Shared Risk Formulation in Forensic Psychiatry [2019]

Patients in forensic mental health care have a difficult journey through inpatient rehabilitation and re-integration into the community. Risk assessment guides this progress, usually with clinician-based processes that use structured risk-assessment tools. Patients’ understanding of their own risk is important to inform risk assessment and the chances of successful rehabilitation. The emergence of shared decision-making approaches provides an opportunity to consider shared risk assessment and formulation. We reviewed the literature to explore models of patients’ involvement in risk assessment and the impact on outcomes in forensic mental health care. We conducted searches of three databases (Medline, PsychINFO, and EMBASE) to identify papers that employed shared risk understanding for violence risk. Additional records were identified through review of citations, with articles being selected using a predetermined set of inclusion and exclusion criteria. We found five studies that met the inclusion criteria for patient involvement in risk assessment with measurement of construct or predictive validity. The studies employed diverse methodologies, but they suggest that patient involvement in assessing risk is feasible when correlated with staff ratings. There is encouraging evidence of the predictive validity of self-rated risk alongside staff-rated risk assessment.

Shared decision-making (SDM) is a tool proposed in recent years to enhance service-user involvement in mental health care decisions, although this movement has often lacked careful evaluation.1 Tilley et al.2 described user involvement as the extent to which the patient is involved in defining problems and setting the targets that constitute the plan of care. In mental health, SDM is considered a middle ground between paternalism and autonomy, and a potential alternative to coercive interventions.3 A recent meta-analysis found equivocal results for the impact of SDM on outcomes for persons with psychosis, a small effect enhancement of subjective sense of empowerment, and a trend toward a reduction in coercive interventions with SDM.4

In forensic mental health care, a recovery framework must balance a patient’s best interests with public safety concerns.5 Forensic recovery presents dual issues of enhancing autonomy while also giving due consideration for public safety. Care is provided within a coercive framework. A recent meta-synthesis of forensic patient accounts of recovery called for developments to enhance patient inclusion to increase patients’ sense of safety and understanding in the process of forensic recovery.6 Similar themes have been found in the more recent work of Livingston7 in patients and family members defining success in forensic recovery. It is possible that important information that could guide risk-management plans may be overlooked if patients are not involved in the process. Risk assessment plays a key role in guiding the decision-making processes of risk management.

SDM brings together patients and treatment teams in making health care decisions. Being involved may enhance patients’ sense of self-efficacy and responsibility by contributing to important decisions regarding their care. In addition, it gives clinicians a chance to get a better view of the patients’ insight into the issues pertaining to their risks. Applied to risk assessment, this involves a joint process of contributing to an understanding of key risk issues and effective risk management.

Given the above, we sought to explore examples of SDM as applied to risk assessment and management of violence in forensic psychiatry. To do so, we conducted a literature review of quantitative studies of shared risk formulation using structured risk-assessment tools in forensic mental health practice. The aims of the review were to describe the methodologies employed and the settings where they were applied, and to examine their reliability and validity.

Ipsita Ray and Alexander I. F. Simpson
Journal of the American Academy of Psychiatry and the Law, January 2019