The challenges of using structured risk assessment instruments in forensic psychiatric care

Background: The purpose of psychiatric forensic care is to provide treatment for mentally ill offenders and to prevent future acts of violence and other adverse events. During care, the type of restrictions of freedom, the patient’s continuous need for involuntary treatment and readiness for discharge, are continuously evaluated based on the assessment of risk the patient pose to themselves and others as well as the progress achieved with treatment. The use of structured risk assessment instruments is recommended in clinical guidelines to assess such risks. However, unstructured clinical assessments, considered to be less valid, are often used in clinical practice. There is insufficient research evidence concerning several aspects related to the clinical use of structured risk assessment instruments in terms of guiding the planning and realization of care and risk management interventions. There is also a lack of knowledge about what patients themselves perceive to be mediating factors for their use of violence. Overall aim: The overarching aim of this thesis was to investigate the implementation and use of structured risk assessment instruments to prevent violence and other adverse events in forensic settings and to improve understanding of the factors that influence such events among forensic patients. Methods: Several methods were used for data collection and data were analysed by different types of content analysis. In the first paper, a systematic review of previous research studies on implementation determinants for structured risk assessment instruments in forensic settings was conducted to investigate implementation determinants for such instruments. The second paper evaluates a pilot project of the implementation of a structured risk assessment instrument at a forensic clinic in Östergötland using focus group interviews with staff members who had used the instrument. Their perceptions of the instrument and barriers and facilitators to its implementation and clinical use were investigated. The third paper investigated the actual clinical use of structured risk assessments to guide the planning and realization of care and risk management interventions documented in forensic patients’ records. In the fourth paper, patient perspectives of factors increasing and decreasing the risk for violence were investigated by individual semi-structured interviews with forensic patients. Results: There is a wide variety of determinants for the implementation and clinical use of structured risk assessment instruments, which make such missions complicated. The determinants relate to the characteristics of the implementation object, characteristics of users, the inner setting in which the implementation occurs and the implementation process. Limiting the need to change current routines, and hence the strain on the organization by reducing complexity, and the need for resource allocation seem especially important. Most of the planned risk management interventions in structured risk assessments were realized according to patient records. However, structured risk assessments largely overlap with unstructured risk assessments in terms of planned care and risk management interventions. Noteworthy, most of the interventions realized were not documented as planned. Forensic patients described several risk factors that increased and decreased their use of violence. These factors related to themselves, external influences, social and relational aspects and situational factors. Most patient accounts of mediating factors overlapped with those listed in commonly used risk assessment instruments and previous research. Additional factors identified by patients related to the outer context and interpersonal aspects. Conclusions: There are many barriers and facilitators to the implementation and use of structured risk assessment instruments, implying the need for a multifaceted approach to address determinants at several system levels. Considering the clinical context is important when selecting a structured risk assessment instrument to be implemented, but also the complexity of the instrument, the required change of routines and the provision of continuous resources and interventions to achieve and maintain clinical use. Despite the many barriers, there is evidence of clinical use of both unstructured clinical and structured risk assessments in terms of informing and guiding care and risk management interventions. The large overlap, however, makes it difficult to draw definite conclusion about which type of assessment actually influenced the interventions that were realized. Realized care and risk management interventions are most often not documented as planned. This increases the risk of subjective decisions and provision of interventions, which also make such interventions difficult to evaluate. Forensic patients are actively managing their risk of violence and are capable of identifying and communicating many different mediating factors for their violence risk. They are knowledgeable and important stakeholders and should be involved in their own risk assessments, as well as in research