Setting

The action takes places in an exceptionally seedy conference room. Lighting is dim. Coffee-stained mugs litter the table. Back issues of Hello magazine are scattered on the adjacent worn out sofa. There is a pervasive atmosphere of ennui – no one caring very much about anything. The DSM-IV and the ICD-10 lie on top of the bent, unlocked filing cabinet. A spirit of preservation has decreed that they not be sullied – both are wrapped in their original plastic sheathings.

Cast of characters

Case conference: 11.00 h

1. A I just saw Mr Lucas and, of course, I read the clinical file. I think you have all seen him and looked over the record? This is a pretty serious offence: attempted murder, death threats, etc. Lucky his father wasn’t killed. From what I can figure, he could be bipolar with, possibly, some features of personality disorder. There’s some paranoia floating about here as well.

   I recently came across a systematic way of assessing violence risk. It’s called Historical, Clinical, Risk Management – 20 (HCR-20). There are 20 items: 10 historical, 5 current clinical, and 5 risk items directed to the future. It scores as: 0, meaning it isn’t there, 1, meaning it may be present, and 2, it is present. Total score is out of 40, although assessors are expected at the end to give an overall rating of low, moderate or high risk. There is a manual which I have [Holds up manual]. But you don’t really have to read it. The one page checklist is at the back and I’ve photocopied this for you [Hands round]. Any of you ever heard of this thing?

2. B Yes, I attended a workshop on it last year. The trainer mentioned that for clinical purposes the scores of 2, 1 and 0 could be replaced by coding each item as ‘yes’, ‘maybe’ and ‘no’ respectively.

3. C I was there too.

4. D I haven’t been to a workshop, but I ordered a copy of the manual some time ago and have read it from cover to cover.

5. A Well, that’s great. We’re on the same page. My idea is that we should try the thing out on the case of Mr Lucas. I guess it could speed things up. Maybe we could get this done in 10 minutes. Should impress the Court.

   So, let’s start with item H1, previous violence. Looks to me as though he is either a 0 or 1 on this. It may be a 1 as there are two or three minor incidents of aggression in his records. A couple of threats when he was 19 years old. He’s now 26.

6. B Well, actually, no. He rates a 2 according to me.

7. A Why so? This stuff is pretty trivial and not very well substantiated.

8. B Well, you should note that the present alleged offences are to be included. That is, attempted murder, threatening death, false imprisonment and so on. That’s what it says on page 29.

9. A [Looks up page] You’re right. It’s a 2. [Marks it down]

   Item H2, young age at first violent offence. These couple of documented threats of violence at age 19, call for a 2 then? [All nod]

   Then there’s this matter of relationship instability under H3. From what I can see from the record and from interview, Mr Lucas had a pretty strong relationship with his mother all through his life, right up until she died 2 years ago. Too bad he didn’t do as well with his father. Also, Mr Lucas has had maybe half a dozen solid friendships with former school mates. So he merits a 0 on this item.

10. B No, I don’t think so. This item hinges entirely on romantic relationships. There is no evidence at all that he has had any kind of sustained, intimate relationship with any woman, or man for that matter. He has never dated.

11. A If you say so. So I suppose that you all agree that this is a 2? [All nod]

    We now deal with H4, employment problems. He’s never worked at any job for more than a month. There has been a succession of short-run labouring jobs. Mostly, he’s been fired abruptly. It would seem that once he gets bored and once he gets paid, he fails to show up again. He’s failed to complete numerous training programmes and has received a lot of social benefits. Surely, then, he scores a 2.

12. C Yes, no question about that. [All nod]

13. A Now we get to H5, substance use. So, as far as I can see, he’s misused a fair number of substances, including alcohol. Still does. But really, when you look at it, the problem mainly is that he spends great chunks of his life wangling prescription drugs. He goes from doctor to doctor and often shows up at accident and emergency departments. So I think the actual substance use problem is pretty minor. Probably a 0. But we could go for a 1, I guess.

14. C Hang on a moment. The manual stresses that prescription drugs count as misuse (page 37).

15. A That may be, but it seems unfair to me. Let’s give him a break and allot a score of 0.

16. D I don’t think we can bend the coding rules like that. Either we are administering this thing the way it is supposed to be applied, or we are doing something else altogether. No, I opt for a 2 based on my reading of the file.

17. A [Grudgingly] OK then, if you insist. [Marks down a 2]

    He has never been hospitalised. That makes H6, major mental illness, straightforward. So I’d figure that would leave him with a 0.

18. B True. He may never have been in a psychiatric hospital, but there is more than a suggestion in the records, which he does not disconfirm, that he has received periodic mental health services on an out-patient basis. In fact, he’s attended various clinics, albeit not in sustained ways. A range of diagnoses are noted in the various reports on file. Mood disorder is mentioned quite often and paranoia crops up too. So, really, he meets criteria for a score of 1. [C and D nod. A marks down 1]

19. A H7 is called psychopathy. I’ve interviewed this guy and he is a psychopath if ever I saw one. He is straight out of Cleckley’s The Mask of Sanity (Reference CleckleyCleckley 1941). He knows it all. He boasts. He lies. He’s got a big ego. He’s manipulative. He’s a 2 for sure.

20. D Now just a second, please. The manual on page 41 specifically warns against including this item when the person has not been formally evaluated according to the PCL-R or PCL:SV.Footnote a If we haven’t done this, we’d best omit the item, at least for now. We should, in fact, administer Hare’s scheme as soon as possible.

21. A OK. Let’s omit and we will pro-rate the historical scale score. Early maladjustment is next. Item H8.

22. C I read all the reports. They go way back. He has faced a very unfortunate past. Difficulties with his father extend a long way back. Victimised in school. Sent to various foster parents at different times. To me, it’s a 2. [All agree. A marks it down]

23. A Now for H9. This should be easy and surely we are all agreed that he has got some features of a personality disorder. It is therefore a 2.

24. C I dislike being a drag on the proceedings, but I don’t think a 2 is right.

25. A Why so?

26. C Well, all we have here is some hints about a personality disorder. We’ve not examined this systematically and we’ve certainly not used tests. We haven’t considered specific DSM-IV or ICD-10 definitions. If he does indeed have some traits, then a 1 might be justified. That’s what it says on page 45 of the manual.

27. A OK then. [A marks it down]

    So as far as H10, prior supervision failure, is concerned, he has never actually been in prison, or in a mental hospital for that matter. So it’s hard to see if he can have escaped. It’s got to be a 0.

28. C True. He hasn’t escaped, but he has in fact failed at least once to comply with an order to show up in court. It may seem a bit technical, but the manual would indicate that a 1 score would be about right. Also, he’s never finished any of the programmes and courses which have been arranged for him.

29. A OK. It’s a 1 then. But at the rate we are going, this guy is looking utterly beyond hope. So far, out of nine scored items we have a total score of 15 out of 18. It seems a bit rough.

30. D Small point, but the idea, if I get it right, is neither to aim for a low score nor a high score. The goal is to be as impartial and disinterested as possible.

31. A Anyway, that’s history behind us. On to current clinical factors, starting with C1, lack of insight. From my talks with him, I can’t see that he possesses much in the way of self-knowledge. He seems quite unaware that he is out of step with most of society. He is very quick to blame others, very slow to accept any kind of responsibility for his own actions and reactions.

32. D Yes, we are going to have a challenge as we try to engage him in some kind of treatment plan. We’re probably right to assign a 2 score but, really, we’ve now got to start figuring out the precise ways in which his insight is limited.

33. A Negative attitudes, C2. His criminal record and current alleged offence pretty much speak for themselves. A 2 then?

34. D No. We should be thinking about his present attitudes. On the basis of my meetings with him, he seems not to be particularly antisocial in outlook. He is fairly optimistic. I think a 1 would be right, at least for now. [B and C nod, A writes it down]

35. A Active symptoms of major mental illness, C3. What does everyone think?

36. C There are some definite indications of paranoid symptoms right now. I think, since the diagnostic picture is not yet fully clear, we should simply score him as a 1 provisionally.

37. B Alright. We’ll start a proper diagnostic assessment.

38. A Impulsivity, C4. I’m not really clear about this. Some of you lot see him on a day-to-day basis. What do you think?

39. D He really does find it difficult to focus. His attention span is limited; when he wants something, he wants it now. He can’t inhibit himself in any sustained way. At the very least he’s at a 1 level. I would like to see him properly tested in this area. Why can’t we score him provisionally at a 1 level and really look into this before our next meeting.

40. A I’m getting a bit nervous that we are not pinning all our scores down to a correct answer.

41. B I can’t see why we worry about this. Part of the idea of the HCR-20, if I get it right, is to locate the areas which are in need of further examination. We can easily run through the process once again, once we have more information. I was recently reading something by this guy William Reid. He made the point that ‘risk assessment is not a three-minute business’.Footnote b This is a pretty serious case. We need to be as sure of our opinion as we reasonably can be.

42. A So now let’s turn to C5, unresponsive to treatment. He’s a 2 for sure. He has almost no education, no interest in attending our substance misuse programme, no interest in our great social skills programme – the one our service manager raved about last month.

43. B Wait a minute, please. My impression is that he is now beginning to form a really constructive and supportive relationship with his primary nurse, Susie. She says he is beginning to engage with her and the programme.

44. A [Wearily] OK, OK, let’s go for a 1. [All nod] OK, we are three-quarters of the way through now. Just five items to go. It’s taking a lot longer than I’d hoped.

45. D Yeah, but I’m beginning to feel more confident and I like the idea that we’re trying to reach a common understanding – one that should be helpful to our patient and also the court.

46. A R1, plans lack feasibility. There is no plan. 2, right?

47. B Well actually, very slowly over the past couple of weeks a bit of a plan is beginning to emerge. He’s been with the Miracle Programme a couple of times in the past. Bob, our new social worker, has been to see the team over there and, I’m glad to say, they have some ideas that might work. Mr Lucas is grateful for this and is keenly interested. It will take another couple of weeks, but we may end up being able to propose to the court a workable plan. It’s not a 2. Maybe a 1. [All nod]

48. A Let’s try R2, exposure to destabilisers. I gather these are environmentally or situationally driven triggers. I even had to look this up in the manual. I don’t think much of some of the characters in the group home he was in previously. He seems easily led by them. A 2 if ever there was one.

49. C This is perhaps not right. He’s here in the hospital now and will likely be here another couple of weeks at least. He is perfectly stable here. No one, or no particular set of circumstances, has so far set him off in here. At least, not in any serious kind of way. Notice that there is a box at the top of the ‘R’ factors on the coding sheet. He could be rated either as ‘in’, meaning in the hospital, or ‘out’, meaning in the community. I would say that we rate him as ‘in’. So he is at a 0.

50. A I suppose we could, if we wanted, rate him both ‘in’ and ‘out’? If he were about to be released we could have a good look at the post-release circumstances and, depending on what they look like, we’d elevate a score to a 1 or perhaps even a 2?

51. D That’s right.

52. A So now we’re at item R3, lack of personal support. Ideas?

53. B I’ve been a little surprised of late. He’s had a number of visits from friends, a few of whom I’ve met. They seem perfectly law abiding and they do express a strong interest in him and his future. One even offered him a job in a printing company. It’s not the 2 he would automatically accrue. But, clearly, it’s not a 0 since this apparent support is tenuous and of recent origin. Let’s score it as a 1 as if he were ‘out’. In here he is well supported – probably a 0. [All nod, A writes it down]

54. A At the rate we are going, our patient, despite these charges, is going to receive some sort of diploma for perfection in mental health.

55. B Well, I’m not quite saying that. But it does occur to me that whatever risk assessment scheme we elect to use should force us to consider all the options from all the angles. Properly used, this or any other similar scheme, should help us find solutions or opportunities, which would help the patient without jeopardising the safety of other people – including our staff members.

56. A OK, last but one item: R4, non-compliance with remediation attempts. He’s never adhered to anything in the past. Surely he’s an automatic 2.

57. C It’s true the history is not reassuring. But we mustn’t forget that item H10 has to do with adherence in the past. We scored him a 2 on that. What we are attempting to do here is look towards the future. Certainly, he is talking seriously about getting some education and getting a job. Now it’s true that a lot of this may have to do with trying to impress the court with the idea that he has reached some sort of epiphany, but there is, I think, some genuineness about this. Certainly, he’s doing better and better in observing the rules of the unit. And he’s started to attend the educational upgrading programme, even though he may not be here long enough to complete it. He has not, since admission, rejected his psychotropic medication. In here, he is a 0. Were he to be on the outside right now he would likely be a 2. So can we settle for a 1, at least for now? [All nod, A writes it down]

58. A Last item, R5, stress. Ideas?

59. B Well, actually, there are a whole lot of things which cause him stress which we haven’t yet considered. One is his physical appearance. He’s very worried about persistent acne. Another has to do with his debt load. He can’t seem to get on top of his money. This bothers him no end. Another thing which hasn’t yet been discussed is an emerging diabetic condition. He is taking medication, but now worries constantly about being hypoglycaemic. Then there’s the issue of possible misuse of prescription drugs, which we’ve talked about. Then, of course, there’s the issue of his father (who, by the way, has visited on a few occasions). There will be a great deal of difficulty in coping with his dad. But both of them seem to be trying in a guarded way. So in here, right now, he is coping very well. At a 0 level. But if we were to look at the immediate future out of here, we’d be entertaining a 1 or more likely a 2.

60. A OK, so we are more or less done. According to my additions, he scores 25/38 (or 31 if he were to be coded as ‘out’), which I suppose means moderate risk. There doesn’t seem to be any norms at the back of the manual, but common sense would suggest this – he is best classified as moderate risk.

61. B I can’t agree. The manual is quite explicit in pointing out that, although there may be some general correspondence between the total score out of 40 and assigned overall risk level – the higher the score, the more likely he’ll be found as ‘high risk’ – there will be some exceptions. This is discussed on page 22. No, on the assumption that he would be discharged to the community in the near future (on bail or whatever), it looks to me that he is actually high risk. He continues to express strong intent to kill his father. More specifically, his father will be at high risk of being attacked again until Mr Lucas’s current paranoid symptoms abate. I’m glad to say he is now taking medication. A return home is not recommended in the near future. He represents a high risk to the father at present. And his father needs to be made fully aware of this.

62. A I am struggling to see the value in using this manual if we are going to ignore scores.

63. C It seems to me that we now have a better shared understanding of the relevant risk factors in this case. I skimmed a recent Department of Health documentFootnote c which states that these types of structured risk assessment tools should be used to assist and not totally replace time-honoured conventional approaches to risk assessment. In many ways it might be better not to refer to the numbers at all. Stepping back, we’re going to have to help him use the cards he already possesses. He is not without some strengths. With what we now know, we can begin to figure out a plan for discharge to the community, one that’s as safe as we can manage. We also need to construct a plan to deal with any future crisis.

64. B [Brightly] I think the speaker at the workshop also said that it can be a good idea to go through these items again from time to time to check the integrity of our risk management plans. I’d be really interested to see if our ‘C1 lacks insight’ rating changes following his use of medication and with the increased individual help we’re now providing.

65. A [Looking at watch] Now that would be very interesting. I’m afraid I need to get going. Well, I guess we should probably talk about using the HCR-20 routinely in our cases. What say I put it on the agenda for our next clinical governance meeting? [All nod violently].

Epilogue

There followed the novel but edifying sight of this team of professionals leaving a meeting with banter and some purpose. The team gradually introduced the HCR-20 into practice with adjustments to make it fit their local circumstances. Paperwork was cut down and procedures were amended to allow proper and thoughtful use of the scheme. Over the months, each practitioner became cognisant of their colleagues’ individual contributions to the team effort. Naturally, professional differences, splits and other disagreements still occurred, but with time, the team found a way to maintain cohesion and make more effective decisions to keep patients such as Mr Lucas safe from harm.

MCQs

Select the single best option for each question stem

1. 1 Best Practice in Managing Risk (Department of Health 2007):

   1. a states that structured professional judgement should replace clinical decision-making

   2. b argues that clinicians must be wary of taking carers’ opinions into account

   3. c applies exclusively to forensic mental health services

   4. d supports multidisciplinary involvement when devising risk management plans

   5. e states that the HCR-20 is the best available risk assessment tool.

2. 2 The HCR-20:

   1. a is best thought of as a checklist

   2. b can only be completed by a consultant psychiatrist

   3. c is a psychological test

   4. d can be conceptualised as a clinical guideline

   5. e primarily concerns itself with the prediction rather than prevention of violence against other persons.

3. 3 When coding the HCR-20:

   1. a it is acceptable to stop referring to the manual once fully trained

   2. b case-specific factors not included in the list of 20 items are not considered to be relevant

   3. c it is permissible to code each item as ‘yes’, ‘maybe’ or ‘no’ instead of ‘2’, ‘1’ and ‘0’ respectively

   4. d it is best to decide in advance the service user’s level of risk and allot item scores accordingly

   5. e someone with a low total score cannot be judged to present with a high risk of violence to others.

4. 4 To be proficient in the use of the HCR-20, it is necessary:

   1. a to attend a 2-day workshop and achieve a passing grade

   2. b to continue referring to the manual with each case in hand

   3. c to pay limited attention to the relevant scientific and professional literature

   4. d to ignore any information that does not directly refer to the 20 stated risk factors

   5. e to have statistical expertise.

5. 5 The HCR-20 can aid risk management by:

   1. a specifically isolating critical factors related to emerging suicide risk

   2. b promoting interdisciplinary discussion and planning

   3. c providing extremely accurate predictions of violence potential

   4. d removing any reliance on clinical acumen

   5. e creating a cut-off score above which a violence outcome is almost certain.

MCQ answers

1

d

2

d

3

c

4

b

5

b