Clinical prediction of assaultive behavior among male psychiatric patients at a maximum-security forensic facility.

OBJECTIVE: Patient characteristics associated with the clinical prediction of assaultive behavior in a forensic psychiatric hospital were compared with characteristics associated with actual assaultive behavior. METHODS: Treating psychiatrists at a New York forensic psychiatric hospital were asked to predict which of a sample of 183 recently admitted male patients were likely to show assaultive behavior during a three-month period. The predictions were compared with incident reports of actual assaultive behavior. Several patient characteristics, including race, legal status, age, education, criminal history, psychiatric symptoms rated independently by raters other than the treating psychiatrists, and ward behavior, were examined for their association with predicted and actual assaultive behavior. RESULTS: Clinicians' rate of correct prediction of assaultive behavior was 71 percent, with a diagnostic sensitivity of 54 percent and a diagnostic specificity of 79 percent. Characteristics associated with the prediction of assaultive behavior were race, transfer from a civil facility because of violence or dangerousness, age, education, arrests for violent offenses, childhood physical abuse, hostility, temper (or nurses' assessment of the patient's irritability), and inability to follow ward routine. Characteristics associated with actual assaultive behavior were transfer from a civil hospital, dual diagnosis of schizophrenia and substance abuse or dependence, childhood physical abuse, age, thought disorder, and temper. CONCLUSIONS: Clinicians were significantly more accurate than chance in prospectively predicting which male forensic patients would show assaultive behavior. However, some of the factors associated with clinical prediction, such as race, ability to follow ward routine, and arrest history, were not associated with actual assaultive behavior. In addition, clinicians failed to use dual diagnosis of schizophrenia and substance use disorder as a predictor.

The ongoing risk assessment in the treatment of forensic patients on conditional release status.

In New York State, patients who have been found not criminally responsible by reason of mental disease or defect, eventually become outpatients while still under the supervision of the courts. The treatment of these patients on outpatient orders of condition poses special problems. Treatment needs to center on the issues related to patient's potential for harmful/violent behavior. Therefore, outpatient clinicians need to conduct periodic risk assessments and must continuously monitor identified risk indicators. The author outlines steps for information gathering and evaluation necessary for risk assessment. Treatment of these patients is conceptualized as ongoing clinical risk identification and management. It is framed by a treatment contract that integrates mandates of the Orders of Conditions with information gathered through ongoing risk assessments and spells out legal and other consequences that may arise from non-compliance.

The assessment of dangerousness and predictions of violence: recent research and future prospects.

Recent research on clinical and actuarial assessments of dangerousness leaves many important questions unanswered regarding the relative validity and utility of such assessments. Moreover, the focus that has existed on determining the false-positive and false-negative rates of predictions of violence may be fundamentally misplaced. Clinical evaluations of dangerousness should be viewed as assessments of risk rather than as predictions of violence; and future research should focus on understanding and evaluating how clinical assessments of dangerousness-regarding truly representative types of possibly dangerous patients--are (or should be) made. In the meantime, the research to date on clinical assessments of dangerousness cannot properly be taken to conflict with the Supreme Court's recent affirmations of the admissibility of such assessments in courtroom proceedings.