Risk assessments in the mental health field
Risk assessments in the mental health field are evaluations conducted by mental health professionals to estimate the likelihood of specific behaviors or events, such as suicide or violence, occurring within a designated timeframe. These assessments are crucial for informing treatment decisions and managing safety in both clinical and forensic settings. The two main types of risk assessments are clinical and actuarial. Clinical assessments rely on interviews and observations, but research indicates that they can be less reliable than desired. In contrast, actuarial assessments utilize standardized instruments and statistical models, allowing for a more evidence-based approach to predicting risk based on both static factors (e.g., gender) and fluid factors (e.g., substance use). Studies like the MacArthur Violence Risk Assessment Study have contributed to understanding the complex relationship between mental health and violence, revealing that certain historical and psychological factors can indicate future risk. Additionally, assessing the risk of suicide is particularly challenging, with limited accuracy in prediction methods. Despite ongoing research and the development of various assessment tools, many clinicians still base their judgments on clinical interviews and self-reported information, highlighting an area in need of continued improvement and innovation.
Subject Terms
Risk assessments in the mental health field
- TYPE OF PSYCHOLOGY: Psychopathology; psychotherapy
Risk assessments are tests conducted by professionals to determine the likelihood of a specific event or behavior occurring or reoccurring during a specified time period. Most risk assessments are made by experts in mental health or criminal justice.
Introduction
Risk assessments are conducted by a variety of specialists within their respective fields of mental health. The primary reason for a risk assessment is to offer a qualified professional opinion as to the probable rate of risk for a specific event or behavior occurring or reoccurring during a certain time period.
Although the need for a risk assessment can arise in any area of human services, it is most common in the areas of mental health and criminal justice. A common area of inquiry in mental health, for example, might revolve around knowing a client’s risk for suicide or violence. In criminal or juvenile justice, for example, a parole board might be interested in a prospective parolee’s risk of recidivism.
Types of Risk Assessment
In the field of mental health, there are primarily two types of risk assessment: clinical and actuarial. Clinical risk assessment is the older of the two types of assessment. A mental health professional conducts an interview with and observes the subject, then makes a prediction of risk based on the professional’s experience working with similar individuals. Unfortunately, research has shown that basing a risk assessment simply on an interview and observations is not much more accurate than making a guess. In forensic settings (jails, prisons, hospitals for the criminally insane, locked units in general hospitals) especially, clinical risk assessments have often been very inaccurate.
Actuarial risk assessment has developed out of the need to make risk assessment more accurate and predictive. It involves the use of valid and reliable risk assessment instruments and statistical models to predict the likelihood of a future event. The best of these instruments examine the static and fluid risk factors associated with the probability of repeating a behavior. Static risk factors (for example, gender and race) are those that do not change, and fluid risk factors (for example, substance use) are those that change. A wide variety of risk assessment instruments can be used, depending on the question to be answered.
A good actuarial risk assessment instrument has been standardized and empirically validated based on a sample population that mirrors the target population. The instrument should have validity scales. In a forensic setting, there are a variety of commonly used risk assessment instruments available to practitioners. Some of these instruments are appropriate for a general offender population: the Psychopathy Checklist-Revised (PCL-R), the Violence Risk Appraisal Guide (VRAG; which can also be used with sexual offenders), and the Historical Clinical Risk Management scale (HCR-20).
A number of risk assessment instruments have been especially designed for use with sexual offenders, including the Rapid Risk Assessment of Sexual Offense Recidivism (RRASOR), Static-99, Sex Offender Need Assessment Rating (SONAR), and Minnesota Sex Offender Screening Tool-Revised (MnSOST-R).
Risk assessment instruments have also been developed for use with the general juvenile population and the juvenile sex offender population. These include the Juvenile Sex Offender Assessment Protocol (J-SOAP), the Estimate of Risk of Adolescent Sexual Offender Recidivism (ERASOR), the Youth Level of Service/Case Management Inventory (YLS/CMI), the Structured Assessment of Violence Risk in Youth (SAVRY), the Psychopathy Checklist: Youth Version (PCL:YV), and the Child and Adolescent Functional Assessment (CAFAS).
MacArthur Study
The MacArthur Violence Risk Assessment Study was a groundbreaking study of the risk of violence in a mental health population. The study was conducted between 1992 and 1995, and initial findings were published in 1998. The study led to the conclusion that discharged mental patients as a whole were not more likely than the general population to become violent. (Since the initial study was conducted, the original data has been further analyzed by a number of researchers.)
The MacArthur study also identified risk factors associated with and predictive of violence in the community after release. The study concluded that prior violence, seriousness and frequency of having been abused as a child, a diagnosis of substance abuse, hallucinations of voices commanding a violent act, persistent daydreams and thoughts of violence, and high levels of anger were all associated with future violence.
From the study, the first violence risk assessment software, the Classification of Violence Risk (COVR) was developed and released in 2005. This interactive software measures forty risk factors to determine the risk of a patient’s becoming violent.
Suicide Risk
Although risk assessment for possible violence or repeat offending behavior presents many challenges, risk assessment for suicide is even more complex. Some researchers have stated that it is almost impossible to predict suicidal behavior with any great accuracy, and many suicide assessment instruments and psychological tests have not proven to be very useful. Most clinicians make a judgment of suicide risk based on a clinical interview and observation. Yet, like all risk assessments based on clinical interviews, these assessments are not reliably accurate.
Many of the available suicide risk assessment instruments are not theoretically based. Studies have looked at risk factors (such as depression) and risk mediators (such as moral objections against suicide and strong social support), yet many clinicians use self-reported suicidal ideation (thoughts of suicide) and previous attempts as predictors of future suicidal behavior.
A few instruments have been noted as being valuable to use with a student population. These include the Suicide Probability Scale (SPS), the Self-Reporting Depression Scale (SDS), the Suicidal Behaviors Questionnaire (SBQ), the Reasons for Living Inventory (RFL), and the Multi-Attitude Suicide Tendency Scale (MAST). Several have been successfully used with adult populations, including the Suicide Probability Scale (SPS), the Adult Suicidal Ideation Questionnaire (ASIQ), the Beck Scale for Suicide Ideation (BSI), and the II (BDI-II).
As rates of suicide rose significantly in the early twenty-first century, researchers continued to search for improved ways to predict deaths by suicide in high-risk patients.
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