Psychiatric Bulletin (2005) 29: 394. doi: 10.1192/pb.29.10.394
© 2005 The Royal College of Psychiatrists
Psychiatric Bulletin (2005) 29: 394
© 2005 The Royal College of Psychiatrists
Violence risk assessment
Dan Beales, Specialist Registrar in Forensic Psychotherapy
The Red House, Bolton, Salford and Trafford Mental Health NHS Trust, 78
Swinton Road, Salford M27 8GB, e-mail:
Daniel.Beales{at}edenfield.bstmht.nhs.uk
Dr Maden’s editorial (Psychiatric Bulletin, April 2005,
29, 121-122) in response to the article by Higgins et al
(Psychiatric Bulletin, April 2005, 29, 131-133) neglects a
fundamental aspect of risk assessment and his recommendations therefore need
to be treated with caution. Higgins et al refer to the different
contexts in which risk assessment forms were being used, but Dr Maden does not
appear to have taken this fully into account in advocating the routine use of
the Historical/Clinical Risk-20 (HCR-20) in adult general psychiatry.
There is no doubt that the HCR-20 is a useful tool in forensic settings,
where it is already widely used. However, there would be significant time and
cost implications to introducing it routinely into general adult settings, and
it could be argued that this would not be sensible or cost-effective. Although
Dr Maden starts by advocating ‘a more systemic approach in marginal
cases’ which it is hard to disagree with, his advocacy of the routine
use of the ‘ideal’ HCR-20 does not appear to address whether this
is a feasible option with non-marginal cases. The HCR-20 can be very effective
in supporting teams in assessing and reviewing ongoing risks, but it is not
clear that it is a practical solution to supporting, for example, the risk
assessment and management decisions of a junior psychiatrist doing an
assessment of a new patient in an accident and emergency department in the
middle of the night.
Dr Maden notes that Higgins et al reported that many consultants
did not attend the (presumably free) half-day training on violence risk
assessment already on offer within their services. To suggest 3-day external
fee-based training specifically for violence risk assessment seems a
disproportionate response when other priorities in mental health (for example
assessing the risk of self-harm) are not identified as requiring such
expensive formalised training.
It is a pity that neither Higgins et al nor Dr Maden were able to
expand on the possible utility of the CARDS project
(Watts et al, 2004) that the study of Higgins et al was part of. This appears to be a
worthwhile collaborative attempt at developing a more standardised approach to
risk assessment in general adult psychiatry. It is also free and potentially
more easily integrated into routine clinical practice than the wholesale use
of the HCR-20.
References
WATTS, D., BINDMAN, J., SLADE, M., et al
(2004) Clinical assessment of risk decision support (CARDS): The
development and evaluation of a feasible violence risk assessment for routine
psychiatric practice. Journal of Mental Health,
13, 569
-581.[CrossRef]
