Process Of Unstructured Clinical Judgement Health And Social Care Essay
However, there continues to be an increasingÂ interestÂ andÂ expectationÂ on professionals from the public and the criminal justice system in regards to the potentialÂ dangerÂ posed byÂ seriousÂ offendersÂ being releasedÂ back into the community and the need for the offenders to be better managed, in orderÂ to adequately protectÂ the public from dangerous individuals (Doyle et el, 2002). As the assessment of riskÂ is madeÂ at various stages in the management process of the violent offender, it isÂ extremelyÂ 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 thatÂ are usedÂ to reduce potential danger to others, when integrating violent offenders back into the community. These three approaches are unstructured clinical judgement, structured clinicalÂ judgementÂ and actuarialÂ assessment.
It is not intended, in this paper, to explore the various instruments used in the assessment process for theÂ respectiveÂ actuarial and structured clinical approaches.
Unstructured Clinical Judgement
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Unstructured clinical judgement is a process involving no specific guidelines, but relies on the individual clinician'sÂ evaluationÂ having regard to the clinicians experience and qualifications (Douglas et al, 2002).Â Doyle et el(2002, p650) refers toÂ clinicalÂ judgement as "first generation", and sees clinical judgement as allowing the clinicianÂ completeÂ discretion in relation to what information the clinician will or will not take notice of in their final determination of risk level. The unstructured clinicalÂ interviewÂ has been widely criticised because itÂ is seenÂ as inconsistent and inherently lacks structure and aÂ uniformÂ approachÂ that does not allow forÂ test, retest reliability over time and between clinician's (Lamont et al, 2009). ItÂ has been arguedÂ that this inconsistency inÂ assessmentÂ can lead toÂ incorrectÂ assessment of offenders, as either high or low risk due to the subjective opinion inherent in the unstructured clinical assessmentÂ approachÂ (Prentky et al, 2000). Even with these limitations discussed above the unstructured clinicalÂ interviewÂ is still likely to be the most widely usedÂ approachÂ in relation to the offender's violence risk assessment (Kropp, 2008).
Kropp (2008), postulates that the continued use of the unstructured clinicalÂ interviewÂ allows for "idiographic analysis of the offendersÂ behaviour" (Kropp, 2008, p205).Â Doyle et al (2002) postulates, that clinical studies have shown, that clinician's using the risk analysisÂ methodÂ of unstructured interview, is not asÂ inaccurateÂ asÂ generallyÂ believed.Â Perhaps this is due, largely to the level of experience andÂ clinicalÂ qualifications of those conducting the assessment. The unstructured clinicalÂ assessmentÂ methodÂ relies heavily on verbal and non verbal cues and this has the potential of influencing individual clinician's 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).Â A major flaw with the unstructured clinical interview, is the apparent lack of structured standardized methodologyÂ being usedÂ toÂ enableÂ aÂ testÂ retest reliabilityÂ measureÂ previously mentioned.Â However, the lack of consistency in the assessment approach is aÂ substantialÂ disadvantage in the use of the unstructured clinical interview.Â The need for a more structuredÂ processÂ allowing forÂ predictableÂ test retest reliability wouldÂ appearÂ to be aÂ necessaryÂ component of any risk assessment in relation to violence.
ActuarialÂ assessmentÂ was developedÂ toÂ assessÂ various risk factors that would improve on the probability of an offender's recidivism. However, Douglas et al (2002, p 625) cautions that the ActuarialÂ approachÂ 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 instrumentsÂ has been developedÂ to predict futureÂ probabilityÂ of violence amongst offenders who have a history of mental illness and or criminal offending behaviours. (Grant et al, 2004)
The use of actuarialÂ assessmentÂ has increased in recent years as more non cliniciansÂ are taskedÂ 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,Â backgroundÂ or necessaryÂ clinicalÂ qualifications toÂ conductÂ a standardised clinicalÂ assessmentÂ of offender risk. This actuarialÂ assessmentÂ methodÂ has been foundÂ to be extremelyÂ helpfulÂ 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).Â Whilst such instruments may provide transferableÂ testÂ retest reliability, there is a need for caution when the instrumentsÂ are usedÂ within differing samples of theÂ testÂ populationÂ used as the validationÂ sampleÂ in developing theÂ testÂ (Lamont et al, 2009).Â Inexperienced andÂ untrainedÂ staffÂ may not be aware that testsÂ are limitedÂ by a range of variables that may limit the reliability of the test in use. The majority of actuarial toolsÂ were validatedÂ in North America (Maden, 2003). This hasÂ significantÂ implications when actuarial instrumentsÂ are usedÂ in the Australian context, especially when indigenous cultural complexities are not taken into account. Doyle et al (2002) postulates that the actuarialÂ approachÂ are focusedÂ on prediction and that risk assessment in mental health has a much broaderÂ functionÂ "and has to beÂ linkÂ 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 social variables.Â Therefore, static risk factorsÂ are takenÂ as remaining constant.Â Hanson et al (2000) argues that where the results of unstructuredÂ clinicalÂ opinionÂ areÂ openÂ to questions, the empirically based risk assessmentÂ methodÂ can significantly predict the risk of re offending.
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To relyÂ totallyÂ onÂ staticÂ factors thatÂ are measuredÂ 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 professionalÂ model, wouldÂ appearÂ to have followed a process of evolution since the 1990s.Â ThisÂ progressionÂ has developed throughÂ acceptanceÂ of the complexity of what risk assessment entails, and the pressures of the courts andÂ publicÂ in developing an expectation of increased predictive accuracy (Borum, 1996).Â Structured professional judgement brings together "empirically validated risk factors, professional experience and contemporary knowledge of the patient" (Lamont et al, 2009, p27).Â Structured professional judgement approach requires aÂ broadÂ assessmentÂ criteria covering both static and dynamic factors, and attempts to bridge the gap between the other approaches of unstructured clinical judgement, and actuarialÂ approachÂ (Kropp, 2008).Â The incorporation of dynamic risk factors that are takingÂ accountÂ of variable factors such as current emotionalÂ levelÂ (anger, depression, stress), social supports or lack of and willingness to participate in the treatment rehabilitation process.Â The structured professional approach incorporatesÂ dynamicÂ factors, whichÂ have been found, to be also crucial in analysingÂ riskÂ of violence (Mandeville-Nordon, 2006).Â Campbell et al (2009) postulates that instruments thatÂ examineÂ dynamic risk factors are moreÂ sensitiveÂ toÂ recentÂ changes that mayÂ influenceÂ an increase or decrease in risk potential. Kropp (2008) reports that research has found that Structured Professional Judgement measures alsoÂ correlateÂ substantiallyÂ with actuarial measures.
Kroop, (2008) postulates that either a structured professional judgement approach, or an actuarial approach presents the most viable options for risk assessment of violence.Â The unstructuredÂ clinicalÂ approachÂ 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.Â There wouldÂ appearÂ to be a valid argument that unless there is consistency inÂ trainingÂ of those conducting risk assessments the validity and reliability of any measure, either actuarial or structured professional judgement, will fail toÂ giveÂ theÂ levelÂ of predictability of violence thatÂ is sought.Â Risk analysis of violence will always be burdened by theÂ limitationÂ which "lies in the fact thatÂ exactÂ analyses are notÂ possible, andÂ riskÂ will never be totally eradicated" (Lamont et al, 2009, p 31.). Doyle et al (2002) postulates that a combination of structured clinical and actuarial approachesÂ is warrantedÂ to assist in risk assessment of violence. Further research appears to be warranted to improve the evaluation andÂ overallÂ effectiveness of risk management.
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