Editorial Reviews. Review. "This small volume is remarkable this is a superb little volume that Foundations of Forensic Mental Health Assessment (Best Practices in Forensic Mental Health Assessment). Foundations of Forensic Mental.
Table of contents
- Why are clinicians involved in violence risk assessment?
- Where can I get my book appraised?
- Best Practices for Forensic Mental Health Assessments - Oxford University Press
- Evaluation for Risk of Violence in Adults (Best Practices for Forensic Mental Health Assessments)
- Violence risk assessment as a medical intervention: ethical tensions
The assessment of risk of violence by mental health professionals has been the subject of ethical criticism because of the potential harm done to patients without justification in terms of patient benefits or respect. However, it is also a core duty of psychiatric services mandated by a number of clinical and legal frameworks. The assessment of risk of violence is a core function of all psychiatric services, particularly in forensic psychiatry.
This includes not only the statistical properties of the process itself, such as sensitivity and specificity further defined below but also using accepted models of biomedical ethics for its analysis. In this special article we argue that if violence risk assessment is a clinical intervention like an X-ray or magnetic resonance imaging scan , then it should be subject to the same bioethical framework as other medical interventions.
In support of this argument, we explore four related questions: The third question looks at the key features of different approaches to risk assessment and whether they pose common or unique ethical dilemmas; and the fourth question explores whether traditional bioethics assists us to know what approach to the risk assessment process clinicians ought to adopt, both now and into the future.
To address these questions, we have used analogous arguments about the assessment of risk in general medicine, for example in cardiac care. In relation to mental health services, this includes reducing violence by people with mental disorders to themselves or others. Although mental disorders make a relatively small contribution to the risk of violence to others compared with risk factors such as substance misuse, 3 there is thought to be sufficient contribution to generate a prima facie duty to reduce the risk.
The costs of homicides and suicides by people with mental illness are therefore considerable, not just in terms of the emotional harm caused to victims and their families, as well as perpetrators themselves, but also in terms of financial costs to healthcare providers. The General Medical Council GMC guidance on good medical practice 5 and confidentiality 6 sets out the duties and responsibilities of a doctor.
The doctor must weigh the harms that are likely to arise from non-disclosure of information against the possible harm of disclosure both to the patient and to the overall trust between doctors and patients. The onus is on the clinician to assess the risks of the situation in order to make a decision compatible with this guidance. The NHS staff guidance on confidentiality supports a much broader remit for disclosure and states that clinicians are justified in disclosing clinical information which leads to the detection, prevention and investigation of serious crime.
In legal terms, Article 8. The Public Health Control of Disease Act restricts the liberty of individuals who are thought to be carriers of communicable diseases. Further, mental health legislation in England and Wales gives power to approved professionals to detain citizens on the basis of perceived risk to self or others, 9 which not only implies that risk assessment is part of every implementation of the Mental Health Act , but also requires that the assessment needs to be justified and performed to a good standard. There is case law, both from the UK and the USA, which supports the duty of healthcare professionals to protect the public.
A particularly famous case is that of Tarasoff 10 where the Californian Supreme Court found that healthcare professionals including therapists had a duty to protect the public. In the case of Egdell, 11 the court found in favour of a doctor who sent an unfavourable report about a patient to the Home Office. The patient sued for negligence on the basis of a breach of confidentiality, but the court found that there was a duty to share information about danger with public bodies.
In the case of Palmer, 12 the court found that a health trust had no duty of care to unnamed and unidentifiable victims of a man whose mental condition made him a risk to others, although one inference might be that if there was an identifiable victim, healthcare professionals would have duty of care to them, as well as to their patient.
Why are clinicians involved in violence risk assessment?
An example is the use of psychiatric evidence at sentencing and parole hearings for prisoners detained under Indeterminate Sentences for Public Protection IPPs. Courts and parole boards ask for psychiatric evidence as to future risk, which affects the detention of the prisoner.
Although IPPs are now no longer open to judges as a sentencing option, existing orders still run and psychiatrists may be asked to assess risk in offenders on IPPs. Indefinite detention on the grounds of risk is also possible under the Mental Health Act for individuals with a mental disorder.
The Section 41 order can only be imposed by a crown court judge who has heard from psychiatrists who have assessed the defendant as posing a risk of serious harm to others. This framework argues that doctors have at least prima facie duties to respect the autonomous choices of individuals; act in ways that promote their welfare and minimise harm; and respect commonly held principles of justice.
The framework includes two schools of moral philosophy: The principles of respect for autonomy and justice reflect a deontological stance, whereas the principles of beneficence and non-maleficence reflect a consequentialist stance. It has been commented that the relative dominance of these two schools is itself a consequence of the dominance of left-brain thinking 17 in Western culture, where the left hemisphere logically calculates risks and benefits and finds reasons for what people should or should not do.
Although the four principles framework was widely accepted as a basis for general medical bioethics, other frameworks have also been influential. These schools of ethical thought have been explored and developed in relation to general psychiatry, especially values-based practice and virtue ethics. English mental health legislation reflects similar ethical values in the presumption of capacity that underlies the Mental Capacity Act and the emphasis on risk and benefit that justifies the overriding of autonomy in the English Mental Health Act.
However, there has been much less analysis of how ethical frameworks apply to forensic psychiatry, especially in relation to the duty to respect justice processes.
Forensic psychiatrists may look for ethical guidance from the GMC and the Royal College of Psychiatrists, but these bodies do not provide guidance on how psychiatrists should conduct risk assessments that are ethically sound, i. Classical ethical theory has particular limitations in relation to forensic psychiatry and risk assessment.
Deontological theory struggles when ethical duties seem to conflict, such as the duty to protect the public v. The theory does not allow for the ranking of duties, leaving practitioners without a practical solution. There is also no rule-based way to rank order the values of each outcome for each stakeholder in a risk assessment process to come up with the best course of action.
Consequentialist theory raises complex questions about how to assess likely benefits, and empirical questions about the accurate estimation of probabilities of certain outcomes occurring. In the case of violence risk assessment, there are concerns that there is a lack of accurate information in relation to possible negative outcomes that would be needed to justify intrusions into liberty and autonomy.
It might even be argued that there is no actual information about possible risk but only anxiety of others that risky events may occur. In ethical terms, risk assessments cause tension between the welfare of the individual and the welfare of others. Both the restriction of liberty and the breach of privacy are usually justified with reference to the benefit of harm prevented. Patients assessed as high risk are likely to lose their liberty which is a harm ; but if the process of risk assessment is flawed, then they are also treated with less justice than other people which is a wrong.
If misleading or false data are used as a justification for detention, then this is an unjust process, just as it is unjust to admit false or misleading evidence into a criminal trial. There is a parallel argument here with research ethics: Risk is defined as the probability that a harmful event will occur.
Risk assessment is therefore about assessing the likelihood that something bad will happen, which will cause distress and harm to others: Risk is a multidimensional construct, its most common dimensions being its nature, its probability, its severity, its imminence and its frequency. Risk assessment must address all of these areas to enable a risk management plan to be formed, and must also include the possibility of beneficial or positive things happening that reduce the negative effects or outcomes.
The output of any risk assessment usually leads to a decision to take action that is intended to reduce either the likelihood of the negative event happening or the negative impact of the event.
Specifically in relation to psychiatry, if an individual with a mental disorder is assessed as being at high risk of causing severe harm in the near future, steps will be taken to reduce the likelihood of his acting harmfully, and also to reduce the impact of any harm. Legal powers to detain that patient and restrict his actions may be used as a risk management strategy.
It is also possible to reduce risk by a warning the potential victim, b altering the mental state that gives rise to the risk, and c both. There are three recognised approaches to risk assessment: Unstructured clinical judgement refers to a purely clinical opinion on risk, without necessarily following a set structure. This approach has the advantage of being flexible, quick and idiographic person centred , and it was the traditional way of assessing risk for many years.
Actuarial approaches to assessing risk are similar to those operated by the insurance industry. These approaches are based on established statistical relationships between measurable predictor and outcome variables. The outcome of the assessment is determined by fixed and explicit rules, and there is no attempt to elucidate an explanatory model between the predictor variable and the outcome variable: Actuarial tools, such as the Violence Risk Appraisal Guide VRAG , 23 sometimes combine static predictors that do not require clinical judgement to rate with dynamic factors that still require clinical judgement.
The process remains actuarial in that the total score is used to reflect the risk and gives rise to probabilistic statements. This enhances reliability and statistical predictive validity over unstructured judgement.
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The structured professional judgement SPJ approach involves clinical judgement with a structured application. Each SPJ instrument follows a core methodological process. The items are derived from the empirical literature for their association with the outcome variable, but, unlike actuarial tools, they are not optimised from one sample, which enhances generalisability.
Each item is operationally defined to enhance interrater reliability. The relevance of each item to future risk can be rated. Case-specific items can be considered: This is often expressed in a risk scenario or risk specificity statement that addresses questions such as: What risk needs to be considered? Who is at risk and over what time period?
How likely is that risk and how severe may it be? Unlike actuarial tools, multiple scenarios can be considered, depending on the decision in question. The risk is then summarised as low, medium or high, which then guides development of a risk management plan. Before describing their unique ethical issues, there are three areas where any type of risk assessment method can come under ethical criticism. Failure to obtain consent is a basis for action in negligence as a breach of duty of care, under tort law, the law that governs civil wrongs between one individual and another. An analogous situation is the use of the exercise tolerance test ETT to assess cardiac risk.
Before an ETT, the patient undergoes a consent procedure that should enable them to make an informed decision about participation. This would be evidenced by a written consent form. In the case of a patient who lacked capacity, a best interest decision would have to be made about the risks and benefits of the procedure. A patient who fails an ETT cannot be detained in hospital even if this is in his own best interests, unless he lacks capacity.
Best Practices for Forensic Mental Health Assessments - Oxford University Press
If consent is obtained for an ETT which carries some degree of risk to health , then one may ask why consent should not be obtained in the case of violence risk assessment. The patient could be provided with information about the risks and benefits of risk assessment, and refusal to participate could be interpreted in the light of other known data. Without such a consent process, the patient might argue that an intervention done without his consent and which results in his continued detention is a tortious act, especially if it is done badly or using a tool known to be flawed.
Even if the law allows breaches of confidentiality for legal purposes e.
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Emphasis on risk and risk assessment in mental health may also breach the principle of justice fairness in terms of resources allocation. In the past 10 years, there has been a diversion of resources towards forensic mental health: Spending on healthcare has risen most in those perceived as highest risk, but this does not necessarily correlate with highest need.
Assessment of cost-effectiveness of this has not been undertaken. Szmukler 29 and others have suggested that the base rates of violence i. Table 1 shows the potential outcomes of a violence risk assessment. Clearly, the aim of accurate risk assessment is to maximise the frequency of true positive and true negative predictions. This argument cast doubt on whether any form of violence risk assessment could be carried out with sufficient accuracy.
This situation posed significant ethical challenges in the management of individual patients because it was difficult to confidently justify any restrictions as being proportionate to the risk. More recently, this pessimism has been countered by studies showing that the base rates of violence in those with mental disorder are higher than first thought, as well as by advances in statistical methods.
Technically, risk assessment instruments do predict better than chance. Their accuracy is currently based on receiver operating characteristics ROC and the area under the curve AUC which provide an index of precision.
Evaluation for Risk of Violence in Adults (Best Practices for Forensic Mental Health Assessments)
The AUC represents the likelihood of correct risk prediction with the chance level being 0. An AUC of 1. An AUC of 0. However, the base rate of violence in risk assessment remains important because of the difficulty of translating the AUC value into clinically meaningful information by itself. Numbers needed to detain is the inverse of PPV, and, like the ROC, derives from sensitivity, specificity and the base rate.
The NND rises as the base rate of violence falls. On the face of it, the NND figure of 5 compares very favourably with an analogous measure of clinical effectiveness, the number needed to treat NNT. Perhaps a fairer comparison would be the NND to prevent one act of fatal harm to others, not all acts of violence. In this instance, the NND would rise considerably from 5, due to the low prevalence of fatal harm. Therefore, base rates, if known, provide a context in which to make proportionate decisions resulting from a risk assessment.
A key challenge in psychiatry is that base rates are often not known, are low and vary for different types of violence. The issue is not unique to mental health. For example, the negative predictive value NPV of an exercise electrocardiography ECG for future cardiac events is high, meaning those predicted not to have a cardiac event will probably not have one; 34 however, the PPV is only The key ethical difference is that those deemed to be at high risk of a cardiac event are not detained in hospital to prevent that event or improve their cardiac health.
Violence risk assessment as a medical intervention: ethical tensions
Citizens are left alone to deal with their own risk as they see fit. Citizens with histories of mental illness, however, are not left to make their own decisions, but may be detained using statutory legislation. The question is then why we persist in attempts to predict risk behaviour, given the error rates?
Even though the chance of preventing one serious event is low, it could be argued that the benefit outweighs the harm done by detention based on false positives. Sign In Register Help Cart 0. Cover may not represent actual copy or condition available. Add to cart Add to wishlist E-mail a link to this book. Oxford University Press, Includes bibliographical references and index. Log-in or create an account first! Add to cart Add to wishlist. Ask the seller a question. Where can I get my book appraised?
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