Process Of Unstructured Clinical Judgement Health And Social Care Essay

Process Of Unstructured Clinical Judgement Health And Social Care Essay However, there continues to be an increasing  interest  and  expectation  on professionals from the public and the criminal justice system in regards to the potential  danger  posed by  serious  offenders  being released  back into the community and the need for the offenders to be better managed, in order  to adequately protect  the public from dangerous individuals (Doyle et el, 2002). As the assessment of risk  is made  at various stages in the management process of the violent offender, it is  extremely  crucial that mental health professionals have a structured and consistent approach to risk assessment and evaluation of violence. (Doyle et el, 2002). This paper will examine three models of risk assessment that  are used  to reduce potential danger to others, when integrating violent offenders back into the community. These three approaches are unstructured clinical judgement, structured clinical  judgement  and actuarial  assessment. It is not intended, in this paper, to explore the various instruments used in the assessment process for the  respective  actuarial and structured clinical approaches. Unstructured Clinical Judgement Unstructured clinical judgement is a process involving no specific guidelines, but relies on the individual clinicians  evaluation  having regard to the clinicians experience and qualifications (Douglas et al, 2002).  Doyle et el(2002, p650) refers to  clinical  judgement as first generation, and sees clinical judgement as allowing the clinician  complete  discretion in relation to what information the clinician will or will not take notice of in their final determination of risk level. The unstructured clinical  interview  has been widely criticised because it  is seen  as inconsistent and inherently lacks structure and a  uniform  approach  that does not allow for  test, retest reliability over time and between clinicians (Lamont et al, 2009). It  has been argued  that this inconsistency in  assessment  can lead to  incorrect  assessment of offenders, as either high or low risk due to the subjective opinion inherent in the unstructured clin ical assessment  approach  (Prentky et al, 2000). Even with these limitations discussed above the unstructured clinical  interview  is still likely to be the most widely used  approach  in relation to the offenders violence risk assessment (Kropp, 2008). Kropp (2008), postulates that the continued use of the unstructured clinical  interview  allows for idiographic analysis of the offenders  behaviour (Kropp, 2008, p205).  Doyle et al (2002) postulates, that clinical studies have shown, that clinicians using the risk analysis  method  of unstructured interview, is not as  inaccurate  as  generally  believed.  Perhaps this is due, largely to the level of experience and  clinical  qualifications of those conducting the assessment. The unstructured clinical  assessment  method  relies heavily on verbal and non verbal cues and this has the potential of influencing individual clinicians assessment of risk, and thus in turn has a high probability of over reliance in the assessment on the exhibited cues (Lamont et al, 2009).  A major flaw with the unstructured clinical interview, is the apparent lack of structured standardized methodology  being used  to  enable  a  test  retest reliability  me asure  previously mentioned.  However, the lack of consistency in the assessment approach is a  substantial  disadvantage in the use of the unstructured clinical interview.   The need for a more structured  process  allowing for  predictable  test retest reliability would  appear  to be a  necessary  component of any risk assessment in relation to violence. Actuarial Assessment Actuarial  assessment  was developed  to  assess  various risk factors that would improve on the probability of an offenders recidivism. However, Douglas et al (2002, p 625) cautions that the Actuarial  approach  is not conducive to violence prevention. The Actuarial approach relies heavily on standardized instruments to assist the clinician in predicting violence, and the majority of these instruments  has been developed  to predict future  probability  of violence amongst offenders who have a history of mental illness and or criminal offending behaviours. (Grant et al, 2004) The use of actuarial  assessment  has increased in recent years as more non clinicians  are tasked  with the responsibility of management of violent offenders such as community corrections, correctional officers and probation officers. Actuarial risk assessment methods enable staff that do not have the experience,  background  or necessary  clinical  qualifications to  conduct  a standardised clinical  assessment  of offender risk. This actuarial  assessment  method  has been found  to be extremely  helpful  when having risk assessing offenders with mental health, substance abuse and violent offenders. (Byrne et al, 2006). However, Actuarial assessments have limitations in the inability of the instruments to provide any information in relation to the management of the offender, and strategies to prevent violence (Lamont et al, 2009).  Whilst such instruments may provide transferable  test  retest reliability, there is a need for caution when the instruments  are used  within differing samples of the  test  population  used as the validation  sample  in developing the  test  (Lamont et al, 2009).  Inexperienced and  untrained  staff  may not be aware that tests  are limited  by a range of variables that may limit the reliability of the test in use. The majority of actuarial tools  were validated  in North America (Maden, 2003). This has  significant  implications when actuarial instruments  are used  in the Australian context, especially when indigenous cultural complexities are not taken into account. Doyle et al (2002) postulates that the actuarial  approach  are focused  on prediction and that risk assessment in mental health has a much broader  function  and has to be  link  closely with management and prevention (Doyle et al, 2002, p 652). Actuarial instruments rely on measures of static risk factors e.g. history of violence, gender, psychopathy and recorded so cial variables.  Therefore, static risk factors  are taken  as remaining constant.  Hanson et al (2000) argues that where the results of unstructured  clinical  opinion  are  open  to questions, the empirically based risk assessment  method  can significantly predict the risk of re offending. To rely  totally  on  static  factors that  are measured  in Actuarial instruments, and not incorporate dynamic risk factors has led to what Doyle et al (2002) has referred to as, Third Generation, or as more commonly acknowledged as structured professional judgement. Structured Professional Judgment Progression toward a structured professional  model, would  appear  to have followed a process of evolution since the 1990s.  This  progression  has developed through  acceptance  of the complexity of what risk assessment entails, and the pressures of the courts and  public  in developing an expectation of increased predictive accuracy (Borum, 1996).  Structured professional judgement brings together empirically validated risk factors, professional experience and contemporary knowledge of the patient (Lamont et al, 2009, p27).  Structured professional judgement approach requires a  broad  assessment  criteria covering both static and dynamic factors, and attempts to bridge the gap between the other approaches of unstructured clinical judgement, and actuarial  approach  (Kropp, 2008).  The incorporation of dynamic risk factors that are taking  account  of variable factors such as current emotional  level  (anger, depression, stress), social supports or lack of and willingness to participate in the treatment rehabilitation process.  The structured professional approach incorporates  dynamic  factors, which  have been found, to be also crucial in analysing  risk  of violence (Mandeville-Nordon, 2006).  Campbell et al (2009) postulates that instruments that  examine  dynamic risk factors are more  sensitive  to  recent  changes that may  influence  an increase or decrease in risk potential. Kropp (2008) reports that research has found that Structured Professional Judgement measures also  correlate  substantially  with actuarial measures. Conclusion Kroop, (2008) postulates that either a structured professional judgement approach, or an actuarial approach presents the most viable options for risk assessment of violence.  The unstructured  clinical  approach  has been widely criticised by researchers for lacking reliability, validity and accountability (Douglas et al, 2002). Kroop, (2008) also cautions that risk assessment requires the assessor to have an appropriate level of specialized knowledge and experience. This experience should be not only of offenders but also with victims.  There would  appear  to be a valid argument that unless there is consistency in  training  of those conducting risk assessments the validity and reliability of any measure, either actuarial or structured professional judgement, will fail to  give  the  level  of predictability of violence that  is sought.  Risk analysis of violence will always be burdened by the  limitation  which lies in the fact that  exact  an alyses are not  possible, and  risk  will never be totally eradicated (Lamont et al, 2009, p 31.). Doyle et al (2002) postulates that a combination of structured clinical and actuarial approaches  is warranted  to assist in risk assessment of violence. Further research appears to be warranted to improve the evaluation and  overall  effectiveness of risk management.