Risk Assessment

Authors: E J Blowers and RA Munton

This guidance will introduce concepts of risk, identify key themes in risk assessment, and propose ways in which CPNs may manage risk in clinical practice. CPNs will be managing risk as an everyday activity: this paper will be of assistance in relating theoretical concepts to practice. It will be necessary to return to the literature referred to in order to gain deeper understanding.

Definitions of Risk
There are several definitions of the term risk:
Adams (1995) defines risk as:

“the probability of an adverse future event multiplied by its magnitude” (p.69)

Risk by this definition involves two dimensions of assessment: probability, that is how likely the event is to occur, and magnitude, that is the significance of the event. In short, how likely is this event, and how bad will it be?
This raises the critical debate at the heart of risk assessment: prediction of violence as a form of risk is an inexact science (Allen 1997). This inexactitude may be a result of several factors:
A client may exhibit behaviour which presents a risk for the first time;
The CPN may not be party to all the information needed to make a thorough assessment;
There may be different perceptions about the significance of the potential event.

Mental Illness and Risk
In mental health nursing, the issues of suicide and violence to others are prominent risks. The incidence of these is very different: suicide is by far the more common. 1992, 5541 suicides and undetermined causes of death were recorded: Reed (1997) proposes that the vast majority of these people would have been mentally ill. By contrast, the number of homicides in any one year would not exceed 500-600 (Reed 1997). The Royal College of Psychiatrists (1996) Confidential Report found that 39 homicides in England were committed by clients in the 33 months period of the inquiry.
This emphasises the greater risk of suicide as opposed to violence, yet a major thrust of contemporary policy is in response to media representations and public fear of violent incidents, where the mentally ill are portrayed as axe wielding murders (Reed 1997, p.4).
Infact, when violence to others does occur, the victims of such violence are most likely to be known to the perpetrator, often being family members and children (Oates 1997).
Therefore it can be argued that public and government response to issues of risk may be misleading, as the great majority of those with mental illness present no increase of violence to others (Reed 1997).
Although the core concepts of risk assessment and practice may be equally applicable to both suicide and violence, indeed to any risk, the remainder of this paper will focus primarily on the risk of violence.

Assessment of Risk
In assessing risk, the literature is unequivocal: the best predictor of the future is the past:
“Nothing predicts behaviour like behaviour” (West Midlands Health Authority 1991; Gunn 1990). Research show’s that there are a number of factors which indicate a higher level of risk: these are the same for the general population and those with a diagnosis of mental illness. They are gender (male), younger are (i.e. teenage to twenties), lower social class, substance abuse and previous violence (Crighton 1995). These are described as “actuarial indicators”, that is those factors which indicate an increased likelihood of an event taking place. To use a car insurance analogy, a young man with a 3 litre sports car would be perceived as at a high risk of having an accident: his youth and type of vehicle being the actuarial indicators. Mental health risk assessment based solely on actuarial evidence is incomplete (Allen 1997). For example, a person with mental illness may find themselves denied their freedom as a result of risk assessment based purely on suck indicators, where a broader assessment would have indicated a less restrictive response.
Bacon (1997) argues that differences exist in the way in which a convicted criminal can be releases without follow up after a period of detention, whilst those with mental illness are obliged to have their future “risk assessed”. He suggests that there may be difficulties in a patient convincing professionals that they are no longer at risk.
This raises ethical dilemmas for the CPN in clinical practice. The CPN might consider whose risk is infact being assessed: their own risk of “getting into difficulty”, termed defensive practice by Harrison (1997), or actual risk to the client. The freedom and autonomy of clients and their rights may be compromised in the over zealous attempt to eliminate risk.

Key issues for the CPN
There is a contemporary imperative to be able to defend clinical decisions (Harrison 1997). The Care Programme Approach (1990), The Supervision Register (1994a) and Aftercare under supervision (Department of Health 1995) all provide frameworks within which CPNs can address risk. The Care Programme Approach (1990) stipulates that key workers fulfil an assessment of need including assessment of risk; agree a package of care; nominate a key worker and regularly review and monitor of the care plan.
Despite the controversy and complexity of risk, there are key elements which CPNs must incorporate into their practice, in line with the National Health Service Executive (1994).
? Consider actuarial indicators of risk for both suicide and violence. The practitioner has a responsibility to assess risk in the context of the research evidence about predictors
? Avoid minimization of previous episodes of violent behaviour. There is evidence from the inquiries into the cases of Christopher Clunis and Andrew Robinson which clearly demonstrate downgrading reports of previous violence (Richie 1994; Blom-Cooper, Hally & Murphy 1995)
? Pay particular attention to client’s self reports at interview, and note incongruencies between what is reported and what is observed, (National Health Service Executive 1994)
? Seek information about the client and his or her history from all sources: there is evidence from inquiries that this has not always happened (Royal College of Psychiatrists 1996)
? Ensure communication between team members and disciplines is thorough: rigorous follow up is a key issue

Conclusion
Risk assessment and management are complex, dynamic and culturally defined (Douglas 1992). They are core components of the CPN’s daily activity, and therefore merit considerable attention and debate. This handbook insert has introduced some of the key issues and made some recommendations for practice. Training, support and clinical supervision will be essential to effective risk management, and these may be scarce within current resource limitations.
Allen (1997) provides a succinct summary:
“Best practice is defined as a thorough assessment, utilising a theoretically based framework. Such frameworks need to include the consideration of demographics, psychiatric symptoms, personal proclivities and situational variants. There is also a strong argument for the identification of societal factors that may impinge upon the patient in the form of discrimination, stigma, isolation and poverty. The balanced use of all these indicators may limit over prediction and the damage this may do to the lives of service users and their families” (p8).

Bibliography

Adams J (1995) Risk University College Press

Allen J (1997) Assessing & Managing Risk of violence in the mentally disordered in Journal of Psychiatric and Mental Health Nursing 4, 000-000p1-9

Bacon P (1997) Assessing Risk: Are we being overcautious? In British Journal of Psychiatry 170 (suppl.32.) 30-31

Blom-Cooper L, Hally H & Murphy E (1995) Report of the committee of inquiry into the Events leading up to and surrounding the fatal incident at the Edith Morgan Centre Torbay in 1st September 1993 London Duckworth

Crighton J (1995) (Ed) Psychiatric patient violence, risk and repsonse London Duckworth

Department of Health (1990) The care programme approach for people with a mental illness referred to the specialist psychiatric services HC (90)23/LASSL(90)11, DH 1990 Department of Health (1995) Mental Health (Patients in the Community) Act: London HMSO

Douglas M (1992) Risk & Blame: Essays in Cultural Theory London Routledge

Gunn J (1990) Clinical approaches to the assessment of risk in Risk taking in mental disorder: analyses policies and practical strategies in Carson D Chichester SLE Publications

Harrison G (1997) Risk Assessment in Climate of litigation in British Journal of Psychiatry 170 (suppl.32.) p37-39

National Health service Management Executive (1994a) HSG (94)5 Introduction of Supervision Registers for Mentally Ill people from 1st April 1994 London DOH

National Health service Management Executive (1994b) HSG (94)27 Guidance on the discharge of mentally disordered people and their continuing care in the community London, DOH

Oates M (1997) Patients as parents: the risk to Children in British Journal of Psychiatry 170 (suppl.32.) 22-17

Richie J (1994) Report of the Inquiry into the care and treatment of Christopher Clunis London HMSO

Royal College of Psychiatrists (1996) Report of the Confidential inquiry into homicides and suicides by mentally ill people London RCP

Reed J (1997) Risk assessment and Clinical Management: the lessons from recent inquiries in British Journal of Psychiatry 170 (suppl.32.) 4-7

West Midlands Regional Health Authority (1991) Report of the Panel of Inquiry appointed to Investigate the case of Kim Kirkman Birmingham, West Midlands Regional Health Authority.