Textbook of Violence Assessment and Management

I know a fair amount about violence. Having done research on substance abuse and violence and youth violence, I was somewhat skeptical about having much to learn from this textbook. Furthermore, it is rare for me to approach a textbook with bated breath. Much to my surprise, the chapters gripped me. The authors’ and editors’ seriousness of purpose made me read closely, but I was also rewarded for paying attention. Each chapter highlighted important ideas in tables, as well as in a list of key points at the end. These well-written lists helped me to focus on what I had just read, reinforcing the complex ideas. OK, so it was a good read—but what did I get from this book?

First, I learned what to do about the uncertainty that is always present in managing violence. The authors take that uncertainty seriously. Even the best structured interviewing techniques fall short in the prediction of violence. The management of complex disorders—and especially comorbidities—is imperfect and the systems within which we work are fallible. Yet we can make the most of structure, communication, and respect, those basic actions and values that are instilled in every young psychiatrist and that must be used to their maximum effectiveness in the presence of the violent patient.

This message is threaded through the chapters. Lim and Bell, in their chapter on cultural competence in the assessment of risk for violence, stress ways in which to communicate respect. “It is important,” they assert, “not to micro-insult or micro-aggress against the patient in the process of the evaluation” (p. 46). They give an excellent list of examples, ranging from the disrespect implied in a young white doctor calling an older black person by his first name to that contained in denying the existence of racism and its effects. Lim and Bell provide a strong rationale for the ways in which the communication of respect creates the appropriate basis for a trusting conversation. It is in that context that the sensitive and essential information will be exchanged.

Second, I was given much food for thought in the crisply written case vignettes that enliven every chapter. The complexities and limitations are thus given living, breathing form in the lives of people. I appreciated this. Much of the management of violence lies outside the limits of our effectiveness. I appreciated the clinician-authors sharing stories of life at the edge of practice.

Lindemayer and Khan, in their chapter on emergency services, walk the reader through common situations in the assessment and management of the violent patient presenting to an emergency service. They offer a detailed explanation of the organization of clinical services they utilize. In their case vignettes, they use four subsections: initial symptoms, past history, initial examination, and treatment and course of illness. This window into their practice allows us to see their decision making when time is of the essence, and the patient is at risk for being violent at the moment the assessment is being made. Like Lim and Bell, they argue for and demonstrate how respect and communication are fundamental to good practice.

Third, I got an excellent picture of what needs to be done to move the field forward, both in clinical and research domains. The authors are sharp in their critique of existing knowledge; they are in accord that more research must be done if we are to improve the effectiveness of clinical practice. As a researcher, these are not simply good marching orders: the collective assessment is motivational. In order to expand the knowledge base, we will need to convince the larger mental health collective that this is needed, and this book does a wonderful job of presenting the case.

Violence is a serious problem, and our methods of prediction and treatment are imperfect. One problem that is highlighted in the volume is the problem of adoption of new practices. Monahan’s chapter on structured risk assessment demonstrates that this method is better than unstructured clinical interviews, which lack sensitivity and specificity. Yet few clinicians have changed their mode of practice. This is a troublesome problem and one that people doing intervention research encounter over and over. The gap between “best practices” and “usual practices” is uncomfortably large. This volume helps us to see a clear and urgent agenda for new knowledge as well as better ideas for transferring knowledge from researchers to clinicians.

I think this is one of the best textbooks I have read. It should be required reading in every residency program. I urge every practicing psychiatrist to spend some time with this book: think of it as a Red Cross lifesaving program. The textbook will also be useful to people who study substance abuse, aging, school safety, and many other problems that intersect with violence.