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Risk assessment as collective clinical judgement
1South London and Maudsley NHS Trust, Department of Forensic Psychiatry, London, UK. Drdjmurphy@aol.com
Introduction:
Risk assessment occupies an increasingly important position in psychiatry. This paper contends that collective judgement is the optimal method of assessing risk.
The Meaning Of Risk:
Risk has a dual meaning: emotional and judgemental.
Risks Faced By Staff:
Assaults, threats and survival anxiety.
The Effects Of Danger On The Group:
Staff wariness and resistance, attribution of blame.
The Ambiguous Task:
For a group to function well it must have a clear task. Custodial roles can lead to ambiguity.
The Emotions Of Larger Groups:
Externally directed hostility, internal homogenization of views.
Social Defences:
Rituals can develop in forensic institutions, as well as militarism. ANTI-THERAPEUTIC CULTURE: Sadism may develop where a marked power differential develops.
The Role Of The Leader:
Danger intensifies the feelings about leaders, perhaps idealization, perhaps disaffection. Leaders and others need to agree on risk assessment or fragmentation will occur.
The Modification Of Risk:
The assessment of risk may modify it. Mutual hostility must be reduced. Dialogue and understanding are needed.
A Climate For Risk Assessment:
The environment should be less authoritarian and more democratic, so that patients can join a group and internalize its values. Reflective space is also required.
Conclusions:
Risk assessment is best described in terms of human endeavour, not in the language of scientific measurement.