Chapter 18 Using standardised tools
Despite the current lack of a standardised rating scale that can be used on a regular basis by a general mental health clinician for a wide variety of presentations, it would be remiss not to recognise that the rating scales that are available are of immense use and importance in many areas of mental health work. Furthermore, as understanding of risk factors for specific risks has been increased and refined, the development of standardised rating scales has advanced. Within a forensic environment, standardised rating scales are used extensively.
Standardised rating scales were initially developed within forensic environments to provide a highly structured format to facilitate the assessment of violence. These scales raise an ‘index of suspicion’ of risk whilst clinical skills allow the context and other factors to be incorporated into a meaningful formulation. Standardised rating scales are the means for assessing which risk factors have relevance for particular risks and have applications in both research and everyday clinical life. ‘They enable the clear articulation of the basis for specific estimates of future risk and can clarify sources of disagreement where these occur.’1 These scales can form an important part of risk management processes when used in conjunction with clinical assessment, although there are disadvantages (as described on page 63). Standardised rating scales draw on research evidence of factors known to be associated with the identified risk. Note should be made once more of the limited usefulness in everyday clinical practice of standardised rating scales that do not include dynamic factors. Scales that limit themselves to static risk factors are of some use in prediction of risk at a population level but have limited place in care of individual patients.
For the general mental health clinician:
… the initial risk assessment exercise should consist of a structured process of more or less standard questions aimed at eliciting factors increasing the risk (and which will reflect the evidence base around the risk) and which assists clinical judgment. It could be called an aide-memoire or a framework. After the clinician addresses these standard questions, it will be possible to determine whether a more in-depth assessment is needed using existing, evidenced-based toolkits for the particular population.2
There is no one toolkit which fits all patients and covers all risks. A list of toolkits can be found in Appendix 1 of the UK Department of Health document entitled ‘Best Practice in Managing Risk’ (2007).3 New toolkits have been published, including the ‘Forensicare Risk Assessment and Management Exercise’ (FRAME),4 in an attempt to incorporate a standardised tool into case management and psychiatric treatment. As yet, for the risks of suicide and self-harm, there is no instrument with a sufficiently strong evidence base.5 However, Bouch and Marshall (2005) have suggested a useful tool which is worth considering.6 The most commonly used scale for the assessment of risk of violence on which several of the newer scales are based — the HCR-207 — was published in 1997 and has been widely used throughout Canada, America, Europe and Australasia. It is included here (Figure 18.1
