Consider an illustrative scenario: after intoxication has resolved, a person continues to express persecutory beliefs about neighbors. A bare “high risk” label can sound decisive while leaving the clinical reasoning hidden. The task is not to infer violence from psychosis. It is to describe a plausible pathway to harm, name what remains unknown, and connect that account to decisions about care and safety. That is the purpose of a violence risk formulation.
A formulation is a pathway, not a risk label
A risk formulation is a concise, individualized explanation of how a person’s history, current state, and circumstances may combine to make a particular harm more or less plausible within a stated time frame. It should guide prevention and reassessment. It is not a diagnosis, a checklist total, or a guarantee about what someone will do.
A useful formulation answers four linked questions: What harm? To whom? Through what pathway and in what setting? What might increase or reduce the likelihood? “Risk of violence” is too broad to guide action; “possible reactive assault on the neighbors during a confrontation at home in the next few days” is more clinically useful, if supported by the facts.
| Formulation question | What to establish in this case |
|---|---|
| What harm and when? | Specify the feared behavior and whether the concern is immediate, short-term, or longer-term. Avoid implying precision the evidence cannot support. |
| Who is the target? | The neighbors are named in the persecutory belief. Assess whether any other person has entered that belief system or become a target. |
| What is the plausible pathway? | Does the patient feel threatened, angry, or compelled to confront someone? Is there intent, preparation, access to a weapon, or a history of acting on similar beliefs? |
| Under what conditions could risk change? | Consider returning to a shared setting, contact with the neighbors, renewed substance use, escalation in symptoms, and the availability of support or treatment. |
Historical factors—especially prior violence or threats—help establish vulnerability and patterns. Current clinical and contextual factors help explain whether a particular scenario is more plausible now. They are not interchangeable: a past event may inform the formulation without proving that violence is imminent, while a new threat, preparation, or weapon access may change the near-term picture substantially.
Keep delusional content in proportion
A persecutory belief can matter because it identifies a possible target and a perceived reason for retaliation. But the presence of a delusion alone does not establish that violence will occur. Research findings are more nuanced than the shortcut “paranoia equals violence”; the clinical question is how the belief connects to affect, intent, behavior, and opportunity in this person.
Ask what the patient believes the neighbors are doing, how they feel about it, and what they think they need to do next. Clarify whether they have confronted, followed, threatened, or approached the neighbors; whether they have made preparations; and whether they can pause or accept distance from the perceived threat. A statement such as “they are watching me” is not equivalent to a plan to harm them.
If command hallucinations are part of the case, their presence alone does not establish compliance. Ask what the voice says, whether it directs harm, how powerful or authoritative the patient believes it to be, whether the patient has obeyed it before, and what helps them resist. Similarly, intoxication that has resolved is no longer an active state, but it does not erase persistent psychosis or answer whether substance use may recur.
The baseline history matters. Establish past aggression, prior threats, previous episodes of psychosis or intoxication, treatment response, substance-use pattern, and usual functioning. If these details are missing, state that uncertainty rather than filling the gaps with assumptions. Do not infer weapon access, medication nonadherence, a history of violence, or command hallucinations unless the interview or collateral actually establishes them.
Write a scenario, then make it conditional
A compact formulation can state the concern without pretending to predict an event:
One scenario to assess is a possible reactive assault on the neighbors in the immediate-to-short-term period if the patient returns to a setting where contact is likely while the persecutory beliefs remain active. The beliefs alone do not establish that the patient will act; assess whether they connect to anger, intent, behavior, and opportunity. Recent intoxication may have increased concern during the episode, but it has resolved. The level of concern depends on information still to be clarified, including prior violence, current intent or preparation, access to weapons, the patient’s response to any command voices, and available support. Risk to staff should be described only if assessment shows how staff could become involved in the same perceived threat or a confrontational interaction.
This paragraph is useful because it names a target, time frame, possible mechanism, setting, and important unknowns. If the full case establishes recent command voices, a weapon, a specific threat, or preparation, include those details and explain how they change the scenario. If it does not, do not add them to make the formulation sound stronger.
“High risk” may still be a reasonable summary in a particular setting, but it cannot substitute for the narrative. A categorical label does not show whether the concern is targeted or generalized, whether it depends on contact with a particular person, or which changes would alter the assessment. Keep estimates calibrated: a formulation organizes evidence to guide decisions; it does not predict an individual outcome with certainty.
Let the formulation shape reassessment
The next questions should test the proposed pathway. Interview the patient about intent, plans, preparations, access to weapons, recent confrontations, substance use, and what they would do if they encountered the neighbors. With appropriate permission and attention to confidentiality requirements, collateral from people who know the patient may clarify baseline functioning, recent behavior, access, and supports. Reassess as symptoms, intoxication status, access, or the care setting changes.
Risk management should address the scenario, not just the label. Depending on the assessment and local procedures, this may include preventing an immediate confrontation, addressing active psychosis and substance-related needs, agreeing on a practical plan for early warning signs and support, and arranging appropriate monitoring and follow-up. A formulation informs disposition; it does not by itself establish the legal criteria for detention. In inpatient settings, brief tools such as the Brøset Violence Checklist or DASA-IV can support short-term monitoring, but they do not replace a broader, target-specific formulation for decisions about contact with neighbors after discharge.
Practical takeaways
- Describe a plausible harm, target, time frame, and setting—not just a risk category.
- Link symptoms to a possible pathway through emotion, intent, behavior, and opportunity; do not treat diagnosis as a proxy for violence.
- Separate known facts from questions still needing assessment, including baseline history and weapon access.
- State what could increase or reduce concern and review the formulation when circumstances change.
- Use brief tools for the settings they were designed to support; do not let a score stand in for clinical reasoning.
