UTILITY OF THE INITIAL THERAPEUTIC ALLIANCE IN EVALUATING PSYCHIATRIC-PATIENTS RISK OF VIOLENCE

Objective: Evaluation of patients' potential for violence is an import ant component of care in psychiatric emergency and inpatient settings. Although situational variables are widely acknowledged to influence t he risk of violence by psychiatric patients, most past research has be en limited to patient attributes and has neglected the interpersonal c ontext in which violence occurs. To the authors' knowledge, this is th e first study to assess a new type of situational risk factor, the qua lity of the initial therapeutic alliance between the therapist and pat ient, as a predictor of the risk of violent behavior during short-term hospitalization. Method: The admitting physician's written initial ev aluation of each of 328 patients hospitalized on a locked inpatient un it was reviewed by using a standardized alliance scale. The checklist measures the patient's level of active collaboration with the treatmen t process. Acute symptoms were rated at admission by physicians using the Brief Psychiatric Rating Scale. Nurses rated aggressive behavior i nt eh hospital with the Overt Aggression Scale. Results: Patients who had a poorer therapeutic alliance at the time of admission were signif icantly 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 correlated of violence were considered concurrently. Conclusions: The results suggest a new class of situati onal, interactional variables-reflected in the quality of the therapeu tic relationship-that may be useful in evaluating patients' potential for violence. Implications for risk management are discussed.