Assessment issues
(written by Helen Sheppard, DipSW, and Sarah Galvani, DipSW)

The initial assessment process should include a history of the person’s substance use, including current use, as well as a history of their mental ill health.  This is in addition to the assessment of their other social and health care needs.

Hawkings and Gilburt (2004: 23) suggest the following core principles for effective assessment:

• The chronology of presenting problems (using timelines)
• The relationship (if any) between them
• Whether the disorders require independent treatment, or
• Whether treating one will help alleviate the other

However, determining whether treating one will help the other is hard to do without resorting to bouncing people between services and this is where people can begin to fall through the net.  To stop this happening the assessment and early stages of intervention need to be supported by a multi-disciplinary team of people who are committed to working with each other for the sake of the client and who may need to increase or decrease their involvement in the person’s care at different times during the assessment and intervention processes.

Risk Assessment
Risk assessment is a part of the Care Programme Approach (CPA) within Mental Health services. There are a number of reasons why the assessment and management of risk of harm in clients with dual diagnosis is particularly necessary:

1. There is the failure of substance use and mental health services to meet the needs of clients with dual diagnosis leading to an increased risk that people will fall through the gap between services and may be lose contact with services altogether
2. People with mental ill health and substance problems often find themselves in the homeless or prison population
3. They may also be at increased risk of perpetrating, or suffering, aggressive or anti-social behaviour, which may exacerbate their mental distress
4. There is a high rate of suicide among people suffering both problems. The National Service Framework for Mental Health sets ‘suicide reduction’ as one of its seven key target areas. Alcohol users are a high risk suicide group as are those with a diagnosis of schizophrenia and depression. Further, research has shown that an alarming 10% of people diagnosed with schizophrenia take their own lives (Mulholland & Cooper, 2000).
5. There is also the risk of harm to others although this is lower than the risk to themselves. Dual diagnosis has been found to be a significant factor in homicides committed by people with mental health problems. Ward & Applin (1996) examined 17 reports into murders committed by people with mental health problems in the UK and found that 13 of these involved significant substance use.

What is involved in a risk assessment?
The purpose of conducting a risk assessment with someone is to identify whether they pose a risk to themselves or others.  There are many different types of risk assessment from formal tools, eg. those that assess violent behaviour or suicidal thoughts, to sets of questions on a comprehensive assessment forms.  The assessment type will vary from one organisation to the next. 

Two important points to consider when conducting risk assessments are that they are completed in partnership with the person concerned (where possible) and that the information is shared with relevant agencies (with consent unless there are grounds for breaking confidentiality).

The key components of a risk assessment usually cover the following areas:

• Current symptoms of mental ill health that suggest possible risk, for example, hearing distressing voices, suicidal thoughts, thoughts of harming others, impulsivity
• Current behaviour that suggests increased risk of harm to self or others, for example, making threats, problematic drug and alcohol use, risk to children or vulnerable adults
• History of service use, for example, has the person previously a) stopped attending services against advice, b) stopped taking medication prescribed, c) had compulsory hospital admission, d) had contact with forensic services
• Personal circumstances that might increase risk, eg. homelessness, financial vulnerability, concern expressed by others, recent severe stress, relationship problems, contact with criminal justice system.

For people who use alcohol and drugs, it is important to have a discussion with them about how their substance use relates to, and impacts upon, their mental health.  They may experience their substance use as having positive and/or negative effects and it is important to understand their experience and not to see any substance use as negative (see ‘Why people use substances’ in the ‘Background and Context’ section of this website).

NB.  It is important not to jump to conclusions about risk based on one factor alone, for example, if someone is hearing distressing voices it does not mean they are automatically going to harm themselves or others. However, thoughts of harm to themselves or others will need further assessment and discussion.

Once the risk assessment has been carried out, it should result in a joint decision (with the service user where possible) about the level of risk and a joint plan for managing this risk.  In most cases the plan will be multi-disciplinary because it will involve both social and health care professionals. It is vitally important that it is shared with other people involved in the individual’s care

** A risk assessment is of no use if it is not shared
with appropriate professionals and carers. **

Poor risk assessment may lead to individuals being placed in inappropriate services with insufficient support.

What is dual diagnosis? | Working with both issues | Treatment issues | Websites