Risk assessment by client and case manager for shared decision making in outpatient forensic psychiatry

Background In outpatient forensic psychiatry, assessment of re-offending risk and treatment needs by case managers may be hampered by an incomplete view of client functioning. The client’s appreciation of his own problem behaviour is not systematically used for these purposes. The current study tests whether using a new client self-appraisal risk assessment instrument, based on the Short Term Assessment of Risk and Treatability (START), improves the assessment of re-offending risk and can support shared decision making in care planning. Methods In a sample of 201 outpatient forensic psychiatric clients, feasibility of client risk assessment, concordance with clinician assessment, and predictive validity of both assessments for violent or criminal behaviour were studied. Results Almost all clients (98 %) were able to fill in the instrument. Agreement between client and case manager on the key risk and protective factors of the client was poor (mean kappa for selection as key factor was 0.15 and 0.09, respectively, and mean correlation on scoring −0.18 and 0.20). The optimal prediction model for violent or criminal behaviour consisted of the case manager’s structured professional risk estimate for violence in combination with the client’s self-appraisal on key risk and protective factors (AUC = 0.70; 95%CI: 0.60–0.80). Conclusions In outpatient forensic psychiatry, self-assessment of risk by the client is feasible and improves the prediction of re-offending. Clients and their case managers differ in their appraisal of key risk and protective factors. These differences should be addressed in shared care planning. The new Client Self-Appraisal based on START (CSA) risk assessment instrument can be a useful tool to facilitate such shared care planning in forensic psychiatry. Electronic supplementary material The online version of this article (doi:10.1186/s12888-015-0500-3) contains supplementary material, which is available to authorized users.


Lacking concern for others
Lying. Difficulty understanding why others feel sad. What you want is more important than what other people want.

Stopping or misusing medication
Not taking prescribed medication. Or using it in a different way than prescribed. Doubting the need for medication.

Difficulty to keep to the rules
Finding it hard to see the point of rules, or to obey them. Resisting checks, such as a drug test.

Behaving unpleasantly towards others
Bullying or frightening others. Insulting others. Stealing or destroying property. Sexually harassing others.

Being unsure about your strengths and weaknesses
Unclear to you why you get into trouble sometimes. It always catches you by surprise when things go wrong with you.

Missing a goal and plans
Being unsure about what you really want. Having plans you know are unrealistic, or bad for others.

Difficulty handling problems
Problems overwhelm you. Make you anxious. Are often too much for you. Coping with changes is difficult for you.

Difficulty cooperating with your treatment
Doubting whether treatment is necessary. Pretending to cooperate. Others should change, not you.

Problems dealing with sexuality
Missing a sexual partner. Having disturbing or inadmissible sexual urges, fantasies, or behaviors. Unsafe sex. Being addicted to sex.
Protective points -Protective points are things in yourself or in your life which can help things go well with you, and keep you out of contact with the police and legal system. -Please indicate for the points below whether they are a protective point of yours, or not -Use the squares to mark your answer. We will come back to the use of the circles later again.

Point
Protective point? Major points (3 or more) Yes Somewhat No

Able to make contact with others
Able to strike up a conversation with somebody. Participating in group activities. Enjoying contact with others.

Able to build relationships
With friends, a partner, care providers. Getting along with others. Feeling close to others.

Enjoying your work or education
Having work or getting an education. Being able to do your work or school well. Showing initiative in the classroom or your job.

Having leisure activities
Having hobbies. Being able to entertain yourself.

Adequate self-care
Keeping your house clean. Preparing meals. Washing your clothes. Taking a shower regularly. Leading a healthy life.

Thinking clearly
Able to focus your mind on something, and to think things through clearly.

Having a stable and positive mood
Feeling pleasant. Calm. Hopeful. Having a sense of humor.

Having control over your alcohol and drugs usage
Keeping off drugs. Drinking in moderation. Accepting treatment for this, if necessary.

Self-control
Able to control yourself. To have a grip on yourself. To think first and act later. Able to deal with disappointments.

Withstanding bad influences
Resisting friends who want you to do the wrong things. Having friends who help to do the right things. Making up your own mind.

Having support of people around you
Having people who support you (family, friends or care providers). Who mean well with you.

Respecting others
Being open and honest to others. Showing concern for others. Seeing others as equals.

Making appropriate use of medication
Using prescribed medication, and in the right way. Understanding the need for medication.

Obeying rules
Understanding why rules are necessary. Cooperating with checks, such as a drug test.

Behaving pleasantly towards others
Respecting other people's property. Being considerate about others and their safety. Arriving on time for appointments.

Knowing your strengths and weaknesses
Knowing why you get into trouble sometimes. Recognizing when you are no longer doing well. Aware of your problem areas.

Having a goal and plans
Having something to strive for, which is not at the expense of others. Having realistic plans.

Able to handle difficulties
Being able to solve your problems. To deal with stress and changes. To ask for help, if needed. To look on the bright side.

Cooperating with your treatment
Being committed to your treatment. Wanting to succeed. Cooperating, because you want it yourself.

Managing sexuality adequately
Having a good sexual relationship. Having control over your sexual urges, fantasies and behavior. Safe sex for both.
You just selected your major vulnerability and protective points. These are the points for which you marked the circle on the right side of the page.
Please copy your choices to the tables below. Write the numbers of your major vulnerability points in the top table, and the numbers of your major protective points in the bottom