The decision to move a forensic mental health patient from conditions of high to medium to low security is one of the most important decisions taken by forensic mental health professionals but has seldom been studied. Risk assessment has evolved into structured professional judgement instruments which guide decision makers by identifying risk factors for violence or suicide but do not claim to make 'diagnostic' ratings for risk status. The DUNDRUM toolkit is a suite of structured professional judgement instruments developed at the Central Mental Hospital Dundrum, Dublin, Ireland [1
]. The toolkit is a set of instruments designed to assist clinical decision making when assessing the need for therapeutic security (DUNDRUM-1 triage security) [2
] and urgency of need for therapeutic security (DUNDRUM-2 triage urgency) [3
], assessing a patient's programme completion (DUNDRUM-3) and recovery (DUNDRUM-4) and therefore their ongoing need for security as well as a self rated instrument in which patients assess their own need for therapeutic security [1
The content of these instruments is different from but complementary to risk assessment. When making decisions regarding moving a patient from high to medium and on to low levels of therapeutic security or discharging patients to the community, clinicians are likely to take more than risk assessment alone into account. Factors such as mental health, physical health, self care and activities of daily living, family and social networks, use of leave from the hospital and other such factors are all given strong consideration. These items are often included in clinician’s reports to mental health tribunals and review boards to assist these bodies in their decision making with regard to a patient’s readiness for a move to a less secure place. The items scored in the DUNDRUM-3 and DUNDRUM-4 include the above items and are based on motivation theory, cycle of change and engagement. The DUNDRUM-3 programme completion instrument consists of seven items - physical health, mental health, drugs and alcohol, problem behaviours, self care and activities of daily living, occupation, education and creativity and family and social networks. The six items of the DUNDRUM-4 recovery scale are stability, insight, rapport and working alliance, leave, HCR-20 dynamic risk items and victim sensitivity. Each item is accompanied by a series of definitions and rated from ‘0’ to ‘4’. A patient scoring mostly ‘4’s is unlikely to be ready for a move to a less secure place, a patient scoring mainly ‘3’s is likely to be ready to move from high to medium security, mainly ‘2’s is likely to be ready to move from medium security to PICU, mainly ‘1’s is ready for placement in the community and mainly ‘0’s is likely to be ready for an absolute discharge.
We have shown that these scales have excellent psychometric properties and in a naturalistic cross-sectional study of patients in a forensic hospital, these instruments distinguished between those who are or are not allowed unaccompanied leave and between those who have progressed to pre-discharge units [4
These instruments are designed to enable clinicians to present assessments regarding the readiness for moves to less secure places in a way that is transparent and evidence based. The content of the instruments is derived from an iterative process [1
]. The factors making up the items are broader than risk assessment, although there is good evidence that risk assessment is relevant to the success or failure of moves from higher to lower levels of therapeutic security [5
]. The examination of the decision making process leading to success or failure in the placement is a therapeutic departure from the more commonly studied outcomes such as violence or criminal recidivism [8
] and addresses long standing problems with revolving door patients and the need for reliable international benchmarks [10
]. The DUNDRUM Toolkit instruments can be used in ways that are complimentary to risk assessment instruments when engaging with service users in planning their treatment and when presenting evidence at mental health review tribunals and boards concerning detention under mental health legislation, when measuring outcomes for health service commissioners and for service users.
In this prospective study we examined whether the DUNDRUM-1, DUNDRUM-3 and DUNDRUM-4 along with other assessment instruments could distinguish between those who subsequently moved from more secure to less secure units, and those who were moved from less secure to more secure units. Because the HCR-20 is established as a predictor of moves and recalls [5
], we hypothesised that any other measure would have to have a significant effect even when correcting for HCR-20 dynamic risk. We further hypothesised that the risk of violence or self-harm, combined with the seriousness of the risk, would be significant determinants of the decisions to move patients, based on the original formulation of Scott concerning risk and the seriousness of the risk [11
]. We hypothesised that the need for therapeutic security, as measured by the DUNDRUM-1 triage security instrument, and the DUNDRUM-3 programme completion and DUNDRUM-4 recovery instruments, which record progress, would represent Scott's concept of 'seriousness' or 'gravity'. In a subsequent paper, we will report on whether these instruments predicted those who were eventually conditionally discharged.