However, the two groups of wards were not matched for levels of violence before the trial and after the intervention the incidence of violence in the experimental wards returned to the level of the control wards, suggesting that the results obtained were a result of regression to the mean rather than a true effect. Reference Abderhalden, Needham, Dassen, Halfens, Haug and Fischer9 This study reported a significant reduction in violence in the experimental wards. The one exception to this is a cluster-randomised trial of nine psychiatric wards that examined violence for 3 months after the adoption of structured risk assessment. Reference Langan24 The empirical arguments against risk assessment include the near complete absence of published evidence that the adoption of risk assessment can result in a reduction in any form of harm.
Reference Ryan21, Reference Large, Ryan, Nielssen and Hayes22 Another ethical problem with risk assessment is the way it devalues patients by underestimating their capacity for choice Reference Mossman23 and alienates them from participating in decisions about their own care. Reference Mossman16- Reference Szmukler20 Ethical arguments against risk assessment include the potential for the denial of care to those classified as at low risk Reference Large, Nielssen, Ryan and Hayes7 and the discriminatory treatment of people who have been categorised as being at high risk but do not go on to cause or experience harm. Statistical arguments note the lack of accuracy of predictions and highlight both the high rates of false-positive predictions for most forms of harm and the failure to identify many cases. Reference Hendin, Al Jurdi, Houck, Hughes and Turner13- Reference Hockberger and Rothstein15Ĭriticisms of risk assessment have been made on statistical, ethical and empirical grounds. 2- 4 Assessing whether an individual is likely to harm themselves or others is part of the mental health law in most high-income countries, Reference Anfang and Appelbaum5- Reference Large, Nielssen, Ryan and Hayes7 and the routine use of structured instruments to estimate the probability of future harm, often referred to as actuarial methods, are widely believed to be a way of reducing the incidence of violence Reference Roaldset, Hartvig and Bjorkly8- Reference Carroll12 and self-harm.
#Risk probability loss who developed professional
The ability to assess risk is regarded as an essential skill for mental health practitioners Reference Weisman and Lamberti1 and the practice guidelines issued by governments and by professional bodies suggest that we are able to predict and prevent many forms of harm. The term ‘risk assessment’ is used in a variety of ways, from the opinion of an experienced clinician about dangerousness to the use of a score derived from a checklist of factors associated with a range of harmful behaviours, particularly violence to others or suicide. The aim of risk assessment is to identify individuals who are at greater risk of harm and provide those patients with a higher level of treatment and supervision, thereby reducing the incidence of harm. We should admit that our ability to assess risk is severely limited, and make clinical decisions in a similar way to those in other areas of medicine – by informed consideration of the potential consequences of treatment and non-treatment.Īssessment of the probability of future harm, often referred to as a ‘risk assessment’, has been widely adopted in mental healthcare settings in an attempt to reduce the incidence of violence and self-harm. The inability of instruments to distinguish between the risk of common but less serious harms and comparatively rare catastrophic events is a particular limitation of the value of risk categorisations. Although assessments of the probability of future harm based on actuarial instruments are generally more accurate than the categorisations made by clinicians, actuarial instruments are of little assistance in clinical decision-making because there is no instrument that can estimate the probability of all the harms associated with mental illness, or estimate the extent of the resulting losses. However, risk assessment in its current form is mainly concerned with the probability of adverse events, and does not address the other component of risk – the extent of the resulting loss. Risk assessment has been widely adopted in mental health settings in the hope of preventing harms such as violence to others and suicide.
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