Process Of Unstructured Clinical Judgement Health And Social Care Essay

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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 clinician's 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 clinician's (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 clinical 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 offender's 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 clinician's 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 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). A major flaw with the unstructured clinical interview, is the apparent lack of structured standardized methodology being used to enable a test retest reliability measure 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 offender's 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 social 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.


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 analyses 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.