Evans Psychotherapy

 

Beckenham and Online

t: 0208 650 0177

 e: info@evanspsychotherapy.co.uk

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https://www.bps.org.uk/psychologist/we-need-inquiry-not-inquisition

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The Link Between Risk Assessment and Clinical Assessment

Predicting future behaviour is challenging, and it’s often easier to identify mistakes in hindsight than to foresee them. Despite these limitations, risk assessment remains crucial in mental health care, requiring us to evaluate potential risks as accurately as possible. For me, effective risk assessment is deeply rooted in a thorough clinical evaluation that considers the patient’s history, including patterns of illness behaviour, while also seeking to understand the person behind the often-bizarre symptoms. Although predicting behaviour is difficult, the strongest predictor of future actions is typically past behaviour, as patterns frequently repeat.

In my experience, drawn from years of reviewing forensic and mental health case studies, I’ve encountered numerous instances where serious consequences arose due to missed psychotic states. Denial and rationalisation often obscure these states, leading to care failures.

Context

Since I qualified as a psychiatric nurse in 1983, there has been a growing tendency to idealise community services at the expense of inpatient care. While we are obligated to provide the least restrictive care possible—ensuring maximum freedom and autonomy while safeguarding patient safety—there remains a critical need for inpatient psychiatry within the broader mental health care system, particularly for long-term cases. Unfortunately, bed shortages mean that only the most acutely ill patients are admitted, often being discharged as soon as possible. This cycle contributes to the “revolving door” phenomenon, where patients are released at the first sign of improvement, only to be readmitted later due to relapse.

I am not opposed to neuroleptics; however, I believe that we have overly idealised their curative powers, often at the expense of investing in comprehensive psychiatric and rehabilitative services.

I’ve encountered numerous cases where patients with significant risk factors are discharged too early, often due to the pressure on mental health teams. This creates a "folie à deux" scenario where the patient, distressed by their condition, encounters a team eager to alleviate distress and may rush the discharge process.

The Psychotic Wavelength

Richard Lucas, an esteemed mentor, often spoke of the need to “tune in” to the psychotic wavelength—a concept referring to the hidden influence of psychosis on a patient’s mind. Psychosis can be deceptive, manifesting through denial and rationalisation, which Lucas considered the two most significant symptoms of the condition. These mechanisms conceal the illness from the patient and obscure it from clinicians, who may overlook vital clues during risk assessment. Consequently, rapid discharges can occur even when underlying issues persist.

It is essential that clinicians pay closer attention to historical patterns in both services and patient behaviour when conducting risk assessments. While predicting or preventing all acts of violence is impossible, the risk, including that of relapse, would be reduced with appropriate, long-term care for patients who cannot manage their psychosis independently—despite their insistence otherwise. In assessing risk, clinicians must remain aware that patients with psychotic illnesses may deny their condition and rationalise their behaviour, which can significantly impact the accuracy of their evaluations.

For some treatment-resistant patients—those who refuse medication or avoid therapy—the delusional experience may be more tolerable than confronting the depressive realisation of a chronic condition. Medication and the partial insight it brings can threaten the defence mechanisms that protect them from this realisation. Freud viewed delusions as a response to a fragmented or depressive state of mind. In these cases, the psychiatric team’s efforts to reduce psychosis may be at odds with the patient’s need to maintain their delusional defences.

Dynamic Risk Assessment and Service Integration

Risk assessments are merely snapshots in time, and risk levels change as patients move between different settings, from psychiatric intensive care to acute admission wards or from inpatient care to the community. This fluctuation underscores the need for continuous assessment and integrated services that operate as a cohesive family, supporting patients through different stages of their condition.

Mental health assessments should be dynamic, incorporating the immediate clinical picture and the relationships between the patient, their illness, and their environment. For instance, consider two patients with psychosis: John, who is supported by both family and community psychiatric services that ensure regular medication and day centre attendance, is in a significantly different situation from Paul, whose sole caregiver recently passed away, leaving him isolated, unmedicated, and using marijuana. Richard Lucas emphasised that community mental health teams provide external support for fragile internal psychic structures that are easily swayed by psychotic states.

The Importance of Therapeutic Relationships

Therapeutic relationships are the cornerstone of high-quality mental health care. Yet clinicians must constantly navigate the delicate balance between providing the least restrictive care and ensuring patient safety. Accurate risk assessment is critical and depends on a deep understanding of the patient's mental state, environment, and perception of care.

Individualized and compassionate care is essential for patients with chronic mental health conditions. Services should emphasise long-term therapeutic relationships, offering continuity and deeper insights into the patient’s challenges beyond immediate symptoms. This comprehensive and empathetic approach is key to delivering the best care.

Challenges in Mental Health Care

Frontline mental health professionals face immense pressures—balancing limited inpatient beds, high-risk community cases, and the tension between least restrictive care and patient autonomy. These challenges underscore the need for skilled, compassionate practitioners who are equipped to handle the complex dynamics of mental health care.

Psychotic states are inherently unpredictable, making risk assessment difficult as mental states can rapidly shift. Clinicians must be aware that patients may present as stable while concealing severe symptoms, which can lead to inaccurate evaluations if not approached with caution.

#mentalhealth #therapeuticrelationships #psychotherapy #psychoanalysis

About the Author

Marcus Evans is a Fellow of the British Psychoanalytical Society with over 45 years of experience in mental health. He served as a consultant psychotherapist and mental health nurse, and from 1998 to 2018, he was the Head of Nursing at the Tavistock & Portman NHS Trust. He also co-founded FitzJohn’s Service, aimed at treating patients with severe mental health conditions and personality disorders. Evans is the author of several influential books in the field, including Making Room for Madness in Mental Health (2016), Psychoanalytic Thinking in Mental Health Settings (2020), and Gender Dysphoria: A Therapeutic Model for Working with Children, Adolescents, and Young Adults (2021), co-authored with Susan Evans.