Adrian Cree PiCEncouraging mental health patients with forensic needs to internalise their own risk assessment/decision making model could help to reduce future risk of violent behaviour, a new paper has claimed.

The paper, ‘Achieving transparency in forensic risk assessment: a multimodal approach’ by forensic psychologists Dr Adrian Cree and Amy Horstead, also advocates a collaborative approach between patients and clinicians.

It looked at an existing service within a 52-bed secure hospital for forensic patients over a 6 month period. The service wanted to move from a system where patients were not involved in their own risk assessments through to full collaboration where the patient would create their own safety plan and possibly their own assessment.

Best practice guidelines by the Department of Health on risk management and violence prevention in mental health services highlight the importance of transparency and collaboration with service users.

The starting point was a psychology-led patient educational group on risk and risk assessment, and a commitment to overcoming a patient’s negative preconceptions that risk assessment would have a negative impact upon them or be linked in some way to ‘punishment’.

Three risk assessment tools used were:
• Historical Clinical Risk Tool (HCR-20)
• Short Term Assessment of Risk and Treatability (START)
• Structured Assessment of Protective Factors for Violence Risk (SAPROF)

The researchers recommend that patients are not only educated on risk and risk assessment tools but are in a trusting relationship with their clinicians on the subject of risk prior to their inclusion in a multi-disciplinary risk assessment meeting. Once ready to participate, patients formed part of the multi-disciplinary team group using a consensus decision-making model to agree their own risk assessment.

Additionally, researchers noted that this multi-modal approach would avoid problems associated with inclusion or exclusion of patients from risk assessment. If excluded, the patient doesn’t hear their risk assessment at all; if included before they have a full understanding of risk assessment tools they are at a disadvantage; they may have a negative experience of the meeting – their view of their own risk may differ from the clinicians – and it could lead to a reduction rather than an increase of trust in the relationship between patient and clinician.

The paper concludes that if risk assessment and management are to be truly effective, they should be done in the spirit of collaboration, with the goal of helping patients to become better assessors and managers of their own risk. This is more likely to be achieved if they are able to internalise a risk assessment model that they can apply to everyday life.

It needs a plan for implementation that considers the current framework of the risk assessment process and how it needs to be developed to facilitate true collaboration. It is likely to involve a patient education process, regular risk assessment meetings that include the patient, with a consensus model of risk coding and a rethinking of how risk information is presented to patients and carers in Care Programme Approach meetings and other settings.

Dr Cree, who is Partnerships in Care’s clinical director for London and South East region, said: “Many patients with forensic needs are poor decision makers and this includes decisions about risk. It is the natural progression of risk assessment that we attempt to internalise the risk assessment process to the individual concerned. There are limitations to how effective clinical risk assessment can be as the patient moves into the community.  If as part of their care they have learned to internalise their own risk assessment/ decision making model then this should enhance their ability to assess, think and behave which will assist in reducing their future risk.”

The full paper is published in the September issue of Advances in Psychiatric Treatment.