mullen, 2006).
There is an empirically established relationship between
serious mental illness and violence based on studies of pris-
oners, mentally ill offenders, mentally ill people who do not
offend and the general population (Mullen etal., 2000;
Swanson etal., 1990, 2006a; Wallace etal., 2004). This
relationship is mostly studied in those with schizophrenia
and psychosis not otherwise specified. Douglas etal. (2009)
and Fazel etal. (2009) in comprehensive meta-analyses
Australian & New Zealand Journal of Psychiatry, 47(8)
730 ANZJP Articles
investigated the relationship between psychosis and vio-
lence. Results revealed a modest yet statistically significant
and clinically important relationship even when controlling
for moderating variables. While psychosis alone is a statis-
tically significant risk factor for violence, the risk becomes
greater when a patient has co-morbid substance misuse
(Douglas etal., 2009; Fazel etal., 2009; Wallace etal.,
2004) and/or an antisocial personality disorder (Tengstrm
etal., 2004). Many other, less statistically significant, fac-
tors also have a moderating influence on the relationship
between psychosis and violence (Douglas etal., 2009).
Violence by those with mental illness has a significant
impact on the victim, the victims family, the perpetrators
family, carers, staff and the patient. Violence adds to the
stigma that those with mental illness are to be feared. The
publicity that follows a violent offence committed by a
patient with mental illness, in particular where there is a
coroners finding that psychiatric care was inadequate, does
damage to the public image of patients with mental illness
and public confidence in mental health services (Hall, 2011).
Violence also causes significant difficulties for the patients
themselves. Most patients dislike acting in an aggressive
manner, often request assistance to refrain from such behav-
iour, and often suffer considerable guilt and shame after-
wards. Their aggression erodes relationships, and results in
restrictions on liberty including confinement in restrictive,
anti-therapeutic environments such as prison.
In addition there are important clinical decisions that
require careful consideration of the potential of the risk
posed. For example, there are circumstances where confi-
dentiality can be breached to protect third parties. Professional
codes of ethics allow (and when children are involved,
expect) clinicians to disclose confidential information under
certain circumstances, such as serious concern about risk of
violence (Kaempf etal., 2009) to a named person.
Dealing with uncommon events
Commentary suggesting that violence risk assessment is
inappropriate because the prevalence (base rate) of vio-
lence is too low (Large etal., 2011) requires explanation.
The argument that one cannot accurately predict who will
or will not be violent is an old one, emphasised years ago
by Monahan (1981), based on his review of studies using
unstructured clinical judgement, in the absence of adequate
research. Monahans findings led to the development of
better assessment procedures.
There is no one fixed rate of violence in the mentally ill.
Reported rates of violence vary according to the severity
and nature of violence measured, how information on vio-
lent behaviour is sourced, the population studied and the
duration of follow-up.
Swanson etal. (2006a) examined a wide spectrum of
patients with schizophrenia, and found a 6-month preva-
lence of 3.6% for serious violence. Douglas etal. (1999)
Australian & New Zealand Journal of Psychiatry, 47(8)
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found that 10% of patients involuntarily hospitalised in
general psychiatric hospitals discharged to the community
were either arrested or convicted for a violent offence (seri-
ous violence) during a follow-up period of approximately
20 months (1999). On the other hand, base rates for any
violence over a period of 1 year in the general community
has been reported to be between 25% and 30% for general
psychiatric patients and higher for specific populations of
people with mental illnesses and offence histories (Douglas
etal., 1999; Hodgins etal., 2007; Nicholls etal., 2004;
Steadman etal., 1998; Swanson etal., 2006a; Walsh etal.,
2001; Wootton etal., 2008). Steadman etal. (2000) found
that more than one-third (35.7%) of 10,000 involuntarily
committed patients released to the community engaged in
some form of violence within 20 months of discharge.
In psychiatric hospitals the base rate of violence is much
higher, with low severity aggressive behaviour being
remarkably common (Daffern and Howells, 2002).
Assessing risk of aggression in this context is critical, and
risk-related decision making is central to decisions about
leave, escorting requirements, the need for a patient to be
moved to a high-dependency unit and even the need for
medication (Ogloff and Daffern, 2006).
Rates of violence increase, to a point, with the presence of
additional risk factors. For example, in the Wallace etal.
(2004) study, the rate of violent offending in those with
schizophrenia alone was 8%, but rose to 26% in those with
schizophrenia and a co-morbid substance use disorder. In a
study by Wootton etal. (2008), 22% of general psychiatric
patients discharged and followed up for 2 years committed
an assault but 37% of those who manifested other risk factors
(younger age and male, assault in the previous 2 years and
substance abuse in the previous 1 year) committed an assault
within 2 years. In the MacArthur Foundation study (Steadman
etal., 1998) the 1-year aggregate prevalence of violence was
17.9% for patients with a major mental disorder discharged
from general psychiatric hospitals and 31.1% with a co-mor-
bid substance abuse diagnosis were violent; substance abuse
contributed significantly to violence in this population.
To illustrate the above point, we consider the assessment
of violence risk in a general psychiatric population using
the Historical, Clinical Risk, Management-20 (HCR-20), a
tool to guide the structured professional judgement (SPJ)
approach (discussed below) to violence risk assessment
(Webster etal., 1997). The tool has been subject to more
than 130 studies, finding good reliability (e.g. inter-rater
reliability = 0.800.85) and moderate to strong predictive
validity (e.g. area under the curve = 0.650.89) (Douglas
and Reeves, 2010). A study in Canada examined the accu-
racy of the HCR-20 in involuntary psychiatric patients dis-
charged to the community from the hospital (Douglas etal.,
1999; Nicholls etal., 2004). The rate of any violence
(any violence included acts of physical violence (any
attacks on persons), non-physical violence (serious threats to
harm, verbal attacks), and criminal violence (criminal charges
Allnutt et al. 731
or convictions for contact offences or robbery)) within 20
months of discharge to the community from general psychiat-
ric inpatient services was approximately 38%. Patients who
scored above 25 (out of a potential 40) on the HCR-20 at dis-
charge fell into a population of patients of whom about 75%
engaged in any violence within approximately 20 months.
Patients who scored below 15 fell into a population of patients
of whom about 10% engaged in any violence.
These prevalence rates are not insubstantial and on this
basis it would be fair to say that patients with schizophrenia
(and to a lesser but not inconsequential extent patients with
other serious mental illnesses) are at an increased risk of
aggression particularly within certain settings. Furthermore,
higher scores on some risk assessment instruments should
cause clinicians to pause, carefully consider their care plan-
ning and put in place risk management strategies to avert
violence and other aggressive behaviours.
While the HCR-20 is an SPJ tool it can, for research pur-
poses, produce numerical scores by totalling the 20 items,
producing total scores in the range 040. This actuarial
approach is not advocated in clinical practice (nor do the
authors of the HCR-20 advocate this approach), because it is
a tick box approach and ignores other clinical factors.
In practice, however, it is not researchers or commenta-
tors who determine what is or is not an acceptable threshold
required for an intervention. Rather, it is the clinician, hav-
ing regard to clinical, personal and social context of the par-
ticular patient that defines the intervention. For example, if
a patient was assessed (on an actuarial or SPJ assessment) to
cause concern for aggression and was incorporating their
mother, with whom they lived, into their delusional system
and making threats to harm her (that is, on clinical assess-
ment), the clinician might regard more frequent home visits
and/or temporary placement in alternative accommodation
as appropriate. If, however, the same person was assessed to
be of concern for aggression (on an actuarial or SPJ assess-
ment), was not living with their mother, or incorporating her
into a delusional system or making threats (clinical assess-
ment), the clinician might consider less restrictive alterna-
tives. Arguments against risk assessment based on rates of
violence found in empirical studies always overlook indi-
vidual contexts in which clinical decision making occurs
(Douglas and Skeem, 2005).
Further, empirically reported base rates of violence are
likely underestimates of the true base rate for a number of
reasons: family members are commonly victims and less
likely to report violence; people with mental illness are
often diverted into mental health services rather than the
criminal justice system; self-report is probably limited by a
need to avoid sanction or achieve social acceptability; there
are problems with recollection; and clinical documentation
is often inaccurate with regard to violent incidents.
Empirically reported rates of violence are also concerned
with people released to the community and followed up by
mental health services, thus reflecting rates of violence
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despite management of the patient. One can only be con-
cerned what the empirical rates would be if mental health
services did not actively manage violence in those deemed
to be at risk. Most studies are of managed patients.
Finally, lower base rates of serious violence (as
opposed to any violence) should not cause particular con-
cern to scholars and clinicians involved in violence risk
assessment. While it has long been accepted that events
with especially low base rates, such as homicide, will be
nearly impossible to predict (Szmukler, 2001), most forms
of violence have much higher base rates, but are also harm-
ful and low severity aggression often precedes serious vio-
lence. The base rates of any violence in specific
populations (such as those involuntarily detained in civil
psychiatric hospitals, and more so in those with a high load-
ing of risk factors) are significantly higher than the general
population noted above.
The ultimate goal is to manage specific populations of
patients with an increased propensity for any violence
(those with risk factors). This approach is more likely to
capture those at risk for more serious and sometimes rare
violent events such as homicide. Not just serious violence,
but any violence engaged in by patients requires the best
clinical attention. This certainly does not mean that these
patients always require involuntary admission, as suggested
in recent publications (Large etal., 2011; Ryan etal., 2010).
In most cases what they require is adequate psychiatric
assessment, treatment and care to address clinical needs.
Risk assessment in the mental health
context
The process of violence risk assessment is similar to other
diagnostic and prognostic processes in other fields of medi-
cine. That is, risk factors are identified through clinical
enquiry. Consider the task of determining the risk of a per-
son suffering a cardiac event; this is often based on the
presence or absence of risk factors such as hypertension,
smoking, prior cardiac events, family history and high cho-
lesterol. The clinician integrates objective information with
subjective perception about whether or not a patient falls
into an at-risk population, and decides on the intervention
and course of action/treatment. Risk assessment and man-
agement is a fundamental medical process.
Simply allocating patients to a category of low, medium
or high risk, within the complexity of real-world risk man-
agement decisions is of course insufficient, as it would be
in the assessment of a cardiac event. A more nuanced
approach is now recognised in sophisticated critiques of the
field of violence risk assessment (Mossman, 2006).
Contemporary approaches to risk assessment and risk man-
agement require clinicians to formulate and understand the
risk. Risk formulation is a description of the potential
nature of violence, the patterns (escalation, de-escalation
and persistence), potential victims, underlying motives,
Australian & New Zealand Journal of Psychiatry, 47(8)
732 ANZJP Articles
antecedents, and perpetuating and protective factors. Some
suggest also reporting on the most likely scenarios to arise
if the behaviour is to recur (Mullen and Ogloff, 2009). This
provides others with a far better understanding of the prob-
lem rather than a statement that the person is low, medium
or high risk. These categories are relatively meaningless in
clinical situations (unless there is a shared understanding of
the definition of these terms and they are attached to a par-
ticular intervention protocol).
Such categorical statements are more relevant in legal
situations where experts are asked to provide an opinion on
risk of recidivism in categorical terms. In those circum-
stances the proportionality of the risk is legally determined
and often complex. For example, the proportional level of
risk required to further detain a serious sex offender after
expiry of a term of incarceration has been determined to be
not higher than 50%. (The Court of Appeal in Tillman v
Attorney General for New South Wales [2007] NSWA 327,
referred to the term likely in s 17 (3) of the Crimes
(Serious Sex Offenders) Act 2006 to mean a degree of
probability at the upper end of the scale, but not necessarily
exceeding 50 per cent.)
Nevertheless, it is worth noting that there is evidence that
legal adjudicators who receive information in a descriptive
form that demonstrates an analysis of risk factors and pro-
vides a risk management plan are more likely to release
patients found not guilty by reason of mental illness than if
they received information that was only categorical or pre-
dictive form (Dolores and Redding, 2009). This supports the
view that proper risk assessment reduces inappropriate
detention rather than aggravating it. This also provides a
degree of reassurance to clinicians that the literature sup-
ports the assumption that management recommendations
will be acknowledged and potentially incorporated into dis-
positional options by legal decision makers.
The argument against violence risk assessment is some-
times based on the concern that an unacceptable number of
people will have their rights impinged, because an unac-
ceptable number of patients who would not have been vio-
lent will be involuntarily detained (Buchanan, 2008;
Buchanan and Leese, 2006; Large etal., 2011). Arguing
against risk assessment based on the potential consequence
of involuntary admission is to confound the issue. If the
option of involuntary admission based on risk was removed
from the statute, the need for the assessment of violence
risk in mentally ill patients would remain, and probably be
of even greater significance given that aggressive behav-
iour is a complication of severe mental illness and a poten-
tial mechanism to manage it in some cases, removed.
The predictive utility of risk assessment instruments is
sometimes (but rarely) measured by the number of people
needed to be detained to prevent one violent episode (NND)
(Buchanan, 2008; Buchanan and Leese, 2006). This is an
unhelpful way of expressing utility if it is read as implying
that the purpose of risk assessment is to identify those
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requiring involuntary admission. It also improperly implies
that involuntary admission is the only intervention in cases
where risk of violence is identified. Obviously, this is not
the case. Given that the purpose of assessment is to assess,
violence risk assessment is not and should not be consid-
ered an intervention or treatment. The intervention or treat-
ment is the risk management. It would be preferable to
consider the number of patients needed to assess (NNA) to
correctly identify one patient who goes on to be violent.
Whether or not psychiatry should have a role in the
removal of a persons civil rights is a valid and worthy
argument. While the practice of psychiatry occurs in the
context of a coercive backdrop of Mental Health Acts
(MHAs), the presence of a MHA is a legislative fact that
psychiatrists are expected to have regard to. Until there is
legislative change, if there is an expectation of psychiatrists
to involuntarily detain, then decisions should be made uti-
lising the best available evidence, even if violence risk
assessment has limitations. Utilising a non-empirical and
unstructured clinical approach will result in even more peo-
ple being erroneously detained because these types of
judgements are the most inaccurate risk assessment method,
and unstructured risk assessments typically result in an
overestimation of risk.
Some have regarded violence risk assessment in psy-
chiatry as a new process, becoming the focus of mental
health practice, seeking to bring the present into the future
and making it calculable, making clinicians agents of con-
trol and in the process contributing to social exclusion and
discrimination of patients (Rose, 1998). As stated already,
risk assessment is not new to medicine; it is integral to
daily medical practice in diagnosis and prognostication.
It is worth noting that to a large extent forensic mental
health services are a repository for patients who have been
failed by the mental health system, which sometimes does
not see the risk and so does not manage it, thus adding to
the stigma that those with mental illness are to be feared.
Nevertheless, it is important that strengths as well as risk
factors are elicited. Patients need to be seen as more than
the sum of risk factors.
Approaches to assessment
Violence is a complex and multiply determined behaviour.
No risk assessment approach is perfect, and clinicians
should be aware of the limitations and benefits of the differ-
ent approaches.
A common argument against violence risk assessment
that the authors experience in clinical practice is that it is
too rigorous and requires a specialist approach. A proper
risk assessment requires little more than a comprehensive
psychiatric assessment in most cases. The problem is not
that general clinicians are untrained in risk assessment or
that it is too rigorous. The problem is that they are often
insufficiently focussed on the application of information
Allnutt et al. 733
they have already obtained in a usual comprehensive inter-
view, to the evaluation of violence risk. There is little in a
tool such as the HCR-20 that does not form part of such an
evaluation. Almost all factors associated with violence risk
are embraced in a multidisciplinary approach to the treat-
ment of patients.
Beginning in the 1970s, systematic evaluations appeared
of the predictive validity of mental health professionals
assessments of dangerousness (as it was then known).
These were first-generation approaches. Cocozza and
Steadman (1976) found that there were no differences in
subsequent recidivism or violent recidivism among 257
forensic patients assessed by psychiatrists and designated
as dangerous (of whom 49% offended and 14% offended
violently) or non-dangerous (of whom 54% offended and
16% offended violently). They concluded there was clear
and convincing evidence (p. 1084) of mental health profes-
sionals inability to accurately predict violence. Studies
such as this have uniformly denounced unstructured clini-
cal judgement as an acceptable method of risk assessment
(Heilbrun etal., 1999).
Monahan (1981) identified errors with the unstructured
clinical approach including lack of specificity in defining
the outcome, ignoring statistical base rates of violence,
relying upon illusory correlations (i.e. variables misper-
ceived to have a relationship with violence), and failing to
incorporate environmental or contextual information into
assessments.
The second-generation (actuarial) approach to vio-
lence risk assessment focussed on the identification of
empirically determined variables associated with violence.
They provide objective, formal mathematical weighting of
risk variables to arrive at a decision on risk level (Grove
and Meehl, 1996). Actuarial tools are developed solely on
the statistical relationship between a range of predictive
variables (risk factors) and the likelihood of violence.
Aside from the clinical judgement needed to obtain the
information for each predictor, the final assessment of risk
is purely mechanical (Quinsey etal., 2005).
Actuarial methods provide a systematic, transparent,
objective approach. They are, however, limited by a range
of factors. They rely on static/historical factors, provide lit-
tle information pertaining to dynamic (changeable) current
and circumstantial factors and thus neglect factors amena-
ble to treatment. Actuarial methods are insensitive to
change over time and have problems with generalisability
(Davis and Ogloff, 2008; Mullen and Ogloff, 2009). They
do not allow for consideration of important aspects specific
to the individual case. They are largely comprised of risk
markers associated with but not necessarily causally
related to violence (Mullen and Ogloff, 2009).
Notwithstanding this, numerous studies show that even
simple actuarial methods consistently outperform unstruc-
tured clinical judgements in a variety of tasks (Dawes
etal., 1989), including violence risk assessments (gisdttir
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etal., 2006; Gardner etal., 1996; Hanson and Morton-
Bourgon, 2009; Mossman, 1994; Olver etal., 2011). The
amenability of actuarial tools to scrutiny provides grounds
for arguments about their limitations.
The third-generation structured professional judge-
ment (SPJ) approach relies on a combination of static risk
factors, dynamic risk factors (addressing the fluctuating
nature of risk) and case-specific factors (individualised and
contextual), anchored by the items in the instrument. Rather
than providing mathematical probability estimates (as with
actuarial approaches), the SPJ approach enables a more in-
depth and individualised understanding of the persons pro-
pensity for violence, and informs a more specific and
individualised formulation and treatment plan.
The SPJ approach goes beyond simply summing items
to generate a total score, as with pure actuarial instruments.
Structured means that the opinion is not statistical, but is
still informed by empirical research, unlike unstructured
assessment. The SPJ approach allows for the consideration
of the personal circumstances of the patient, the nature of
the victims, underlying motivations, prior patterns of
aggression, context, prior experience of the patient and
other case-specific risk factors relevant to the individual
(de Vogel etal., 2004). An SPJ tool provides a structured
guide to enable clinical decision making and risk manage-
ment anchored around empirically derived risk factors.
There is evidence that a structured approach to clinical
decision making can be as accurate, and in some cases
more accurate, than a purely actuarial approach. Guy
(2008) found four studies that tested the predictive validity
of the HCR-20 completed in two ways. The first approach
produced numeric scores totalling the 20 risk factors on
the HCR-20 (the actuarial approach), and the second, sum-
mary scores where the HCR-20 was totalled and clinicians
were able to modify the overall level of risk using their
clinical judgement after considering all of the information
available (the SPJ approach), arriving at ratings of high,
moderate or low risk. Guy found that in all of the studies
multivariate analyses demonstrated that the summary rat-
ings (the SPJ approach) added incrementally to the simple
numeric use of the instrument (see also Douglas etal.,
2003).
Using a structured instrument as a guide avoids many of
the clinical biases identified by Monahan (1981). SPJ
schemes encourage specification of the criterion, minimise
the deleterious effects of making illusory correlations, and
in some cases, encourage consideration of contextual fea-
tures, thereby enabling flexible use.
Managing risk in mental health
There is argument made that, because there is no evidence
that violence risk assessment reduces harm, clinicians
should probably abandon the practice (Large etal., 2011).
In general medical practice, finding that mere observation
Australian & New Zealand Journal of Psychiatry, 47(8)
734 ANZJP Articles
of a fever does not change the outcome of the infection, and
thus coming to the conclusion that clinicians should not
take a temperature would be regarded as incorrect. Taking a
temperature is risk assessment for a fever, a fever is a risk
factor for infection, and an antibiotic is risk management of
an adverse outcome (possibly mortality). Violence risk
assessment is not an intervention and conducting an assess-
ment of violence risk does not change the outcome. Simply
conducting a risk assessment without a plan to manage risk
factors would attract severe criticism in most other areas of
medicine.
Structured risk assessment leads to risk management
strategies that mediate between the risk assessment and
aggression (Belfrage etal., 2012). The question therefore is
not, Does violence risk assessment reduce harm? but
rather Does management of risk factors associated with
violence (identified by risk assessment) reduce harm?
There has been limited investigation into how services
use risk assessment to influence management of potentially
violent individuals. The research that does exist, however,
is promising. Abderhalden and colleagues (2008) con-
ducted a cluster randomised controlled trial of the imple-
mentation of structured risk assessment in acute psychiatric
admission wards. Treatment units were those that intro-
duced a standardised risk assessment following admission
with a mandatory implementation of prevention in high-
risk patients. The control units were business as usual.
The results showed that the incidence of aggression
decreased substantially in the treatment units, with little
change in the control units. Two other studies found that the
risk factors from the HCR-20 validly predict risk level and
that intense management of moderate- and high-risk
patients reduces violent outcome (Dernevik etal., 2002;
Pedersen etal., 2012; see also Torrey etal., 2008).
There is evidence that antipsychotic medication reduces
aggression in some patients with serious mental illness
(Arango and Bernardo, 2005; Chengappa etal., 2002).
Clozapine has superior effects on aggression in treatment-
resistant patients with schizophrenia (Dalal etal., 1999;
Krakowski etal., 2006; Volavka and Citrome, 2008). But
mere prescription of antipsychotics and a focus on symp-
tom management is not enough to reduce violence in the
longer term. However, increased frequency of clinical con-
tact reduces the occurrence of aggression (Monahan etal.,
2001). While it is accepted that assertive community treat-
ment (ACT) is clinically advantageous and cost effective in
reducing re-hospitalisation and time in hospital (because it
focuses on symptom reduction), neither standard care nor
ACT has been shown to be effective in reducing violence in
the community over a period of 2 years (Walsh etal., 2001).
In the absence of longer-term treatments that focus on psy-
chosocial factors associated with increased risk of violence,
the effect of antipsychotics on violence diminishes with
time (Bobes etal., 2009; Swanson etal., 2006a, 2008).
Antipsychotic medications reduce violence in those
Australian & New Zealand Journal of Psychiatry, 47(8)
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without a history of conduct problems but less so in those
with a history of conduct disorder (Swanson etal., 2008).
Antipsychotic medication is likely to be more effective
in reducing violence in patients where there is a more direct
relationship between symptoms and aggression; but as
chronic illness exerts its effect on psychosocial functioning
over time, psychosocial circumstances likely begin to
mediate and increase the risk of violence over and above
illness symptoms. Other factors such as personality and
conduct disorder, disadvantaged social circumstances, sub-
stance abuse, poor social and familial supports, and employ-
ment problems (Bonta etal., 1998) make a larger
contribution to violence in the longer term than symptoms
of serious mental illness. Thus, risk management of pro-
pensity for violence requires consideration of a wide vari-
ety of risk factors and the use of a range of interventions,
not just the prescription of medication.
It is notable that many forensic patients, once discharged
from a forensic hospital and followed up by community
forensic mental health services, commonly have a more
stable lifestyle and less offending in the community than
before their acquisition of forensic status and involvement
in more comprehensive management (Hodgins etal., 2007;
Ong etal., 2009). This is probably attributable to long-term
intensive care with a focus on risk factors that include but
extend beyond the management of mental illness symptoms
alone. Programmes that are multidisciplinary, have small
patient to staff ratio, address criminogenic factors, incorpo-
rate legal mechanisms to maintain adherence, as well as
residential programmes and substance abuse rehabilitation
have been shown to reduce violent behaviour (Cusack
etal., 2010; Gilbert etal., 2010; Swanson etal., 2001,
2006b).
Conclusions
In the face of the available evidence, violence is often a
complication of mental illness that affects a disproportion-
ate number of mentally ill people. The community is
unlikely to absolve clinicians of playing a role in managing
this public health problem, no matter what the statutes say
(Maden, 2007). Reducing morbidity and mortality due to
illness is the primary goal of most medical specialties, men-
tal health included. To better manage the propensity for
violence by those suffering serious mental illness, clini-
cians need to understand the problem and become better at
identifying that propensity. The primary purpose of risk
assessment is to identify risk and protective factors associ-
ated with violence in order to manage the risk factors and
build on the protective factors. Risk assessment should not
be an exercise with the end goal of categorising the person,
although this is often an unavoidable outcome, particularly
in some legal contexts (where the limits should be
explained). Risk assessment is a precursor to treatment and
management aimed at preventing harm.
Allnutt et al. 735
Violence risk assessment is also not a task that is in the
exclusive domain of forensic mental health professionals;
it is a clinical process with which all mental health profes-
sionals should gain familiarity. General mental health ser-
vices are on the frontline and are regularly confronted
with patients who have a propensity for violence; and
many carers who cannot manage them are frightened and
worry those in their care will harm themselves or others.
It is an unavoidable reality of daily general mental health
practice that violence risk is an issue that needs to be
addressed. To do so, general mental health practitioners
would benefit from developing expertise and employing a
structured, evidence-based approach to assessment, treat-
ment and management. To avoid utilising a structured
approach or reverting to an unstructured approach because
risk assessment is an inexact science is arguably
unacceptable.
Acknowledgements
The authors are grateful to Professor Jay Singh who offered com-
ments on an earlier version of the article, and Professor Dan
Howard SC for the useful comments on the final draft.
Funding
This research received no specific grant from any funding agency
in the public, commercial, or not-for-profit sectors.
Declaration of interest
The authors report no conflict of interest. The authors alone are
responsible for the content and writing of this paper.
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