week 2/3 - assessment and management of risk

• Risk


  • Chance or odds, unrelated to danger
  • Hazard or danger: any negative outcome
  • Combined measure of chance and negative outcome: the product of the probability of the event and a measure of the impact of the event
• Risk factors


  • Personal characteristic or contextual circumstance which causes or facilitates a negative event
  • Static: unchangeable historic factors
  • Dynamic: changeable over time
  • Chronic/stable - usually change only slowly
  • Acute - change rapidly and can act as triggers
• Actuarial approach to risk assessment

  • Mathematical means of combining risk factors to offer a prediction
  • Can be cumbersome, thus most widely used in research
  • Due to the low prevalence of predicted outcomes, risk factors have low predictive value even in high-risk groups
  • Predictive capacity only applies when a patient comes from the same population on which the tool was developed
  • The emphasis on unchangeable static risk factors can limit clinical usefulness
  • Tend to ignore less common risk factors and don't account for the inevitable uncertainty of an individual behaviour
• Unstructured clinical approach to risk assessment


  • Information about risk factors is collated and interpreted through personal judgment (including their 'gut feeling') by a clinician
  • A measure of the clinicians strength of belief in the presence or absence of particular risk factors
  • The lack of structure means that important factors may be missed
  • Notoriously overestimates the degree of risk
• Structured professional judgement approach to risk assessment


  • Clinician makes a judgement about risk on the basis of combining: A structured pro forma based on risk factors derived from research, and Clinical experience and knowledge of the service user
  • Although derived from research evidence, the clinician's discretion is seen as a vital element – especially with formulation and subsequent risk management plan
  • Offers the most potential where risk management is the objective
• The outcome of risk assessment was traditionally expressed in binary terms - either 'high' or 'low' risk
• The assumption that patients can be accurately described as low or high risk is false: uncertainty is a defining feature of risk
• Assessment has moved away from binary classification to acknowledging intermediate risk levels
• Tips for gathering a risk history


  1. Consider whether you and your colleagues are safe

  2. Gain consent for the risk assessment

  3. Maintain a focus regarding the purpose

  4. Prepare - gather information from as many reliable sources as possible

  5. Be empathic - therapeutic engagement make assessment more accurate

  6. Include a patient's narrative about their own risk

  7. Be curious and comprehensive - think about what you don't know

  8. Where there is a substance misuse, always enquire about violence

  9. Identify any treatable conditions that are present

  10. Involve the service user and carers/relevant others - where appropriate

  11. Consider goals and motivation to change
• Risk formulation


  • To bring together an understanding of personality, history, mental state, environment, risk factors and protective factors
  • To take into account the dynamic nature of risk, specifically factors likely to increase or mitigate it, as well as signs that indicate increasing risk
  • It should provide answers to: How serious is the risk? How immediate is the risk? Is the risk specific or general? How volatile is the risk? What are the signs of increasing risk? Which specific treatment, and which management plan, can best reduce the risk?
• Five P's of risk formulation


  • Presenting problem
  • Predisposing factors
  • Precipitating factors
  • Perpetuating factors
  • Protective/positive factors
• Risk management


  • Strategies aimed at preventing a negative event from occurring or, if this is not possible, minimising the harm caused
  • Risk cannot be eliminated, but it can be assessed and managed
  • Risk assessment without risk management has no value
  • Having identified risk, clinicians have a responsibility to take action to mitigate it
• Risk can change – sometimes over very short timescales, especially with dynamic risk factors such as relationship issues or alcohol use
• Risk management is an ongoing process, involving regular planned assessments and the flexibility for an earlier review if required
• Possible interventions for risk management


  • Trusting therapeutic relationship
  • Medication
  • Psychological interventions
  • Interventions for substance or alcohol misuse
  • Opportunities for social recovery
• Interventions should take account of any special needs that the patient has e.g. language barriers, physical problems, intellectual disability
• Carers and family should be offered support
• Recognising strengths/protective features


  • Risk management is a collaborative process
  • Protective factors as well as risk factors
  • Strengths can reduce symptomatology and increase resilience
  • Strengths can be utilised to mitigate risk
  • Identification of strengths can increase therapeutic optimism and contribute to a positive therapeutic relationship
• Positive risk management


  • Acknowledge that risk can never be completely eliminated
  • Overdefensive practice is bad practice: avoiding all risk can be counterproductive in the longer term
  • Positive risk management will weigh up the potential costs and benefits of choosing one action over another
  • Positive risk management will ensure that the service user, carer and others who might be affected are fully informed of the plan and the reasons
  • As long as a decision conforms with relevant guidelines; is based on the best information available; is documented; and the relevant people are informed- it will be the best decision that can be made at the time
• Safety first


  • Circumstances will arise when risk management is dominated by immediate concerns about the safety of the patient or other
  • Where risk is associated with mental disorder or impaired capacity, clinicians may have to take decisions on behalf of the individual to protect the person or others
  • The use of the Mental Health Act may be part of the most appropriate risk management strategy at such times
  • A collaborative approach based on the principles of positive risk management is still the aim, but clearly will require special efforts in the early stages
• Information sharing


  • Risk management plans should be clearly and comprehensively recorded
  • Communicating the management plan with others is essential
  • Consider what information should be shared and with whom
  • Know your local information-sharing agreements
  • Relevant professionals to inform may include: GPs, substance-misuse services, specialist mental health teams, social services, forensic and offender teams, safeguarding teams, police, multi-agency public protection arrangements (MAPPA), multi-agency risk assessment conference (MARAC)
• Summary/Key take home messages

  • The assessment and management of risk is an important part of psychiatric practice
  • Risk is the product of the negative impact of an event and its probability
  • A 'structured professional judgement' approach is recommended for risk assessment
  • Risk formulation helps us understand 'why this person is presenting with this risk at this time' and what interventions may be best to mitigate the risk
  • Risk management is a collaborative process, recognising strengths and should take a positive risk management approach
  • However safety of the service user and society is paramount and in some circumstances legal frameworks such as the Mental Health Act may be required