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Issues in Mental Health Nursing

ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: https://www.tandfonline.com/loi/imhn20

Investigating the Evidence for the Effectiveness of Risk Assessment in Mental Health Care

Timothy Wand

To cite this article: Timothy Wand (2011) Investigating the Evidence for the Effectiveness of Risk Assessment in Mental Health Care, Issues in Mental Health Nursing, 33:1, 2-7, DOI: 10.3109/01612840.2011.616984

To link to this article: https://doi.org/10.3109/01612840.2011.616984

Published online: 06 Jan 2012.

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Issues in Mental Health Nursing, 33:2–7, 2012 Copyright © 2012 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2011.616984

Investigating the Evidence for the Effectiveness of Risk Assessment in Mental Health Care

Timothy Wand, MHN RN NP DAS(Nurs) Grad. Dip.(MHN) MN(Hons) Royal Prince Alfred Hospital, Emergency Department, Camperdown, Australia and University of Sydney, Sydney Nursing School, Camperdown, Australia

Risk assessment pervades mental health care policy, practice, and legislation. This paper aims to establish the research evidence for the effectiveness of a risk assessment approach in mental health. A search was conducted of the professional literature on risk as- sessment in mental health, specifically seeking any research on the effectiveness of risk assessment in reducing risk of harm to self or others. The search found limited research on the effectiveness of risk assessment. “Structured professional judgment” possibly reduces aggression risk but there is no evidence that risk assess- ment is effective in relation to self-harm or suicide reduction. The implications for practice are discussed and alternatives to a risk assessment approach are considered.

Evidenced Based Practice has been adopted globally and in many specialties of health care, including nursing, psychology, medicine, occupational therapy, and social work. The promi- nence of Evidenced Based Practice has evoked controversy and criticism, however, it continues to wield widespread influence on health care policy and practice. Evidence Based Practice re- lies on a hierarchy of evidence that enables clinicians to gauge the strength of research findings in terms of efficacy or effective- ness. Investigations providing the strongest levels of evidence include meta-analyses, national clinical practice guidelines, and systematic reviews of randomized controlled trials (RCT). A single well-designed RCT provides moderate evidence, and the weakest evidence is derived from non-randomized investiga- tions, case studies, cohort studies, and qualitative or descriptive studies. The lowest level of evidence is associated with the opin- ion of authorities and/or reports of expert committees (Fisher & Happell, 2009).

Risk assessment and management have become a central fo- cus in mental health policy, practice and legislation. Due to the dominance that risk assessment exerts in contemporary mental health service provision, this paper investigates the available evi-

Address correspondence to Timothy Wand, Royal Prince Alfred Hospital, Emergency Department, Missenden Road, Camper- down, 2050 Australia, or University of Sydney, Sydney Nurs- ing School, Mallet Street, Camperdown, 2050 Australia. E-mail: [email protected]

dence for the effectiveness of this approach in reducing risk; par- ticularly in relation to risk of harm to self or others. A search of the literature was conducted using PsycInfo, CINAHL, Medline, and Google Scholar from the year 2000 to 2011. Key terms (e.g., risk assessment) and combinations of terms (e.g., risk assess- ment and management, mental health, psychiatry, suicide, self- harm, self-injury, psychosis, aggression, violence) were used. Reports and consensus guidelines from professional bodies also were considered. A systematic review was not possible given paucity of studies evaluating the effectiveness of risk assess- ment in mental health care. The majority of publications are from the lowest level of evidence available. This paper presents the research that is available investigating the effectiveness of risk assessment as well as a general review and discussion of the literature related to the topic. The implications for practice and alternatives to a focus on risk assessment are considered.

PERSPECTIVES ON RISK ASSESSMENT IN MENTAL HEALTH

In a report titled “Rethinking Risk to Others in Mental Health Services” the UK Royal College of Psychiatrists (RCP; 2008) expressed concern that a focus on risk assessment appears to have had a negative impact on clinical practice, consumers, and the public. The result is a culture of blame, leading to defensive and overly coercive practices and policies that demonstrate little understanding of the complexities inherent in clinical settings. Furthermore, the RCP contend that as a negative consequence of such policies and practices, consumers are subsequently less likely to access services out of fear of further coercion (RCP, 2008).

Despite efforts made to improve awareness of mental health, Lakeman (2006) reports that the public remains anxious about mental illness and the perception remains that mental illnesses are associated with dangerousness to self or others. Such pub- lic perceptions continue to exert influence on policy and prac- tice. Risk has therefore become an acceptable form of stigma whereby “high-risk patients in the community” become a legiti- mate source of moral concern (Undrill, 2007). These sentiments are echoed by the RCP (2008) who state that due to a focus on

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EVIDENCE OF EFFECTIVENESS OF RISK ASSESSMENT 3

risk, people with mental illness are portrayed in a negative man- ner and, typically, as dangerous. This is likely to contribute to the continuing stigma of mental illness while the far greater danger to the public is posed by people who misuse alcohol and other drugs (RCP, 2008).

Crowe and Carlyle (2003) view risk assessment as an at- tempt to control the actions and behaviours of consumers and clinicians to best suit the needs of the organisation rather than the interests of patients. Risk assessment is conceptualised by Undrill (2007, page 294) as a “neurotic organisational attempt to tame anxiety,” however Undrill contends that such defensive practices generate further anxiety. Clinicians become anxious about the risk management tools they are given, and then work to reduce this anxiety by discharging their share of the risk. Risk adversity then becomes responsibility adversity whereby clinicians act out of fear of legal ramifications and/or fear of failure at the expense of patient well-being (Undrill, 2007). Ac- cording to Undrill (2007) risk assessment is a subjective, plas- tic, and context-dependent statement that carries strong moral overtones. However the policy and managerial tendency is for implementing reductionist models and linear frameworks of un- derstanding that fail to appreciate the degree of complexity and randomness in the world.

AGGRESSION AND VIOLENCE RISK The risk associated with violence and aggression in health

care is a subject that has undergone extensive exploration and debate, particularly in the medical and nursing literature. The debate concentrates on issues such as the purpose (to predict or circumvent) and accuracy (actuarial or clinical) of risk assess- ments. Actuarial risks are based on static or historical factors statistically associated with increased risk, while clinical risk assessment is usually based on unaided clinical judgment and intuition (Lamont & Brunero, 2009). Clinicians however are concerned with the reality of assessing and managing aggres- sion and violence risk rather than the formal research task of prediction (Doctor, 2004).

The clinical utility of violence risk assessment tools has attracted particular scrutiny. Maden (2001) observes that most violence risk assessment tools were developed on high-risk populations, usually individuals who had already committed serious offences. They were not designed to be applied to the general population. Therefore attempts to apply violence risk assessment tools developed in the forensic sector to the wider population could result in inaccurate and overly coercive interventions (RCP, 2008). Importantly, actuarial tools developed from predictor variables do not necessarily reflect the experiences of the individual (Crowe & Carlyle, 2003) and are therefore the province of research rather than everyday clinical practice (Undrill, 2007). Stein’s (2002) review of actuarial- based tools used to aid the process of discharge risk assessment in the UK surmised that there are inherent limitations in the predictive power of these types of tools. This review expressed

reservations as to the ability of risk assessment tools to account for the complexity and diversity of human behaviour. For example, different tools may be required for males and females as the predictor variables for one gender may differ from the other. The transferability of actuarial tools from one setting to another or one country to another also is doubtful (Stein, 2002).

The RCP contend there is an absence of research evidence supporting the ability of violence risk assessment tools to re- duce or prevent adverse events and that they provide a false sense of security that risk has been adequately addressed (RCP, 2008). This claim is consistent with the UK National Institute for Clinical Excellence (NICE; 2005) guidelines on the man- agement of aggression and violence, which could recommend no gold standard violence risk assessment tool. By illustration, Hart, Michie, and Cooke (2007) evaluated the margins of error at the group and individual level for risk estimates made using two well-known actuarial risk assessment instruments: the Vio- lence Risk Appraisal Guide (VRAG; Quinsey, Harris, Rice, & Cormier, 1998) and the Static-99 (Hanson & Thornton, 1999). The VRAG is a 12–item test developed from a sample of pa- tients released from a maximum-security psychiatric hospital in Canada. The Static-99 is a 10-item test developed from four diverse samples of offenders and forensic psychiatric patients released from institutions in Canada and the UK. Results from this evaluation indicated that the two tools had poor precision. The margins of error for risk estimates made using the tools were substantial, even at the group level. At the individual level, the margins of error were so high as to render the test results virtually meaningless. Hart et al. (2007) concluded that actuar- ial risk assessment instruments cannot be used to estimate an individual’s risk for future violence with any degree of certainty and should be used with great caution or not at all.

Clearly however, risk assessment processes incorporate more complex dynamics than just clinical experience and/or actuar- ial based information. Subsequently an integrated framework of structured professional judgment has developed as a mul- tidisciplinary approach for reducing incidents of aggression and violence in mental health. Structured professional judge- ment involves consideration of known risk factors, professional experience, and individual knowledge of the patient (Lamont & Brunero, 2009). Operationalizing these principles, Abder- halden, Needham, Dassen, Halfens, and Haug (2008) conducted a RCT to assess whether structured risk assessment decreased the incidence of violence and coercion in acute psychiatric set- tings across Switzerland. The intervention consisted of three elements: (1) a structured short-term risk assessment for every new patient during the first three days of hospitalisation, (2) discussion of preventative measures from a list provided on the risk assessment form for high risk patients, and (3) in cases of very high risk, teams were prompted to plan and implement preventative measures. This process resulted in a significant re- duction in severe events of patient aggression and also reduced the need for coercive measures. The authors do note a number of limitations to the study which might have increased the effect of

4 T. WAND

the intervention; however, findings indicate that action tailored to the individual risk level may be a simple and cost effective way of diminishing the problem of violent incidents in acute psychiatric units.

Recently King, Yassi, Smailes, Lovato, and Koehoorn (2011) investigated the effectiveness of a violence risk assessment alert system in conjunction with existing violence prevention training in a large acute care hospital in Canada. Although the alert sys- tem was considered useful for identifying at risk patients, it had no impact on the rate of violence during either the intervention or post-intervention period compared with the pre-intervention period. The authors posit that the alert system may have raised staff anxiety, resulting in increased reporting of flagged patients. The system also may have influenced the manner in which staff interact with those patients identified as high risk, increasing the likelihood the patient would become violent. In focus groups conducted as part of the investigation, staff recognised that some patients may be incorrectly identified as high risk based only on past history and that flagging had the potential to stay with the patient unnecessarily.

Related to violence risk, research on establishing a link with psychosis and violence is also well represented in the literature. The consensus from research in this field suggest strongly that all acts of harm to others perpetrated by people with a mental illness are not primarily related to their mental illness once substance misuse is taken into account (Davidson, 2005; Elbogen & John- son, 2009; RCP, 2008). This was highlighted by a meta-analysis examining the association between psychosis and violence con- ducted by Douglas, Guy, and Hart (2009). The study found an overall association between psychosis and violence, which was particularly strong when the comparison group consisted of individuals without a mental disorder. However, compared to individuals with externalizing psychopathology, psychosis did not appear to further elevate the risk for violence while comorbid substance-related disorder elevates the risk of violence substan- tially. Therefore it is important to know whether a person with either a psychotic illness or a substance-related disorder has a co- occurring disorder, although the presence of psychosis should be considered neither necessary nor sufficient for a determination of high risk. This conclusion is based on the finding that the over- all magnitude of the psychosis-violence association was small; meaning that most violent individuals are not psychotic and most psychotic individuals are not violent (Douglas et al., 2009).

Hiday (2006) identifies numerous confounding factors that are minimised or neglected in studies undertaken to explore a link between mental illness and violence. Hiday (2006) concurs that once comorbid substance abuse and personality disorder are taken into account, the contribution of psychosis to vio- lence in the community diminishes dramatically. Furthermore, people with mental illness are more likely to reside in violent neighbourhoods and this could be a significant variable, rather than a psychiatric diagnosis. Multiple studies provide evidence that mental illness, substance abuse, and violence are frequently associated with what are frequently called socially disorgan-

ised communities, which are environments characterised by poverty, high unemployment, low education levels, resources deprivation, physical deterioration, and breakdown in micro in- stitutions, especially families. People with a mental illness who grow up in these communities learn to be violent, just as oth- ers in that environment learn that behaviour (Hiday, 2006). The World Health Organisation (WHO; 2004) observes that anti- social and suicidal behaviour have long been linked to strengths or absences of social cohesion. Weak social controls and the disruption of local community organisation have strong associ- ations with increased rates of violent crime and suicide (WHO, 2004). Recognition that mental health problems occur univer- sally, but are much more common among people with relative social disadvantage (Herman & Jane-Llopis, 2005) therefore requires a shift in policy, practice, and research away from a narrow biomedical approach toward a broader health promotion and public health perspective (Magyary, 2002; Wand, 2011).

SELF-HARM AND SUICIDE RISK The terms self-harm and suicide are often used together,

and self-harm (such as low lethality overdose or self-inflicted lacerations) is an established risk factor for suicide (Zahl & Hawton, 2004). Nevertheless it is important to acknowledge that self-harm is not necessarily synonymous with suicidal intent. In reality most self-harm inflicts little actual harm and does not come to the attention of mental health services. Some individuals may initially state that their intentions were to die, however on further exploration it can often be established that suicide was not really the intended goal. The motivation for self-harm is typically an expression of distress, anger, or a desire to escape a troubling situation (Hawton & James, 2005).

Various studies and publications list an extensive number of risk factors associated with suicide. Despite this, the prediction of suicide reveals alarmingly low specificity. Static risk factors may give an indication of an individual’s propensity for suicide but they do not capture the fluctuating nature of risk. Multiple risk factors are not always present in high-risk individuals and only one or two risk factors may need to be present to a serious degree to provide sufficient risk. Risk also can escalate rapidly over a short period and alternatively, if the outcome is not fatal, just as quickly subside (Bouch & Marshall, 2005). Furthermore, most suicides occur in low risk groups for the simple reason that they contain many more members than high risk groups and there is no evidence that addressing risk factors as such has any impact on survival (Undrill, 2007).

Harris and Hawton (2005) verify that studies attempting to identify particular individuals who are more likely to die by suicide have been largely unsuccessful primarily due to the low prevalence even within high risk groups. Harris and Hawton (2005) analysed the predictive value of the Beck Suicide Intent Scale (SIS) based on clinical and demographic data on 4,156 individuals who had self-harmed. Thirty males (2.9%) and 24 females (1.7%) in this sample died by suicide but the positive

EVIDENCE OF EFFECTIVENESS OF RISK ASSESSMENT 5

predictive value of the SIS was low (4%). The authors conclude that it is not possible to use patient information (even infor- mation shown to be strongly associated with suicidal intent) to predict accurately which individual patients will die by suicide and “highlights the dangers of a checklist-style approach” for identifying at risk patients (Harris & Hawton, 2005).

Owens, Wood, Greenwood, Hughes, and Dennis (2005) at- tempted to determine predictors of suicide by undertaking a retrospective study with 976 consecutive patients attending a large Emergency Department (ED) in the UK following nonfa- tal self-poisoning. Their study found that suicide was related to numerous factors evident at the time of self-poisoning but the predictive values of patient characteristics that point to higher than average risk are “just too poor to be useful” (Owens et al., 2005). The researchers’ concluded that employing a high risk strategy is a “hopeless” approach to suicide and self-harm re- duction. Instead they suggest that government initiatives should focus less on risk assessment and more on the assessment of individual needs.

Kapur, Cooper, Rodway, Kelly, Guthrie, and Mackway-Jones (2005) investigated the predictive value of risk assessments after an episode of self-harm and compared assessments made by ED staff with those made by psychiatric staff. They found that ED staff were more likely than psychiatric staff to assess the risk of repetition as high. For both groups however, most repetitions were among people assessed as low or moderate risk. The pre- dictive value of risk assessment after self-harm was low. These authors believe that restricting intervention to people identified as high risk, even assuming a completely effective intervention, would prevent less than one fifth of repeat episodes.

Kapur (2005) contends that any predictability of the risk of future suicidal behaviour following self-harm is problematic because such events are statistically rare and assessment tools are relatively crude. Nevertheless follow-up after self-harm and suicidal behaviour is important and should be prompt. Strate- gies that could be employed to improve follow-up include home visits, the provision of printed information, and aftercare being provided by the health professional who carried out the ini- tial assessment (Kapur, 2005). The Royal Australian and New Zealand College of Psychiatry (RANZP; 2004) practice guide- lines on self-harm also advocate for early engagement of the person and active follow-up. The RANZCP guidelines also rec- ognize that the practice of asking individuals to enter into no self-harm contracts or to guarantee or assure their safety is incor- rectly thought of as an effective method for managing self-harm risk and to protect the clinician from litigation. However these guidelines state that there is no evidence that this or any form of self-harm/suicide contract has any therapeutic benefit and is potentially counter-therapeutic. This is supported by subsequent examinations of this area that identify a lack of evidence for no suicide or self-harm contracts, as well as confirming their lack of medico-legal protection and potential to produce detrimen- tal outcomes (Edwards & Harries 2007; Edwards & Sachmann 2010; McMyler & Pryjmachuk 2008). Kapur (2005) asserts that

reducing our preoccupation with risk assessment may actually assist in improving the management of self-harm and suicide. A shift from risk assessment to needs assessment is indicated which aims to identify psychosocial factors that help to un- derstand an act of self-injury or suicide and contributes to a management plan (Kapur, 2005).

IMPLICATIONS FOR CLINICAL PRACTICE The reality that the prediction of aggression and violence,

self-harm, and suicide by clinicians is poor raises serious ques- tions about the integrity of mental health legislation, which in most jurisdictions is based on a dangerousness standard of a risk to self or others. In response, a growing number of clinicians and academics have called for the abolition of separate men- tal health legislation in favour of a generic mental incapacity act (for examples see Dawson & Szmukler 2006; Large, Ryan, Nielssen, & Hayes 2008; O’Brien, 2010; Ryan 2011; Wand & Chiarella 2006). Concerns have been expressed about the pre- ventative detention component of mental health legislation that allows for apprehension of individuals in advance of violence (a different standard applied to mental health treatment with- out consent than to unconsented treatment for physical health problems) and that separate mental health legislation framed around a category of people and based on a risk criteria rein- forces stigma and stereotypes about the characteristics of people with mental illness. At least until a more accurate and equitable legal resolution can be reached, Wand and Chiarella (2006) ar- gue that it is imperative that current mental health legislation maintain relevance in protecting the rights of consumers. This is achieved by upholding the United Nations High Commission for Human Rights (1991) and WHO’s (1996) principles of a preference for community-based care, an emphasis on volun- tary access to mental health services, and involuntary treatment on the grounds of mental incapacity, only as a last resort and for the shortest time possible.

The current discourse around a recovery orientation to men- tal health service provision runs counter to the discourse on risk. Parsons (2008) highlights the concept of “the dignity of risk” and proposes that there is a double standard for people who are diagnosed with a mental illness and those who are not. People who are not diagnosed as mentally ill are able to make risky and potentially self-defeating choices without intervention from authorities, clinicians, or service providers wishing to protect them from the consequences of their choices. The concept of the dignity of risk acknowledges that accompanying every endeav- our is the element of risk and that every opportunity for growth carries with it the potential for failure. All people learn through a process of trial and error and through taking risks. People often learn as much from mistakes as from successes. When people living with a mental illness are denied the dignity of risk, they are being denied the opportunity to learn and recover. By supporting dignity of risk, service providers and clinicians can help to com- bat learned helplessness and bolster self-esteem, self-respect,

6 T. WAND

empowerment, and hope (Parsons, 2008). In Australia for example, the Fourth National Mental Health Plan (2009–2014) which adopts a population health perspective affirms that mental health service providers should work within a framework that supports recovery both as a process and as an outcome to promote hope, well-being, and autonomy. In this current Plan mental health clinicians are urged to recognise an individual’s strengths including coping skills and resilience, and rights to self-determination (Commonwealth of Australia, 2009).

Risk management must, therefore, move away from a focus simply on assessment and instead on to therapeutic intervention that recognises and promotes the patient’s strengths and sup- ports recovery. The RCP (2008) assert that there is presently an overemphasis on the use of “invalidated tick box” assessment forms that are damaging to clinical practice and patient well- being. The RCP report identifies the propensity for “locally de- veloped assessment forms” to be produced as a means of “back covering” in the event of an adverse incident and that this rep- resents “a lazy and authoritarian approach to delivering health care.” Contemporary formats for undertaking mental health as- sessments are typically structured to seek out problems, illness, and pathology in the individual. However, rather than producing a comprehensive assessment, the profile of the individual ob- tained is biased toward identifying only negative characteristics. Some consideration of protective factors such as religious be- liefs or concerns for family and friends or pets may occur; though no attempt is usually made to balance an assessment with an ex- ploration and documentation of the person’s strengths, abilities, resources, coping skills, past successes, goals, hopes, and the broader context of the individual’s life and social circumstances. Further, Undrill (2007) argues that the amount of information gathered during the typical assessment process is often super- fluous to the current presentation and has the potential to over- complicate clinical decision making. Undrill (2007) proposes that a stance of “bounded rationality” may be more beneficial to make decisions on less information rather than expend time and energy on accumulating and documenting excessive amounts of personal information that is of marginal utility.

WHAT IS THE ALTERNATIVE? In contrast to a risk assessment focus, a substantial level

of interest has been generated in promoting the positive as- pects of health and well-being, which concentrates on wellness rather than illness (Parham, 2008). Research from the field of positive mental health for example has been found to result in impressive and enduring positive effects on multiple areas of individual functioning and also has the dual effect of reducing risk (Barry & Jenkins, 2007). Positive mental health acknowl- edges that a mental illness or disorder may impede, but does not preclude, positive emotion, engagement, purpose, positive relationships, and positive accomplishments (Seligman, 2008). Interventions adopting a positive mental health framework are primarily concerned with building capacity and self-efficacy in

diverse areas of life and signal a shift from a disorder-focused perspective to one that embraces psychological strengths and re- silience. An emphasis on positive emotions, such as optimism, promotes resilience, immunizes individuals against depression, and enhances adaption to stressful life events (Magyary, 2002). Building individual capacity also increases options available for people to exercise more control over their own health and over their environment to make choices conducive to health (Jane- Llopis, Barry, Hosman, & Patel, 2005). This is compatible with newer therapeutic approaches such as solution focused therapy (SFT) that represent an alternative way of thinking and working with people that is more optimistic, more enabling, and accepts that individuals will ultimately make their own decisions. SFT has broad utility for working with an array of mental health and substance misuse problems and is increasingly popular across a spectrum of health settings with a growing evidence base. The SFT approach is based on solution building rather than problem solving. Instead of a focus on problems, pathology and risk, SFT utilises questions aimed at surfacing an individ- uals strengths, abilities, resources, and the person’s vision for the future; thereby helping the person to formulate solutions to problems rather than dwell on problems themselves (Wand, 2010).

CONCLUSION Despite the heavy emphasis on risk assessment in mental

health there is little evidence that this approach is effective in reducing risk of harm to self or others. Moreover, there are in- dications from the available research that a focus on risk assess- ment has been ineffective in reducing self-harm and suicide risk and that alternative approaches need to be considered. Risk as- sessment is conceptualised as a managerially driven agenda that has resulted in mental health service provision being consumed by a state of nervous paternalism. The uncertainty with which risk of harm to self or others can be anticipated by clinicians has resulted in a culture of overly defensive practices and increased use of coercion; whereby the fear of medico-legal reprisal takes priority over the impact such intervention has on the individual. This, in turn, has consequences for the establishment of positive working relationships between clinicians and consumers and is at odds with a recovery orientation. Organisations and health authorities would be wise to invest more time and resources in public awareness campaigns and initiatives that promote men- tal health and well-being. There is a need to recognize from a public, policy, practice, and research perspective that the root cause of problems such as self-harm and suicide, aggression, violence, and substance misuse are predominantly socially de- termined and, as such, should be addressed by a broader public health approach rather than through a narrow biomedical lens.

Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.

EVIDENCE OF EFFECTIVENESS OF RISK ASSESSMENT 7

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