Heuristics

The process of decision-making using insights from the field of cognitive psychology has useful implications for risk assessment and management. Heuristics as a method of decision-making were introduced briefly in Chapter 2. Heuristics are ‘cognitive shortcuts that allow decisions to be reached in conditions of uncertainty’,² or ‘rules that guide cognitive processing to help make judgments’.³

These are all situations when decisions about risk management may be made. However, reliance on heuristics leads to cognitive bias and ‘severe and systematic errors’⁹ and these have now been termed ‘cognitive errors’¹⁰ or ‘heuristic biases’. The opposite process of using heuristics is one of rational-deductive decision-making in which all necessary evidence for and against any potential course of action is carefully examined and weighed. This assumes no bias on the part of the decision-maker and also assumes optimal time and resources.¹¹ Errors are more likely to be made using heuristics than when rational-deductive decision-making is used.

Heuristics can be seen as being closely allied to the concept of intuitive decision-making based on ‘what feels right’ or so-called ‘gut feelings’. The differences between intuition and reason in decision-making can be outlined as shown in Table 10.1.¹²

Table 10.1 Intuition and reason in decision-making

For many risk decisions made in everyday life, such as whether to cross the road or not, heuristics are used. We have neuropsychological systems responsible for such automatic choices,¹³ based on habits derived from practice or from cognitive associations that have been learned over time. As is readily apparent, the capacity to make choices quickly has substantial adaptive value, but if the situation has changed subtly or if there are variables that have not been factored in, heuristic biases may creep in. There is a need to check the cognitions that are used for heuristics on a regular basis otherwise errors will creep in because of personal bias. To complicate matters, the use of heuristics is characteristic of doctors with good clinical acumen¹⁴ so the best practice that is recommended is that, as far as possible, heuristics should be used consciously with an awareness of their pitfalls.¹⁵

The risk/benefit analysis (rational-deductive decision-making)

A lot of the time, clinicians use heuristics and weigh up whether the intervention is going to be administered at the right time, whether the patient is ready for the intervention, whether they can manage the insight gained.

For junior practitioners or when the possibility of heuristic bias is present, the slower process of rational decision-making can be a very useful option. In this method risks and benefits are carefully considered. The risk/benefit analysis is an iterative process about deciding which treatment option to take. It may occur during the assessment or during management and should be considered as a tool to be utilised whenever uncertainty exists. When the treatment option has been chosen and implemented, the outcome will be reviewed and further options considered in another risk/benefit analysis. This follows the thinking of Carson’s (1996) ‘Risk Path’ in which a series of small ‘steps’ are taken.²⁰ The evaluation should consider the benefits and the opportunities presented by the situation as well as the risk. There will be situations where there will be high risk but also potentially better outcomes. There will also be situations where the obligation to protect society from a potentially violent person is in conflict with the patient’s right to be treated in the least restrictive environment. These situations of cognitive dissonance need to be evaluated carefully.

There are several phrases that are commonly used to acknowledge that a risk has been considered.

These are all examples where a risk/benefit analysis has occurred.

It is not uncommon for an individual clinician or a team to become hamstrung in their treatment because the risk issues seem insurmountable or the risk issues seem to take precedence. The risk/benefit analysis focuses on the opportunities involved when choosing treatment directions whilst taking risk issues into account. It is a useful tool to use when the options are unclear or if there is disagreement within the clinical team. This can be either in the acute situation or in circumstances when time is not paramount.

Utilising a risk/benefit analysis is an effective, straightforward and easily documented way of evaluating the treatment options involved. It is especially useful when clinicians are anxious about the consequences of the risk; for example, if one staff member says, ‘we can’t do this, it’s too risky’. If a clinician on the team is risk-avoidant, using risk/benefit analyses as a team exercise can help immensely. It facilitates a more objective exploration of the situation.

In situations where there is risk or a certain amount of trial and error, or uncertainty, ‘thinking out loud for the record’²¹ can be useful. In the risk/benefit analysis the pros and cons, including known risks, advantages and disadvantages, are carefully documented. The reasons why a certain course of action is taken will then be clear. This will improve transparency should there be a poor outcome, as the decision-making process will have been clearly documented. If there is a claim for negligence in the future, having a documented risk/benefit analysis in the notes can be protective.

Whichever option is chosen, it will involve taking a risk of some kind. Once the treatment direction has been agreed, it is usual for some on-going risk still to be present. Clinicians, patients, families and managers need a process for living with this as nobody can live in a risk free environment. The risk/benefit analysis helps generate an awareness of the degree of on-going risk likely to be involved which can then be addressed in risk management. In some literature, this is referred to as risk mitigation; that is, mitigating the consequences of risk outcomes if they occur. For example, trying to reduce access to the means for committing suicide or reducing the frequency of drugs being dispensed are ways of mitigating risk.

Apart from the risk/benefit analysis being a step which facilitates risk management, it has several other useful spin-offs:

With reference to the last bullet point, in the majority of cases, clinical, ethical and legal concerns are aligned. However, the potential for a risk-management pitfall looms when different values in the same system of thought compete, such as when the obligation to protect society from an imminently violent mentally ill person competes with the right to treatment in the least restrictive setting.²²

The risk/benefit analysis is also a tool to help minimise the number of false-positives. False-positives are those situations where the risk behaviour is predicted to occur when in fact it does not. False-positives are tolerated in mental health services to protect life. It is important to try and minimise false-negatives (missing those who do go on to display the risk behaviour) by utilising good risk assessment. Risk events such as violence or suicide are rare events even in mental health settings. Predicting if and when they may happen is a difficult task. It is important to err on the side of caution but at the same time not be overcautious and end up denying patients their freedom.

Below is a case example with a model for documenting a risk/benefit analysis. As will be seen, it occurs after the assessment has been completed and knowledge of patterns and risk factors will be available.

The risk/benefit analysis process should help clinicians, the patient and their family decide how to proceed with care and treatment.

The decision taken may be one of higher risk but the potential for a better outcome is seen as important. Once the treatment option is chosen, it is important to remember that in many situations it does not need to be implemented straight away. There will often need to be some planning and preparation undertaken before the treatment gets under way.

Risk Management is not just about trying to reduce the level of risk; it also involves helping the patient get better. Clinicians will often mull over many of the following questions before adopting a treatment and risk management strategy. Many of these questions can be included in the discussion during the risk/benefit analysis.

When these questions arise in routine clinical practice, a risk/benefit analysis will often help clarify uncertainty.

Several exercises for risk/benefit analyses have been included below as it is an important tool, which is often under-utilised.

Exercise 1 — Colin (continued)

Refer to Chapter 9, exercise 3 (page 77) and exercise 6 (page 82) for Colin’s story thus far.

At the end of the interview, Colin has declined to take any medication and is making it clear to you that he does not need any further treatment and he can sort all his problems out on his own. You feel that you have developed a reasonably good rapport with him and he has said that he will come back to see you in a few weeks to let you know how he is going. On the other hand, you are concerned about the possibility of him acting on his delusional preoccupations and wonder if he needs to be brought into hospital for treatment involuntarily. He says that he can control his anger and will not be violent.

Complete a risk/benefit analysis for Colin (Table 10.3). The completed risk/benefit analysis chart appears in Appendix 3.

Table 10.3 Risk/benefit analysis for Colin

Exercise 2 — Fred

Fred is a 45-year-old man suffering from chronic schizophrenia. He has unremitting positive symptoms. You want to try a course of clozapine instead of the monthly injection of Haldol^TM. There are some worries about compliance.

Fill in the risk/benefit chart in Table 10.4. The completed chart appears in Appendix 3.

Table 10.4 Risk/benefit analysis for Fred

Exercise 3 — Jane

Jane is a 32-year-old married woman who is 12 weeks pregnant. This is her first pregnancy. She is currently in a medical ward where she was admitted over the weekend as she had concerns about her pregnancy. The doctors have asked you to assess her as they are concerned about her mental state. When you see her, she is in a single room and her husband and her parents are also present. She immediately tells you that there is nothing wrong with her and that she has never felt better. When you ask her the reason for this, she says that since the angels came to visit her, everything has been all right. She then expands on this and tells you that the room is so full of angels that she wonders how you have been able to get into the room. She then tells you that you are the best angel of them all as you have the biggest wings! Her husband tells you that she has been like this for 5 days but says that she has been slightly different for the last 2 weeks. Although there is no past history of anything like this, her mother tells you that Jane had a brief psychotic episode 8 years ago which did not require hospitalisation and settled within 2 weeks. None of the family nor Jane can remember if she needed medication on that occasion. On talking to her further, there are no other symptoms and signs of psychosis and she does not seem to be suffering from a mood disorder. She is slightly preoccupied with the various angels in the room but other than this, you can detect no other abnormalities on mental state examination. The medical staff have cleared her and say that she can be discharged from their ward.

Jane and her family are adamant that she is well enough to go home and Jane agrees to take medication if you feel that it is necessary although she also says that she would prefer not to take medication. As the interview progresses, you find yourself confused as to what the diagnosis may be and how best to manage this situation as you have not come across anything like this before.

Do a risk/benefit analysis for as many management and treatment options that you can think of. Use the same chart format as per Table 10.4. The completed chart appears in Appendix 3.

Exercise 4 — Roger

Roger is a 32-year-old architect who has worked extremely hard to obtain a senior position in a big firm in the city. He came from a well-to-do family but was sexually abused by an uncle for 2 years between the ages of 8–10. He had been in a stable relationship with his partner, Joanne, for 3 years but this broke down 9 months ago when she was unfaithful. Roger became depressed initially but this revealed underlying traits of borderline personality disorder (BPD). Roger has taken several major overdoses and has been admitted to hospital on each occasion. He is currently in the inpatient ward and has self-harmed on one occasion in the ward and taken one overdose whilst on day leave. Complete a risk/benefit analysis, considering whether Roger would be better off staying on the ward longer or if his treatment should continue in the community. Use the same chart format as per Table 10.4. His depression is currently well treated and in remission. The completed chart appears is in Appendix 3.

Exercise 5 — alcohol and drug example (Gillian)

Gillian is 28 years old and in a de facto relationship with Nathan. She is currently being treated with methadone substitution at a dose of 115 mg per day. She has 3 take-away doses per week. She has three children from previous relationships, all of whom are in care. It is likely that she suffers from BPD with several traits of antisocial personality disorder. This has never been confirmed as she refuses to attend for a psychiatric assessment.

Physically Gillian is well. She has previously been treated with methadone but on each occasion was involuntarily withdrawn from the program for diversion or use of illicit drugs. The decision to put her back on methadone again was not taken lightly but it was felt that, on balance, Gillian would be better off with it. Nathan has just been released from prison and within 2 months Gillian tells you that she is pregnant again. When she is 16 weeks pregnant, she diverts her methadone again and gives it to a friend who injects it. The friend dies from an overdose.

Complete a risk benefit analysis about whether to continue with methadone treatment. Use the same chart format used in the previous risk/benefit exercises. There are likely to be more than two treatment possibilities. The completed chart appears in Appendix 3.