This assignment will discuss the contribution of research to understanding violence risk factors and management. The debate surrounding clinical judgement will be discussed and how this has brought about new research methods. Models of risk assessment wil

INTRODUCTION

This assignment will discuss the contribution of research to understanding violence risk factors and management. The debate surrounding clinical judgement will be discussed and how this has brought about new research methods. Models of risk assessment will be evaluated in light of the progression of research and the efficacy of care management in relation to mentally disordered offenders.

The last 10 years has seen an increase in public and political interest in the assessment and management of risk in relation to mentally disordered offenders. Over this time, the concept of risk has evolved considerably. Bonta (1998) outlines that, pre 1995, in the early phase of research into risk; the primary objective was to understand the actual risk posed by mentally disordered offenders. Popular belief about the risk posed by these individuals was examined and more realistic hypotheses about the links between mental disorder and violence eventually proposed. More recently the risk assessment field has evolved further to include discussion about the legislative provision for the management of individuals with a history of offending behaviour, including The Scottish Executives (2006) Order for Lifelong Restriction in Scotland. Regardless of legislative changes, public and political criticism remains focused towards mental health and forensic services for their perceived failures in managing risk effectively.

It is possible, through the delivery of a high standard of care, to avert the deterioration in mentally disordered offenders, thus avoiding disaster. However, Davies et al (2001) is keen to emphasise that not all acts of violence can be predicted by offenders, just like they can’t be predicted in the wider community. It is too easy for public condemnation to focus on overstretched mental health services when something goes wrong. There has been a shift in community care from care by networks of family and friends to that of professionals, and with this has come the expectation that professionals will always get it right. There are and always will be people in the community who are a risk to others, whether or not they suffer from a mental disorder or have an offending history, and singling out different professional groups for blame, whether they should be social workers, psychiatrists or doctors in general wont alter this.

MAIN BODY

‘Risk’ Mullen (2000) suggests, can be defined as a calculation which involves uncertainty as to whether some kind of damage or loss will occur as a result of that calculation. In essence, the outcome of the decision is down to ‘chance’ and it is the responsibility of the decision-maker to weigh up the consequences of potential damage or loss, before proceeding to act or not.

Perceptions of risk are individual and can be affected by a number of personal factors. Tversky & Kahneman (1973) suggests that the amount of information available about a particular risk will affect how people regard its likelihood and the more information that is available on a potential risk event, the more it will be regarded as likely to occur e.g. publicity of a murder committed by a psychiatric patient causes an increase in public thinking that the risk of it occurring again is greater than reality would predict.

As supporting view is provided by Slovic et al (1998) who suggest that peoples perception of risk is also affected by the degree of control they feel they have over the risk, whether it is voluntarily taken on, how evenly its effects are distributed, how time affects the risk and familiarity. Whether a risk is societal or individual, public or private, positive or negative, will also affect perceptions. Fear resulting from lack of understanding and the media portrayal of mental illness has contributed to the stigma and often social isolation of people with mental health problems. Paterson (2006) discusses the ongoing public concern over their safety in relation to mentally disordered offenders and psychiatric patients living in the community. This fear has increased in recent years, especially with the emergence of high-profile investigations into the deaths of Jonathon Zito, Georgina Robinson and Frederick Graver, amongst others. Bandura (1993) state that aggression is a form of social behaviour that may be acquired and maintained like other forms of socials behaviour. This social learning theory suggests that aggression is acquired due to biological factors and learning, which is instigated through incentives, instructions, bizarre beliefs aversive treatment and arousal. It is with this in mind, that increased attention has been drawn to the efficiency of methods for assessing violence ‘risk’ and bringing about a constant drive to produce more efficient means of predicting, assessing and managing ‘risk’.

Mullen (2000) suggests that risk assessment and risk management have emerged as central elements not just in forensic practice but in all mental health practice. The long term viability of community care, which has become the central plank of most modern mental health services, is dependant on assuaging the anxieties of the public, and politicians, about the dangerousness of mentally disordered offenders.

Exaggerated and misplaced though such public fears may be on occasions, they never the less have the capacity to damage, seriously, or destroy, the progress made towards less oppressive and custodial mental health services.

Mental health services have a responsibility to do all they can to provide appropriate care and support to those mentally disordered offenders with an increased probability of acting violently, be it towards themselves or towards others. The aim is to identify and manage such risks before they manifest into violence.

The government has made a significant contribution to public misperceptions about mental illness and risk by emphasising risk in many of its Health Select Committee (2000) announcements. Holloway (1996) suggests that over recent years the primary concern appears to have been to manage risk, with the objective to provide better health outcomes for mentally disordered offenders put in second place. This is a regrettable shift in the political agenda, which appears increasingly to be ruled by the desire to avoid adverse headlines and to shift responsibility. The result has been a change in the climate of forensic services, which inevitably become risk orientated.

Kropp et al (2002) suggests risk assessment, is defined as the process of speculating in an informed way about the aggressive acts a person may commit. This process then determines the steps that should be taken by professionals to prevent those acts, minimising their negative consequences. There are two broad approaches to the assessment of risk, actuarial and structured professional judgement. Hart (2003) states that the two approaches are frequently compared, however, some work remains to be done to establish the optimal use of each approach to individuals with differing characteristics.

Elbogen et al (2002) state that there ...

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Elbogen et al (2002) state that there still appears to be a deficiency between research evidence and clinical practice. Their research found that while clinicians perceived research on risk factors to be relevant, they were not necessarily employing the recommended assessments. Monahan (1992), for example, concluded that more than 1 in 3 clinical predictions of future violence within institutionalised populations were accurate. However, contradictory evidence from Faust & Ziskin (1988) has shown that the accuracy of judgements by psychologists and psychiatrists do not necessarily surpass that of lay-persons. It has been further argued by Ennis & Emerly (1978) that mental health professionals’ predictions of dangerous behaviour were wrong about 95% of the time.

Grove & Meehl (1996) state that unstructured clinical decision making or ‘first generation approach’ involves professional opinion or judgements where there is complete discretion over which information should be considered and there are no constraints on the information the assessor can use to reach a decision. However, Kemshall (1996) suggests that the clinical approach is plagued by various sources of bias and error as information is highly dependant upon interviewing, observation and self-report. Therefore the argument exists, that bias prone heuristics, misconceptions of chance and the selective perceptions that affect peoples every day judgement and perceptions of risk have the same impact in clinical decision making. This prompted a rethink in the approach of risk assessment in relation to mentally disordered offenders and subsequently the ‘second generation’ of research was born.

This next generation integrated statistical evidence into violence prediction and was defined as the actuarial approach. This approach Monahan (1992) would suggest is based on assessors reaching judgements based on statistical information according to fixed explicit rules.

The approach was an attempt to overcome methodological and conceptual problems. Initially it seemed of little doubt that the actuarial approach was statistically superior to unstructured clinical judgement as it improved predictive accuracy. However, Gottfredson & Goffredson (1998) state that there became apparent, limitations to the actuarial approach, as it appeared to ignore potentially crucial case specific, idiosyncratic factors. There also seemed to be a tendency to focus on static factors, leading to passive predictions. The actuarial approach would also exclude crucial risk factors, or ‘broken-leg’ cues, on the basis they have not been proven empirically, even though they may be entirely logical (e.g. explicit threats of violence). This approach would also lead to not-optimal, even bizarre, decisions when applied in different settings. Hart (1998) suggest that criticism of clinical prediction ability, could be slightly unjust as the poor performance of clinicians in predicting violent behaviour would mean that a successful prediction leads to prevention as clinicians would therefore be ethically and legally bound to prove themselves wrong.

Logan (2005) states that approaches utilising structured clinical judgement advocate the measurement of variables that are both static and dynamic, and encourage the monitoring of risk factors in order to detect changes in risk. Thus the emphasis of such approaches is on prevention rather than prediction. A popular example of violence risk assessment by structured professional judgement is Webster et al (1997) HCR-20 risk assessment guide. The HCR-20 is a set of guidelines for use by practitioners in their assessment of historical, clinical and risk management factors regarded as relevant to violent behaviour in male or female offenders with a history of mental illness. These guidelines were developed from reviews of the scientific, professional and legal literatures and reflect common sense practice as well as the findings of empirical research.

Grubin & Logan (2002) suggest that structured professional judgement approaches appeal to practitioners as they support and endeavour to improve upon what practitioners already do rather than propose that clinical judgement is flawed. Logan (2005) suggests that the HCR-20 sets good practice parameters that systematise and make explicit clinical assessment with the aid of known risk factors. O’Rourke (1999) argues that nothing will change until risk assessment is no longer considered a ‘one stop’ activity and instead a starting process for comprehensive risk assessment and case management in relation to mentally disordered offenders. Fransson (2000) states that the HCR-20 in particular has gained positive support due to its uncharacteristically simple, paper-and-pencil coding sheet and descriptions of ways to reduce risk behaviour.

However, Munro & Rumgay (2000) suggest that the perception that risk assessment and management will reduce the rate of adverse incidents is flawed. Munro & Rumgay (2000) analysed the findings of public inquiries held after homicides by mentally disordered offenders in the UK and concluded that improved risk assessment has only a limited role in reducing homicides by people suffering from mental illness.

Steadman et al (1996) suggests that generally, risk assessment tools are of limited usefulness and will always be of limited value in predicting rare events accurately.

One critical view suggested by Szmukler (2000), suggests that the stark reality is that however good our tools for risk assessment become, whether clinical or actuarial, professionals will not be able to make a significant impact on public safety. How then does this impact on forensic services?

Forensic mental health has been defined more broadly by Mullen (2000), as an area of specialisation that, in the criminal sphere, involves the assessment and treatment of those who are both mentally disordered and whose behaviour has led, or could lead to offending. In the civil sphere, forensic mental health has a more complex remit. It is not only involved in the assessment and treatment of those who have potentially compensatable injuries, but also providing advice to courts and tribunals on competence and capacity.

Defining forensic psychiatry in terms of the assessment and treatment of the mentally disordered offender delineates an area of concern that could potentially engulf much of mental health. Offending behaviour is common in the whole community, and among adolescents is universal. Petch (2001) suggests that even criminal convictions are spread widely through society and more widely among people with mental disorder. Petch suggests that the borders of forensic mental health need a clearer marker than offensive behaviour, or even criminal among mentally disordered offenders.

Mullen (2000) questions the current dilemma facing generic services. This is due to practice as, patients often gravitate to forensic services when the nature of their offending, or the apprehension created by their behaviour, is such to overwhelm the tolerance or confidence of professionals in the general mental health services. Currently escalating rates of referral to forensic services are being fed, in part, by increasing anxieties about the potential for violent behaviour in certain categories of patients. They are also driven by the emerging culture of blame in which professionals fear being held responsible for failing to protect their fellow citizens from the fear-educing, or frankly violent, behaviour of those who have been in their care. Gunn (2000) suggests that the shift of mental health services that are community based and rely on general hospital units for in-patient facilities has tended, understandably, to decrease further the confidence that the general mental health services have in their facilities, or even skills, to manage the more challenging and potentially frightening patient. Compounding these influences are changes in our society which tend to decrease the tolerance for difficult and intrusive behaviour increase the demand where by professionals, rather than neighbours and family control such deviance.

This is particularly the case when the threat is perceived as arising from mental disorder. Given those influences, Gunn (2000) states that it can be predicted with confidence that whatever the definition boundaries forensic mental health services, they are going to be larger and more obvious in the future.

In overemphasising the importance of accurate risk assessment there is a heavy price to pay by society for the inevitable false negatives and false positives. By succumbing to public pressure to avoid false negatives at all costs i.e. those who are assessed as low risk that become violent, the threshold for action is reduced.

This consequently increases the rate of false positives i.e. those falsely assessed as being at risk of violence, and this group is exposed to unnecessary restrictions of civil liberties and increased coercion. This therefore attracts resources away from those not assessed as posing a risk. Taylor & Gunn (1999) suggests that such targeting results in altered perception of the public, politicians and the press that people suffering from mental illness are dangerous, despite the rate of such violence being essentially unchanged.

Despite the dominance of the need to protect the public in government policy, some of these initiatives will have a negligible effect on public safety. As reflected by The Department of Health (2000), the government has accepted without question the recommendations in the Report of the Review of Security at the High Security Hospitals, that £30 million be spent improving perimeter security of the special hospitals. This, however, does not make sense when there has not been a breach for at least 6 years and it has been acknowledged that many in special hospitals do not require the level of security already provided. Secondly, The Department of Health & Home Office (1999) suggests that the proposal for provision of special services to manage those with ‘dangerous severe personality disorders’, essentially a preventative detention, have been heavily criticised on many grounds, not least that they will not serve to protect the public. If protecting the public is really paramount, the money required to establish such services for individuals suffering from dangerous severe personality disorders would be better spent on proposals that would impact on public safety. For example, the vast majority of recorded crime in the UK is related to the ingestion of psychoactive substances, both drugs and alcohol, especially by young men. Substance misuse is a well documented and potent risk factor for violent behaviour, in mentally disordered offenders. A supportive view is posed by Soyka (2000) who suggests that until substance misuse is effectively tackled and services are provided to respond to this massive problem, the public will never be protected from harm in the way ministers’ hope.

Munro & Rumgay (2000) are keen to emphasise that better mental health care for all, especially for those about to relapse, irrespective of the risk of violence, would be more likely to prevent incidents occurring than simply targeting resources of those assessed as being high risk.

Not only do general psychiatrist have to manage the largest pool of mentally disordered offenders, they also as discussed by Holloway (1997), often face the greater challenge of managing those who may be about to offend.

Over recent years there have been calls for closer integration between forensic and general mental health services, and for forensic services to be extended into the community where mentally disordered offenders will eventually return. Mullen (2000) suggest that sharing the responsibility and burden of difficult to manage patients who have stretched the tolerance of general services too far is an important motive for seeking forensic opinions. Another may be the perception that forensic psychiatrists have a set of specialist skills that general psychiatrists do not possess.

Snowden (1997) would question this, suggesting the only difference may be that forensic professionals may have more resources in terms of time to apply basic clinical skills. The decisions required in managing risk require detailed analysis of vast quantities of information from different sources.

Many general psychiatrists simply do not have the time. Their time is engulfed in travel, reading large quantities of notes, discussions with members of the multi-disciplinary team, lengthy interview with patients (and informants) and preparation of detailed report that aim to highlight specific problems, areas of particular risk and recommendations regarding future management.

The focus is shifted from controlling or imprisoning those mentally disordered offenders deemed to be dangerous to an agenda of prevention by care and treatment. It is only the latter form of prevention for which the skills and knowledge of mental health professionals are appropriate.

Mullen (2000) suggests that risk assessments, are the proper concern of health professionals to the extent that they initiate remedial interventions that directly or indirectly benefit the person assessed. Decreasing a mentally disordered offender’s chance of injuring others is a benefit to them as well as the future victims. Such prevention is part of a health professional’s legitimate activity if, and only if, it is part of therapy for a mental disorder or for psychological or emotional disfunction. Confining and containing offenders as punishment, or simply to prevent further offending, may be legitimate for a criminal justice system but should have no place in a health service.

CONCLUSIONS

Through research for this piece of work it has become apparent that what will never be possible is for mental health services to prevent all violent acts in their patients, any more than such perfection of prevention can be obtained in the wider community. What will almost certainly remain highly problematic is identifying in advance that tiny minority of mentally disordered offender who may go on to inflict serious or fatal I injury on others. Conversely, there is much to be gained from the open discussion of improved methods of identifying and managing potentially aggressive patients, as well as from programmes for anaysing and learning from the inevitable incidents and failures, however minor. Such quality assurance practices only work, however, if they focus on improving future clinical practice and training rather than on assigning blame and criticising individuals.

Risk assessment and management need to be put in political and epidemiological perspectives. As Snowden (1997) argues, these are not specific skills but rather an approach to clinical practice. They are not easily taught in a specific teaching session, but need to be developed hand-in-hand with sound clinical skills. High quality clinical training requires well resourced mental health services because without this, no amount of training in risk assessment and management will make a difference.

Additional revenue for the NHS is proposed each year; some of which will be dedicated to mental health services. Are these resources really aimed to improve services and benefit patients, or aimed at addressing the moral panic of risk in psychiatry?

If these proposals translate into real improvements in services by, for example, increasing the number of adequately trained professionals working within mental health services, workloads may be reduced and access to appropriate interventions for mentally disordered offenders may be increased. The apparent priority of improving mental health services will start to be achieved and improvements in the management of risk will naturally follow.

The public are rightly concerned about the criminal justice system and the way that mentally disordered offenders are treated. In particular there have long been questions about the system of early release from prison, especially automatic early release. In response to this, The Scottish Executive appointed an independent, judicially led Sentencing Commission to make recommendations, now contained in the Custodial Sentences and Weapons (Scotland) Bill (2006).

The Bill was intent to build upon existing legislation, including The Management of Offenders (Scotland) Act 2005. It aims to provide a clear picture of the effect of sentences when they are imposed. Prisoners release would now be much more dependant on an assessment of their risk of re-offending and risk of causing serious public harm. Risk assessment will become much more widespread and far more central the criminal justice process, with a greater role for the parole board.

If prisoners are released early, license conditions may be imposed which are tailored to their individual risk and need, including treatment for mental health issues, drug and alcohol addiction and close supervision by social workers and the police. However, O’Rourke (1999) suggests in the main body, that risk assessment only has any practical value if it is coupled with risk management, which means working to reduce or contain the risk in a practical and focused way.

REFERENCES

Bandura. A. (1993) Psychological mechanisms of aggression. Academic Press.

San Diego. 1-40.

Bonta. J. (1998) The prediction of criminal and violent recidivism among mentally disordered offenders: A meta-analysis. Psychological Bulletin. 123. 123- 142.

Custodial Sentences & Weapons (Scotland) Bill (2006). Available from:http//www.scottish.parliament.uk (Accessed 27/2/7).

Davies. S, Amos. T, & Appelby. L. (2001) How much risk training takes place in mental health services? A national survey of training and policies. Psychiatric Bulletin. 25. 217-219.

Elbogen. E. G, Mercado. C. C, Scalora M. J, & Tomkins. A. (2002) Percieved relevance of factors for violence risk assessment: A survey of clinicians. International Journal of Forensic Mental Health. 1. 37-47.

Ennis. B. T, & Emerly. R. D (1978) The Rights of Mental Health Patients. Avon Books. New York.

Faust. D. & Ziskin. J. (1988) The expert witness in psychology and psychiatry. Science. 241. 31-35.

Fransson. R. (2000) Assault against psychiatrists in out-patient settings. Journal of Clinical Psychology. 49. 338-345.

Gottfredson. S. & Gottfredson. D. (1998) Accuracy of prediction models: Criminal careers and career criminals. National Academy Press. Washington DC.

Grove. W. & Meehl. P. (1996) Comparative efficiency of informal and formal prediction procedures: The clinical statistical controversy. Psychology, Publications Policy & Law. 2. 293-323.

Grubin. D. & Logan. C. (2002) Risk assessment: Structured clinical judgements and actuarial approaches in practice. University Press. University of Cardiff.

Gunn. J. (2000) Future directions for treatment in forensic psychiatry. British Journal of Psychiatry. 176. 332-338.

REFERENCES

Hart. S.D. (2003) The role of psychopathy in assessing risk for violence: Conceptual and methodological issues. Legal & Criminological Psychology. 3. 121-137.

Health Select Committee (2000) Provision of Mental Health Services. 4th Report. The Stationery Office. London.

Holloway. F. (1997) The assessment and management of risk in psychiatry: Can we do better? Psychiatric Bulletin. 21. 283-285.

Home Office & Department of Health (1999) Managing Dangerous People with Severe Personality Disorders. The Stationery Office. London.

Kemshall. H. (1996) Reviewing Risk: A review of research on the assessment and management of risk and dangerousness: Implications for policy and practice in the Probation Service. Home Office. London.

Logan. C. (2005) Clinical use of the Risk of Sexual Violence Protocol. Paper presented at the annual meeting of the Association for the Treatment of Sexual Abusers. Montreal. Canada.

Monahan. J. (1992) Mental disorder and violent behaviour: perceptions and evidence. American Psychologist. 47. 511-521.

Morris. R, Gask. L, & Battersby. L. (1999) Teaching frontline health and voluntary workers to assess and manage suicidal patients. Journal of Affective Disorders. 318. 77-83.

Mullen. P.E. (2000) Forensic Mental Health. The British Journal of Psychiatry. 176. 307-311.

Munro. S. & Rumgay. R. (2000) Dilemmas in Risk Assessment Research. Baxter Fellows Tutorial. London.

O’Rourke. M. (1999) Dangerousness: How best to manage risk. The Therapist.6.2.

Paterson. B. (2006) Newspaper representations of mental illness and the impact of events on social policy: The ‘framing’ of Isabel Schwarz and Jonathon Zito. Journal of Psychiatric Mental Health Nursing. 13. (3). 294-306.

Petch. E. (2001) Risk management in UK mental health services. Psychiatric Bulletin. 25. 203-205.

REFERENCES

Snowden. P (1997) Practical aspects of clinical risk assessment and management. British Journal of Psychiatry. 170. 32-34.

Soyka. J. (2000) Substance misuse, psychiatric disorder and violent and disturbed behaviour. British Journal of Psychiatry. 176. 345-350.

Slovic. P, Fischoff. B, & Lichtenstein. S. (1998) Facts and Fears: Understanding perceived risk. Good Practice in Risk Assessment and Risk Management. Jessica Kingsley Publishers. London.

Steadman. H, Mulvey. E, & Monahan. J. (1998) Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighbourhoods. Archives of General Psychiatry.55. 393-401.

Szmukler. G. (2000) Homicide Inquiries. What sense do they make? Psychiatric Bulletin. 24. 6-10.

Taylor. P. & Gunn. J. (1999) Homicides by people with mental illness: Myth and reality. British Journal of Psychiatry. 174. 9-14.

The Department of Health (2000) The NHS Plan. The Stationery Office. London.

The Management of Offenders (Scotland) Act (2005) Available from: http//www.opsi.gov.uk (Accessed 27/2/07)

The Scottish Executive (2006) Order for Lifelong Restriction. Available from: http//www.scotland.gov.uk (Accessed 27/2/07)

Tversky. A. & Kahneman. D. (1973) Availability: A heuristic for judging frequency and probability. Cognitive Psychology. 5. 207-232.

Webster. C.D, Douglas. K. S, Eaves. D, & Hart. S. D. (1997) HCR-20: Assessing Risk for Violence. Version 2. Burnaby. British Columbia. Simon Fraser University.

This assignment will discuss the contribution of research to understanding violence risk factors and management. The debate surrounding clinical judgement will be discussed and how this has brought about new research methods. Models of risk assessment wil

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