Table of Contents

Dangerousness in Psychiatry

Dangerousness is defined as" a propensity to cause serious physical injury or lasting psychological harm". Dangerousness is an unpredictable and untreatable tendency to inflict or risk serious, irreversible injury or destruction. Psychological harm in itself can be a consequence of some sexual offences and verbal aggression.

In general any consideration of dangerousness must include an assessment of the risk of inflicting serious violence on others, the risk of causing serious psychological harm, and the risk of damaging property where there is a risk of physical injury to others.

Concepts

There are no scientific measures to predict dangerousness accurately. Dangerousness is not a measurement but a judgment and as such is open to errors of validity and of reliability. An individual may be dangerous by chance, i.e. during a heated argument or when drunk, or conditionally dangerous or by inclination. Some dangerous individuals are opportunity seekers. Others are unconditionally dangerous and opportunity makers.

It is important to always remember that nothing predicts behaviour like past behaviour. However, dangerousness is not constant and liable to change over time. It depends on an individual’s relationship with others and the stability of his mental state.

Psychiatrists perform poorly in predicting dangerousness. Predicting dangerousness is a skill that needs to be developed and it can wither if under-used. One should always be aware of who you are trying to please when deciding upon dangerousness. Try to clarify in your own mind whether you are attempting to estimate the probability of a dangerous act occurring or, in the event of a dangerous act occurring, just how dangerous is it going to be.

ASSESSMENT OF DANGEROUSNESS

A psychiatrist may be asked to assess dangerousness of an offender when making a psychiatric report requested by court or a solicitor in criminal cases.

The basis is a full history from the offender and others and a meticulous mental state examination.

1. Structure of the interview

The assessor should decide if he should be alone with the interviewee. Is the assessor able to escape? Is there an alarm system and backup? Could the interviewer’s gender place her at risk?

“If you don’t ask the right questions you won’t get the right answers”.

2. The offence

The offence is a result of the interaction between the offender, the victim and circumstances. It is essential to enquire about what actually happened, when and why. Who did what, when and where? That what one is charged with and offence does not necessarily reflect what he did or what he intended to do. Ask yourself was this impulsive or prepared? Was this provoked or spontaneous?.

3. Criminal record and past behaviour

//Violence predicts violence.//

Aggression appearing at an early age and in several situations and the presence of aggression in father and siblings means that the violent behaviour is likely to persist. Watch out for the quiet over-controlled offender where stress has led to a complete loss of control. When looking at previous offences be aware of those who were under-charged and acquitted and who had unrecorded events and had spent convictions.

4. Personal data

  • Age: Youths have highest rate of offending. Scott suggests that sexual of fences directed towards orgasm -become less common with age.
  • Sex: Women are less dangerous than men in that they are less likely to seek violent solutions but when they do so they show the same level of violence as males..
  • Marital Status: failure to achieve sexual partnership in an offender committing violent sexual offence is ominous.
  • Personality Traits: There is no characteristic profile. There two broad types: the under-controlled and the over-controlled. Check for jealous feelings, paranoid thoughts, suspiciousness and sadistic trends.
  • Occupation: for example a butcher.
  • Childhood: the triad of enuresis, fire setting and cruelty to animals.
  • Cruel sadistic parents. Fascination with paraphernalia e.g. Nazi symbols. Violent pornography. Explore fantasy world. Determine the degree of egocentricity. Is the individual capable of empathy?. What is the individual’s sense of self esteem and how do they react if this is threatened?.

5. Relationship with mental illness

The link here is not very clear and research findings vary. The usual variables such as the course of the illness, the symptoms, the response to medication, the compliance with medication, the acceptability of psychiatric involvement and a need for sectioning must all be considered in the light of any relationship they may have with violence. Does the patient suffer from paranoid schizophrenia or have a psychopathic personality disorder?. Epilepsy is not especially linked to arson, rape or murder.

6. Progress in custody/hospital

Check the records, clinical notes and chat to staff. Have the offender settled because he is beyond the reach of alcohol, drugs, women or children and will you need to test this out in a less secure environment? Have they made genuine progress or are they conforming (having learned to manipulate the system perhaps)? Have they become dependent on the enforced structure of their environment?.

7. Present mental state

If at all possible obtain objective accounts before interview. Pay particular attention to your own subjective sense of unease with the patient. How frank is the patient? What does his reply “I can’t remember” means? Ask about psychotic symptoms directly. Never leave the patient before doing a formal cognitive assessment..

MANAGEMENT OF DANGEROUS PATIENTS

It is a multidisciplinary team approach. Communication between all team members is essential. When things go wrong it is usually because of an accumulation of multiple minor errors rather than because of major shortcomings within a team. Difficulties and dilemmas should be shared. The peer process is a vital component in management. Sometimes there is no one particular way forward and it is essential to air the various alternatives with other clinical teams and thereby benefit from their advice and support.

As dangerousness varies it is important that the clinical team can listen to individual team members who at any one time may be more involved with the patient than others and whose sense of subjective unease may be the only indicator of developing problems. Sometimes it is only by sheer good luck that nothing has happened..

In a forensic setting community supervision often takes the form of fine balance between a patient’s right to confidentiality and the team’s duty to society. This is particularly evident for restricted patients where the team has a statutory relationship to the Home Office which is very different to the voluntary relationship that general psychiatric teams have to their community patients.

When following up forensic patients in the long term it is important that the key worker have access to copies of the original depositions (details of the offence) to remind themselves of the reason why their monitoring needs to be intrusive and to prevent complacency.

Advisory Board on Restricted Patients

This is an independent, non-statutory body, appointed by the Home Secretary that concerns itself with restricted patients only. Approximately 15 - 20% of restricted patients are reviewed prior to their release. The patients chosen include sadists, arsonist and sex offenders. The common features are usually a mixture of unpredictable behaviour, poor response to treatment, incomplete understanding of motivation for the offence, or where there is grave concern that there is a risk of the patient harming others. Its main function is to advise the Home Secretary regarding charge and transfer of any such patient where the risk of further serious offending is judged to require special care in assessment. The main concern of the Committee is to explore projected release plans and to identify the degree of provision that will be provided in the long term..