A model for assessing and managing the probability of violence

The probability that any individual will in the future commit an act of significant violence is influenced by a multiplicity of factors. Furthermore, many of the relevant influences are in constant flux. In an attempt to provide a structured approach Monahan (38> divided the relevant influences into the following types.

1. Dispositional factors which include relatively enduring characteristics of the person such as impulsivity, anger, and psychopathy.

2. Clinical factors related to the types, and symptoms, of mental disorders.

3. Historical factors which include past experiences and prior history of offending.

4. Contextual factors which refers to aspects of the current environment that may be conducive to the occurrence of violent behaviour.

This approach has been employed to organize the assessment of risk. (39,4°) However, these subdivisions are not mutually exclusive and perhaps lack the dynamic aspects desirable in a model for the assessment and management of risk.

Visual models and representations are useful in focusing attention to relevant areas and illustrating both interactions between influences and response pathways. The problem is that models which are too simple irritate clinicians who confront the complexities of reality, whereas overly detailed models finish up with dozens of boxes linked by a multiplicity of criss-crossing arrows looking more like a painting by Jackson Pollock than any kind of guide to understanding or acting.

In Fig 1 an intentionally simplified scheme is presented of the influences on the probability of violent behaviour (this is freely developed from a model of prison suicide given by Leibling(4!>).

Fig. 1 A schematic representation of those areas of importance in assessing the probability of violent behaviour and the pathways for responding so as to reduce such risks. The influences on the probability of violent behaviours (solid lines) and pathways for decreasing, aggravating, and augmenting protective factors (broken lines) are illustrated. The probability of violent behaviour is in constant flux in any mentally disordered individual and in most will be no higher, and quite possibly lower, than in a non-disordered individual of a similar age and gender. In those where the probability is increased remedial action is often possible through managing the mental disorder, controlling any substance abuse, reducing social and interpersonal stressors as well as improving supports, and finally attempting to resolve current distress and situation provocations.

The individual's current state of mind is determined by the interactions of the following factors.

1. Pre-existing vulnerabilities, which include age, gender, personality, intellectual function, and a history of childhood abuse or disruption.

2. The protective and aggravating influences in the social and interpersonal environment, which includes the adequacy of social networks, marital status, living conditions, and employment status.

3. Mental disorder.

4. Substance abuse, which is of such critical importance as a predictor it justifies independent status.

The current state of mind reflects these influences and in turn is affected by changes in the immediate environment which bring about states of affairs likely to act as situational triggers. Situational triggers induce emotions such a fear and anger which in their turn influence fluctuations in the probability of violent behaviour.

Recognizing an escalating predisposition to violence, or of factors conducive to such an escalation, allows remedial action. A failure to recognize and respond appropriately increases the probability that the potential for violence will be realized.

This scheme will now be used as a structure for discussing influences on the probabilities of violent behaviour in the mentally disordered. It is the author's opinion, claims of actuarial enthusiasts notwithstanding, that in the current state of knowledge only guidance and broad generalities are possible not precise ascriptions of risk. However, this is currently an area of active research and it can be expected that in the life of this text book more firmly based predictive paradigms will be advocated.

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