Constant news headlines about violent crime have begun raising questions about the role of mental illness in violence, which remains a significant public health concern. It’s estimated that 12 million American adults are involved in intimate partner violence each year, and approximately 16,000 homicides occur annually. The United States is also home to the greatest number of public mass shootings in the world.¹ There were three documented mass shootings in 2000, but by 2020, that annual figure had increased to 40.⁵ According to the CDC, more Americans died of gun-related injuries in 2020 than in any other year on record, representing 14% increase over 2019 and a 43% increase since 2010. However, the vast majority of individuals who display 
mental illness symptoms don’t actually commit acts of violence. In reality, mental illness symptoms are only a potential contributing factor in a constellation of other factors, and mental illness shouldn’t be viewed as a causal explanation. Violence is a multi-faceted issue with no singular cause or solution. Even so, mental health treatment providers are more frequently being asked to assess whether an individual is safe to return to school or work settings to help mitigate violence risks.¹ 

MENTAL ILLNESS SYMPTOMS & RISK OF VIOLENCE

Although mental illness symptoms may play a role in conjunction with several other factors, some mental illnesses are more closely associated with an increased risk of violence, such as schizophrenia spectrum and psychotic disorders, some personality disorders, and paraphilic disorders.¹ Pertinent mental health symptoms include psychosis, especially when an individual believes they are being threatened or controlled by an external force. Paranoid individuals are also at an increased risk of harming someone they misperceive as an attacker. In addition, command hallucinations, primarily when associated with a delusion, expand the risk of violence. Individuals who lack insight into their mental illness are also more likely to be non-compliant with antipsychotic medication regimens and at a higher risk of violence.¹

Beyond mental illness symptoms, there are social risk factors that can increase the likelihood of perpetrating violence, including a lower educational level or socioeconomic status and unstable employment. Additional contextual factors for consideration in violence risk assessments include a lack of social support, current or new stressors, weapon availability, access to alcohol or drugs, and the presence of similar circumstances that may have led to any past violent behavior.¹ Two other foundational risk factors for violence include active psychiatric symptoms and substance use. In fact, the prevalence of violence is 16 times higher among individuals with other drug use disorders and 12 times greater for individuals with alcohol use disorder.

MENTAL HEALTHCARE PROVIDER LIABILITY

Behavioral health treatment providers can help mitigate the risk of violence against others by adequately assessing patients under their care. The right assessments can not only help protect people from harm, they can also help prevent professional liability claims and lawsuits. Claims involving patients who have seriously injured others are among the top five most frequent claims filed against behavioral healthcare providers. Such claims typically fall under professional liability policies for mental health care facilities and providers. These providers can be sued when the patient injures someone and the assessment and/or safety plan falls below the standard of care. If mental health clinicians fail to carry out their duty to warn or protect when a situation requires it, such as when there is an imminent threat of serious harm toward an identifiable victim, they are at significant risk of liability if the patient harms a third pary.¹

From a malpractice perspective, mental health clinicians aren’t required to predict who will commit violence, nor are they expected to prevent all acts of violence.¹ Generally, the standard of care requires that a “psychiatrist exercise the degree of skill, care, and diligence of an ordinary or reasonably prudent psychiatrist practicing in similar circumstances” once a treatment relationship has been established.¹ A reasonable level of care typically involves conducting an adequate violence risk assessment when indicated. For at least the last 25 years, specialists in their respective fields have been constructing evidence-based instruments to help guide behavioral healthcare professionals in decisions about patients at risk of violence/danger to others. These tools guide behavioral healthcare professionals in assessing the risk, creating a treatment plan, and how to keep both the patient and others safe. Unfortunately, behavioral healthcare professionals often inappropriately use a standard format for suicide risk safety planning to develop a safety plan for potentially violent patients. However, the two risks are very different, and the safety plan for suicide risk focuses solely on the patient when an adequate plan for third-party violence should address the patient and others.

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. A safety plan should also determine how and who will treat or address each relevant risk factor, how the patient will be monitored going forward, and how and who will address a potential victim’s needs. In reality, mental healthcare providers are less likely to be liable for a patient’s violent act if an appropriate violence risk assessment was conducted and interventions were offered to meet the perceived risk level. This is particularly critical if the patient threatens violence against another or displays clear evidence that she or he is at a higher risk for violence.¹

HOW AGENTS CAN HELP

One of the best ways to help behavioral healthcare clients mitigate violence risk is to stay aware of the leading loss drivers in this class of business. When assessing an insured’s need for professional liability insurance, agents can also ask important questions about the violence risk management tools clients use to ensure an appropriate standard of care is provided to patients. Outlining how providers create safety plans for patients who may be dangerous to others can help underwriters accurately evaluate an insured’s level of exposure and keep premium costs in line with the risk.

Agents can also serve clients’ best interests by ensuring they partner with risk management specialists attuned to emerging trends and issues in the field. In addition, it’s important to keep an eye out for subtle exclusions, notification requirements, or other issues that can ultimately make a client’s professional liability policy useless in a claim scenario. Agents can help clients avoid those coverage pitfalls by partnering with insurance providers that specialize in coverage for behavioral healthcare, addiction, and social service providers.

BOTTOM LINE

Behavioral healthcare providers can help mitigate growing violence rates by adequately assessing the risk of violence a patient presents toward others. The proper evidence-based assessments can save others from harm and help insurers feel more comfortable underwriting behavioral healthcare, addiction counseling/care, or social service providers. It may seem more cost-effective to obtain professional coverage with a carrier that doesn’t specialize in behavioral healthcare risks, but the final cost of premium savings can be high when it comes to coverage scope and quality. Contact your CRC Group Producer today to learn how we can help your insureds obtain the right coverage at the right price today. 

Contributor

• Susan Cohen holds a Master of Social Work and is the Executive Vice President of Negley Associates, a CRC Group Program. Sue and team are located in Parsippany, NJ where they specialize exclusively in the behavioral healthcare, addiction, and social services space.

About Negley Associates

Over the last 50 years, Negley Associates - a division of CRC Group - has built a solid reputation as a leading insurance provider for the behavioral healthcare, addiction, and social service industries. Negley strives to meet the unique needs of behavioral healthcare providers by bringing together world-class insurance experts to create a broad spectrum of customized insurance coverage options.

Combining deep industry knowledge, unmatched underwriting expertise, excellent claim services, and top-quality risk management programs ensures that each client benefits from the most comprehensive insurance programs available in today’s market. Negley also offers the industry’s first Individualized Risk Management Program (IRMP) at no additional cost to policyholders, expertly guiding insureds through an innovative risk reduction plan that empowers them to focus time and energy where it is needed most – delivering top-quality care to clients.

END NOTES

1. Malpractice Liability Due to Patient Violence, Focus, November 7, 2019. https://focus.psychiatryonline.org/doi/full/10.1176/appi.focus.20190022
2. What is Mental Health Malpractice, Rob Levine & Associates. https://www.roblevine.com/what-is-mental-health-malpractice/
3. Malpractice Law and Psychiatry: An Overview, Focus, November 7, 2019. https://focus.psychiatryonline.org/doi/full/10.1176/appi.focus.20190017
4. Understanding Workplace Violence Prevention and Response, SHRM. https://www.shrm.org/resourcesandtools/tools- and-samples/toolkits/pages/workplace-violence-prevention-and-response.aspx
5. What the Data Says About Gun Deaths in the U.S., Pew Research Center, February 3, 2022. https://www.pewresearch.org/fact-tank/2022/02/03/what-the-data-says-about-gun-deaths-in-the-u-s/