Risky business

Providing up to date risk assessments of mental health service
users is second nature to staff in this field. But few question the
nature of the procedure despite often unjustified media criticism
of mental health workers for their perceived failure to protect the
public against violent clients.

For a picture of how risk assessments are carried out, we
examined seven community mental health teams across England and
Wales. There were substantial regional variations. Most used a tick
box to rate their clients on a scale but the risk categories were
not all the same. Despite the availability of formal risk
assessment tools, staff were often directed to use tools created by
their employers. Consequently, in multi-disciplinary teams various
forms were in use as each specialism undertook its own
assessment.

Worryingly, in forensic teams – usually those with the most
risky clients – the most renowned tool is the Hare psychopathy
checklist.¹ This has been criticised for its lack of
attention to an individual’s motives, which can be the most
predictive clinical variable.² In addition, there are
many variables associated with possible violence, such as being
young, male and abusing alcohol or drugs. Clearly, some mental
health users are in this category although they may also have
psychotic symptoms such as hallucinations where voices order people
to carry out violent acts. But, in reality, clients are likely to
have only a few risk factors as a result of their illness. Others
derive from social circumstances and personality.

Mental health inquiry findings emphasise that there should be no
short cuts in risk assessment, which should include a patient’s
background, present mental state, social functioning and past
behaviour. This takes significant time if carried out properly and
has massive resource implications – it is not simply a matter of
formalising good practice.³ But none of the teams had
any extra resources, leaving risk assessments to be tagged on to
the work already completed. They were likely to be rushed and
inadequately made; those that were completed well were done so to
the detriment of other interventions.

Also, in five of the teams there were wide variations in what
happened or was supposed to happen once an assessment had been
completed. Usually, the form took pride of place at the front of a
client’s file, but this was often all that would be done. Each team
had a different approach, and within these there were different
plans designed by each worker. This lack of standardisation is a
concern in itself.

Another feature identified was a belief that an up-to-date
assessment was a means of “covering your back”, although failure to
carry out any part of the risk plan could still be deemed
negligent. This raises a question about whether staff would choose
not to develop plans at all for fear of being unable to carry them
out later. This was compounded by the fact that some staff felt
that assessments and plans were out of date as soon as they were
completed.

It is obvious that major problems exist in relation to staff
attitudes to the whole process of risk assessment, with many
feeling that the process is used mainly to keep tabs on clients who
have a history of violence. Should we not be as concerned about the
service we offer to all our clients, no matter how vulnerable they
are?

Another point of concern is clients’ human rights. Many teams
did not discuss their risk assessment with the client. This is not
only a major flaw in building a therapeutic relationship with the
client, but also denied clients a right to know how their carers
viewed their behaviour. Most risk assessments are formulated via a
process of “Chinese whispers” and allowing the client to tell you
their version of events may lead to more enlightened
practices. 

Recommendations

– All risk assessments should be multi-disciplinary. 

– Regular reviews of all assessments.

– Assessments should be carried out in co-operation with client
and carer.

– Implementation should not be the responsibility of one
worker. 

– Management should ensure that all staff are aware of the risks
posed by clients.

– Record-keeping of risk should not just consist of ticking
boxes.

Lance Carver is an approved social worker and Mike
Lehane is a community psychiatric nurse in a community mental
health team in south Wales.

References

¹ R Hare, Manual for the Hare Psycopathy
Checklist – Revised, Multi-health Sysytems, 1991

² G Andrews and R Jenkins,
Managing Mental Disorders, Volume 2, World Health
Organisations, 2000

³ R Grounds, ” Risk management in clinical
context” in J Crichton (ed) Psychiatric Patient Violence – Risk
and Response, Duckworth, 1995