Am J Psychiatry 1997; 154:1272-1276
Copyright © 1997 by American Psychiatric Association
Utility of the initial therapeutic alliance in evaluating psychiatric patients' risk of violence
JE Beauford, DE McNiel and RL Binder
Department of Psychiatry, University of California, San Francisco, USA.
OBJECTIVE: Evaluation of patients' potential for violence is an important
component of care in psychiatric emergency and inpatient settings. Although
situational variables are widely acknowledged to influence the risk of
violence by psychiatric patients, most past research has been limited to
patient attributes and has neglected the interpersonal context in which
violence occurs. To the authors' knowledge, this is the first study to
assess a new type of situational risk factor, the quality of the initial
therapeutic alliance between the therapist and patient, as a predictor of
the risk of violent behavior during short-term hospitalization. METHOD: The
admitting physician's written initial evaluation for each of 328 patients
hospitalized on a locked inpatient unit was reviewed by using a
standardized alliance scale. The checklist measures the patient's level of
active collaboration with the treatment process. Acute symptoms were rated
at admission by physicians using the Brief Psychiatric Rating Scale. Nurses
rated aggressive behavior in the hospital with the Overt Aggression Scale.
RESULTS: Patients who had a poorer therapeutic alliance at the time of
admission were significantly more likely to display violent behavior during
hospitalization. Logistic regression analysis showed that the quality of
the initial therapeutic alliance remained a strong predictor of violence
even when other clinical and demographic correlates of violence were
considered concurrently. CONCLUSIONS: The results suggest a new class of
situational, interactional variable--reflected in the quality of the
therapeutic relationship--that may be useful in evaluating patients'
potential for violence. Implications for risk management are discussed.
