Clinical Decision Making About Psychopathy and Violence Risk Assessment in Public Sector Mental Health Settings

Violence in society is not just a law and order problem, for it is a persistent area of concern for mental health professionals as well. Mental healthcare facilities in public sector thus serve a dual role – 1.Helping create a harmonious society and 2. Helping ailing individuals recover from their violent tendencies. Before, mental healthcare professionals can draw up prognostic plans for patients, they first have to assess risk of violence for a particular case. One way of achieving this is by seeking to develop “actuarial risk assessment tools to help improve clinicians’ ability to evaluate patients’ risk of violent behavior in practice by statistically optimizing predictions of violence”. (Elbogen,, 2005, p.133-141)

As research team of Eric Elbogen, Matthew Huss, Alan Tomkins and Mario Scalora suitably illustrate in the article, several such tools are currently being employed by psychiatric practitioners in clinical settings. And a consensus seemed to have emerged among the practitioners and researchers establishing a strong correlation between psychopathy (usually measured by the Psychopath Checklist – PCL; and presently PCL-Revised) and future violent behavior. The results indicate that

“Clinical staff in public sector settings would be very amenable to using the PCL; the PCL would seem to have great intuitive appeal to clinicians. However, that more experienced staff perceived PCL results to be available reveals a need for more effort to target disseminating risk measure results.” (Elbogen,, 2005, p.133-141)

The total psychopathy score is arrived at through chart review and semi-structured interview. Measurements are done across two primary dimensions – “first, an affective-interpersonal factor (characterized by lack of empathy, deceitfulness, lack of remorse, and failure to accept responsibility) and second, a socially deviant factor (characterized by lack of realistic goals, irresponsibility, impulsivity, juvenile delinquency, and poor behavioural controls).” (Elbogen,, 2005, p.133-141)

This assessment method has the backing of a majority of psychiatrists; and meta-analytic reviews show that “psychopathy is one of the strongest risk factors for assessing violence across a number of populations”. (Elbogen,, 2005, p.133-141) And hence psychopathy should be critically considered for assessing risk of violence in a candidate. The research team of Elbogen, have done precisely this, by way of employing a “multimethod design to investigate clinical decision making about psychopathy and violence risk assessment in public sector mental health settings.” (Elbogen,, 2005, p.133-141)

Hierarchical linear regression was also used by the research team to analyze data on dangerousness judgments. Participants “indicated considering clinical data most often when assessing violence risk, reporting that clinical data were also most readily available. Conversely, clinicians perceived formal testing information (e.g., PCL) to be least available and considered these data least often when they assessed patients’ violence risk.” (Elbogen,, 2005, p.133-141) More importantly, participants with longer clinical experience thought of testing information more often and saw PCL results to be more readily available. Moreover, even though participants did not expressly specify using the PCL when measuring violence risk, they did indirectly rely on psychopathy factors in making judgments of dangerousness. Also, the study found that “clinicians in crisis settings reported less availability of historical data typically needed to complete the PCL.” (Elbogen,, 2005, p.133-141)

Beyond establishing the link between psychopathy and assessment of violence risk, the article reveals other implications for the research. For example, the results suggest that

“Clinicians in public sector mental health settings may rely on readily available clinical information but at the same time discount less readily available historical and testing information, even though the latter variables have been shown to be most predictive of violence… Also, staff training or focus groups on risk assessment can be used to specifically address the need to incorporate historical and testing variables as well as clinical factors into decision making (especially for paraprofessionals)…” (Elbogen,, 2005, p.133-141)


By Elbogen, Eric B.; Huss, Matthew T.; Tomkins, Alan J.; Scalora, Mario J., (Sum-Fal 2005), Psychological Services, Vol 2(2), p.133-141.