Challenging assumptions about risk factors and the role of screening for violence risk in the field of mental health

Abstract

Research demonstrates that mental illness is not a major cause of violence yet assumptions about a link and concern about the risks posed by mentally disordered people has resulted in the predominance of a public safety role for mental health services (Munro and Rumgay 2000). In consequence, screening, classifying and monitoring individuals considered to pose a potential risk to others due to their potential for violence has become a key responsibility. The purpose of healthcare screening is to identify a disease or condition, or its associated risk factors, to provide treatment or encourage preventative action on the part of ‘at risk’ individuals. Mental health screening differs since neither a disease entity nor a causal model to link mental disorder and violence exist (Leitner et al. 2006). Mental health service users are typically marginalised and screening may occur without their consent, knowledge or involvement. They may also disagree that they have the condition in question, i.e. a propensity to violence. The expectation upon professionals to promote service user involvement in care and treatment sits uneasily with these processes. This paper reviews the ongoing but unsuccessful efforts to develop effective screening for violence amongst people defined as mentally disordered and explores the implications for mental health services in the light of this evidence. It also considers the continuing lack of service user involvement in risk assessment. First however, the paper considers correlates for violence since screening depends for its efficacy upon risk factors thought to be positively associated with the condition of concern.

Keywords:

• screening
• risk to others
• mental disorder
• mental illness
• antisocial personality disorder
• mental health problems
• actuarial tools
• structured clinical judgements
• service user involvement
• patient involvement

Notes

1. Terminology is problematic in mental health given the controversial and contested terms ‘mental disorder’, ‘mental illness’ and ‘personality disorder’ (Pilgrim 2001, 2005, Bentall 2009). The author's use of these terms should not be seen as leading credence to the view that these are objective or unproblematic concepts.

2. The Care Programme Approach is seen as the bedrock of mental health policy and practice and before the recent amendments applied to everyone using specialist mental health services. It has four elements:

•	Systematic assessment of the person's health and social care needs.
•	The development of a care plan to meet those assessed needs.
•	A named keyworker to be the main point of contact between the service users and professionals delivering the care plan.
•	Regular review and monitoring of the care plan that includes the service user.