15 - Structured professional judgment

Structured professional judgment

© SPMM Course Approaches to risk assessment Clinical approach In this approach, a clinicians’ subjective, intuitive judgment informed by experience and knowledge is used to estimate risk and guide decisions about treatment. But professional opinions are often highly variable for a given case and have poor predictive value, not supported by many policymakers. Most risk assessment currently performed by clinical methods. They are based on clinical experience, individuals knowledge and person-specific assessment to reach a conclusion. Only 1/3rd of pure clinical judgments are estimated to be correct in retrospective studies. Actuarial approach This approach is very popular in forensic services. This uses formal, algorithmic and objective procedures for quantifying risk as a numerical probability of a future outcome: e.g. patient A has a 60% chance of killing herself in the next 2 years, etc. It is found to be superior to other methods of predicting the risk of violence and sexual offending, but does not inform the clinician much about the risk factors that require targeting to mitigate risk. There are hardly any actuarial tools available for self-harm and suicide risk, but there are many available for violence risk assessment. Problems of actuarial tools include:

1. Historical aspects are given more importance – so a pessimistic view of risk with insensitivity to change results.
2. High false positive rates using these tools.
3. As mentioned above generalisation of actuarial tools developed in one setting to the other is difficult.
4. Further, actuarial approaches are often too focused on static and stable risk factors rather than dynamic and modifiable factors. Thus, though actuarial instruments more accurately identify at-risk groups, structured risk instruments may be more clinically useful for enhancing clinical decision-making. Structured professional judgment Structured professional judgment is an approach that aims to combine the evidence base for risk factors with an individual clinical assessment to complement psychiatric opinion. A structured, scales-based assessment is used when formulating risk management plan. Several risk assessment instruments are available to support structured professional judgment (e.g. HCR–20 to assess risk for violence in forensic settings) It is important to note that neither actuarial nor structured judgments should replace conventional clinical assessment; they must be employed as an additional aide for systematically identifying and addressing relevant risk factors.