Occupational Therapy Risk Assessment in Forensic Mental Health Practice: An Exploration
Cordingley, Kevin, Ryan, Susan, British Journal of Occupational Therapy
There are guidelines for occupational therapy risk management, within which risk assessment is integrated (College of Occupational Therapists [COT] 2006). This provides a useful general framework for risk assessment because it includes identifying any hazards and potential risks, the potential for harm and what might be the consequences (COT 2006). Clinical risk assessments completed by various disciplines in 64 out of 67 forensic psychiatric units in the United Kingdom indicated no uniformity in the assessments used and inadequately developed tools, potentially causing a lack of continuity in care through the system (Kettles et al 2003). It was recommended that risk assessment should be standardised, drawing on a stronger research base for the current tools (Kettles et al 2003). This study was concerned with the specific requirements for occupational therapy risk assessment in forensic mental health settings.
Kettles (2004) used concept analysis to explore and evaluate the meaning of forensic risk, producing a modified version of Wood's definition (2001, cited in Kettles 2004, p491):
... the clinical probability of a negative consequence, related specifically to the behaviour of those patients who are committed by law, or who are diverted from custody, to forensic settings and who have the potential to cause serious, physical and psychological harm to others. This includes those fear-inducing, impulsive, intimidating, manipulative and destructive behaviours that are displayed or have been known to be displayed ...
One aspect not included in the above statement, but noted in the Reed Report (Department of Health and Home Office 1991), is the individual's clinical condition and the circumstances that he or she is in at any given time, which can influence different forms and levels of risk. The process of risk assessment is therefore dynamic, varying across time and situations and between people (Crighton 1999). This reflects Scott's (1977) useful equation of offender + victim + circumstances = the offence.
The forensic occupational therapy literature has defined risk in a number of ways. Flood (1993) and Duncan (2008) used levels of dangerousness. Others have suggested that risk is the potential for physical and psychological harm to others and oneself (Chacksfield 1997, Rogowski 1997). However, Kettles (2004) did not include harm to oneself. The definition above, along with the possibility of risks being of different levels and changing across time and circumstances, as well as the clinical condition, including self-harm, is used as the basis for this study.
Risk assessment involves making a prediction, based on an evaluation of the potential of an individual carrying out risk behaviours (Blackburn 2000). Work by Crighton (1999), Kettles (2004) and COT (2006) includes the probability or prediction of how likely it is that harm will occur. The forensic occupational therapy literature implies that risks are assessed by therapists using information gained from patients and the multidisciplinary team to inform their clinical decisions. The crucial issue in any prediction is to make the correct prediction of risks, both because of the effects on human rights and moral issues, which could also lead to unnecessary public spending (Duncan 2008), and public safety issues. Thus, risk assessment is critical to effective practice, requiring a strong evidence base.
Occupational therapy and risk assessment
A study by Duncan et al (2003) identified forensic occupational therapy research priorities, highlighting the need for risk assessments for safety reasons and requiring the development of a specific tool. Risk assessment fell in the highest of three research priorities, but participants favoured this less strongly (Duncan et al 2003). The rationale to assess risk for safety is understandable, but does not fully justify the need for a forensic occupational therapy risk assessment. …