I don’t normally discuss risk assessment of repeat self harm. I’m more interested in suicide, and this paper does not report such data. Instead it looks at a more common event — recurrent self harm within six months. The authors used a series of measurements — the ReACT tool, the Manchester rule, the SAD persons scale and an impulsiveness scale.

All did poorly. Clinician impression did better. Risk assessment tools do not help: this is another paper to add to

The results of this multisite prospective cohort study indicate that risk scales generally performed poorly in terms of predicting repeat self-harm. High sensitivity scales tended to have poor specificity and vice versa. Possible exceptions to this were clinician- and patient-rated measures of global risk. Contrary to our hypothesis, formal risk scales performed no better than the global assessments and in some cases there was evidence (on the basis of ROC curves) that performance was significantly worse. Using our available study data to select optimal cut-offs in this sample resulted in better performance , but these were essentially post hoc estimations of ‘best case’ predictive utility and would not be generalisable to other samples. Our findings suggest that risk assessment tools have limited clinical utility in the assessment of self-harm.

This is one of the few studies to compare widely used risk scales following self-harm in a ‘head-to-head’ prospective cohort study. The risk scales were administered by treating clinicians and prospectively evaluated in a large real-world sample of patients referred to liaison psychiatric services for self-harm. We used clear consistent terminology across sites and had near-complete patient follow-up, although it is possible that some patients could have moved or died during the study period without the knowledge of the clinical services. We used a broad definition of suicidal behaviour consistent with UK research and clinical practice. In fact, a post hoc analysis involving the 357 self-poisoning episodes (which would be consistently included in most definitions of suicidal behaviour internationally) generated similar results.

There is a risk of sampling bias as patients who refused to complete the research assessments or who were deemed inappropriate to participate were not included in the study, which may affect the generalisability of the results. Recent large multi-centre studies of self-harm in England suggest our sample was similar to overall patient samples in terms of gender,19,41,50,51 method of self-harm,3,19,41,50 and age.41,50,51 Our recruitment rates are comparable with trials that involve obtaining individual consent from patients who have self-harmed.6,28 However, the proportion of the sample with a prior history of self-harm (74.3%) and the repetition rate in our sample within 6 months (30%) was high,40 possibly suggesting comparatively high levels of underlying morbidity and need.

The British Journal of Psychiatry Jun 2017, 210 (6) 429-436; DOI: 10.1192/bjp.bp.116.189993

Roger Mulder wrote an editorial on this at the beginning of this decade. He notes that risk assessment may lead to detention or treatment, not to protect the patient (and there is no evidence that detention does anything to reduce the risk of suicide) but to cut the clinician or service anxiety. Risk assessment is not without risk.

To the patient.

It is worth repeating his advice.

Therefore our current preoccupation with risk assessment has the potential to harm patients, clinicians and the organizations in which they work. It has created a mythology with no evidence to support it, a sense of unease among clinicians and a culture of blame when things go wrong. What can be done to change this?

First, we need to acknowledge the uncertainty of our knowledge base and that risk assessment is problematic and may carry its own risk. We need to re-educate the public that we are poor at predicting rare events like suicide and that mental illness models are neither necessary nor sufficient to explain suicidal behaviour.

Second, the best way to manage organizational risks is to improve core tasks of patient care. Risk should primarily, but not exclusively, be seen in terms of risk faced by the patient. The psychiatric interventions associated with reducing the risk of suicide such as clozapine, lithium and structured cognitive behaviour therapy are given because they are effective treatments, not for the purpose of reducing risk.

Third, organizations should take steps to protect their staff from the necessity of secondary risk management. Risk assessments should be used where appropriate and be a consensual process with the patient and clinician striving towards a realistic conceptualization of the risk then deciding how best to manage it. Detailed and complex risk assessments should be curtailed since they may amplify rather than reduce anxiety,

We may be able to provide shelter as an organization, comfort as individuals, and treatment for conditions that increase risk. But the main thing we can do is remind people in crisis that this, too, will pass. We need to keep their hopes up.

And this, human, endeavour cannot be captured in any risk stratification instrument. The current ones have poor predictive validity. Let us look at other methods, or accept the best clinical advice: all that self harm are at risk of doing it again. And need shelter from the storm, in a means of their choosing.