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In a recent paper published in this journal, Douglas and Ogloff assert that the predictive accuracies of risk assessments depend critically on the kinds of archival data available to researchers (2). Generally, the more sources that are obtainable, the stronger is the relation between forecasts and actual outcome. They conclude (reasonably) that “It is important in practical and research terms for studies of psychiatric patient violence to use multiple sources of outcome data” (2, p 734). We agree. Indeed, we wish to amplify their point here by drawing attention to the frequent practical clinical issues raised when, despite all efforts, it is virtually impossible to obtain any archival data for the purpose of conducting a violence risk assessment. The substantive information we have developed over the past 25 years or more on the link between possible predictors of violence and actual outcome derives mainly from large-scale research studies (3–5). Such studies are extremely expensive to conduct and require almost heroic expenditures of effort to assemble both background and outcome data. Even when unimpeded by legal and ethical constraints or by other administrative difficulties in the conduct of necessarily intersystem research, the task of collecting appreciable amounts of accurate, to-the-point data still remains arduous. Nevertheless, it is generally agreed that unnecessary prediction errors will occur unless correct, detailed information is available. This is the point made by Douglas and Ogloff. Blumenthal and Lavender (6), relying in part on an earlier appeal by Gunn (7), figure that step 1 in conducting a risk assessment entails making “a detailed history from birth using every available informant and agency for validation” (6, p 122). In step 4, these authors call for “a detailed account of any criminal and/or antisocial behaviour,” reminding readers that “police records should be sought wherever possible, remembering that an uncorroborated account from the patient is insufficient” (6, p 123). Snowden makes the same point: “There is no substitute for obtaining information on the patient from all available sources. A proper assessment cannot be made without members of the care team setting aside time to collect and record information about the patient’s background, present and past mental state characteristics, social functioning, and past behaviour” (8, p 33). Snowden discusses the necessity of contacting general practitioners, people who have provided care, relatives, social workers, friends, neighbours, housing authorities, police departments, probation services, and the like. “Data-lack” errors can also have serious consequences at the practical day-to-day case level for individual patients, prisoners, parolees, and potentially, society at large. Practising clinicians are placed in an awkward position when they are expected, sometimes in the absence of complete files, to give an accurate and complete scientific opinion to courts, review boards, and other such bodies. There is no solution to the problem of how best to fill information gaps. However, it does seem worthwhile to document a half-dozen major difficulties that crop up routinely for Canadian mental health professionals. Difficulty 1: Absence of Fundamental InformationIt is not unusual for forensic patients to be remanded for psychiatric assessment when there is virtually no background information and the individuals are entirely without social connections and support. Indeed, they are often sent precisely because the courts themselves are at a loss for information. An example would be a homeless person with serious mental illness who is remanded for a fitness examination following assault charges. Even with the benefit of a 30-day inpatient stay, it can be virtually impossible to take a history that will establish country of origin, date of birth, marital status, and perhaps even correct name. A search of RCMP identification services (that is, the Canadian Police Information Centre) might reveal a single charge of assault a dozen or more years previously and an indication that sentence on the charge was suspended. The person’s current mental condition, one unlikely to resolve quickly, may conspire against obtaining any kind of definitive history. In such a case, the only piece of pertinent information would likely be the prior assault charge. Even so, the record would likely show no detail of what actually transpired during the incident leading to arrest. The possibility also exists that, because of its salience, this single piece of “captured” information might receive undue emphasis. Difficulty 2: Destruction and Extreme Purging of RecordsMany organizations are not legally required to maintain their records indefinitely. The school system is one example. Educational records are important in risk assessment because they reflect academic accomplishments and also note possible conduct problems. However, they may no longer exist, having possibly been destroyed as a matter of routine policy or in accordance with legal requirements. Even when files still exist, it is common practice for school administrators forwarding reports to eliminate critically important information about suspensions and expulsions. As well, information about presumed or known abuse to a child is rarely included. Recently, hospitals have resorted to purging records to cope with the increasing cost of storage. There is little recognition that psychiatric records are valuable in that even old ones often contain essential information that may bear on current problems. Also, where hospitals do preserve records of psychiatric hospitalizations, the consultative notes to other services may be lost. Difficulty 3: Between-System ImpenetrabilityAssessors working within a particular system, such as Correctional Service Canada, have a solid advantage over colleagues who must themselves gather information from multiple agencies (9). To a large extent, the work of assembling a file has already been accomplished by the time the evaluations are started. Indeed, the challenge is often to decide what information is pertinent and what is not. Dickey notes, “It helps to have had years of practice in reading institutional files, and it requires some discernment to decide which previous reports deserve particular attention and which do not” (9, p 168). In contrast, most psychiatrists and their mental health colleagues working in hospitals or community programs have to grope for information from police, prosecutors, correctional services, parole boards, probation officers, managers of halfway houses, and the like. These organizations do not necessarily refuse to provide the information requested (given the consents where required), but their best efforts are usually directed inward. As they respond to external requests for information, they tend to restrict what they supply to edited summaries. Only in the occasional big case or decision is it relatively easy to get enough timely information to assemble the basis for a comprehensive risk assessment. This is a pity because those who make records in detention facilities, jails, and penitentiaries are usually scrupulous in documenting violent incidents. In the absence of access to these records, the responsible psychiatrist often has to settle for a few informal remarks about recent or current conduct made by a compliant colleague in the right place inside the criminal justice or correctional system. Obtaining substantial historical information about violence over a protracted period is very hard. Records from federal police sources, though undoubtedly accurate, contain information that is so cryptic that its pertinence to the issue at hand is often questionable. Even these kinds of records are not necessarily easy to obtain without considerable administrative legwork. They can also arrive after crucial reports have been submitted. Difficulty 4: Glacial Bureaucratic Response Time and Record SanitizingEven when the necessary information has been saved and agencies are willing to respond to legitimate requests for information, mechanical difficulties can sharply reduce the chance that the information will become available in a sufficiently timely fashion. Frequently, key records are in storage, quite possibly on microfiche. In the latter case, it often turns out that reproductions of handwritten notes are essentially indecipherable. Most institutional records departments are understaffed and have neither the personnel nor the time to search out the precise information that would interest forensic or general psychiatric clinicians. Although comprehensive documents that would help mental health workers may exist, they tend not to get forwarded. All that might arrive is the discharge summary. Social work notes and psychological reports may not be included, and psychologists’ raw data, not being part of the chart, will never be sent. These data are the personal possession of the psychologist and may therefore be unavailable if he or she moves or retires. In this way, much information crucial to violence risk analysis is lost or essentially irretrievable. An additional difficulty is that, when cooperating institutions do send information, if only in synoptic form, they are normally careful not to include records from other organizations. Forensic or other mental health clinicians tend to face the task of assembling material sequentially. Not knowing what will result from a particular request, they may be tempted to wait and see what arrives before undertaking the time-consuming process of making multiple simultaneous bids for previous reports, which can further delay the building of the file. In addition, any reports received may be of recent origin only. By the time historical information is requested and received, the assessment period may be over. Difficulty 5: Institutional Reorganization, Mergers, and DivestmentsOrganizations constantly change their structure and functions, and the number of mergers has accelerated in recent years. Whole levels of management have disappeared, and sometimes strange-seeming amalgamations have occurred. This can mean that an organization such as a forensic service no longer “owns” the records it has created over the years. Although these records continue to exist, they may have been combined with other types of files and perhaps even been moved to a new location. Thus organizational change can have unanticipated consequences for information retrieval. In Ontario and elsewhere, some provincially run hospitals have been “divested,” that is, turned into stand-alone facilities (even though they are largely provincially funded). This changeover has resulted in many years of records, viewed as government property, being moved into storage facilities remote from the hospital. Access to these past records requires a lengthy bureaucratic procedure. This can be an especially irksome problem inasmuch as many forensic units have recently become part of such divested entities. Difficulty 6: Formal Expungings and Legal ImpedimentsCanadian law has moved over recent decades to protect the rights of individuals: We now have the Canadian Charter of Rights and Freedoms. As well, there are federal and provincial laws concerning access to information and protection of privacy. These rights protect persons from being permanently entrapped by their past acts, which seems particularly essential in the case of children or adolescents who commit acts of violence. Since children aged under 12 years cannot be prosecuted, there is no possibility of a criminal justice paper trail. The new federal Youth Criminal Justice Act is quite explicit about the fact that information about offences is not to be released to all and sundry. Adults declared to be not criminally responsible by reason of mental disorder do not, of course, receive a criminal record for the index offence. Further, it is possible for convicted persons to apply for and receive pardons. Although some persons clearly commit crimes, and even admit to them, they are able to arrange to have the charges stayed. These and other such legally backed stratagems have become available to individuals for good and understandable reasons. Nevertheless, none of these aid in the preparation of comprehensive, defensible assessments of current and possible future violence risks. ConclusionOur intention is not to criticize the fact that the information most needed by clinical assessors is often not available or, if procurable, not within a useful time frame. There are doubtless many sound reasons for protecting the privacy of individuals from undue incursions by the mental health and criminal justice systems, but there is not much point in insisting that prediction accuracy and comprehensive risk assessments absolutely require dependable, accurate, historical information (10, p 59) when there are substantial impediments to obtaining it. Courts, review boards, and parole boards should perhaps take these actualities into account as they weigh the evidence put before them by mental health professionals. It is important that these professionals not be seen as contributing substantive information where none exists. As Monahan pointed out years ago, unless mental health workers are careful, they can too easily find themselves “laundering” for the courts, boards, and tribunals information that would come nowhere close to meeting basic legal evidentiary standards (11). Clinicians should exercise care in protecting themselves and their reputations by disclosing fully both the sources of information that were available to them in the conduct of an individual assessment and what reports or other information could not be procured. Funding and SupportNo funding or support was received for this paper. References1. Tyler A. Searching for Caleb. Toronto: Random House; 1975. p 38. 2. Douglas KS, Ogloff JRP. Violence by psychiatric patients: the impact of archival measurement source on violence base rates and risk assessment accuracy. Can J Psychiatry 2003;48:734–40. 3. Menzies RJ, Webster CD, Sepejak D. The dimensions of dangerousness: evaluating the accuracy of psychometric predictions of violence among forensic patients. Law Hum Behav 1985;9:49–70. 4. Harris GT, Rice ME, Quinsey VL. Violent recidivism of mentally disordered offenders: the development of a statistical prediction instrument. Crim Justice Behav 1993;20:315–35. 5. Monahan J, Steadman HJ, Silver E, Appelbaum PS, Robbins PC, Mulvey EP, and others. Rethinking risk assessment: the MacArthur study of mental disorder and violence. New York (NY): Oxford University Press; 2001. 6. Blumenthal S, Lavender T. Violence and mental disorder: a critical aid to the assessment and management of risk. London (UK): Jessica Kingsley; 2001. 7. Gunn J. Dangerousness. In: Gunn J, Taylor PG, editors. Forensic psychiatry: clinical, legal and ethical issues. Oxford (UK): Butterworth-Heinemann; 1993. p 624–45. 8. Snowden P. Practical aspects of clinical risk assessment and management. Br J Psychiatry 1997;170(Suppl 32):32–4. 9. Dickey R. Assessing inmates for risk of future violence. CPA Bulletin 2000;32:168–70. 10. Webster CD, Harris GT, Rice ME, Cormier C, Quinsey VL. The violence prediction scheme: assessing dangerousness in high risk men. Toronto (ON): Centre of Criminology, University of Toronto; 1994. 11. Monaghan J. Predicting violent behaviour: an assessment of clinical techniques. Beverley Hills (CA): Sage; 1981. AuthorsManuscript received June 2004, revised, and accepted July 2004. 1. Staff Psychiatrist, Forensic Service, St Joseph’s Healthcare Hamilton, Centre for Mountain Health Services; Assistant Clinical Professor, Department of Psychiatry and Behavioural Neurosciences, Faculty of Health Sciences, McMaster University, Hamilton, Ontario. 2. Senior Research Consultant, Forensic Service, St Joseph’s Healthcare Hamilton, Centre for Mountain Health Services; Professor, Department of Psychiatry and Behavioural Neurosciences, Faculty of Health Sciences, McMaster University, Hamilton, Ontario. 3. Clinical Legal Coordinator, St Joseph’s Healthcare Hamilton, Centre for Mountain Health Services; Assistant Professor (part-time), Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario. Address for correspondence: Dr CD Webster, St Joseph’s Healthcare Hamilton, Centre for Mountain Health Services, 100 West 5th Street, PO Box 585, Hamilton ON L8N 3K7 e-mail: christopherwebster@sympatico.ca
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