An examination of violence risk communication in practice using a structured professional judgment framework

Implementation of risk assessment tools in psychiatric services

Violence remains a major risk management concern in psychiatric services with implications on the safety and well-being of patients, staff, and the public. Serious physical and psychological consequences of violence involving property damage, bodily injuries, and threat to life have been reported in mental health services. Risk assessment tools are important safeguard measures; however, research on clinical implementation is presently limited. Structured professional judgment (SPJ) risk management tools that incorporate professional discretion with analytical understanding of evidence-based risk factors are widely accepted for risk assessment. However, clinical utility is suboptimal due to several barriers, including those related to the tool, the clinical setting, and resistance from health professionals. To better understand the challenges militating against optimal implementation of risk assessment tools, we reviewed and presented some lessons from the implementation of clinical practice guidelines on a general scale and our experience implementing an SPJ tool called Hamilton Anatomy of Risk Management across a variety of psychiatric services. In summary, the clinical utility of risk assessment tools improves if the tool is psychometrically sound, concise, consensus rated, time efficient, and practical for planning risk management. User feedbacks on the tool utility are also important to sustain implementation.

Adherence to planned risk management interventions in Swedish forensic care: What is said and done according to patient records

Both structured and unstructured clinical risk assessments within forensic care aim to prevent violence by informing risk management, but research about their preventive role is inconclusive. The aim of this study was to investigate risk management interventions that were planned and realized during forensic care by analysing patient records. Records from a forensic clinic in Sweden, covering 14 patients and 526 months, were reviewed. Eight main types of risk management interventions were evaluated by content analysis: monitoring, supervision, assessment, treatment, victim protection, acute coercion, security level and police interventions. Most planned risk management interventions were realized, both in structured and clinical risk assessments. However, most realized interventions were not planned, making them more open to subjective decisions. Analysing risk management interventions actually planned and realized in clinical settings can reveal the preventive role of structured risk assessments and how different interventions mediate violence risk.

Risk assessment communication difficulties: An empirical examination of the effects of categorical versus probabilistic risk communication in sexually violent predator decisions

Expert testimony concerning risk and its communication to the trier of fact has important implications for some of the most significant legal decisions. In a simulated sexual violent predator hearing, we examined how mock jurors interpret and use recidivism risk expert testimony communicated either categorically, using verbal labels, or probabilistically, using numeric values. Based upon the STATIC-99R, we compared mock jurors' decision-making and verdicts when we manipulated the style of risk communication across four different risk levels. In terms of verdict decisions, we found that higher risk levels were associated with more commitment decisions, but that this relationship only existed for the categorical risk-communication format. We also replicated previous research demonstrating that participants overestimate recidivism risk in general, especially when higher risk is communicated categorically. Finally, our participants did not differentiate well between the four levels of risk offered, instead apparently employing a more simplistic dichotomy between "low" or "high" risk for both their verdict decisions and their thresholds for commitment. The legal and policy implications of our findings are discussed, as well as suggestions for more effective presentation of expert risk testimony.

The case against categorical risk estimates

Risk estimates can be communicated in a variety of forms, including numeric and categorical formats. An example of the latter is "low/medium/high risk." The categorical format is preferred by judges and practitioners alike, and is mandated by the most commonly utilized forensic risk assessment instruments (the HCR-20 and the Static-99). This article argues against the practice of communicating risk in categorical terms on empirical and normative grounds. Empirically, there is no consensus about what level of risk corresponds to a particular category, such as "high risk." Moreover, recent studies indicate that categorizing an otherwise continuous risk estimate does not add incremental predictive validity to the risk estimate. Normatively, categorization obscures what is fundamentally a value judgment about the relative costs and benefits of correct (e.g., true positive) and incorrect (e.g., false positive) outcomes. Such a judgment is inherently non-scientific and invades the province of the jury. Indeed, categorical risk estimates are in principle no different than "dangerousness predictions," which are simply binary and which have been denounced by the field. The fact that alternative risk communication formats have limitations does not justify continuing the pervasive practice of communicating categorical risk estimates.