Wednesday, July 28, 2021

Risk of what?

By David S. Prescott, LICSW, and Kieran McCartan, Ph.D.

In a recent discussion of assessment measures, an ATSA member referred to an instrument saying in essence, “Don’t forget that it is not a risk assessment instrument; it assesses areas of risk.” Among professionals who conduct risk assessments across diverse settings, this sentence actually makes perfect sense. Translation: While the instrument helps assess risk factors as part of a broader assessment process, it does not provide a total picture of the specific risk for a specific risk outcome (for example, “individuals with Mr. X’s score have been found to re-offend at a rate of Y over Z number of years”). It is not simply an academic discussion; different assessment instruments are designed for very different purposes, ranging from estimations of the likelihood for re-offense to case formulation and planning. Static-99r is an excellent choice for the former but might not be as helpful in many aspects of case formulation. On the other hand, some measures can aid case planning but lack the empirical support of Static-99r for arriving at a baseline.

Assessing risk has eternally been an area of great importance in our field, and rightfully so: How can we design empirically grounded programs without some idea of what kinds of risk, a person poses and what level of intervention they require? On the other hand, we often benefit from taking a step back and reflecting on how we conceptualize “risk.”

 A quick Google search on “definition of risk” yields a top result of “expose (someone or something valued) to danger, harm, or loss” as in, "He risked his life to save his dog." Right away, there is a question within “risk assessment” of whether we are trying to understand the danger, the exposure to danger, or the likelihood of the worst outcome. One could argue we each conduct a risk assessment each time we cross a busy street.

These questions, in turn, provide more opportunities for reflection. It is not uncommon to hear the expression “risk prediction” which begs the question of whether the professional is assessing, predicting, or some combination. Assessment and prediction are not the same things. If they are predicting, are they trying to predict re-offense itself or simply the exposure to danger or harm described above. Are we trying to predict what circumstances will be in place in the future? Or are we saying “prediction” when we are actually examining historical risk factors that might become present in the future? When we say “risk assessment” do we mean assessing risk itself or the circumstances under which risk would become unmanageable? Should we clarify this in our reports?

In the context of civil commitment “risk” is defined in the statutes that give rise to the assessment itself. In other circumstances, risk assessment may be a broader term covering many areas, which professionals use because it is so common. For example, “risk assessment” in the juvenile world often indicates a more comprehensive process that encompasses the identification of treatment needs and strategies for producing the best outcomes.

Further questions remain, such as the risk for what? Often, risk assessments consider some areas but not others. Assessors sometimes focus on specific areas, such as the risk for violence and general criminality, as well as for sexual re-offending. All too often, the same reports are silent on the possible risks of self-harm, suicide, or simply not living up to one’s full potential (which is often the highest risk of all). While we often talk about victim access in general, we seldom reflect on what risks might exist for those who have been harmed. Unfortunately, this area can be far less clearly defined in our referral questions.

Strikingly absent in many discussions of risk assessment are considerations regarding risks to the health and welfare of those who have been abused.  Few of our processes (and the actions of the criminal justice systems beyond) were designed to calculate how assessment or treatment can aid those who have been harmed, including by involving them or leaving them alone. Mistakes in this domain of our work only seem to create new risks of harm to others.

It also behooves us to consider the fundamental purpose of understanding risk. Clearly, it should enable rehabilitation and safe community integration. It’s also about management and incapacitating truly high-risk cases. One challenge in risk assessment is the perennial question of who manages the different risks? Is it the professional’s job to manage and be responsible for the individual’s risks? Or specific risks? Or is it the client’s responsibility to manage their own risk? Or specific risks? Or is it somewhere between the two?

These can be difficult conversations, as risk changes depending on the context and the place that the person is at in their rehabilitation. Central to the process can be helping the client to identify and manage risk(s). Of course, not every client is ready, willing, or able to do that. Ultimately, risk assessment creates a space in time to understand the context of that individual, which is why it’s an ongoing process, frequently redone and refined.  No one can fully predict future offending. We can only make our best judgments based upon the existing data and using the most appropriate research.

While some of these reflections may mystify some and be crystal clear to others (and there are many more considerations that we can’t discuss within the space limitations of a blog post), we have to acknowledge that with the explosive growth in our understanding of risk and risk assessment across the past thirty-plus years, our answers continue to pose new questions. For our communications, however, the very idea of risk itself may be in danger of being clearer in our minds than in our reports.

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