Recent inquiries show that there is a need for a better understanding of the relationship between mental disorder and risk, about what is involved in risk assessment and risk management, and for better training for all involved, whether in health and social care services or in the criminal justice system. This paper sets out the basis for this conclusion and describes some recent central initiatives to promote better understanding of risk and risk assessment and management.

The infamous Hungerford Massacre, the multiple murders committed by Michael Ryan in the Berkshire town of Hungerford on 19 August 1987, remain firmly in the public's imagination. It would have been difficult for anyone reviewing the newspapers of that and subsequent days not to conclude that Michael Ryan was mentally ill – headlines ranged from “Day of the Maniac” to “Matricide Points to Schizophrenia”. Because Ryan killed himself and thus there was no possibility of a court case, psychiatrists were free to comment about his mental state and psychiatric diagnosis.

Not everyone thinks that psychiatrists have much to offer in a discussion of dangerousness. The first point made by the advocates of this position is that psychiatrists get it wrong much of the time when they predict violence. The second point is that they do not use clinical information to predict. Exactly how much of the time they get it wrong is the subject of some debate. Those hostile to the idea of medical involvement in risk assessment argue that psychiatrists and psychologists are wrong 95% of the time when they predict violent behaviour (Ennis, 1972). Even sometime supporters of clinical intervention contend that psychiatrists and psychologists are wrong at least twice as often as they are right when they predict violence (Monahan, 1984).

With the exception of a very few prolific offenders, sex offending is not a high rate activity. Even recidivist offenders will commit only a small number of offences in their careers, and these may be separated by intervals of years. Because of this, anyone setting out to predict reoffending by sex offenders will do best if they simply assume that none will reoffend, in which case they will be right more often than not. But such an approach, of course, would be criticised for being oversimplistic. Sex offenders have a history, and there is a common belief that if we know enough about an individual's past we should be able to predict his future with great accuracy. This has led some workers to claim that if the right variables can be discovered and plugged into a risk assessment algorithm, then the resulting desktop prediction of risk will outperform any competing clinical method.

Traditionally adult psychiatrists have been more concerned with their patient's family of origin than with the family of procreation. When considering the management of the seriously mentally ill, the family is regarded as a potential source of stress or care, and little attention is given to the role of the patient as a parent (Rutter, 1966; Bennett, 1996). This position is exemplified by the absence of questions relating to childcare on the Health of the Nation Outcome Scale (HoNOS; Wing et al, 1995). This scale is likely to be widely used in the Care Programme Approach in England and Wales as an indicator of illness severity and outcome. Such questions should include the effect of the illness and disability on the physical and emotional development of the child, and the patients' ability to manage the responsibilities of childcare.

Peter Scott's (1975) characterisation of the concept of dangerousness as potentially dangerous in itself could not be more relevant than today. The principal focus of mental health policy over the last six years has been the care and treatment of seriously mentally ill people and mentally disordered offenders, and central to the successful care of the former and many of the latter is the competent assessment of the risk they pose: mostly to themselves, but occasionally to others.

In this paper, I wish to address three questions: “are we being overcautious in the assessment of risk?”; “should we actually assess risk?”; and “are clinicians the right people to be assessing risk?”.

It is debatable whether the notion of dangerousness now has any utilitarian value for psychiatry. The presence or absence of dangerousness is very much in the eye of the beholder. It is an all or nothing term – you either have it or you do not! While there is usually little disagreement about the few very violent individuals “who, for 24 hours a day, and in any situation, are likely to cause harm to others” (Chiswick, 1995), most patients are not in this category and “little bit dangerous” is unlikely to be of much comfort to clinical staff. It is unhelpful to deny that dangerousness is any more than an adjective which has been elevated into a pseudoscientific construct whose definitions (Scott, 1977; Walker, 1978; Home Office & DHSS, 1975) amount to little more than “past harm predicts future behaviour”.

Risk assessment has always been an essential part of all medical practice, and doctors have always been trained to make rapid assessment of risk. Much of the early training of doctors in both medicine and surgery centres on risk assessment. However, the method of acquiring that knowledge is predominantly through the apprenticeship model with observation by the trainee of the trainer's decision-making process. Those decisions, however, are often skewed and biased by a whole variety of influences, rather than always being based on scientific evidence. Clearly the increasing influence of evidence-based medicine will help this. At one extreme, however, there are heroic surgeons taking unnecessary risk or taking on cases which might more appropriately have been left without treatment, and at the other extreme, consultants who may feel demoralised or depressed might well become nihilistic about medicine and therefore might not attempt to treat cases that are treatable.

There has been a sea change in public attitudes toward the use of litigation in medicine over recent years. Mental health professionals are beginning to add an additional factor to their risk calculations when managing difficult patients: the assessment of risk (of a civil action) to themselves in the event of an untoward incident. This development must be recognised and anticipated if we are to assess fully the potential benefits, and the costs, of closer surveillance of vulnerable patients in the community.