Implementation of violence risk assessments into forensic psychiatric care in Scotland

Abstract

Background. A central role of mental health professionals within the criminal justice and forensic mental health system is the assessment, management and communication of an individual’s risk of future violence (Webster & Hucker, 2007). The current methodology favoured by clinicians is the structured professional judgement (SPJ) approach (Farrington, Joliffe & Johnstone, 2008). These instruments act as guides in clinical practice in that practitioners are encouraged to apply clinical judgement on the relevance of empirically validated risk factors to each client. In this way, identified risk factors can be directly used to inform individual care and treatment, i.e. risk management. Yet, research on SPJ tools is typically based on retrospective or pseudo-prospective designs, which lack in ecological validity. Furthermore, findings are based on risk assessments completed by researchers rather than clinicians. This is an issue as risk ratings differ significantly depending on professional background (de Ruiter & de Vogel, 2004). Aims. This thesis presents five studies with the aim of examining the link between violence risk assessment and management in vivo. This includes two studies focussing on the predictive validity of SPJ tools following clinical implementation; a description of the implementation procedure; a traditional research study on the predictive power of dynamic risk factors and a pilot evaluation of a short term risk assessment tool for imminent inpatient violence. Methodology. The primary research site was the State Hospital, the high secure psychiatric facility for mentally disordered offenders in Scotland and Northern Ireland. The research population consisted of 115 male forensic patients who were followed up across different risk settings for a mean of 31 months. The SPJ instruments under investigation were the HCR-20 (Webster et al, 1997), the SVR-20 (Boer, Hart, Kropp et al, 1997) and the RSVP (Hart et al, 2003). All assessments were exclusively completed by clinicians and resulted in active risk management strategies. Additionally, the predictive validity of dynamic risk factors was examined through psychometric measures of anger, impulsivity, psychiatric symptoms, unmet needs and imagined violence. The risk of imminent violence was assessed with the Dynamic Appraisal Situational Appraisal – Inpatient Version (DASA-IV, Ogloff & Daffern, 2006). Results and Conclusions. Findings indicate that clinically implemented SPJ tools are not predictive of future violence, both within and outwith secure settings. Comparison with a previous study at the State Hospital implies that the implementation process of the HCR- 20 facilitated the knowledge transfer from assessment to management, and therefore incidents were prevented. This noted the results also highlight that clinicians may accept risk tools into practice when these have not been scientifically scrutinised. This was the case with the RSVP in that there is little published data on the psychometric properties of this tool, yet its introduction replaced the SVR-20 across the State Hospital. With regards to dynamic risk factors, the severity and chronicity of psychiatric symptoms were the strongest predictors of violence. This is further corroborated by the finding that the DASA-IV predicted violence within 24 hours of ratings provided. All findings are discussed in the context of previous research and the experienced obstacles of implementing changes within NHS settings. Clinical implications and recommendations for violence assessment and management are provided in the light of acknowledged limitations.