title: Understanding Clinicians' Use of Cues When Assessing the Future Risk of Violence: A Clinical Judgement Analysis in the Psychiatric Setting.
abstract: Research is sparse on how clinicians' judgement informs their violence risk assessments. Yet, determining preferences for which risk factors are used, and how they are weighted and combined, is important to understanding such assessments. This study investigated clinicians' use of static and dynamic cues when assessing risk in individual patients and for dynamic cues considered in the recent and distant past. Clinicians provided three violence risk assessments for 41 separate hypothetical cases of hospitalized patients, each defined by eight cues (e.g., psychopathy and past violence severity/frequency). A clinical judgement analysis, using regression analysis of judgements for multiple cases, created linear models reflecting the major influences on each individual clinician's judgement. Risk assessments could be successfully predicted by between one and four cues, and there was close agreement between different clinicians' models regarding which cues were relevant for a given assessment. However, which cues were used varied between assessments: history of recent violence predicted assessments of in-hospital risk, whereas violence in the distant past predicted the assessed risk in the community. Crucially, several factors included in actuarial/structured risk assessment tools had little influence on clinicians' assessments. Our findings point to the adaptivity in clinicians' violence risk assessments, with a preference for relying on information consistent with the setting for which the assessment applies. The implication is that clinicians are open to using different structured assessment tools for different kinds of risk assessment, although they may seek greater flexibility in their assessments than some structured risk assessment tools afford (e.g., discounting static risk factors).
  
  
  CONCLUSIONS
  Across three separate violence risk assessments, clinicians' risk assessments were more strongly influenced by dynamic cues that can vary over time (e.g., level of violence) than by static cues that are fixed for a given individual (e.g., a diagnosis of psychopathy). The variation in the factors affecting risk assessments for different settings (i.e., in hospital versus in the community) was greater than the variability between clinicians for such judgements. The findings imply a preference for risk assessment strategies that offer flexibility: either using different risk assessment tools for different purposes and settings or employing a single tool that allows for different inputs into the risk assessment depending upon the nature of the assessment. The appropriateness of these clinical intuitions about violence risk that are implied by our findings warrants further investigation.
authors: University of Essex, Colchester, UK.|James Paget University Hospital, Gorleston, UK.
authors: Barbara
authors: B
authors: Brown
authors: University of Essex, Colchester, UK.
authors: Tim
authors: T
authors: Rakow
mesh_terms: D000328:Adult; D003463:Cues; D005260:Female; D005555:Forensic Psychiatry / Q000379:methods*; D006801:Humans; D007600:Judgment; D008297:Male; D001523:Mental Disorders / Q000523:psychology*; D011586:Psychology, Clinical / Q000379:methods*; D018570:Risk Assessment; D012307:Risk Factors; D014754:Violence / Q000523:psychology*
keywords: Clinical Prediction; Clinical Reasoning; Dynamic Risk Assessment; Judgement Analysis; Risk Factors; Violence Risk Assessment