7.3.4 Risk Management
Risk Management Planning in Forensic Psychiatric Practice
Risk management planning is a crucial part of forensic psychiatric practice to minimize the potential risk of harm to individuals, staff, and society. It involves identifying the risks and implementing strategies to mitigate them. Forensic psychiatrists need to assess the risk of violence, self-harm, suicide, and absconding in their patients and develop individualized risk management plans accordingly.
The National Institute for Health and Care Excellence (NICE) provides guidelines for managing violence and aggression in mental health care settings. These guidelines emphasize the importance of risk assessment, communication, and de-escalation techniques to prevent violence and aggression. Furthermore, the guidelines recommend the use of a structured professional judgment approach to risk assessment, which takes into account both clinical and non-clinical factors.
| Type of Violence Risk Assessment | Description | Criticisms | Example |
| Clinical | Traditionally unstructured, guided by research literature | Lack of reliability, validity, and transparency | N/A |
| Actuarial | A statistical approach based on multivariate analyses of factors predicting further violence | Factors identified are historical, unchangeable attributes; considered inflexible and unable to inform risk management | Violence Risk Appraisal Guide (VRAG) |
| Structured Clinical | Combines historical factors of actuarial approach with dynamic factors in a structured way | N/A | Historical, Clinical, and Risk 20 (HCR-20) |
| Information Sources | Examples |
| Records | Psychiatric, general practice, social work, prison, school, criminal |
| Interviews | Patients, relatives, staff |
| Psychometric | e.g., PCL-R (Psychopathy Checklist-Revised) |
Note: The process of risk assessment should take a multidisciplinary approach and use as many sources of information as possible.
HCR-20:
- This is a structured clinical guide used for assessing the risk of future violent behavior.
- It features a checklist of 20 items identified as risk factors for violence.
- The checklist encompasses static historical data, current clinical conditions, and future risk management variables.
- The SVR-20 serves a similar purpose but is specifically focused on assessing the risk of violent sexual offenses.
PCL-R:
- The Psychopathy Checklist-Revised (PCL-R) is a tool used to identify psychopathic traits.
- It includes various items that assess presentation, affective state, lifestyle, and personality characteristics.
- Some studies suggest psychopathy is a more accurate predictor of violence than psychiatric diagnoses or substance abuse.
- However, it’s not validated for the general population and remains a subject of debate. Critics question its reliance on the concept of psychopathy as primarily defined by Robert Hare, arguing it lacks substantial objective support.
VRAG:
- The Violence Risk Appraisal Guide is designed to predict the likelihood of violent reoffending in community settings.
- Its approach is similar to the HCR-20, involving a detailed review of records and the assignment of scores to various items, which are then used to calculate a percentage risk of reoffending.
- The Sex Offender Risk Appraisal Guide (SORAG) is a related tool, but it is tailored for assessing the risk of reoffending among sex offenders.
Another important aspect of risk management planning is the use of psychosocial interventions such as cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT) to address the underlying factors that contribute to the risk of offending behavior. These interventions aim to develop coping skills, problem-solving strategies, and emotional regulation techniques.
Moreover, forensic psychiatric services must collaborate with other agencies such as the police, probation services, and social services to ensure effective risk management. This collaboration can help in developing comprehensive risk management plans that address the individual needs of patients and minimize the risk of re-offending.
In conclusion, risk management planning is an integral part of forensic psychiatric practice that involves identifying, assessing, and managing risks to prevent harm to individuals, staff, and society. Effective risk management planning requires a multidisciplinary approach that involves collaboration with other agencies and the use of evidence-based interventions.
References:
- National Institute for Health and Care Excellence (NICE). (2015). Violence and aggression: short-term management in mental health, health, and community settings. Clinical guideline [CG25].
- Davies, S., Clarke, M., Hollin, C. R., & Duggan, C. (2007). The management of violence and aggression in forensic settings. The Lancet, 369(9564), 694-701.
- Cullen, A. E., Jewell, A., Tully, J., Coghlan, S., Dean, K., Fahy, T., … & O’Brien, C. (2016). A review of violence risk assessment and management in mental health care. Risk management and healthcare policy, 9, 49-62.