Clinical Risk Clinical Risk AssessmentAssessment

Wallace BrinkWallace BrinkStR Forensic PsychiatryStR Forensic Psychiatry

Langdon HospitalLangdon Hospital

Student who Student who killed motherkilled motherand unborn and unborn twins sent to twins sent to RamptonRamptonSaturday Telegraph Saturday Telegraph May 6May 6thth 2006 2006

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

Risk

Depends on the individual and the Depends on the individual and the contextcontext

ObjectiveObjective DynamicDynamic Not equal to DANGEROUSNESSNot equal to DANGEROUSNESS

Not dangerous 1---5---10 Very Not dangerous 1---5---10 Very dangerousdangerous

Types of risk assessmentClinical assessment

Unstructured or clinicalStructured (e.g. HCR 20)

Actuarial approach

Clinical Risk AssessmentClinical Risk Assessment Awareness that risk is dynamicAwareness that risk is dynamic Adopt a structured approachAdopt a structured approach Explicit workingExplicit working Consider protective factors as Consider protective factors as

well as risk factorswell as risk factors

Clinical Risk AssessmentClinical Risk Assessment Gather necessary informationGather necessary information Keep good recordsKeep good records Communicate your assessmentCommunicate your assessment Base your interventions on the Base your interventions on the

risk assessmentrisk assessment

Practical and SystematicPractical and Systematic Gather information from:Gather information from:

The individual being assessedThe individual being assessed Others who know themOthers who know them RecordsRecords Take a full history Take a full history

Consider the risks Consider the risks involvedinvolved

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?

What is the relationship What is the relationship between risks?between risks?

AbscondingAbsconding

Non complianceNon compliance Substance useSubstance use

Mental state deteriorationMental state deterioration

Physical assaultPhysical assault

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

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%)

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

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

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

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

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

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

Violence is relatively rare and consequently accurate prediction is difficult

Monahan grid Personal / dispositional (static) Historical (static) Contextual (dynamic) Clinical (dynamic)

Personal / dispositional Demographic Personality Neuropsychological Physical

Historical Family and personal history Work and education Psychosexual development PPH and PMH Previous offending and

antisocial behaviour

Contextual Level of support and supervision

(actual and perceived) Availability of victim / weapons /

substances Perceived stress Interests (sexual, violence,

cruelty, racial)

Clinical Delusions, hallucinations,

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

Risk of violence to others: victim

Relationship to perpetrator Particular characteristics Vulnerability Availability

Mullen’s 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.

Pre-existing vulnerabilities

Increase Male Young Disrupted or

abusive Childhood Antisocial Suspicious ImpulsiveIrritable

Decrease Over 35 years of

age Good pre-morbid

personality Stable/nurturing

childhood Sensible

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

Mental DisorderIncrease 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

Substance MisuseIncrease Present

Decrease Absent

State of MindIncrease 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

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

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

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

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

W v Egdell [1990] Duty of confidence to the patient is

not absolute

Balance between the interest in confidentiality and in public safety

Thoroughness Attention to detail Accurate and detailed record

keeping Comprehensive history taking Avoid minimising incidents Linking incidents “Asking the unaskable”

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

Interagency working Healthcare Social Services Housing departments Police Probation Day centres/hostels

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

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

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

HCR-20HCR-20ASSESSING RISK ASSESSING RISK FORFOR VIOLENCE VIOLENCEVERSION 2 - 1997VERSION 2 - 1997Christopher D. WebsterChristopher D. WebsterKevin S. DouglasKevin S. DouglasDerek EavesDerek EavesStephen D. HartStephen D. Hart

Mental Health, Law, and Policy InstituteSimon Fraser University

Scope & PurposeScope & Purpose

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

General Principles for Improving General Principles for Improving Prediction AccuracyPrediction Accuracy ““What exactly is the referral question?”What exactly is the referral question?” ““Opinions formed about risk under one set of circumstances Opinions formed about risk under one set of circumstances

(e.g., risk for violence in the community) may have limited (e.g., risk for violence in the community) may have limited pertinence to another set (e.g., violence while institutionalised).”pertinence to another set (e.g., violence while institutionalised).”

““Clinicians who have been seeing patients for psychotherapy Clinicians who have been seeing patients for psychotherapy may wish to decline offering assessments of risk for such may wish to decline offering assessments of risk for such patients”patients”

““Very hurried or pressured assessment, or those based on partial Very hurried or pressured assessment, or those based on partial information, invite inaccuracy”information, invite inaccuracy”

““The scientific knowledge from which the assessment is The scientific knowledge from which the assessment is formulated should be current”formulated should be current”

General Principles for Improving General Principles for Improving Prediction Accuracy 2Prediction Accuracy 2 ““The particular scheme chosen should correspond as closely as The particular scheme chosen should correspond as closely as

possible to the type of population from which the assessee is possible to the type of population from which the assessee is drawn”drawn”

““Whenever possible, the base-rate of violence in pertinent Whenever possible, the base-rate of violence in pertinent populations should be obtained or estimated. It is important that populations should be obtained or estimated. It is important that this base rate, which may be quite low in some populations, this base rate, which may be quite low in some populations, guide the eventual statement of risk”guide the eventual statement of risk”

““Particular importance should be ascribed to historical Particular importance should be ascribed to historical considerations, which should anchor such modifications as considerations, which should anchor such modifications as might be suggested by analyses of clinical and situational might be suggested by analyses of clinical and situational factors… Cross-checking of information is crucial at every factors… Cross-checking of information is crucial at every step”step”

Organisation of the HCR-20Organisation of the HCR-20

““An important aspect of the HCR-20 is that it includes An important aspect of the HCR-20 is that it includes variables which capture relevant past, present, and future variables which capture relevant past, present, and future considerations. Historical, or static factors are weighted as considerations. Historical, or static factors are weighted as heavily as the combined present clinical and future risk heavily as the combined present clinical and future risk management variables”management variables”

20 item structure:20 item structure: Historical – 10 past history factorsHistorical – 10 past history factors Clinical – 5 present variablesClinical – 5 present variables Risk Management – 5 future issuesRisk Management – 5 future issues

AdministrationAdministration

““Current research is revealing the necessity of multiple Current research is revealing the necessity of multiple sources of information in making risk assessments… A sources of information in making risk assessments… A thorough and thoughtful review of all available files must be thorough and thoughtful review of all available files must be completed”completed”

““Assessors ought to include in their reports all sources which Assessors ought to include in their reports all sources which they did consult, they did consult, did not consult, or were unable to consultdid not consult, or were unable to consult””

Defining ViolenceDefining Violence

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

Historical(Past)

Clinical(Present)

Risk Management

(Future)H1. Previous ViolenceH2. Young Age at First Violent IncidentH3. Relationship InstabilityH4. Employment ProblemsH5. Substance Use ProblemsH6. Major Mental IllnessH7. PsychopathyH8. Early MalajustmentH9. Personality DisorderH10. Prior Supervision Failure

C1. Lack of InsightC2. Negative AttitudesC3. Active Symptoms of Major Mental IllnessC4. ImpulsivityC5. Unresponsive to Treatment

R1. Plans Lack FeasibilityR2. Exposure to DestabilisersR3. Lack of Personal SupportR4. Noncompliance with Remediation AttemptsR5. Stress

Coding ItemsCoding 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 Don’t Know – There is insufficient valid information to permit a decision concerning the presence of absence of the item.

H1. Previous ViolenceH1. 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”.

H2. Young Age at First Violent IncidentH2. 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.

H3. Relationship InstabilityH3. 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.

H4. Employment ProblemsH4. 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.

H5. Substance Use ProblemsH5. 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.

H6. Major Mental IllnessH6. 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.).

H7. PsychopathyH7. 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 PCL:SV.

It may be appropriate to modify the scoring ranges according to local (e.g. UK) populations.

H8. Early MaladjustmentH8. 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.

H9. Personality DisorderH9. 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).

H10. Prior Supervision FailureH10. 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.

Clinical ItemsClinical Items

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

C1. Lack of InsightC1. 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.

C2. Negative AttitudesC2. 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.

C3. Active Symptoms of Major C3. Active Symptoms of Major Mental IllnessMental 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).

C4. ImpulsivityC4. 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.

C5. Unresponsive to TreatmentC5. Unresponsive to Treatment0 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.

Risk Management ItemsRisk Management Items

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

R1. Plans Lack FeasibilityR1. 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.

R2. Exposure to DestabilisersR2. 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.

R3. Lack of Personal SupportR3. 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.

R4. Non-compliance with R4. Non-compliance with Remediation AttemptsRemediation 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.

R5. StressR5. 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.

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

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 Blame’Risk 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.

“Prediction is very difficult, especially about the future”

Niels Bohr (1885-1962)