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As psychiatrists who both teach and work at the acute coal-face, we appreciate the frustrations described by the anonymous author of this essay[1] and agree with their emphasis on the need for a humane and quiet clinical environment.
It is possible to integrate care and obtain, over time, enough information to understand and formulate a person’s symptoms, in part to see if they may be part of a psychotic disorder, or relate more to depression, anxiety, or interpersonal difficulties. Such distinctions matter a great deal as they help guide the choice of treatment. However, all of this takes time: to develop trust, to recover, to communicate, and to plan together.
We suggest that the development of such shared goals and an alliance between sufferer and carer, patient and doctor, is what allows for good and safe practice. Not documentation, but care. Not risk assessment, but shared goals that include assessment and management of risk. Not multiple assessments without shelter, but shelter allowing for shared assessments.
We have participated in multiple attempts to use mandated risk assessments and forms, generally brought in as “best practice” without adequate (or any) trials of effectiveness. These forms are typically ignored or, worse, completed robotically; the patients left unseen unheard, feeling confused, not reassured and not wanted.
The limitations in our ability to predict risk, in particular the high false positive rates that bedevil standardised assessments, have been noted in a recent systematic review [2].
“…the low base rate for violence and the weak contribution of mental health variables to violence in society combine to make all our risk assessment activities …open to high rates of false-positive error. In every high-risk population identified, nonviolent individuals outnumber violent individuals.”
Despite these concerns, shared with many patients and families, formulaic risk assessment has too often become mandatory, listening and personalised formulation optional.
Each of us has worked in systems lacking beds, respite, and care: where the assessments are disjointed. We have also worked in places where there is enough shelter and safety that a basic sense of trust can be developed between patient and nursing staff and doctor: and where there is a little less turnover and a lot more caring.
We suggest that the defensive processes that produce such mandatory ‘risk assessment’ forms lead to bad practice. Formulation and explanation, over time, in asylum or respite is good practice. With shelter and time to make shared assessments we encounter less risk, fewer incidents, and thereby protect the morale and humanity of both patients and clinicians; both stand to lose if the function of asylum is lost in a false search for efficiency.
References
1. Anonymous. Psychiatric assessments: how much is too much? BMJ 2015;351:h3503.
2. Yang M, Wong SC, Coid J. The efficacy of violence prediction: a meta-analytic comparison of nine risk assessment tools. Psychol Bull. 2010;136(5):740-67.
Christopher Gale MPH FRANZCP (a)
David Menkes MD PhD FRANZCP (b)
Paul Glue MD FRCPsych (a)
a) Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
b) Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
Competing interests:
No competing interests
04 August 2015
Christopher K Gale
Consultant Psychiatrist and Senior Lecturer
Paul Glue, David Menkes
Department of Psychological Medicine, Dunedin School of Medicine
University of Otago, P. O. Box 913 Dunedin 9054 New Zealand
Mental illness is surreal hypersensitivity to reality. But normal sensitivity can also ignite frightful insights. Troubled with demons and fears, but bubbling with dreams and ideas, sensitivity enlightens and enlivens us with crucial, creative insights. So let’s listen, learn, solace, and support, not stigmatize, marginalize, ostracize, or hospitalize. Sensitivity is creativity, not negativity.
Assessment needs to be part of humane care
As psychiatrists who both teach and work at the acute coal-face, we appreciate the frustrations described by the anonymous author of this essay[1] and agree with their emphasis on the need for a humane and quiet clinical environment.
It is possible to integrate care and obtain, over time, enough information to understand and formulate a person’s symptoms, in part to see if they may be part of a psychotic disorder, or relate more to depression, anxiety, or interpersonal difficulties. Such distinctions matter a great deal as they help guide the choice of treatment. However, all of this takes time: to develop trust, to recover, to communicate, and to plan together.
We suggest that the development of such shared goals and an alliance between sufferer and carer, patient and doctor, is what allows for good and safe practice. Not documentation, but care. Not risk assessment, but shared goals that include assessment and management of risk. Not multiple assessments without shelter, but shelter allowing for shared assessments.
We have participated in multiple attempts to use mandated risk assessments and forms, generally brought in as “best practice” without adequate (or any) trials of effectiveness. These forms are typically ignored or, worse, completed robotically; the patients left unseen unheard, feeling confused, not reassured and not wanted.
The limitations in our ability to predict risk, in particular the high false positive rates that bedevil standardised assessments, have been noted in a recent systematic review [2].
“…the low base rate for violence and the weak contribution of mental health variables to violence in society combine to make all our risk assessment activities …open to high rates of false-positive error. In every high-risk population identified, nonviolent individuals outnumber violent individuals.”
Despite these concerns, shared with many patients and families, formulaic risk assessment has too often become mandatory, listening and personalised formulation optional.
Each of us has worked in systems lacking beds, respite, and care: where the assessments are disjointed. We have also worked in places where there is enough shelter and safety that a basic sense of trust can be developed between patient and nursing staff and doctor: and where there is a little less turnover and a lot more caring.
We suggest that the defensive processes that produce such mandatory ‘risk assessment’ forms lead to bad practice. Formulation and explanation, over time, in asylum or respite is good practice. With shelter and time to make shared assessments we encounter less risk, fewer incidents, and thereby protect the morale and humanity of both patients and clinicians; both stand to lose if the function of asylum is lost in a false search for efficiency.
References
1. Anonymous. Psychiatric assessments: how much is too much? BMJ 2015;351:h3503.
2. Yang M, Wong SC, Coid J. The efficacy of violence prediction: a meta-analytic comparison of nine risk assessment tools. Psychol Bull. 2010;136(5):740-67.
Christopher Gale MPH FRANZCP (a)
David Menkes MD PhD FRANZCP (b)
Paul Glue MD FRCPsych (a)
a) Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
b) Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
Competing interests: No competing interests