Risk assessment as collective clinical judgement.

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.