Challenging assumptions about risk factors and the role of screening for violence risk in the field of mental health

Research demonstrates that mental illness is not a major cause of violence yet assumptions about a link and concern about the risks posed by mentally disordered people has resulted in the predominance of a public safety role for mental health services (Munro and Rumgay 2000 Munro, E. and Rumgay, J. 2000. Role of risk assessment in reducing homicides by people with mental illness. British journal of psychiatry, 176: 116–120. Crossref, PubMed, Web of Science ® , Google Scholar). In consequence, screening, classifying and monitoring individuals considered to pose a potential risk to others due to their potential for violence has become a key responsibility. The purpose of healthcare screening is to identify a disease or condition, or its associated risk factors, to provide treatment or encourage preventative action on the part of ‘at risk’ individuals. Mental health screening differs since neither a disease entity nor a causal model to link mental disorder and violence exist (Leitner et al. 2006 Leitner, M. 2006. Systematic review of prevention and intervention strategies for populations at high risk of engaging in violent behaviour, London: Department of Health. Final project report to the NHS National Forensic Mental Health R&D Programme Google Scholar). Mental health service users are typically marginalised and screening may occur without their consent, knowledge or involvement. They may also disagree that they have the condition in question, i.e. a propensity to violence. The expectation upon professionals to promote service user involvement in care and treatment sits uneasily with these processes. This paper reviews the ongoing but unsuccessful efforts to develop effective screening for violence amongst people defined as mentally disordered and explores the implications for mental health services in the light of this evidence. It also considers the continuing lack of service user involvement in risk assessment. First however, the paper considers correlates for violence since screening depends for its efficacy upon risk factors thought to be positively associated with the condition of concern.