Risk Assessment and Management in Forensic Mental Health - Essay Example

?Risk Assessment And Management In Forensic Mental Health When assessing risk, it is important to understand how an individual is shaping their life once they are incarcerated. An understanding of whether they are able to stay out of trouble once they leave incarceration must be decided by those who work with the individual outside of jail or prison. When looking at a new person coming into prison there are three ways that they can be assessed. In the beginning, the clinician would use their own structured professional judgment in looking at the individual. Secondly, they may use an assessment tool, and then they may use professional guidelines. Each of these has its own merit and used together, they can render a judgment that is more accurate than using only one method. Risk for a mental health patient generally means an assessment of whether the individual will become violent against themselves or against others. In one respect, a clinician can only make judgments about an individual based on what they have observed or what the assessment tool tells them. Unfortunately, the individual may be able to get through evaluations and still have an episode of violence. This is one of the reasons why Carroll (2007) suggests that more formalized instruments for assessing risk should be used instead of relying on programs that are developed locally. The reason this is important is because locally devised programs are often lacking in validity and reliability. Carroll points out however, that using more than one source for assessing risk is very important. Professional Judgement Laureau suggests that although structured professional judgment is used by many people, there are times when the decision must include other assessment instruments, especially when an individual has a secondary problem. In this case, the individual was Bipolar and it was found that although the professional judgement of the psychiatrist was that the individual was able to go out into the community, the fact remained that he had killed two people during a manic phase. In this situation, when the individual went to trial, it was determined (through emotional evidence by the prosecutors) that the individual should not be released, even though he was gong to be released into a community program. This information seems to indicate that if there had been more than one assessment, which looked at several issues for this particular individual, there may have been a different ruling. Unstructured professional often comes under scrutiny because it is based on a clinician's intuition and therapeutic experience with the incarcerated individual. It uses psychiatric evaluation, clinical notes and the personal experience of the person evaluating the individual. This type of assessment is still used today, although it may be the least reliable (Gowensmith, n.d.). Structured professional judgement has a combination of static and dynamic information, is flexible, and allows different scenarios to be developed. Bottom line on this is to answer the question of whether the individual is going to be safe to be released, and it has a 70% change of being correct (Gowensmith, n.d.). In addition, Bouch and Marshall (2005) suggest that structured professional judgement is useful because it supports evidence-based practice and it also is useful in "increasing the transparency of decision making for the purposes of clinical governance" (p. 85). This suggests that professional judgement is very useful, but in conjunction with other types of risk assessment. Assessment Tools There are many assessment tools that some clinicians use in order to create an understanding of risk management. The PCL-R (Psychopathy Checklist: Screening Version-Revised) is a 20 item assessment that according to Buchanan (2009) score items like alcohol abuse, separation from parents before the age of 16 and whether the individual failed on other release attempts. This seems to be a rather harsh instrument that may or may not allow for an individual to improve over time. This instrument also allows a lot of leeway for the clinician because they have to also use structured judgement in using this instrument. Two other scales, the Offender Group Reconviction Scale (OGRS) and the Level of Service Inventory Revised (LOSI-R), were reviewed by McIvor, Moodie, Perrott, and Spencer (2001). They found that the OGRS was more accurate in differentiating between those offenders who were at medium and high risk of getting into trouble again. However, the two instruments were not accurate on everything. An interesting note was that those offenders who scored high on either test had higher reconviction rates. Unfortunately, it seems that structured assessments are again, only one type of tool to use when determining whether someone will offend again. Carroll (2008) reviewed the Forensicare Risk Assessment and Management Exercise (F.R.A.M.E.) that combines three instruments: the Historical Risk Profile, the Current Risk Profile and the Crisis Plan. In using these three instruments, the clinician is able to obtain information on specific issues of risk history, general signs of signature risk, and the current risk patterns that the individual is currently showing. This instrument is more flexible than others because it gathers a large amount of information in one spot. This instrument seems to be a better way of understanding exactly what the individual is exhibiting currently and how they are developing now. It gives the clinician more information than the others and seems to be more detailed. Professional Guidelines Heilbrun, DeMatteo, Marczyk, and Goldstein (2008) suggest that clinicians should distinguish between standards of care and professional standards. They define standards of care as the rules that are handed down from the courts that say how an individual should be treated within a certain situation. Professional standards are defined as the way that things are usually done in a field and are usually created by the field rather than by the courts. The challenge is that there are no universal standards of care. According to the researchers, part of the reason this is so is because of the history of psychology and the ongoing debate between empiricism and theory in the study of assessment. Secondly, there are no real concrete definitions in psychology about forensic mental health. The third reason is that many judicial situations defer to the local definitions of what to do in forensic mental health. They suggest that defining a standard of care would be easier to work through in most situations instead of trying to find a universal way to regulate behaviour. Heilbrun, Marcyk and DeMatteo (2010) note that there are specialty guidelines for forensic mental health that state that practitioners should only work in the areas of forensics that they are trained in. The guidelines speak to the qualifications of the individual, their credentials and can only be claimed in "actual knowledge, skills, training and experience" (p. 175). Forensic mental health, like all careers have specific standards that are guidelines for practicing in this area. These guidelines as stated here are central to the individual's ability to be an effective clinician. This area also speaks to the competence of the individual. Every aspect of a profession is governed by some type of professional standards. Springer and Roberts (2007) speak to the role of forensic social workers in determining how to adhere to professional standards. One of their suggestions is for social workers to adhere to the general practice guidelines that are accepted in their area. This seems to be good advice because all regions have an understanding of what makes good practice in there area. In other words, what works for one region may not work for another. The social worker or other forensic mental health worker should understand the area in which they work from a community and a regional standard. Strengths and Weaknesses In reading about these three areas, it seems that each one has its strengths and weaknesses, and that they are very similar. The strengths of structured professional judgement include the fact that it uses the clinician's personal ideas, intuitions and observation of the individual perpetrator. They are able to assess from past and present behaviour as to whether the person is at risk of hurting themselves or others when they leave incarceration. This method seems to consist of checklists that can help the clinician make a decision. Unfortunately, the structured professional judgment also falls under scrutiny because every individual clinician can decide something different. In other words, there is no way to measure how reliable or valid the information coming form this type of assessment is and the information can be different from each person. The structured assessment is better than the unstructured assessment but it still has challenges because human error can be a part of the information brought forth. Also, this assessment is largely based on the intuition and opinion of the clinician which may have bias if the perpetrator is not well liked. A likability factor is not a scientific way of understanding behaviour. Assessment provides a little stronger understanding of risk assessment but often it is used as a way to determine structured professional judgement. A major weakness is that many of these assessments are checklists where the clinician can go down the list and make a determination (hopefully based on a set of criteria) as to whether the individual is at risk or not. Again, they are based on behaviour and the fact that the clinician must understand how to use the instrument and in what context it should be used. There are generally no scientific determinations of how to score the instrument so it is a set of criteria that the clinician sets up. A strength of the assessment is that it is a checklist and it can give a more uniformed way of looking at the perpetrator's behaviour. All people working with the perpetrator could fill out a checklist and the notes could be compared before a determination of risk was entered. Many clinicians use professional guidelines to understand what to do in various situations. The weaknesses of only using professional guidelines is that they may not all be the same across the board. As an example, many professions have professional organizations in each region and the region makes standards a certain way. As stated before, there are no universal standards to go by so it really depends on what people decide in each region as the "best practices" for that region. Strengths include that there is a standard of guidelines so if a clinician does not understand what to do in a situation, they can always go back and look at the written standards. The conclusion that this researcher has come to is that all of the ways to assess risk are valid, but each one should be a part of a clinical decision for anyone who has been incarcerated. This will insure a better overall judgment. References Bouch, J., and Marshall, J.J. (2005). Suicide risk: structured professional judgement. Advances in Psychiatric Treatment, 11. 84-91. doi:10.1192/apt.11.2.84 Retrieved from http://apt.rcpsych.org/cgi/reprint/11/2/84 Buchanan, A. (2009). Violent offenders, appraising and managing risk, treating violence: A guide to risk management and mental health and violence risk, assessment and management. Book Reviews. The Journal of American Academy of Psychiatry and the Law 37, 3. Carroll, A. (2008). Risk assessment and management in practice: the Forensicare Risk Assessment and Management Exercise. Australasian Psychiatry, 16 (6), 412-417. doi: 10.1080/10398560802068942 Carroll, A. (2007). Are violence risk assessment tools clinically useful? Australian & New Zealand Journal of Psychiatry, 41 (4), 301-307. doi: 10.1080/00048670701213237 Gowensmith, N. (n.d.) Current practices in assessing risk for violence. Adult Mentla Health Divison/Hawaii. Retrieved from http://www.nasmhpd.org/general_files/publications/Hospital%20CEO%20Toolkit /Updated%20PDF%20Toolkit/4.4%20Hawai%E2%80%99i%20Current%20Pract ices%20in%20Assessing%20Risk%20for%20Violence.pdf Heilbrun, K., DeMatteo, D., Marczyk, G., and Goldstein, A.M. (2008). Standards of practice and care in forensic mental health assessment: Legal, professional, and principles-based consideration. Psychology, Public Policy, and Law, 14 (1) 1-26. doi: 10.1037/1076-8971.14.1.1 Heilbrun, K., Marcyk, G.R. and DeMatteo, D. (2010) Forensic mentall health assessment: a casebook. NY: Oxford University Press. Available from http://books.google.com Lareau, C.R. (2007). Violence risk assessment in release decisions for NGRI aquittees: Awareness of practical realities. Journal of Forensic Psychology Practice, 7 (3). 113-124. doi: 10.1300/J158v07n03_08 McIvor, G., Moodie, K., Perrott, S., and Spencer, F. (2001). The relative effectiveness of risk assessment instruments. Scottish Executive Central Research Unit Social WorkResearch Findings No. 40. Retrieved from http://www.scotland.gov.uk/Resource/Doc/158106/0042772.pdf Springer, D.W., and Roberts, A.R. (2007). Handbook of forensic mental health with victims and offenders: assessment. NY: Springer. Available from http://books.google.com Read More