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Dr Paul Rogers RMN, PG Cert ENB 650 (CBT), PG Dip (CBT), MSc (Econ), PhD, MRCPsych (Hon), M.EWI, M.ISRA CBT Therapist and Medico Legal Expert Witness

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Presentation on theme: "Dr Paul Rogers RMN, PG Cert ENB 650 (CBT), PG Dip (CBT), MSc (Econ), PhD, MRCPsych (Hon), M.EWI, M.ISRA CBT Therapist and Medico Legal Expert Witness"— Presentation transcript:

1 Dr Paul Rogers RMN, PG Cert ENB 650 (CBT), PG Dip (CBT), MSc (Econ), PhD, MRCPsych (Hon), M.EWI, M.ISRA CBT Therapist and Medico Legal Expert Witness Paul@drpaulrogers.co.uk

2 What is “risk assessment” within mental health What “risks” are we trying to “assess” How have we tended to do it How good are we (Judgement vs Actuarial vs Structured) What are the main guidelines that inform practice What are the issues with such guidelines 10 Considerations of an expert when examining risk assessment

3 Psychiatric Risk Assessment involves the – 1.Specification of the behaviour of concern 2.Estimation of the probability that the behaviour will occur……. and under what circumstances (over a given time period) 3.Determination of the potential damage or harm from the behaviour Scott (1977)

4 Historically:- Violence Suicide Self Harm In last 5-10 years:- Self Neglect Disengagement with Services Exploitation by others

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6 Probability measure is a measure likeliness …………………of the likeliness ……………….…………….………that an event.............................................................will occur And here lie the issues!

7 Version 1: “The very basic version” YESNO YESNO Risk of Violence√ Risk of Suicide√ Risk of Self-harm√ Risk of X√ Risk of Y√

8 Version 2: “Only a little bit better than the very basic version” RATING Risk of Violence0 Risk of Suicide2 Risk of Self-harm4 Risk of X1 Risk of Y2 0=None; 1=Slight; 2=Moderate; 3=High; 4=Severe

9 Version 1 & 2 – (meaningless) RATING Risk of Violence Risk of Suicide√ Risk of Self-harm√ Risk of X Risk of Y 0=None; 1=Slight; 2=Moderate; 3=High; 4=Severe

10 Probability measure is a measure likeliness …………………of the likeliness ……………….…………….………that an event.............................................................will occur Likeliness is a JUDGEMENT! Here lies the issue - Likeliness is a JUDGEMENT!

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12 “Linda is 31 years old, single, outspoken and very bright. She majored in philosophy. As a student, she was deeply concerned with the issue of discrimination and social justice, and also participated in antinuclear demonstrations. Which of the following is more probable: 1. Linda is a bank teller 2. Linda is a bank teller and is active in the feminist movement Tversky and Kahneman (1974)

13 Which of the following is more probable: 1. Linda is a bank teller 2. Linda is a bank teller and is active in the feminist movement

14 The LINDA test is a famous experiment, the results of which provided a significant contribution in the field of probability judgment. The conclusion being that: Generally humans tend to argue irrational or biased (by personal, societal, or cultural) reasoning.

15 Steadman & Cocozza (1974; 1976) Baxtrom study

16 Johnnie K. BAXSTROM v. HEROLD (US SUPREME COURT NEW YORK 1966) Baxstrom was a prisoner in a prison in a psychiatric hospital Civilly committed at end of his sentence to a hospital Left in hospital even though his sentence had ended and he had no release / discharge date. Writs were dismissed, transfer requests denied Supreme Court ruling: Commitment beyond term without judicial review violated his rights He should be released Other civilly committed patients in prisons had right to hearing

17 Steadman & Cocozza (1974; 1976) & the Baxtrom study As a result of the Baxtrom ruling, 966 detained patients in New York Maximum Security Hospital were released. All were considered a high and immediate risk to others / society Of interest, Steadman & Cocozza followed all 966 up after 4 years and examined their reconvictions……..

18 Steadman & Cocozza (1974; 1976) & the Baxtrom study, 4 years on:- ONLY 20% had been reconvicted of any offence ONLY 2% had been reconvicted for a violent offence!

19 Steadman & Cocozza (1974; 1976) & the Baxtrom study. Prior to release - All 966 were being detained due the immediate danger they posed to others! The findings cast ………………. “serious doubt on the ability of clinicians to predict dangerous behaviour at all”

20 1. Generally speaking, clinicians are poor at predicting risk and shouldn’t be relying on their clinical opinion alone to predict risk. Yet they repeatedly do! 2. Furthermore, research repeatedly shows that when we try to predict risk based upon specific psychiatric factors (e.g., depression, command hallucinations, delusions, etc.) these can be very poor predictors of risk and therefore cannot be relied upon

21 Humans are bad at it Too many variables to weigh up. Not knowing how to weight the variables Tendency to weigh bizarre and unusual factors heavily and neglect everyday but important factors (gender). Professions “slow to revise their judgement despite a mounting body of evidence” (Munro, 1999). Our experience is usually blind to outcomes

22 Scores on risk instruments Violent index offense Poor employment adjustment Index sex offense Hx juvenile delinquency Psychosis Adult criminal history Mood disorder Dysfunctional family background Intelligence -. Antisocial personality disorder Age Hospital admissions Violent offense history Poor Institutional adjustment Single Clinical judgment Substance abuse problems Scores on risk instruments Violent index offense Poor employment adjustment Index sex offense Hx juvenile delinquency Psychosis Adult criminal history Mood disorder Dysfunctional family background Intelligence -. Antisocial personality disorder Age Hospital admissions Violent offense history Poor Institutional adjustment Single Clinical judgment Substance abuse problems Positive associationNo association

23 Overwhelming evidence that we can not predict future risk using our professional judgement We need to turn to techniques that can help us These techniques should be proven by controlled experimental studies

24 Based upon statistical formula to quantify the likelihood of a negative outcome occurring Avoids rater bias Does not need any clinical skills Fast

25 Don’t take into account individual circumstances. e.g. ignores “rich” case specific information (e.g., previous violence, self harm or suicide may have been due to untreated psychosis) They are static factors that do not change or do not change easily (being male, historical suicide attempts, where you live). “unchangeable” They provide no advice on how to manage risk as the factors are largely “unchangeable”

26 Source: World Health Organization (WHO) Actuarial factors in predicting suicide

27 1.Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care (NICE, 2004) http://publications.nice.org.uk/self-harm-cg16 * http://publications.nice.org.uk/self-harm-cg16 2.Self-harm: Longer term management (NICE, 2011) http://www.nice.org.uk/guidance/cg133 http://www.nice.org.uk/guidance/cg133 3.Violence: The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments (NICE, 2005) http://guidance.nice.org.uk/CG25 http://guidance.nice.org.uk/CG25 4.Best Practice in Managing Risk: Principles and evidence for best practice in the assessment and management of risk to self and others in mental health services (DoH, 2007) http://www.nmhdu.org.uk/silo/files/managing-risk-best-practice.pdf * http://www.nmhdu.org.uk/silo/files/managing-risk-best-practice.pdf

28 Self-harm: longer term management (NICE, 2011 ) Self-harm: longer-term management Implementing NICE guidance November 2011 NICE clinical guideline 133

29 Self-harm: longer term management (NICE, 2011) – Background Self-harm does not often result from the wish to die. Those who self-harm may do so to communicate, to secure help and care or to obtain relief from an overwhelming situation. Service provision for self-harm is varied. About half of those presenting at an emergency department after an incident of self-harm are assessed by a mental health professional.

30 Health and social care professionals should: Be trained in the assessment, treatment and management of self-harm, and Be educated about the stigma and discrimination usually associated with self-harm and the need to avoid judgemental attitudes. Have routine access to senior colleagues for supervision, consultation and support should be provided for professionals who work with people who self-harm. Self-harm: longer term management (NICE, 2011) - Training

31 Self-harm: longer term management (NICE, 2011) - Risk assessment: 1 When assessing the risk of repetition of self-harm or risk of suicide, identify and agree the person’s specific risks, taking into account: methods and frequency of current and past self- harm current and past suicidal intent depressive symptoms any psychiatric illness the personal and social context and any other specific factors preceding self-harm.

32 Self-harm: longer term management (NICE, 2011) - Risk assessment: 2 Also take into account: specific risk and protective factors that may increase or decrease the risks associated with self-harm coping strategies significant relationships that may either be supportive or represent a threat immediate and longer-term risks.

33 Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm. Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged. Risk assessment tools may be considered to help structure risk assessments as long as they include the areas identified in recommendation 1.3.6 Self-harm: longer term management (NICE, 2011) - Risk assessment tools and scales

34 Do not use risk assessment tools and scales to predict future suicide or repetition of self- harm. In 2011, there were 11.8 per 100,000 From a research and risk prediction perspective, they are - “Too Rare to be Usefully Predicted” Self-harm: longer term management (NICE, 2011) - Risk assessment tools and scales

35 Best Practice in Managing Risk: Principles and evidence for best practice in the assessment and management of risk to self and others in mental health services http://www.nmhdu.org.uk/silo/files/managing-risk-best-practice.pdf

36 Identifies six potential evidence based tools for suicide or self harm Two are actually tools for assessing pre and post training outcomes and not risk assessment tools! The four left are – 1.The Beck Hopeless Scale (BHS) 2.Sad-persons (SP) 3.Suicidal Intent Scale (SIS) 4.Scale for Suicidal Ideation (SSI)

37 TOOLEVIDENCE BASE BHSThere is an extensive international evidence base including testing of the tool’s structure and support for hopelessness as a risk factor for completed suicide. Some of the available evidence is derived from the UK. SPThe available evidence is based on American samples and indicates that the tool is adequate as one part of an overall assessment. One review has criticised the lack of evidence indicating acceptable reliability and validity. There is a lack of evidence based on UK samples. SISAn American review concluded that the SIS score was not a risk factor for completed suicide over several years among in-patients hospitalised for attempted suicide. There is a lack of evidence based on UK samples. SSIA major American review Found evidence of an association between scores on the interview (but not the self report) version of this scale and completed suicide in outpatients. There is a lack of evidence based on UK samples.

38 NICE explains, in a document on the legal context of its guidance (2004) that: "Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgment. However, NICE guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian/carer". Thus, while professionals have a duty to be "familiar with relevant guidelines and developments that affect your work" (GMC, Good Medical Practice, paragraph 12) this does not mean that they cannot depart from guidance in specific situations when they consider it is in the patient’s interests to do so.

39 The MDU guidance on guidance! “You must be prepared to explain and justify your decisions and actions, especially if you depart from guidelines produced by a nationally recognised body, such as NICE. It is also important to keep a record of the reasons for your decision and your discussions with the patient”. http://www.themdu.com/learn-and-develop/case-studies/must-doctors-comply-with- guidelines#sthash.Kkh0Zrna.dpuf

40 Anyone experiencing mental health problems is entitled to an assessment of their needs with a mental healthcare professional, and to have a care plan that's regularly reviewed by that professional. Someone might get CPA support if they: are diagnosed as having a severe mental disorder are at risk of suicide, self harm, or harm to others tend to neglect themselves and don't take treatment regularly Are vulnerable. This could be for various reasons, such as physical or emotional abuse, financial difficulties because of their mental illness or cognitive impairment have misused drugs or alcohol have learning disabilities rely significantly on the support of a carer, or have their own caring responsibilities have recently been detained under the Mental Health Act. have parenting responsibilities have a history of violence or self-harm

41 What CPA should provide It's recommended that the person who needs CPA support is involved in the assessment of their own needs and in the development of the plan to meet those needs. There should be a formal written care plan that outlines any risks and includes details of what should happen in an emergency or crisis. A CPA care co-ordinator should be appointed to co-ordinate the assessment and planning process. The co-ordinator is usually a nurse, social worker or occupational therapist. The care co-ordinator should also make sure that the care plan is reviewed regularly. A formal review is made at least once a year. The review will consider whether CPA support is still needed.

42 1.What were the patient’s known risks? How recent were they? 2.What do the organisations policies say should be done? 3.Is risk within the CPA policy? Or standalone? If standalone, how do the 2 policies compare and contrast? Are there any contradictions? 4.What do the policies say should happen? Were the policies reasonable? When were they last updated? Was this when they should have been updated? 5.Were the policies followed? 6.Did staff have the necessary training? What training did they have? How was this recorded? Are there records of training attendance available for the person conducting the risk assessments? How often should such training be refreshed? Did this happen? 7.How was the risk assessment recorded? Was it recorded correctly? Was it completed at the times that it stated it should have? 8.Was the assessment of risk accurate and reasonable given what was known about the patient at that time? If not, how did it falter? 9.Was a plan to manage those risks developed? By whom? Was it reasonable? Was it followed? Was it recorded properly? 10.Why did the event happen? Was the risk reasonably foreseeable?

43 Dr Paul Rogers RMN, PG Cert ENB 650 (CBT), PG Dip (CBT), MSc (Econ), PhD, MRCPsych (Hon), M.EWI, M.ISRA CBT Therapist and Medico Legal Expert Witness Paul@drpaulrogers.co.uk


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