START-ing Risk Assessment and Shared Care Planning in Out-patient Forensic Psychiatry: Results from a cluster randomized controlled trial

The prevention of future violent behaviour is the main aim of forensic psychiatric treatment. Structured risk assessment instruments are commonly used to determine which clients are in need of which treatment and/or supervision. However, there is very limited support for their use as a method for violence prevention. Establishing and maintaining client motivation for treatment is and additional challenge in forensic psychiatry. Both theories and research in other settings suggest that Shared Decision Making (SDM) could be helpful in this respect. Therefore, this thesis examines the effect of an intervention combining structured risk assessment with SDM on levels of recidivism and client functioning and well-being. The Risk Assessment and Care Evaluation (RACE) study was conducted in out-patient forensic psychiatry. Clients improved significantly over time, both in levels of recidivism (which went down) and in well-being and functioning (which went up). However, none of the improvements could be attributed to the intervention. Thus there is currently very limited support for the use of risk assessment instruments as a way of violence prevention. Nor can the changing of treatment policies by introducing the systematic use of structured risk assessment in clinical care be either advocated or opposed at this time. However, the evidence base is limited to 4 studies, including this one. Therefore, investigations of the benefits of risk assessment instruments and their contribution to more effective treatment interventions in terms of reduction of criminal and violent behaviour and ways in which to involve clients more in their treatment are necessary.