Assessing violence risk in general adult psychiatry

AIMS AND METHOD

We aimed to establish current practice in the risk assessmentof harm to others within general adult psychiatry and reviewrisk assessment documentation in use. Consultants working across66 randomly selected trusts across England were surveyed. Aqualitative analysis of risk assessment documentation was carriedout.

RESULTS

Data were obtained from 45 trusts (68%). Consultants reportedthat 30 (67%) of the trusts had standardised forms for riskassessment. Forty-one forms were subjected to content analysis.Wide variation was found in the methods used to identify riskfactors and in approaches to quantifying risk.

CLINICAL IMPLICATIONS

Current risk assessment practice is highly variable, indicatinga lack of consensus about suitable methods.

Introduction

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Introduction

Government policy stipulates that service users’ riskof harm to others should be routinely assessed by specialistmental health services (Department of Health, 2000). Responsibilityfor this assessment and its documentation now affects the practiceof all mental health professionals (Duggan, 1997). This increasing emphasis on risk has not been universally welcomed. It hasbeen argued that it compounds the public perception of peoplewith mental illness as dangerous (Petch, 2001), and consumes resources without a sound evidence base for doing so (Bindman et al, 2000).An analysis of inquiries into homicides by peoplewith mental illness found the role of risk assessment to belimited and concluded that the most effective preventativestrategy would be improving treatment for all patients, regardlessof perceived risk (Munro & Rumgay, 2000).

Proponents of risk assessment argue that it simply requiresbasic clinical skills (Snowden, 1997), that the process itselfcan be valuable (Holloway, 1998), and that it is inseparablefrom risk management (Kennedy, 2001). Research has identifiedrelevant dispositional, historical and situational risk factorsfor violence (Monahan & Steadman, 1994), and it has beensuggested that actuarial methods might enhance predictive accuracy(Dolan & Doyle, 2000). Actuarial methods are, however,unlikely to be of use in populations with low base rates ofviolence, in which large numbers of false positives would begenerated (Szmukler, 2001). This presents a difficulty forgeneralists who are required to assess violence risk routinely(Holloway, 1997), but without clear methods for doing so.

A previous study of the Supervision Register policy, which alsorequired risk assessments within general psychiatric services,showed widespread variations between trusts in the criteriafor identifying high-risk patients and suggested that severaldifferent methods were used (Bindman et al, 2000). We surveyeda representative sample of mental health trusts and aimed tofirst establish current violence risk assessment practice andsecond, describe and evaluate documentation produced at a locallevel with the intention of supporting violence risk assessment.This survey was a component of a wider project (the ClinicalAssessment of Risk Decision Support, or ‘CARDS’study) to develop an evidence-based procedure for assessingviolence risk in patients using adult mental health services (Watts et al, 2004).

Method

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Method

We designed a brief semi-structured questionnaire about theuse of risk assessment documentation, training and guidelinesin trusts (available from the authors). From a database ofall mental health trusts in England developed for a previousstudy (Bindman et al, 1999), 66 were randomly selected. Theywere contacted and the names obtained of two general adultconsultants for each trust. The consultants were sent the questionnaireby post and asked to send copies of their trust’s riskassessment forms and guidelines for their use where these wereavailable. A second questionnaire was sent to non-respondentsafter 6 weeks, followed by a telephone reminder. A contentanalysis of the risk assessment forms was then carried out.Principal themes and the different components used in assessmentswere identified independently by two of the authors (N.H. &J.B.), and a consensus reached.

Results

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Results

Survey response
At least one consultant responded from 45 of the 66 trusts (68%trust response rate). Of these 45 trusts, 30 (67%) were reportedby the consultants to have standardised written forms for assessingthe risk of violence and a further 2 (4%) were in the processof developing forms. Twenty-one trusts (47%) provided trainingfor their use, mostly in the form of half-day multidisciplinarysessions incorporating wider risk issues. It was of note thatwhere training was in place, many respondents commented thatthey had not attended it. Fifteen trusts (33%) provided writtenguidelines. A risk assessment form was usually completed atthe time of referral in 20 trusts (44%); at hospital admissionin 26 trusts (58%); before discharge in 25 trusts (56%); afterexpression of concern about safety to others in 20 trusts (44%); after a violent incident in 22 trusts (49%); or most oftenat the CPA review in 29 trusts (64%). Thirteen (29%) of theforms used included a proposed review date.

Structure and content of risk assessment forms
Forty-one forms were returned for analysis; several trusts hadmore than one form in use, depending on the hospital or communitycontext. All violence risk assessments were subsumed withinor appended to general risk assessment forms that includedself-harm. In broad terms, three objectives from the forms emerged:

identification of specific risk factors
appraisal of overallrisk
risk management planning.

Risk factors were identified by tick box screens, narrativesections or by using a combination of both. Different componentsused with these approaches are shown in Box 1. Risk was summatedin one of four ways, as shown in Box 2.

An example of a structured narrative approach is shown in Box3. This contrasts markedly with forms using tick boxes alone,which recorded answers to questions such as ‘Does theclient have a history of violence?’ as simply ‘yes’or ‘no’ without further elaboration. Although allforms shared the aims of identifying risk factors and appraising overall risk, it was noteworthy that only around half includeda risk management plan or a section prompting further actionfrom a positive screen, e.g. to collate further informationor perform a more in-depth analysis.

Box 1. Methods for identifying risk indicators
Tick box sections

Pasthistory of violence

Current factors increasing risk (e.g. substancemisuse)

Social/demographic factors

Current symptoms (e.g.command hallucinations)

Dispositional factors (e.g. impulsivity)

Possessionof weapons

Threat posed to any identified individual

Historicalfactors (e.g. childhood emotional deprivation)

Narrativesections

Unstructured account of past violence

Structuredaccount of past violence, context and outcome

Unstructuredaccount of current risk indicators

Structured account of currentrisk indicators

Box 2. Methods for summating risk indicators

Dichotomous division:yes or no

Grading: high/medium/low

Scoring (weighted or otherwise)

Narrativeformulation

Box 3. Example of a structured narrative approach

Is thereevidence of violence particularly preceded by changes in mental state? If yes, describe. Give details of any plans or specificthreats to harm a person. Do they have access to potentialvictims, particularly those incorporated into delusional systems?Are there specific trigger factors? Who needs to be aware ofthis risk?

Is there evidence of poor compliance with treatmentor disengaging from services? If yes, then how will this affectthe management of any identified risk?

Is there evidence ofrootlessness or social restlessness (homelessness, social isolation,frequent changes of address or employment)? If yes, then howwill this affect the management of any identified risks?

Isthere evidence of substance misuse? If yes, how does this affect the management of any identified risks?

Are there aspectsof their mental state that may constitute or exacerbate risk(these may include: persecutory delusions, morbid jealousy, passivity)? If yes, describe.

History (chronology of events)

Haveany of the above factors changed recently? If yes, describe.

Opinion

Whatother information is required to complete the assessment? Include:seriousness, immediacy, volatility, specific interventions and treatment that will reduce risk, circumstances that may increaseit. How long is this opinion current?

Discussion

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Discussion

Principal findings
The responses from the survey suggest that most trusts havestandard risk forms incorporating the assessment of violenceand around half provide training for their use, although manyconsultants do not attend. In comparing the forms themselves,there was evidence of striking variation. In identifying riskfactors, forms varied considerably in their content and complexity. Unstructured narrative sections would appear to rely on theknowledge of the person completing the form as to what informationis relevant; tick-box completion, by contrast, has the advantageof prompting the consideration of pertinent factors. However,simply ticking a box to indicate a risk factor as present arguablycommunicates little useful information. For example, how a patientunderstands and responds to passivity experiences, and whatthe person completing the form is describing when they saythey are present, is crucial for putting a risk factor intothe context of actual risk for that individual. Structurednarrative sections appear to combine the best elements of both methods by directing the focus of inquiry while allowing riskfactors to be contextualised. Some forms only identified discreterisk factors; here risk ‘assessment’ is arguablya misnomer, as assessment implies some form of weighing upof available information.

The rationale behind using scoring or grading systems to summariserisk was not clear. Scores may be reproducible, and thus seem‘scientific’, but their validity for use with thegeneral population is questionable. There was often a lackof direction as to how a score or grade should be meaningfullyinterpreted. A score or grade as the conclusion of a risk assessmentmay be a false positive or negative, which may mislead management. A narrative summation has the advantage of collating what isactually known for that individual, and allows the balancingof risk and mitigating factors.

Around half of the forms did not include a plan for managingany identified risk. It could be argued that assessing riskshould not be an end in itself. Clinical management plans aredetailed elsewhere in care programme approach documentation,but these do not necessarily demand a specific focus on risk behaviour.

Strengths and weaknesses of the study
This study is the first to provide an overview of violence riskassessment practice in England. The trust response rate (68%)and the number of forms analysed (41) was sufficiently highto be representative. As this was the first study of its kind,we did not measure form quality in a reproducible way; thereis not as yet any ‘gold standard’ for forms to be judged against. The main limitation of this study was the relianceon the consultants’ reports of trust policies and theirbest estimations of current practice in their area.

Implications
Trusts in England are in the main complying with the Departmentof Health’s requirement to assess risk of violence. Howthis requirement is interpreted varies considerably betweentrusts. This is at odds with a culture of evidence-based practice.

Unanswered questions and future research
A consensus needs to be reached as to what risk assessment shouldentail in general psychiatry. Given the current state of knowledge,we would suggest that this should include semi-structured methodsand not scoring or weighting systems, which in this contextare somewhat specious.

References

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