Occupational therapy risk assessment in forensic mental health practice: an exploration.(Research)(Report)

Introduction

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.

Literature review

Defining risk

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):

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   ... 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.

There appears to be no specific model for risk assessment, but it is proposed here that risk assessment could be mapped using the concepts of person, environment, occupation and performance (PEOP) from models of practice (Baum and Christiansen 2005, Townsend and Polatajko 2007, Kielhofner 2008). The models have a common feature where the concepts of PEOP interact, thus the person performs by the act of doing an occupation in an environment (Baum and Christiansen 2005). The PEOP concepts defined by Baum and Christiansen (2005) have been used here to categorise the relevant literature.

The person includes the psychological, physiological, neurobehavioural, cognitive and spiritual factors (Baum and Christiansen 2005). Aspects of risk assessment would include mental illness and insight (Neeson and Kelly 2003). Another risk is decreased motivation and sense of purpose, resulting from fear of isolation and rejection (Clarke 2003). A multidisciplinary postal survey about risk assessment of violent mentally disordered offenders in secure hospital environments suggested multiple personal factors: the person's psychosexual history or interest, his or her mood or post-traumatic stress disorder and his or her insight and trust in the therapeutic team (Cronin-Davis 1998). In addition, Rogowski (2002) highlighted patients' resentment at their detainment and feeling restricted or persecuted as factors increasing risk.

One aspect of the environment is the physical place for carrying out occupations (Baum and Christiansen 2005). This includes the therapeutic environments, such as craft rooms, workshops, kitchens and gardens, where patients may have access to tools, materials and equipment that could be used as weapons (Fairhead 1997, Seymour and Monks 1997, Taylor et al 1997). Self-harm and suicide can be attempted using tools and dangerous substances (McQue 2003) and patients can hide implements in the environment (Neeson and Kelly 2003).

Other aspects of the environment are cultural and social (Baum and Christiansen 2005). Clarke (2003) acknowledged that patients are in a subculture of people with mental illness and offending behaviour, who are cut off from society. Other risks are linked to how similar the context of therapy is to the offence and possible precipitants, such as the pressure of court appearances or tribunals and the presence of other patients (Rogowski 2002). For example, adding women to create mixed …