Violence risk assessment and management in mental health: a conceptual, empirical and practice critique

Abstract

PurposeThe purpose of this paper is to examine empirical, epistemological and conceptual challenges and clinical narratives in the application of risk assessment and management in mental health.Design/methodology/approachThe authors used a narrative review of empirical, conceptual and clinical literature.FindingsThe worldwide prevalence of violence in mental health settings remains high. Risk assessment and management approaches, while well intentioned as an attempt to reduce harm and increase people’s safety, have negligible effect on both. They are invariably individual centric, ignore wider environmental, societal and behavioural influences that foment violence and have a stigmatising effect on people using mental health services. They also reinforce the myth that people who are mentally unwell threaten society and that through current risk assessment and management approaches, we can minimise this threat.Research limitations/implicationsThere is a need to reconsider the study and application of violence risk assessment in mental health.Practical implicationsThe practice of risk assessment and management in mental health is marred by an overuse of risk assessment measures that are limited in their predictive efficacy. As a result, they have little value in preventing, reducing and/or managing harm. The language of risk punishes and stigmatises service users and reinforces the image of menace. An alternative language of safety may nourish and protect. A collaborative approach to safety assessment based upon recovery-focussed principles and practices may fuse professionals and service users’ horizons. Combining service users’ self-perception, professionals’ sound clinical judgement, assisted by electronically derived risk algorithms and followed by evidence-based risk management interventions, may lessen the threat to service users, reduce harm and transform the practice of violence risk assessment and management.Social implicationsRisk appraisals discriminate against the small number of people who have a mental illness and are risky, an example of preventive detention that is ethically questionable. On the basis of the limitations of the predictive efficacy of actuarial measures, it is ethically dubious to subject people to interventions with limited benefits. Risk assessment processes tend to reinforce stigma by classifying individuals as risky, sanctioning society’s prejudices and fear through scientific authority.Originality/valueThe increasing focus on risk assessment and management to tackle violence in mental health is fraught with empirical, conceptual and practical concerns; the authors have suggested ways in which these concerns can be addressed without compromising people’s safety.