The chance of violent behaviour in this model is a constantly shifting probability influenced by the interaction of the current state of mind with the situational triggers. The approach inherent in the proposed model is not actuarial or even probabilistic, it is a clinical model which aims through an active engagement with the patient and an understanding of their background, their life situation and the pressures upon them to recognize increases in the chances of violence. It also offers a structure to guide actions to reduce such risks. The remedial actions imposed by the model include increasing support, addressing substance abuse, improving the management of the mental disorder, and intervening to defuse increasing tensions in the immediate situation. What this approach is not about is looking for reasons to confine or coerce the patient. It is a model for management of imminent risk and for the long-term strategy of harm minimization into which can be incorporated the risk assessment and risk management strategies of actuarial instrumentalities.
Reviews such as this tend to end by listing each and every potential contribution to violent behaviour which may leave the clinician better informed but no better equipped for the practical business of assessing the probabilities of violence in their patients. Some weight needs to be assigned to the contending influence. If research on the actuarial risks of future violence had reached the level of excellence claimed by some of its advocates something approaching a predictive algorithm could be advanced. In the present state of knowledge, however, broad guidelines still prevail. Table 1 offers a simplified list of factors useful in the prediction of the probability of future violence and more importantly in managing the minimization of that risk
Table 1 A number of factors which may increase or decrease the probability that a particular patient will act in a violent or fear-inducing manner
In the emergency room confusion and clouding of consciousness are probably the most common source of violence. On admission to the wards the best predictors of violence are a combination of the general level of disturbance in the mental state, particularly when manifesting in fear, agitation, and anger, combined with a history of prior violence. On discharge persistent delusions associated with fear, or righteous anger, are of concern particularly in those unlikely to co-operate fully with follow-up treatment. In the community increasing tension between the patient and a relative or neighbour driven by delusional preoccupations raise special concern, particularly when the patient is making threats and rejecting treatment and support. Substance abuse increases the risk of violence in this, as every other, context. Those patients who commit the most serious forms of violence seem often to combine delusional preoccupations with relatively high levels of functioning, with in particular the preservation of drives and motivation.
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