Approaches to risk assessment 1

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Chapter 8 Approaches to risk assessment 1

Risk assessment is not a new technique, although the emphasis is different. It requires no more and no less than a full clinical history and examination.1

As can be seen from the quotation, risk assessment is nothing new. It starts from the first contact that a clinician has with the patient and continues every time the patient is seen until discharge. Risk assessment allows clinicians to paint a picture of where the risk for the patient lies within the context of their illness and their environment. It helps in planning management of both the illness and risk behaviours.

In the general clinical setting, screening, assessment and management of risk will all be occurring simultaneously. Often, the assessment process will be therapeutic in its own right and becomes management. Often, after talking about their suicidal preoccupation, patients say, ‘I’m feeling better now that I’ve told you that. I was scared to let anybody know how I really felt.’

The chapters on clinical skills are written in such a way that an assumption may be made that each skill can be separated out in the clinical situation and applied incrementally. The presentation of risk assessment and management as separate clinical skills is artificial and not intended to reflect clinical practice. The skills and exercises in successive chapters build on those practised in the previous chapters.

The process of risk assessment also allows for the development of rapport with the patient and should always be seen as a component of treatment, not just an exercise undertaken to fulfil bureaucratic requirements. As is increasingly the case with all clinical work, there should be an expectation that documentation will be shared with the patient. Every time the patient is seen, there should be an assessment for the imminence and previously identified patterns of risk. On an inpatient ward, this may happen every few minutes, whilst in an outpatient setting, it may only occur every 3–6 months when a stable patient is reviewed.

It is a process of combining the ‘here and now’ assessment with the knowledge of the patient’s past to try and predict the future. The ‘here and now’ assessment will include the patient’s mental state, the patient’s current circumstances, systemic issues including resources available, geographical factors and consideration of the clinician’s own response to the situation.

The stages of risk assessment/management do not change and are fairly straightforward: screen for whether the risk exists or not, assess the seriousness and imminence, assess the risk factors and address them. Risk assessment is an evolutionary process, not an outcome. It allows a group of clinicians to defend the defensible by documenting the systematic assessment of an individual. As clinicians become more knowledgeable about a patient, they can add more information about the risk factors and the function of the risk. As some risk is inherent for all patients in one form or another, clinicians should constantly be thinking about possible risks. If the full clinical assessment has been done adequately, the risk assessment should develop more easily.

A full clinical history depends on other sources of information as well as the history from the patient. Risk assessment is no different. This includes accounts from relatives and other informants. In practice, the general mental health worker will often have concerns raised by family and friends and these concerns will be used in conjunction with the clinical assessment. Family or friends who live with a patient are often the first to notice problems.

The other vital component of risk assessment is knowledge of risk factors known to increase the likelihood of the risk behaviour. Access to standardised lists of risk factors is a requirement for good risk assessment. See pages 80–81 and 84–85 for examples.

Risk assessment does have a predictive quality to it but primarily because of the dynamic factors, it can never be 100% accurate. Risk prediction tends to be more accurate in the short-term. As with routine clinical practice, when there is uncertainty, taking advice from colleagues or asking for second opinions or discussing it in the MDT meeting is good practice.

The process of risk assessment can be very quick and easy with some patients where the risk is felt to be minimal, whereas for other patients risk assessment and management turns into a very detailed undertaking making use of specialised assessment tools and may occur over a protracted period of time. This tiered approach2 of basic assessment at one end of a continuum to extremely detailed assessment at the other end will be well known to most clinicians and has been advocated as best practice in the UK. Depending on the level of detail required, the documentation will be quite varied.

This book does not cover clinical skills about how to ask specific questions relating to the risk of suicide or violence. These skills are covered in detail in some guidelines for suicide and violence and in books on clinical skills, and should be taught to all clinicians during their training.

Types of risk assessment

There are four major approaches to risk assessment but there is overlap within each.

1. unaided clinical judgment

2. using actuarial tools

3. using a psychodynamic contribution

4. structured clinical judgment.

Unaided clinical judgment

Unaided clinical judgment is exactly what it says. A history is taken, personality functioning is described, the mental state examined and demographic factors considered. Although unaided clinical judgment has importance, it has low inter-rater reliability and relatively low predictive value. A further problem with unaided clinical judgment is that it is also quite vulnerable to heuristic biases. Unaided clinical judgment is not recommended currently. For risk assessment of severe violence, a government committee in Scotland has stated that unaided clinical judgment cannot continue to be supported.3

Actuarial tools

Actuarial tools were primarily developed for research purposes rather than for clinical practice and so they do not always meet the needs of everyday situations. Actuarial risk assessment tools have also been criticised as being less sensitive than clinical risk assessment to individual differences since actuarial tools on specific risks are developed from data on large populations and are therefore not specific to the individual person.

Actuarial risk tools do not inform clinicians about the circumstances, severity or imminence of the act in question. Another, more crucial problem is the inability of this approach to take into account fluctuations in the level of risk as circumstances change.4

However, an actuarial statistical approach to risk assessment can enhance the predictions based on clinical assessments and can communicate the degree of risk in qualitative terms. Actuarial tools do have their place in that factors known to be of relevance for the risk being assessed — for example, criminal history, substance abuse, impulsivity and marital status — can be rated for their presence or not. Actuarial scales tend to focus on static risk factors, less on the dynamic ones. It is the dynamic factors which make the job of risk prediction so difficult for mental health professionals compared to other branches of medicine where there are often fewer changing variables. Actuarial data and standardised assessment tools should inform the risk assessment, not substitute for it. In recent years, standardised scales have increasingly included items for dynamic factors and treatment issues. With this shift, the use of standardised scales which focused only on static factors is lessening.

Standardised scales are discussed further in Chapter 18.

Psychodynamic contribution

A psychodynamic contribution can add important information. The understanding of the risk behaviour for a patient can be enhanced using psychodynamic principles. For example, a violent patient may only attack other men of a certain age because they remind the patient of his father, or a patient with PTSD may only become suicidal on the anniversary of a violent assault. Further useful information may be elicited from feelings that the patient has towards different clinicians and the responses of clinicians towards the patient. Psychodynamic principles used in risk assessment are discussed further in Chapter 16.

Structured clinical judgment (SCJ)

The unaided clinical versus actuarial debate has led to the development of risk prediction instruments which adopt a combined approach and recognise the importance of both static (and dynamic) actuarial variables and the clinical/risk management items that clinicians normally take into account in risk assessments of individuals. The combined approach is called structured clinical judgment (SCJ) and represents a composite of empirical knowledge and clinical/professional expertise. Structured risk assessments act as aides-memoire and make sure that all relevant information is collected.5

Structured clinical judgment is a process which blends structured assessment of risk factors with clinical judgment, including the identification of the patterns of risk behaviours. On top of the usual history and mental state examination, the static and dynamic factors known to be of empirical relevance

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