Clinical Risk Assessment

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Clinical Risk Assessment

• Wallace Brink
• StR Forensic Psychiatry
• Langdon Hospital

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• Student who
• killed mother
• and unborn
• twins sent to
• Rampton
• Saturday Telegraph
• May 6th 2006

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Definitions

• Risk the likelihood of an adverse event.
• Risk Factors features associated with increased
  risk.
• Risk Assessment an estimation of the likelihood
  of particular adverse events occurring under
  particular circumstances. Within a specified
  period of time.
• Risk Formulation organisation of the risk data
  to facilitate risk management.
• Risk Management organised attempts to minimise
  the likelihood of adverse events

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Risk

• Depends on the individual and the context
• Objective
• Dynamic
• Not equal to DANGEROUSNESS

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Not dangerous 1---5---10 Very dangerous
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Types of risk assessment

• Clinical assessment
• Unstructured or clinical
• Structured (e.g. HCR 20)
• Actuarial approach

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Clinical Risk Assessment

• Awareness that risk is dynamic
• Adopt a structured approach
• Explicit working
• Consider protective factors as well as risk
  factors

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Clinical Risk Assessment

• Gather necessary information
• Keep good records
• Communicate your assessment
• Base your interventions on the risk assessment

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Practical and Systematic

• Gather information from
• The individual being assessed
• Others who know them
• Records
• Take a full history

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Consider the risks involved

• Is there a risk of harm?
• What sort of harm?
• What degree?
• Who is at risk?
• How likely is it that harm will occur?
• What is its immediacy?
• How long will the risk last?
• What are the factors which contribute to the
  risk?
• How can the factors be modified or managed?

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What is the relationship between risks?

• Absconding
• Non compliance Substance use
• Mental state deterioration
• Physical assault

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McNeil et al 2003

• Clinical factors may be most relevant for the
  estimation of short term risk in acutely ill
  patients
• Historical factors may be most relevant for
  estimating the long-term risk in treated patients

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ECA Study Swanson 1990

• Major mental disorder 5 fold increase in
  violence compared to those without major mental
  disorder (10-13 verses 2)
• Substance misuse 10 fold increase in violence
  compared to non-drug users (19-35 verses 2)

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Birth Cohort Study Hodgins (1992)

• Odds Ratio of 4 for violence among men with major
  mental illness compared with controls
• Odds Ratio of 27 for violence among women with
  major mental illness compared with controls

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Other factors associated with violence

• Male gender, young age, low socio-economic status
• Swanson, 1990
• Male gender, young age, low educational level
• Link, 1992
• Discharge to poverty
• Silver et al 1999

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MacArthur Violence Risk Assessment Study
Steadman 1998

• Prospective 1 year follow up of 1000 discharged
  patients compared to community controls for
  levels of violence
• No association found between mental illness and
  violence
• May be indication of the success of risk
  management

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Summary of violence literature

• Substance misuse is a major risk factor with or
  without mental disorder
• Socio-demographic factors contribute
  significantly
• Contribution of mental illness is relatively small

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Accuracy of clinical assessment

• Link 1993 predictions in emergency room patients
  
• correct 1 in 2 attempts
• clinicians significantly underestimated risk in
  women
• if used just the historical data on the same
  patients the sensitivity increased at the expense
  of the specificity

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Mulvey and Lidz 1998

• Asked doctors to predict which of the patients
  assessed in the ER would be violent
• The clinicians did reasonably well in predicting
  place, target, severity of violence and
  involvement of alcohol in violence
• Clinicians overestimated the influence of
  non-compliance and drug misuse upon risk of
  violence

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• Violence is relatively rare and consequently
  accurate prediction is difficult

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Monahan grid

• Personal / dispositional (static)
• Historical (static)
• Contextual (dynamic)
• Clinical (dynamic)

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Personal / dispositional

• Demographic
• Personality
• Neuropsychological
• Physical

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Historical

• Family and personal history
• Work and education
• Psychosexual development
• PPH and PMH
• Previous offending and antisocial behaviour

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Contextual

• Level of support and supervision (actual and
  perceived)
• Availability of victim / weapons / substances
• Perceived stress
• Interests (sexual, violence, cruelty, racial)

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Clinical

• Delusions, hallucinations, passivity
• Depression, mania
• Anger/rage, impulse control
• Paranoid disposition, jealousy
• Fantasies
• Personality disorder
• Substance use

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Risk of violence to others victim

• Relationship to perpetrator
• Particular characteristics
• Vulnerability
• Availability

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Mullens approach

• Mullen P. Dangerousness, Risk and the Prediction
  of Probability. The New Oxford Textbook of
  Psychiatry. (Eds M.G. Gelder, J.J. Lopez-Ibor and
  N.C. Andreasen). Chapter 11.4.3. Oxford.

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Pre-existing vulnerabilities

• Increase
• Male
• Young
• Disrupted or abusive Childhood
• Antisocial
• Suspicious
• Impulsive
• Irritable

• Decrease
• Over 35 years of age
• Good pre-morbid personality
• Stable/nurturing childhood
• Sensible

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Social and Interpersonal factors

• Increase
• Poor social network
• Lack of education
• Lack of work skills
• Rootless
• Poverty
• Homelessness

• Decrease
• Good social network
• Stable accommodation
• Employment
• A confidante
• Supportive intimate relationship

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Mental Disorder

• Increase
• Active symptoms
• Poor compliance
• Poor engagement with services
• Treatment resistance
• Lack of insight

• Decrease
• Absence of active symptoms
• Good compliance
• Good engagement
• Good treatment response
• Good insight

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Substance Misuse

• Increase
• Present

• Decrease
• Absent

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State of Mind

• Increase
• Anger/fear
• Threats
• Delusions
• Evoking fear
• Provoking indignation
• Provoking jealousy
• Involving jealousy
• Involving injury/threat from close relative or
  companion
• Clouding consciousness and confusion
• Ideas of influence
• Command hallucinations

• Decrease
• Amotivational

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Situational Triggers

• Availability of weapons
• Loss
• Demands and expectations
• Confrontation
• Change
• Physical illness
• Other provocation

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Good risk assessment

• Reviewed on a regular basis
• Reviewed if there are new concerns
• Multi-disciplinary
• In collaboration with the patient and their carer
• Limitations of your assessment noted
• Includes factors which reduce risk of future
  violence
• Only useful if disseminated
• Informs the management plan

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Define the risk

• Severity best predicted by prior violence
• Imminence best predicted by
• pattern of violence
• statements,
• life circumstances.
• Likelihood best predicted by actuarial models
• Dvoskin and Heilbrun 2001

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Homicide Inquiries why do things go wrong

• Failure to lend sufficient weight to reports by
  carers and members of the public about disturbed
  behaviour
• An undue emphasis on the civil liberties of
  patients at the expense of increased risk of
  suicide or of violent behaviour
• A failure to properly implement the MHA
• A tendency to take cross-sectional rather than
  long-term view of the risk of suicide or violence
• A failure to share information in the best
  interests of the patient

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W v Egdell 1990

• Duty of confidence to the patient is not absolute
• Balance between the interest in confidentiality
  and in public safety

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Thoroughness

• Attention to detail
• Accurate and detailed record keeping
• Comprehensive history taking
• Avoid minimising incidents
• Linking incidents
• Asking the unaskable

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Multi Agency public protection arrangements MAPPA

• Offenders who pose a risk of serious harm to
  others
• Level 1 Caused serious harm previously,
  manageable by a single agency
• Level 2 Pose a serious risk to others but not an
  imminent risk
• Level 3 Pose and imminent and serious risk

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Interagency working

• Healthcare
• Social Services
• Housing departments
• Police
• Probation
• Day centres/hostels

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The defendable decision

• Take all reasonable steps
• Use reliable assessment methods
• Seek information you do not have
• Thoroughly evaluate all relevant information
• Stay within agency policies and procedures
• Record and account for decision making
• Communicate the plan to others involved

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Risk Management CPA

• Actions to minimise the hazards
• Actions to enhance protective factors
• Review date
• Contingency plan to include
• Arrangements for when the co-coordinator is
  unavailable
• Arrangements for when part of the care plan can
  not be provided
• Crisis plan to include
• Action to be taken if mental state is rapidly
  deteriorating

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Positive risk management involves

• Weighing up the potential benefits and harms
• Plans which support the positive potentials and
  minimise the risks
• An element of risk because the potential positive
  benefits outweigh the risks

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HCR-20ASSESSING RISK FOR VIOLENCEVERSION 2 -
1997

• Christopher D. Webster
• Kevin S. Douglas
• Derek Eaves
• Stephen D. Hart

Mental Health, Law, and Policy Institute Simon
Fraser University
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Scope Purpose

• The main aim was to produce a guide which would
  be rooted in scientific knowledge be defined
  precisely, and be designed for efficiency with
  time constraints in mind

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General Principles for Improving Prediction
Accuracy

• What exactly is the referral question?
• Opinions formed about risk under one set of
  circumstances (e.g., risk for violence in the
  community) may have limited pertinence to another
  set (e.g., violence while institutionalised).
• Clinicians who have been seeing patients for
  psychotherapy may wish to decline offering
  assessments of risk for such patients
• Very hurried or pressured assessment, or those
  based on partial information, invite inaccuracy
• The scientific knowledge from which the
  assessment is formulated should be current

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General Principles for Improving Prediction
Accuracy 2

• The particular scheme chosen should correspond
  as closely as possible to the type of population
  from which the assessee is drawn
• Whenever possible, the base-rate of violence in
  pertinent populations should be obtained or
  estimated. It is important that this base rate,
  which may be quite low in some populations, guide
  the eventual statement of risk
• Particular importance should be ascribed to
  historical considerations, which should anchor
  such modifications as might be suggested by
  analyses of clinical and situational factors
  Cross-checking of information is crucial at every
  step

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Organisation of the HCR-20

• An important aspect of the HCR-20 is that it
  includes variables which capture relevant past,
  present, and future considerations. Historical,
  or static factors are weighted as heavily as the
  combined present clinical and future risk
  management variables
• 20 item structure
• Historical 10 past history factors
• Clinical 5 present variables
• Risk Management 5 future issues

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Administration

• Current research is revealing the necessity of
  multiple sources of information in making risk
  assessments A thorough and thoughtful review of
  all available files must be completed
• Assessors ought to include in their reports all
  sources which they did consult, did not consult,
  or were unable to consult

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Defining Violence

• Violence is actual, attempted, or threatened
  harm to a person or persons Violence is
  behaviour which obviously is likely to cause harm
  to another person or persons In a general
  sense, then acts which are serious enough to
  result in criminal or civil sanctions, or for
  which the perpetrator could have been charged,
  should be considered violent, and those that are
  not as serious as this should not be considered
  violent All sexual assaults should be
  considered violent behaviour.

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Historical (Past) Clinical (Present) Risk Management (Future)
H1. Previous Violence H2. Young Age at First Violent Incident H3. Relationship Instability H4. Employment Problems H5. Substance Use Problems H6. Major Mental Illness H7. Psychopathy H8. Early Malajustment H9. Personality Disorder H10. Prior Supervision Failure C1. Lack of Insight C2. Negative Attitudes C3. Active Symptoms of Major Mental Illness C4. Impulsivity C5. Unresponsive to Treatment R1. Plans Lack Feasibility R2. Exposure to Destabilisers R3. Lack of Personal Support R4. Noncompliance with Remediation Attempts R5. Stress
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Coding Items
No The item definitely is absent or does not apply.
Maybe The item possibly is present, or is present only to a limited extent.
Yes The item definitely is present.
Omit Dont Know There is insufficient valid information to permit a decision concerning the presence of absence of the item.
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H1. Previous Violence
- No previous violence
/- Possible / less serious previous violence (one or two acts of moderately severe violence)
Definite / serious previous violence (three or more acts of violence, or any acts of severe violence)
The scoring scheme here is intended to capture
the density of previous violence. For this
reason the number of past violent acts is
combined with the severity of past violence to
determine the score All violence which occurs
up to and including the time of assault is
included as previous violence.
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H2. Young Age at First Violent Incident
- 40 years and older at first know violent act
/- Between 20 and 39 years at first know violent act
Under 20 years at first known violent act
We are aware that, in general, the younger a
person was at his or her first act of violence,
the greater is the probability of future
violence Age is established by considering the
date of the first known violent incident, and not
using the date of the index offence or assessment.
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H3. Relationship Instability
- Relatively stable and conflict-free relationship pattern
/- Possible / less serious unstable and / or conflictual relationship pattern
Definite / serious unstable and / or conflictual relationship pattern
This item applies only to romantic, intimate,
or non-platonic partnerships, and excludes
relationships with friends and family. The item
is geared toward whether an individual show
evidence of having the ability to form and
maintain stable long-term relationships, and
engages in these when given the opportunity.
Instability may show in several ways many
short-term relationships absence of any
relationships presence of conflict within
long-term relationships.
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H4. Employment Problems
- No employment problems
/- Possible / less serious employment problems
Definite / serious employment problems
Individuals who warrant a high score on this item
may refuse to seek legitimate employment, or have
a history of having many jobs within short-term
periods, or of frequently being fired or
quitting. The primary focus of this item is the
presence or absence of employment problems.
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H5. Substance Use Problems
- No substance use problems
/- Possible / less serious substance use problems
Definite / serious substance use problems
The assessor is interested in whether there
exists impairment of functioning in areas of
health, employment, recreation, and interpersonal
relationships which is attributable to substances.
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H6. Major Mental Illness
- No major mental illness
/- Possible / less serious major mental illness
Definite / serious major mental illness
A diagnosis of major mental illness should
conform to an official nosological system such as
the DSM-IV or ICD-10. This item is scored on the
basis of past history and is unaffected by
whether the disorder is currently active or in
remission. This item applies to illnesses
involving disturbances of thought and affect
(e.g., psychotic illnesses, manic mood illnesses,
organic illnesses, retardation, etc.).
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H7. Psychopathy
- Nonpsychopathic
/- Possible / less serious psychopathy
Definite / serious psychopathy
It must be stressed that this rating is to be
made on the basis of an informed and trained
psychopathy assessment using the PCL-R or
PCLSV. It may be appropriate to modify the
scoring ranges according to local (e.g. UK)
populations.
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H8. Early Maladjustment
- No maladjustment
/- Possible / less serious maladjustment
Definite / serious maladjustment
This item includes two very different ways in
which childhood maladjustment predicts later
violence. One way is through childhood
victimisation, the other through being a
childhood victimiser Although both factors
predict adult violence, they clearly have
different implications for intervention.
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H9. Personality Disorder
- No personality disorder
/- Possible / less serious personality disorder
Definite / serious personality disorder
A diagnosis of personality disorder should
conform to an official nosological system such as
the DSM-IV (APA, 1994), or the ICD-10 (WHO, 1992).
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H10. Prior Supervision Failure
- No supervision failure(s)
/- Possible / less serious supervision failure(s)
Definite / serious supervision failure(s)
Failures during any institutional or community
placement are relevant here. A supervision
failure is considered to be serious if it
resulted in the individual being (re-)apprehended
or (re-) institutionalised by a correctional or
mental health agency.
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Clinical Items

• Although historical items have the strongest
  support in terms of predictive acumen, there is
  no dearth of well-established clinical constructs
  that may be relevant to the assessment of risk.

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C1. Lack of Insight
- No lack of insight
/- Possible / less serious lack of insight
Definite / serious lack of insight
This item refers to the degree to which the
assess fails to acknowledge and comprehend his or
her mental disorder, and its effect on others.
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C2. Negative Attitudes
- No negative attitudes
/- Possible / less serious negative attitudes
Definite / serious negative attitudes
We here refer to the kind of pro-criminal and
antisocial attitudes that have some likelihood of
eventuating in violence.
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C3. Active Symptoms of Major Mental Illness
- No active symptoms of major mental illness
/- Possible / less serious active symptoms of major mental illness
Definite / serious active symptoms of major mental illness
Assessors should follow a classification system,
such as the DSM-IV (APA, 1994) or ICD-10 (WHO,
1992).
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C4. Impulsivity
- No impulsivity
/- Possible / less serious impulsivity
Definite / serious impulsivity
Impulsivity refers to dramatic hour-to-hour,
day-to-day, or week-to-week fluctuations in mood
or general demeanour Impulsive persons are
quick to (over-) react to real and imagined
slights, insults, and disappointments.
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C5. Unresponsive to Treatment
0 Responsive to treatment
1 Possible / less serious unresponsiveness to treatment
2 Definite / serious unresponsiveness to treatment
This item includes any treatment designed to
ameliorate criminal, psychiatric, psychological,
social, or vocational problems. It does not
refer to treatments which are largely irrelevant
to criminal or psychiatric tendencies.
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Risk Management Items

• This section centres on forecasting how
  individuals will adjust to future circumstances.
  Although admittedly speculative, the exercise
  serves to stimulate development of appropriate
  risk management plans.

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R1. Plans Lack Feasibility
- Low probability that plans will not work
/- Moderate probability that plans will not work
High probability that plans will not work
Lack of feasibility may be due to the fact that
community agencies are unwilling or unable to
provide assistance. Alternatively, the patient
may have played no role in making plans or be
uninvolved with peers or family.
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R2. Exposure to Destabilisers
- Low probability of exposure to destabilisers
/- Moderate probability of exposure to destabilisers
High probability of exposure to destabilisers
In large part, persons may be exposed to
destabilisers because of inadequate professional
supervision.
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R3. Lack of Personal Support
- Low probability of lack of personal support
/- Moderate probability of lack of personal support
High probability of lack of personal support
This item can be coded present if support
(emotional, financial, or physical) from friends
or family is unavailable, or if such support is
available but the individual is unwilling to
accept it.
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R4. Non-compliance with Remediation Attempts
- Low probability of non-compliance with remediation attempts
/- Moderate probability of non-compliance with remediation attempts
High probability of non-compliance with remediation attempts
Individuals who score high on this item may lack
motivation to succeed and willingness to comply
with medication and therapy, or refuse to follow
rules.
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R5. Stress
- Low probability of stress
/- Moderate probability of stress
High probability of stress
This item can be coded present if the individual
is likely to be exposed to serious stressors.
Alternatively, the anticipated stressors may be
less serious, but the assessor is concerned that
the individual will cope poorly with them.
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HCR 20 scenarios

• Nature
• Motivation
• Victims
• Severity
• Imminence
• Frequency
• Duration of risk
• Likelihood

• Risk-enhancing factors
• Risk-protective factors
• Monitoring
• Treatment
• Supervision
• Victim safety planning

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References

• Guideline for clinical risk assessment and
  management in mental health services. Ministry of
  Health (New Zealand) 1998
• Dangerousness, Risk and the Prediction of
  Probability. Mullen P. The New Oxford Textbook of
  Psychiatry. (Eds M.G. Gelder, J.J. Lopez-Ibor and
  N.C. Andreasen). Chapter 11.4.3. Oxford.
• The state of contemporary risk assessment
  research. Norko MA and Baranoski MV. Can J
  Psychiatry (50) 1, 18-26.
• Best Practice in Managing Risk. Department of
  Health June 2007
• Rethinking risk to others in mental health
  services. Final report of a scoping group. June
  2008. RCPsych.
• Giving up the Culture of BlameRisk assessment
  and risk management in psychiatric practice.
  February 2007. RCPsych
• Risk assessment. A word to the wise. Vinstock M.
  APT (1996) 2, 3-10
• Evaluating risks. Kapur N. APT (2000) 6, 399-406
• Assessing risk of interpersonal violence in the
  mentally ill. Mullen P. APT (1997) 3, 166-173.

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• Prediction is very difficult, especially about
  the future
• Niels Bohr (1885-1962)