Can Mental Health Practitioners Predict Future Violence?

Yesterday, a gunmen killed five and wounded at least eight others at the baggage claim for a Florida airport. Initial news reports allege the shooter had recently experienced psychotic-like symptoms. I am sure that in the coming days we will learn more details about the shooting and about the recent history of the shooter. Among the details there will be plenty of questions. Did anyone know this might happen? Could someone—especially in positions of power (FBI? Mental Health?)—have prevented it by reporting or removing access to guns?

Of course, it is easy to ask these questions and develop opinions after the fact. And yet we need to ask them if there are possibilities to learn from possible mistakes. What follows attempts to give the public a brief but better understanding of risk assessment when mental illness and violence combine. (NOTE: this is not a comment on the above sad situation or those cases where violence is unrelated to mental health.)

A little history of predicting future violence

Violence risk assessment is part of the sub-division of forensic psychology and psychiatry. Expert witnesses are used in court proceedings to report on the existence of mental illness, the probability of imminent dangerous behavior, and the options for most effective/least restrictive treatment required to reduce illness and increase safety.

How do clinicians make these opinions? In the not-too-distant past, expert witnesses usually used their wisdom shaped by years of experience. Much to the chagrin of experts, it turns out that clinical intuition isn’t all that effective. For some professionals, it is little better than chance! (Interested readers can check out Monahan’s 1984 oft-quoted research quoted in this rebuttal article.) Other options include actuarial methods (collecting risk factors just like an insurance company does to determine how much to charge your 18 year old son for car insurance) and test data. Both of these methods seek to eliminate feelings in the decision-making process. Actuarial data can certainly help us. Knowing someone has a history of violence and criminal behavior helps us predict future behavior. Knowing someone has schizophrenia may slightly increase risk of violence, but no more than it would for those who have problems managing impulses. And this would not be a reason to lock someone up (though it may be a reason to limit access to handguns). Assessment tools filled out by the person suspected of violence have a couple of problems with them but the main one is that very few of the most violent have been identified in treatment as possibly benefiting from assessment. And when we do give these assessments, the data rarely is clear—this kind of response means they will be violent, this one means they will not. We’re far better at identifying “faking good” or “faking bad” results than we are in determining whether the results mean future violence.

The best assessment to date requires that we have adequate history, survey of known risk factors, interviews, and test data. But as I said above, if the person suspected has not been in treatment or has done well to present as being merely disturbed but not dangerous, what can be done?

One More Complication

In our current society, we believe deeply that individuals have the right to self-determination. This means they have the right to refuse treatment. This right trumps nearly every other value. It doesn’t matter if the treatment would really help. The person is permitted to refuse. The only exceptions are involuntary commitments to address imminent danger to self or other. And as soon as the danger passes, the treatment can be refused again even if the treatment might avoid a relapse.

Bottom line for Practitioners

We can do better in responding to risk factors that might lead some to violence. We can learn more about these factors. We can equally promote confidentiality and privacy for our most distressed clients and yet be quick to warn others when signs of imminent violence are present. We can ask better questions. We can use non-cognitive approaches to get a better picture of their internal experiences. And yet, we can only work with the information we have. Contrary to popular belief, we are not prophets. In addition, most of our outpatient clients are not even remotely dangerous (in 27 years of clinical work, I have only needed to report two clients for imminent risk to others).

What we can do is assert the need for better and more available treatment options.

Family members are really the frontline of help for most distressed individuals. They are more likely to hear the murmurings that might indicate violence. This requires greater public education about the nature of mental illness and violence risk assessment and the kinds of ways to respond. Church leaders can also be better educated as to what kinds of options are available for those parishioners who are struggling with similar kinds of emotional distress. Let us be willing to lead the way in educating our communities and churches about mental health challenges and healthy responses. If we did a better job surrounding those with severe mental illness (and isolating them less) we would likely have less mental health induced violence.