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Violence Risk Assessment in Behavioral Health

Why we must accurately measure the violence risk of youth

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Some have asked, “Is risk assessment an important behavioral health task?” Here is the case for being informed about violence risk assessment if you are working in the behavioral health field.

1. Behavioral health providers are seeing more people at risk of harming themselves or others. This risk, if the person is not treated, can last a lifetime.

2. Mass violence is at epidemic proportions in the U.S., and the need for a public health approach to this problem is necessary.

3. It is well established that early interventions can prevent future acts of violence.

4. While not all behavioral health clients are dangerous, some are. It is important to know who is more likely to commit a violent act and who is not, for the safety of behavioral health providers, the community, and clients.

5. Increasingly, legal systems are asking behavioral health providers to assess the safety of our clients to be in the community vs. being admitted to a more restricted environment.

6. In crisis intervention work in the community, behavioral health providers need the most accurate information to keep themselves and their co-workers safe from the violence of others and to make good recommendations about the need for inpatient vs. outpatient care.

7. If the violence is engendered by a reaction to severe trauma in childhood, the trauma must be treated effectively. Research shows that effective treatment can change the life course of “at-risk” persons.

8. Maryland has made it mandatory for violence risk and threat assessments to be performed in every school. If behavioral health providers work in schools or receive referrals from schools, they should be familiar with violence risk assessment.

The probability of risk for violence in the future can be identified by using validated risk and needs tools. In fact, research has demonstrated that the accuracy of clinical judgment (through the interview) of the future risk of violence without using validated violence risk assessment risk tools is no better than chance. Scientifically validated risk assessment instruments for youth, such as the SAVRY, CARE-2, and LS-CMI, can give behavioral health providers a more accurate sense of whether someone may be violent in the future.

Risk and resiliency factors and circumstances can raise or lower the estimates determined by risk assessment. Once the risk can be estimated as high, medium, or low, the key is to provide the evidence-informed treatment appropriate for that person and their specific skills, problems, situation, and resiliency factors. That means evaluating the problems and the strengths of the whole person and his or her family. The provider should then base the treatment plan on the list of problems and strengths and subsequently base the dosage of treatment on the complexity, chronicity, and severity of the problems.

Those at higher risk for violence have problems in multiple domains and have few resiliency factors, which can sometimes be a result of past severe and chronic trauma that the person has experienced, especially between the ages of 0 and 5.

Risk factors include:

  • Lack of healthy guidance, support, and monitoring from caregivers
  • Moderate to severe behavior problems at home and at school
  • Lack of academic success
  • Psychological problems
  • Maltreatment as a child
  • Living in chaotic neighborhoods, communities, and homes with a high level of drug use, violence, guns, gang involvement
  • Delinquency and a deviant peer group
  • History of chronic, severe behavior problems and assaults on others, especially if they start before the age of 13
  • Anger management problems
  • Often emotionally out of control with difficulty calming down

Resiliency or protective factors include:

  • A close relationship with a pro-social and supportive adult
  • Opportunities to be successful
  • Appropriate parental discipline (not too lax or severe or inconsistent)
  • Clear standards of behavior set by caregivers throughout childhood and adolescence

The more of these risk factors one has and the fewer the resiliency factors, the more likely that one will be involved in violence.

Approximate high, medium, and low risk can be estimated for anyone who comes in conflict with the law, a work supervisor, or school personnel. Once this risk is measured and assessed, a treatment or risk reduction plan may have to be ordered by a court or be a condition of continued employment or the ability to stay in school after a violent episode for compliance with treatment.

Those people at high risk for violence often do not have the self-management skills needed to follow through with treatment without something to ensure their compliance. They often have personality disorders in adulthood and have been traumatized in childhood, and/or bullied or rejected by peers as a teen. The people who are at risk of being violent often have had problems previously at school or work due to a lack of coping skills and support systems.

We can identify those at risk before a terrible event takes place and provide treatment. The best prevention is stopping child abuse, child neglect, domestic violence, and bullying and increasing coping skills, support systems, and access to mental health for those who need it.