Practical aspects of clinical risk assessment and management

Abstract

It is debatable whether the notion of dangerousness now has any utilitarian value for psychiatry. The presence or absence of dangerousness is very much in the eye of the beholder. It is an all or nothing term – you either have it or you do not! While there is usually little disagreement about the few very violent individuals “who, for 24 hours a day, and in any situation, are likely to cause harm to others” (Chiswick, 1995), most patients are not in this category and “little bit dangerous” is unlikely to be of much comfort to clinical staff. It is unhelpful to deny that dangerousness is any more than an adjective which has been elevated into a pseudoscientific construct whose definitions (Scott, 1977; Walker, 1978; Home Office & DHSS, 1975) amount to little more than “past harm predicts future behaviour”.

Assessing violence risk in general adult psychiatry

“…Proponents of risk assessment argue that it simply requires basic clinical skills (Snowden, 1997), that the process itself can be valuable (Holloway, 1998), and that it is inseparable from risk management (Kennedy, 2001). Research has identified relevant dispositional, historical and situational risk factors for violence (Monahan & Steadman, 1994), and it has been suggested that actuarial methods might enhance predictive accuracy (Dolan & Doyle, 2000).…”

Evaluating risks

“…, 1975;Hawton, 1986). Even for an individual, identified risks can increase or decrease over time, and the nature of the risks may change (Snowden, 1997). This has important implications for risk assessment, which may be no more than a 'snapshot' at one particular moment in time.…”

“…On an individual level this might include the risk of suicide, sideeffects from medication, offending behaviour or violence and aggression. Alternatively, we might wish to consider wider outcomes, such as the potential effects on the public or even the risks to the reputation of individual clinicians and the standing of the clinical service (Snowden, 1997).…”

“…It is a person-specific assessment, which takes into account past behaviour and the context in which it occurred (Vinestock, 1996). It refers to a "balanced summary of prediction derived from knowledge of (Snowden, 1997). Clinical approaches undoubtedly have drawbacks.…”

“…In psychiatry this might involve a clear record of the role and responsibilities of each professional involved with a patient, clinical audit of adverse incidents and predetermined plans of action when concerns arise (Snowden, 1997 …”