The vast majority of people living with mental health disorders never perpetrate an act of violence. But claims involving patients who have seriously injured others are always among the top most frequent claims brought against behavioral healthcare providers.

The most effective way for providers to reduce the risk of being sued is to provide evidence-based services consistent with the latest research. Unfortunately, while often up to date on the standard of care for addressing suicide risk many behavioral healthcare providers find it particularly challenging to provide evidence-based services informed by the latest research for patients who present a risk of violence/danger to others.

For at least the last 25 to 30 years, experts in their respective fields have been constructing evidence-based instruments to guide behavioral healthcare professionals in their decisions about patients at risk of violence/danger to others. The instruments provide guidance about assessing risk and then creating a treatment plan and a plan about how to keep both the patient and others safe.

However, only a minority of professionals routinely employ the available instruments to assess risk and create safety plans for patients who present a risk of violence/danger to others. In fact, quite often professionals inappropriately use a widely accepted standard format for safety planning for suicide risk (the Stanley & Brown format) to create a safety plan for potentially violent patients. But the two risks are very different. The safety plan for suicide risk is for only the patient while the safety plan for the risk of violence should address the patient and others.

At intake, healthcare professionals routinely attempt to assess the risks presented by a patient. Of course, the primary reason for the assessment is to create a treatment plan and a safety plan to reduce or manage an identified risk. Professionals can be sued when somebody is injured by the patient and the assessment and/or safety plan fall below the standard of care. Even worse than being sued, somebody, including the patient, could have been seriously injured when it might have been avoided.

The safety planning process for violence risk begins with identifying evidence-based risk factors relevant to the patient. The provider then creates a plan informed by the risk factors.

Among the possible risk factors is a diagnosis of some few disorders. The four disorders most strongly associated with violence risk are: (1) schizophrenia spectrum and psychotic disorders, (2) substance use disorders, (3) personality disorders, especially antisocial personality disorder and borderline personality disorder, and (4) paraphilic disorders.

Other evidence-based risk factors should be considered, such as the patient's history of possible problems with violent acts, relationships, employment, and traumatic experiences. Structured risk assessment instruments, such as the HCR-20, contain a checklist of evidence-based risk factors and should be consulted when doing a risk assessment.

A safety plan should identify how and who will treat or address each of the relevant risk factors and how the patient will be monitored.

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The Mental Health Risk Retention Group (MHRRG) specializes in providing liability insurance for the behavioral healthcare field. They are endorsed by the National Council for Mental Wellbeing and mhca, two associations representing community mental health centers nationally. The Mental Health Risk Retention Group, a liability insurance company owned by its policyholders, offers stabilized premiums, protection against arbitrary cancellation, quality coverage, and a loss prevention program. Available coverages include professional liability, general liability, directors and officers liability.

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