From risk assessment to risk management' Can it be done in practice A forensic mental health perspec

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From risk assessment to risk management. Can it
be done in practice?A forensic mental health
perspective
Dr Rajan Darjee Consultant Forensic Psychiatrist
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RISK ASSESSMENT
Tools
Audit quality assurance
RISK FORMULATION (SCENARIO PLANNING)
Information sharing
Systems processes
Legislation, policy guidance
Multi-agency working
Education training
Documents forms
Resources
Evidence based practice
RISK MANAGEMENT
INDIVIDUALISED, MEETING ASSESSED NEEDS,
OBJECTIVE, FLEXIBLE, DYNAMIC, DEFENSIBLE
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The origins of violence risk assessment

• Steadman, H. J. Cocozza, J. J. (1974) Careers
  of the criminally insane Excessive social
  control of deviance. Lexington Books,
  Massachusetts.

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• Treatment of mental disorder
• Risk related to mental disorder
• Least restrictive alternative
• Appeal against excessive level of security
• Risk criteria
• Civil compulsory orders
• Restriction order
• Serious harm test

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Mentally disordered offenders

• Care Programme Approach (CPA)
• Multi-Agency Public Protection Arrangements
  (MAPPA)
• Memorandum of Procedures (MOP)

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MAPPA
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Consistency across services
SCOTLAND
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MENTAL DISORDER
OFFENDING
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Bonta, J., Law, M. Hanson, K. (1998) The
Prediction of Criminal and Violent Recidivism
Among Mentally Disordered Offenders A
Meta-Analysis Psychological Bulletin 123 123-142

• POSITIVE RELATIONSHIP
• Objective risk assessment
• Adult criminal history
• Juvenile delinquency
• Antisocial personality
• Nonviolent criminality
• Institutional adjustment
• Hospital admissions
• Poor living arrangements
• Male gender
• Substance abuse
• Family problems
• Escape history
• Violent history
• Drug abuse
• Marital status
• Weapon

• MIXED RELATIONSHIP
• Days hospitalized
• Alcohol abuse
• Employment problems
• Clinical judgment
• Education
• Intelligence
• Socioeconomic status
• Race

• NEGATIVE RELATIONSHIP
• Mentally disordered offender
• Homicide index
• Age
• Violent index
• Sex offence
• NGRI
• Psychosis
• Mood disorder
• Treatment history
• Offence seriousness

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Complex relationship between mental illness sex
offending

• Smith, A. D. Taylor, P. J. (1999) Serious sex
  offending against women by men with
  schizophrenia. Relationship of illness and
  psychotic symptoms to offending. British Journal
  of Psychiatry174 233-237.
• Drake, C. R. Pathe, M. (2004) Understanding
  sexual offending in schizophrenia. Criminal
  Behaviour Mental Health14(2) 108-20.
• Alden, A., Brennan, P., Hodgins, S. Mednick, S.
  (2007) Psychotic disorders and sex offending in a
  Danish birth cohort. Archives of General
  Psychiatry 64(11) 1251-1258.

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Structured professional judgement tools

• Initially pseudo-actuarial
• Now more clinical
• SPJ process is not dependent on tool

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Structured professional judgement approach

• Gather case information
• Assess for presence and relevance of risk factors
• Develop case formulation
• Set out plausible risk scenarios
• Make appropriate risk management plan
• Determine case prioritisation with summary
  judgements on likelihood, imminence harm

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Resources to deliver appropriate interventions
RESOURCES
RISK
PATIENTS
HIGH SECURITY
MEDIUM SECURITY
LOW SECURITY
COMMUNITY
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FORMULATION
OFFENCE ANALYSIS
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MOTIVATION DISINHIBITORS DESTABILISERS
ANTECEDENTS BEHAVIOUR CONSEQUENCES
TYPOLOGIES
OFFENCE ANALYSIS
AETIOLOGICAL MODELS OF SEXUAL OFFENDING
PREDISPOSING PRECIPITATING PERPETUATING
CRIME SCENE ANALYSIS
VICTIM ACCESS VICTIM CONTROL ESCAPE
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PROTECTIVE FACTORS
FORMULATION
STRENGTHS
MAINTAINING FACTORS
OFFENCE ANALYSIS
VULNERABILITY FACTORS
WARNING SIGNS
DYNAMIC FACTORS
TRIGGERS PRECIPITANTS
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Risk Assessment
Static factors
Stable dynamic factors
Acute dynamic factors
Triggers
OFFENCE
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FORMULATION
OFFENCE ANALYSIS
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PSYCHOMETRIC ASSESSMENT
RISK ASSESSMENT TOOLS
CLINICAL ASSESSMENT

LITERATURE
EXPERIENCE
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SCENARIO 2 ESCALATION
SCENARIO 1 REPEAT
SCENARIO 3 WORST CASE

SCENARIO 4 TWIST
SCENARIO 5 BEST CASE
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SCENARIO 2 ESCALATION
SCENARIO 1 REPEAT
SCENARIO 3 WORST CASE

SCENARIO 5 BEST CASE
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SCENARIO 2 ESCALATION
SCENARIO 1 REPEAT

SCENARIO 5 BEST CASE
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SCENARIO 1 REPEAT

SCENARIO 5 BEST CASE
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SCENARIO 2 ESCALATION
SCENARIO 1 REPEAT
SCENARIO 5 BEST CASE

• RISK MANAGEMENT
• PLAN
• Monitoring
• Supervision
• Treatment
• Victim safety

• RISK MANAGEMENT
• PLAN
• Monitoring
• Supervision
• Treatment
• Victim safety

• RISK MANAGEMENT
• PLAN
• Monitoring
• Supervision
• Treatment
• Victim safety

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• RISK MANAGEMENT PLAN
• Monitoring
• Supervision
• Treatment
• Victim safety

• RISK MANAGEMENT
• PLAN
• Monitoring
• Supervision
• Treatment
• Victim safety

• RISK MANAGEMENT
• PLAN
• Monitoring
• Supervision
• Treatment
• Victim safety

• RISK MANAGEMENT
• PLAN
• Monitoring
• Supervision
• Treatment
• Victim safety

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Compare with the usual output of risk assessment

• Risk to children
• Likelihood - medium
• Frequency - medium
• Imminence - low
• Harm - high
• Overall risk level - medium

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Questions Ive addressed using risk formulation
scenario planning

• Should this man who committed an offence against
  a young teenager be allowed to visit his niece?
• Should we be concerned that this man who raped a
  female stranger is hearing voices again?
• Should we be concerned that this man who raped
  and killed a prostitute has just threatened a
  man?
• Has group treatment addressed this mans needs so
  he can move to a less secure hospital?
• Does this man who has committed two rapes pose
  such a risk that he will need a high level of
  supervision for an indefinite period?
• Could this child sex offender benefit from
  anti-libidinal medication?
• Should this man who has committed incest offences
  against young girls be prevented from going to
  playgrounds?
• What should the police be looking out for when
  using surveillance on a man who has committed a
  series of sadistic sexual offences?
• Would it be safe for this man who raped a female
  stranger to work in a shop alongside female staff
  and serving female customers?

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Using risk formulation scenario planning

• You dont need to be a psychologist or
  psychiatrist
• You dont need to use specific tools (e.g.
  HCR-20, RSVP)
• Provides a broad flexible framework
• Allows a shared understanding of risk
• Leads to tailored risk management plans

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A clinical role in criminal justice system cases
RISK ASSESSMENT
Structured Professional Judgement
Multi-agency
Integrated
Complex unusual cases
RMA Guidance
Clinical understanding essential
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Tiered approach to risk assessment and management
Specialist assessment and risk management
Assessment supervision of stable dynamic
risk
Risk screening monitoring
Needs assessment
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RISK FORMULATION (SCENARIO PLANNING)
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• Dr Rajan Darjee Consultant Forensic Psychiatrist
• The Orchard Clinic
• Royal Edinburgh Hospital
• Morningside Terrace
• Edinburgh EH10 5HF
• 0131 537 5866
• rajan.darjee_at_nhs.net