What are risk assessments in the mental health field?

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
surprising 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 variety 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 Beck Depression Inventory II (BDI-II).

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