From risk management to social dangerousness: the professional responsibility of mental health practitioners and the actual powers of the care setting

Abstract

The closure of forensic psychiatric hospitals and the transfer of security measures to community Mental Health Departments have shifted onto healthcare staff a function of controlling violent behaviour formerly entrusted to the penal system. This clinical-criminological and medico-legal contribution follows the continuum from the acute psychiatric ward to community services to argue a single thesis: the professional responsibility of practitioners must be commensurate with the powers actually available in a given setting at a given time, not with powers assumed in hindsight once the outcome is known. The paper reviews the epidemiology of violence in psychiatric settings; its dual nature and the primacy of risk dimensions over categorical diagnosis; the potential and the limits of assessment instruments (structured professional judgement, actuarial tools, machine learning), with attention to low positive predictive values and algorithmic fairness; the conceptual distinction between clinical risk and legal dangerousness; the evolution of the guarantor position under Italian criminal law; and the systemic nature of safety. The conclusions identify four systemic criticalities (the transfer of clinical risk into legal dangerousness, the assignment of custodial functions to services lacking corresponding powers, the gap between legal status and clinical need, and the absence of setting-specific guidelines) and draw three methodological implications for fair liability assessment: ex ante reconstruction of the decision, duties commensurate with actual powers, and judgement of the documented decision-making process rather than of the outcome, which by its nature cannot be guaranteed