Introduction

This chapter examines approaches that underpin risk assessment in contemporary mental health settings. It considers the skills that support good practice in risk assessment and management for mental health nurses and supports you to identify how you may learn about risk and contribute to risk assessment and management.

Risk assessment and management

Assessing and managing risk is an important skill within contemporary mental health nursing practice. Working with risk is a key feature of mental health policy (Department of Health (DH) 1999, DH 2006). It involves recognising, responding to and working with individuals to manage their own level of risk (DH 2004). It can also involve enabling people to take risks to work towards their recovery. This chapter examines risk in the context of mental health nursing practice and uses a scenario to help you explore this critically.

Risks in relation to mental health

Risk is most commonly understood in relation to the risks posed by people with mental health problems, either to themselves through self-harm, neglect or suicide or to others through violence. Identifying and assessing such risk is supported by a variety of risk assessment tools (examined briefly under the actuarial approach below). Within modern mental health services, professionals can often feel that their clinical abilities are judged by their ability to control and manage risk (Repper & Perkins 2003). This reflects the significant role risk has come to occupy within services. In order to understand this fully, it is important to consider the social and historical position of the concept of risk.

Following the advent of community care, people with mental health problems were more present within the community. Chapter 2 recognised that public perception of people with mental health problems is often lacking in understanding. Community care further highlighted this perception towards mental illness. This was exacerbated by a number of high-profile incidents of violence perpetrated by people with mental health problems. The manner in which the media reported such incidents has been identified as perpetuating a link between violence and mental illness (Paterson & Stark 2001). This culminated in a situation where the government, media and sections of the public perceived care in the community had failed.

Following these incidents the government introduced the need to conduct an inquiry into homicides committed by someone who has been diagnosed with mental health problems. This has been criticised as further perpetuating a stereotype linking violence with mental illness. Taylor and Gunn (1999) analysed homicide statistics between 1957 and 1995 (during a growth in community care) and found that the rate of homicides committed by people with mental health problems remained stable while the overall murder rate rose. Marsden’s (2006) analysis of homicides committed by people with severe mental illness showed that these accounted for less than half a per cent of all homicides in England and Wales. This is not to deny the tragedy that each one of these statistics represents. However, it is important to critically explore where the culture of risk assessment and management in mental health arises from.

It is within this context that Care Programme Approach policy was developed, the government announced a review of the Mental Health Act and risk assessment was incorporated into mental Care Programme Approach policy. This has been perceived as fulfilling an agenda to increase surveillance and monitoring in the community (Morrall & Muir-Cochrane 2002).

A number of authors also point to the changing nature of risk within wider society. Beck (1992) suggests that we now all live in a ‘risk’ society in which risks are global and as a society we become pre-occupied with achieving safety and managing risk. Lupton (1999) also highlights how the meaning of risk has changed from previously being associated with opportunity and chance to being dominated by a view of safety and control.

For some mental health professionals the dominance of risk and concern with a perceived link between violence and mental illness has contributed to a culture of blame in mental health services. Practitioners fear that the consequences of their actions may result in a tragic event for which they are held to blame. This can contribute to defensive practice in which decisions are made based upon this fear and an avoidance of situations where people may be exposed to being able to take chances. At best this can lead to hindering the recovery journey and at worst it can lead to unnecessary deprivation of liberty and compromise of personal autonomy. The following discussion explores effective risk assessment and management and considers how this can be conducted to attempt to avoid defensive practice.

Risks to people with mental health problems

It has been highlighted that risk of violence and risk of suicide are important areas for the assessment of risk. However, these are often focused on at the expense of other risks that service users are commonly exposed to. People with mental health problems are at greater risk of poverty and unemployment than other sectors of the population (Office of the Deputy Prime Minister 2004).

There are potential risks posed in terms of social isolation, exploitation and risks posed by other service users and staff. Muir-Cochrane (2006) also examines the risk factors linked with developing physical health problems, particularly associated with schizophrenia. Chapter 2 highlighted that certain physical conditions are more common in people with mental health problems, representing increased risk to optimum physical health. There are also risks that are created by using mental health services; these are known as iatrogenic risks. The most common iatrogenic risks are the side effects and physical conditions, such as tardive dyskinesia, that may result from taking psychiatric medication. This highlights that the potential for risks associated with the experience of mental health problems are many and varied. It also recognises the need to examine the risks that the service user may be exposed to, which may fall outside the common factors highlighted in standardised risk assessment tools.

Risk assessment

Risk assessment has been defined as an examination of the context and the details of past risk incidents in the light of current circumstances. It entails the collection of information used to establish the likely occurrence of a future event and the impact and consequences of that event in terms of harms and benefits (Morgan 1998). In this respect there are two key aspects of the risk assessment process: identifying the potential consequences (the actions) and the potential likelihood of those consequences. It is important to bear in mind that risk can never be eliminated and it is very difficult to create accurate predictions for individuals (Royal College of Psychiatrists 2008). However, there is potential for practitioners and services to work in a way that helps to reduce the potential for risk.

There are two common types of risk assessment: actuarial and clinical. Actuarial approaches to risk assessment are based on statistical population information that is developed from research. They use this statistical information to make predictions in accordance with rules which are fixed (Buchanan 1999, Doyle & Dolan 2002). Risk assessment tools in mental health employ some actuarial measures. These include identifying issues such as unemployment and previous episodes of self-harm as risk factors for suicide, as population data suggest that these experiences are more common in people who have committed suicide.

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