Improving risk assessment of violence among military Veterans: An evidence-based approach for clinical decision-making

https://doi.org/10.1016/j.cpr.2010.03.009Get rights and content

Abstract

Increased media attention to post-deployment violence highlights the need to develop effective models to guide risk assessment among military Veterans. Ideally, a method would help identify which Veterans are most at risk for violence so that it can be determined what could be done to prevent violent behavior. This article suggests how empirical approaches to risk assessment used successfully in civilian populations can be applied to Veterans. A review was conducted of the scientific literature on Veteran populations regarding factors related to interpersonal violence generally and to domestic violence specifically. A checklist was then generated of empirically-supported risk factors for clinicians to consider in practice. To conceptualize how these known risk factors relate to a Veteran's violence potential, risk assessment scholarship was utilized to develop an evidence-based method to guide mental health professionals. The goals of this approach are to integrate science into practice, overcome logistical barriers, and permit more effective assessment, monitoring, and management of violence risk for clinicians working with Veterans, both in Department of Veteran Affairs settings and in the broader community. Research is needed to test the predictive validity of risk assessment models. Ultimately, the use of a systematic, empirical framework could lead to improved clinical decision-making in the area of risk assessment and potentially help prevent violence among Veterans.

Section snippets

Literature review method

Empirical research on violence risk factors among Veterans was reviewed. Medline and PsycINFO databases were used to search peer-reviewed journals for articles describing empirical relationships between risk factors and violence among Veteran populations. Search terms included combinations of the following: “violence,” “violent,” “aggression,” “aggress,” “Veteran,” “military,” “risk,” “domestic,” and “conflict.” Several review articles were also used to identify relevant literature (Beckham et

Dispositional factors

In terms of demographic risk factors for intimate partner violence, younger age has been found be a predictor of intimate partner violence in Veterans and military service members (Fonseca et al., 2006, Forgey and Badger, 2006, McCarroll et al., 1999, McCarroll et al., 2000, McCarroll et al., 2003, Petrik et al., 1983, Rumm et al., 2000). One study of N = 101 Veterans found that 67% of younger men (age ≤ 40 years) reported physically hurting the woman they lived with compared to 43% of older men

Dispositional factors

As with domestic violence, younger age has been found to be related to higher incidence of aggression in Veterans (Beckham et al., 1998, Ganzini et al., 1995, Jakupcak et al., 2007, Taft, Kaloupek, et al., 2007). According to one study of N = 1328 Veterans, the effect of age may be explained in large part by the presence of PTSD symptoms of hyperarousal, since those symptoms were more prominent in younger Veterans (Taft, Kaloupek et al., 2007). Additionally, lower levels of education have been

Conceptualizing risk of violence among veterans

The review finds a large overlap of factors between different types of violence in Veteran populations, although certainly some risk factors were found to be specific to domestic violence (e.g., marital discord and family structure) or to general violence/aggression (e.g., head injury, and homelessness). To depict the results of the review, and to judge the empirical merit of these risk factors, we counted the number of peer-reviewed scientific publications demonstrating a statistically

Applying evidence-based approach to clinical treatment of Veterans

To use this conceptual framework in practice there are several barriers that need to be considered (Baker et al., 2008). First, time and resources are required to gather empirically validated information on violence. While VA Medical Centers do have a computerized patient record system which may contain important risk information, it is estimated that over one half of Veterans do not in fact go to the VA for their health care. As a result, clinicians themselves may need to do the legwork to

Benefits and limits of risk assessment framework

A central thesis of this article is that clinicians can optimize risk assessment by following the conceptual framework in Fig. 1 to guide in the use of empirically supported risk factors in Table 2. The evidence-based method proposed in this article is designed to ensure that clinicians review all the relevant risk domains and investigate empirically supported risk factors within those domains in each and every case. Research on clinical decision-making of violence risk reveals that clinicians

Acknowledgement

We want to thank Stephen Hart, Matt Huss, John Monahan, and Richard Weiner for comments on an earlier draft of this paper. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the National Institutes of Health. Please note there are no conflicts of interest. Preparation of this manuscript was supported by the Mid-Atlantic Mental Illness Research, Education and Clinical Center, the Office of Research and

References (144)

  • E.P. Mulvey et al.

    Conditional prediction: A model for research on dangerousness to others in a new era

    International Journal of Law and Psychiatry

    (1995)
  • L. Apperson et al.

    Short-term clinical prediction of assaultive behavior: Artifacts of research methods

    American Journal of Psychiatry

    (1993)
  • T.B. Baker et al.

    Current status and future prospects of clinical psychology: Toward a scientifically principled approach to mental and behavioral health care

    Psychological Science in the Public Interest

    (2008)
  • J.C. Beckham et al.

    Minnesota multiphasic personality inventory profiles of Vietnam combat veterans with posttraumatic stress disorder and their children

    Journal of Clinical Psychology

    (1997)
  • J.C. Beckham et al.

    Atrocities exposure in Vietnam combat veterans with chronic posttraumatic stress disorder: Relationship to combat exposure, symptom severity, guilt and interpersonal violence

    Journal of Traumatic Stress

    (1998)
  • J.C. Beckham et al.

    Interpersonal violence and its correlates in Vietnam veterans with chronic posttraumatic stress disorder

    Journal of Clinical Psychology

    (1997)
  • D. Begic et al.

    Aggressive behavior in combat veterans with post-traumatic stress disorder

    Military Medicine

    (2001)
  • D.M. Benedek et al.

    Post-deployment violence and antisocial behavior: The influence of pre-deployment factors, warzone experience, and posttraumatic stress disorder

    Primary Psychiatry

    (2006)
  • R. Borum

    Improving the clinical practice of violence risk assessment: Technology, guidelines, and training

    American Psychologist

    (1996)
  • R. Borum et al.

    Improving clinical judgement and decision making in forensic evaluation

    Journal of Psychiatry and Law

    (1993)
  • C. Bradley

    Veteran status and marital aggression: Does military service make a difference?

    Journal of Family Violence

    (2007)
  • C.A. Byrne et al.

    The cycle of trauma: Relationship aggression in male Vietnam veterans with symptoms of posttraumatic stress disorder

    Violence and Victims

    (1996)
  • P.S. Calhoun et al.

    Partners' ratings of combat veterans' anger

    Journal of Traumatic Stress

    (2002)
  • J.C. Campbell et al.

    Intimate partner violence and abuse among active duty military women

    Violence Against Women

    (2003)
  • E.B. Carlson et al.

    Posttraumatic stress and aggression among veterans in long-term care

    Journal of Geriatric Psychiatry and Neurology

    (2008)
  • E.M. Carroll et al.

    Vietnam combat veterans with posttraumatic stress disorder: Analysis of marital and cohabitating adjustment

    Journal of Abnormal Psychology

    (1985)
  • M.G. Chapin

    A comparison of violence exposure and perpetration in recruits and high school students

    Military Medicine

    (1999)
  • L.J. Chapman et al.

    Genesis of popular but erroneous psychodiagnostic observations

    Journal of Abnormal Psychology

    (1967)
  • J.A. Cigrang et al.

    Three American troops in Iraq: Evaluation of a brief exposure therapy treatment for the secondary prevention of combat-related PTSD

    Pragmatic Case Studies in Psychotherapy

    (2005)
  • R.M. Dawes et al.

    Clinical versus actuarial judgment

    Science

    (1989)
  • N.V. Dawson

    Physician judgements of uncertainty

  • J.F. Dileo et al.

    Olfactory identification dysfunction, aggression and impulsivity in war veterans with post-traumatic stress disorder

    Psychological Medicine

    (2008)
  • K.S. Douglas et al.

    Violence risk assessment: Science and practice

    Legal and Criminological Psychology

    (1999)
  • K.S. Douglas et al.

    Multiple facets of risk for violence: The impact of judgmental specificity on structured decisions about violence risk

    International Journal of Forensic Mental Health

    (2003)
  • K.S. Douglas et al.

    Assessing risk for violence among psychiatric patients: The HCR-20 violence risk assessment scheme and the psychopathy checklist: Screening version

    Journal of Consulting and Clinical Psychology

    (1999)
  • K.S. Douglas et al.

    Violence risk assessment: Getting specific about being dynamic

    Psychology, Public Policy, and Law

    (2005)
  • K.S. Douglas et al.

    The HCR-20 violence risk assessment scheme: Concurrent validity in a sample of incarcerated offenders

    Criminal Justice and Behavior

    (1999)
  • E.B. Elbogen et al.

    Assessing risk of violent behavior among veterans with severe mental illness

    Journal of Traumatic Stress

    (2008)
  • E.B. Elbogen et al.

    Clinical decision making about psychopathy and violence risk assessment in public sector mental health settings

    Psychological Services

    (2005)
  • E.B. Elbogen et al.

    The intricate link between violence and mental disorder: Results from the national epidemiologic survey on alcohol and related conditions

    Archives of General Psychiatry

    (2009)
  • E.B. Elbogen et al.

    Perceived relevance of factors for violence risk assessment: A survey of clinicians

    International Journal of Forensic Mental Health

    (2002)
  • S.E. Estroff et al.

    Risk considered: Targets of violence in the social networks of people with serious psychiatric disorders

    Social Psychiatry & Psychiatric Epidemiology

    (1998)
  • S.E. Estroff et al.

    Social networks, social support, and violence among persons with severe, persistent mental illness

  • D.A. Fiellin et al.

    Mental health after deployment to Iraq or Afghanistan: Commentary

    JAMA: Journal of the American Medical Association

    (2006)
  • C.A. Fonseca et al.

    Variables associated with intimate partner violence in a deploying military sample

    Military Medicine

    (2006)
  • A. Fontana et al.

    The role of war-zone trauma and PTSD in etiology of antisocial behavior

    Journal of Nervous & Mental Disease

    (2005)
  • M.A. Forgey et al.

    Patterns of intimate partner violence among married women in the military: Type, level, directionality, and consequences

    Journal of Family Violence

    (2006)
  • T.W. Freeman et al.

    Gun use, attitudes toward violence, and aggression among combat veterans with chronic posttraumatic stress disorder

    Journal of Nervous and Mental Disease

    (2001)
  • M.J. Friedman

    Posttraumatic stress disorder among military returnees from Afghanistan and Iraq

    American Journal of Psychiatry

    (2006)
  • L. Ganzini et al.

    Characteristics of violent elderly in the emergency department

    International Journal of Geriatric Psychiatry

    (1995)

    • Cited by (0)

    View full text
    Published by Elsevier Ltd.