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Collaborative Risk
Assessment
Susan Elliott, Clinical Psychologist
The Broadland Clinic
Plan
• Background
• Service context
• Aims and process of the collaborative risk
assessment process:
– Collaborative training sessions
– Risk and Safety group
– Risk clinics
Background
• Completed by NN / MDT member
• “Tick box” exercise
• Poor completion rates
– 10% at first audit
• Service users unaware
Background• Langan & Lindow 2004:
– Professionals found risk discussions difficult
– Worries included increasing stigma and distress, fears for personal safety, increase risk; decrease engagement, increasing tension / managing disagreements
– Reasons included: service user’s right to know what was being written; increased trust & therapeutic relationship; collaborative risk assessment & management more effective & reduce restrictive practice, inaccuracies
Background
• Recovery approach is the main philosophy used in forensic services.
• Best Practice in Managing Risk. 2007. Department of Health.
• “Risk assessment and management need to become more open, more transparent with service users and staff working collaboratively together. This is particularly important in forensic and high risk settings, where recovery is just as important a principle as it is in any other part of the mental health service”.
Boardman J, Shepard G. 2009. Implementing recovery: a new framework for organisational change. London: Sainsbury Centre for Mental Health. Report.
Background• “Involve service users in all decisions about their care
and treatment, and develop care and risk management plans jointly with them. If a service user is unable or unwilling to participate, offer them the opportunity to review and revise the plans as soon as they are able or willing and, if they agree, involve their carer.”
2015 NICE guideline: Violence and aggression: short-term management in mental health, health and community settings
Background
• My Shared Pathway: Promotes collaborative approaches to care and treatment
• Mental Health Act Code of Practice 2015• Empowerment & Involvement:
“Patients should be given the opportunity to be involved in planning, developing and reviewing their own care and treatment to help ensure that it is delivered in a way that is as appropriate and effective for them as possible. Wherever possible, care plans should be produced in consultation with the patient”
Background• CQUIN: Collaborative Risk Assessments
– “an active engagement programme to involve
all secure service users in a process of
collaborative risk assessment and
management”
• Risk and Recovery Groups for Offenders With Mental
Health Problems:
Bethlem Royal Hospital, South London and Maudsley NHS
Foundation Trust and East London NHS Foundation Trust:
Wolfson House)
Service context• Broadland clinic
– 25 beds
– Males 18 years +
– Intellectual disabilities
– Autism
– Medium Secure
• 1 x Admission ward (Hathor)
• 2 x Rehab wards (Olive & Vega)
• 1 x Discharge ward (Mayflower)
Process
Service
User
Collaborative Risk Training
sessions
Risk
& Safety Group
Risk Clinics
Aims• To promote transparency and awareness of the risk assessment process.
• Person-centred, collaborative & strengths based
• To promote service-user involvement in risk assessment
• Collaborative treatment focus
• Understanding relationships between their difficulties & risks
• Increase discussions about risk related issues
• Promote responsibility taking
• Empowerment to monitor and manage risks
• To help service user to monitor progress
• To integrate risk formulation and management strategies into day to day clinical discussions, decisions and practices
• To promote discussions & coordination with receiving teams & community services
Collaborative Risk Training
sessions
Collaborative Risk Training sessions• A shared workshop for both service users & staff
• Slides designed jointly with services users who have completed risk & safety group
• Facilitated by a service user jointly with a member of staff
• Introduce risk assessment & risk management
• Developing service user & staff understanding of shared risk assessment/management process
• Facilitates positive risk taking & open discussions
• To enhance engagement and communication
Slides from risk training sessions
Types of Risk Risk Assessment Care planning towards
discharge Regular review to keep up to
date Support self-care & self-help Keeping people safe
Harm to self Harm to others Harm to the community Children / vulnerable adults Harm from others
Risk training sessions
Risk assessment
• What?• When?• How?• Where?• Why?• What Makes it more likely to
happen?• What makes it less likely to
happen?
Linked with MSP
Helps with identifying goals
Helps to develop skills
Helps to move you closer to your goal
Increased community leave
Move to Low secure
Move to the community
Staying safe
Risk training sessions
Who should be involved in
your risk assessment?– OBSERVING
• THINGS YOU ARE SAYING & DOING
• YOUR PARTICIPATION & PROGRESS IN TREATMENT
• HOW YOU ARE GETTING ALONG WITH STAFF & PEERS
» HCR-20
» Historical
» Clinical
» Risk
» 20 items
How do we assess risk?
YOU
YOURTEAM
FAMILY/CARERS
MAPPA/POLICE
MoJ
Risk training sessions
HCR20• HISTORICAL:
• Previous violence
• Types of relationships
• Drug or Alcohol Misuse
• Work problems
• Mental Illness
• CLINICAL:
• Understanding of your treatment
• Currently unwell?
• Responding to treatment?
• RISK:
• What are plans for the future?
• What support will you have?
• What types of stress will you have?
What can makes your risks increase or decrease?
Risk training sessions
Risk Management
• Risk
• Plan
Your involvement
Risk training sessionsHow can you be involved?
• Talking to your named nurse
• Individual sessions with named nurse/associate nurse
• Attending therapy sessions
• Attending your CPA meetings
• Attending your risk clinic
• Attending the Risk & Safety Group
Risk and Safety Group
Inclusion criteria:
• Not acutely unwell
• Ability to tolerate a group setting
• Agreeing to attend
• Miss 3+ sessions
Measures
• Semi-structured interviews
Knowledge
about risk –
tailor made
Q.
Plans for
future risk
management
(RPP)
Evaluation
of the group
Participation
in HCR20
Pre-assessmentX X
Post-
assessmentX X X X
Group Structure
• 8-12 sessions
• 2 staff members facilitating. Plus one service user who has completed group / expert
by experience.
• 60 minutes weekly
• Psychoeducation
• Basic structure each week:
– Check in
– Summary
– Session topic
– Exercise
• Mixture of: small and large group activities, discussions, videos and case study
examples, role-plays.
Group content
Session 1Introduction to RISK and SAFETY; group agreement; videos (eg
Eastenders)
Session 2 Introduction to risk assessment: HCR20; first 5 items; case studies - rate
Session 3 Summary; next 5 H items; case studies and rate
Session 4 Summary of H items; MDT role plays; Introduce C items
Session 5 Summary; 5 C items; Case studies and rate
Session 6 Summary; MDT role plays; Introduce R items
Session 7 Summary; 5 R items; Case studies and rate
Session 8 Summary; MDT role plays; Risk reducers, enhancers & RPP
Session 9 Summary; TRIBUNAL role plays
Session 10 Ending; summary; tribunal role play; cake; certificates
Session 11
Session 12
Session 2• H: risky things I’ve done in my past
• C: Things I can change to manage my risks
• R: future risks and how I will manage
• 20 items
• Historical /risky things I have done in my past:• Violence: any actual, attempted or threatened harm
• Other antisocial behaviours
• Relationships: any problems forming or
keeping long term relationships
• Employment: any problems in finding a job,
keeping the job or sticking to the rules
• Substance misuse: alcohol/drugs/prescribed
medications / legal highs
Yes: this
is present
Possible: partially
present
No: this is not present
Case studies: PatrickPatrick is 19 years old.
After he left school he did a mechanics course at college and has been working at the same garage
for the last four years.
Patrick had some difficulties when he was at school: he got into a lot of verbal fights; he had some
difficulties with learning at school and he preferred to act silly in class to avoid having to do
something he felt that he was not good at. He was later diagnosed with Dyslexia. When Patrick
went to college he really enjoyed car mechanics and realised that he was really good at it so he
worked hard, got an apprenticeship at the local garage and has worked there ever since.
Patrick still lives with his mother, step dad and step brothers who are younger than him. They all get
on quite well although he sometimes has arguments with his little brothers. Patrick has a best friend
since school called John and they hang around with 6 other boys who they met at college. He also
has a girlfriend and they have been dating since they left school – for 4 years.
Patrick usually goes out drinking with his friends every Saturday night. He and his friends takes turns
to drive. So sometimes he drinks nothing (if he is the driver) and on other times he drinks up to 10
pints of cider. Last weekend Patrick went out with his friends because it was a bank holiday. They
started drinking alcohol from lunchtime and got really drunk. Patrick’s friend bumped into a girl on
the dance floor and spilled drinks all over her. She complained to the bouncer who decided that
Patrick and his friends all had drank too much and that they needed to leave. Patrick threw a glass
bottle at him but this missed, and then he punched the bouncer really hard– the bouncer was
knocked out and had to go to hospital to have a scan which showed a bleed on his brain. The
bouncer had to have surgery and is now recovering in hospital.
Patrick was arrested and went to court where he was found guilty of GBH
Case study: Seamus
Seamus is 31 years old.
He has been unemployed for many years. He was expelled from 3 schools by 13 years of age for
smashing school furniture and getting into physical fights with other pupils. He has never worked.
Seamus used to spend a lot of time hanging out on the river bank in town, drinking alcohol and
smoking cannabis. He really enjoyed this but struggled to have enough money. He started to enjoy
feeling drink and stoned so much that he began to drink and smoke cannabis alone in his flat. He ate
less to have more money for alcohol and cannabis. One day when he was visiting his mum he
decided to take some of her jewellery from her room and sold it on for drugs. Seamus also has
burgled some of his neighbours for money for alcohol and drug. Patrick smokes cannabis and drinks
alcohol every day from as soon as he gets up in the morning.
The police have given Seamus lots of warnings and he has many convictions for burglary, robbery
and assaults. His first contact with the police was when he was 13 years of age as he injured a girl in
his class at school.
Seamus has had many girlfriends but none have lasted longer than 3 months. Seamus has been
warned and convicted of assault of two of his girlfriends and admits to domestic violence within the
other relationships.
Session 3• Mental health difficulties
• Personality difficulties: repeated and severe problems with regulating and
expressing emotions, behaviours, in relationships, and sense of self.
• Trauma: any harmful or traumatic events
• Violent attitudes / thinking errors
• Treatment / supervision response
Yes: this
is present
Possible: partially
present
No: this is not present
Case studiesPatrick has no mental health difficulties or diagnosed personality problems. When he was younger
he struggled at school but did not think this was traumatic for him. His parents split up when he was
2 and he can’t really remember this but his step-dad moved in before he was 3 years of age and has
lived with them ever since – Patrick said that he is a good role model and that he views this man as
his father.
When Patrick was arrested and had to go to court, he was very upset. He said that he was sorry for
hitting the bouncers and that he felt terrible that someone had been so badly hurt by him, that this
man had to take time off work and that this man needed so much medical care afterwards. Patrick
said that he would never want to hurt anyone again and did the offending group in prison and the
substance misuse group. Patrick said that he does not intend to drink excessively again in the future
and wrote a letter of apology to the bouncer and his family which was shared in court. Patrick said
that he felt glad that the law is there to protect people and that he did not believe it was ever ok to
hurt someone.
Patrick’s psychologist in prison said that he felt he had quite a good understanding of why he had got
into trouble. Patrick had told him that he had drank far too much alcohol and that this had made
the situation worse. Patrick told him that he did not intend to hit or hurt anyone although he
understood that he had picked up a glass bottle to throw it. Patrick said that he had become so
angry at the time because they were trying to impress some girls on the dance floor and the bouncer
had made him feel silly and he thinks that this reminded him of when he was at school. Patrick said
that he thought this might be a “thinking the worst” thinking error because actually the bouncer just
thought they were drunk and was probably not trying to make them look silly. Patrick has attended
some EQUIP sessions and has been working on his thinking the worst thinking errors by practising
the stop and think; anger reducers; self-talk and reversing strategies. Usually Patrick feels that his
mood is quite stable and calm and he feels well.
Patrick’s family and prison team think that he has made good use of the services available to him in
prison. In fact, Patrick agreed to be referred to meet with a probation officer for a few months after
he is released. He is currently in prison but is planning to move back to his flat with his girlfriend
where he has lived for many years and this is near his family and work. There are no problem with
his flat, he pays his rent on time and his landlord said that he pleased that he looks after it so well.
Patrick has received good support from his girlfriend, friends and family. They all regularly phoned
him and visited him when he was in prison and Patrick said that he feels he can talk to them all
about his problems when needed. Patrick’s prison team felt that he had made good progress on the
EQUIP and substance misuse programmes. Patrick agreed with this and said that he is now using the
new techniques to recognise thinking errors sooner. Patrick is secure financially and has no medical
problems or difficulties in his relationships. Sometimes he feels stressed at work when he is very
busy but says that he copes with this by working hard, telling his customers realistic times to pick up
their cars.
Case studiesSeamus was physically abused by his very strict father when he was younger. He also saw his father
beat his mother up many times. Patrick has been to prison many times and went to the treatment
groups but never really listened. He once said that he believes that it is ok to hit a woman if they are
arguing with him or do not disagree with him. He also said that he does not feel sorry for the
assaults and burglary’s because those people ‘deserved’ it. When he was younger he broke many of
his ASBO convictions and has broken bail conditions before. Seamus has been diagnosed with
psychosis in the past and he said that sometimes when he is smoking a ot of cannabis he can hear
voices and feel paranoid. He is under the care of a community mental health team but never keeps
his appointments with them. They are worried that he has a drug-induced psychosis and have asked
him to stop smoking cannabis but he has ignored them.
Seamus does not think he has done anything wrong and says that it is the ‘systems fault’ and the
‘victims fault’ that he keeps getting into trouble. Seamus said that if anyone disses him he will punch
their lights out. He said that if a woman ever messed him around that he would “kill her”. Seamus
can act suddenly and seems to get into a bad mood very quickly and without warning. Only the
other day he suddenly and without warning threw a cup of hot coffee at the wall and did not explain
what he was doing. He continues to decline any of the treatment programmes.
Seamus has broken his bail conditions many times. One of his ex-girlfriends got a restraining order
placed against him which said he should not contact her or be within 10 feet of her. However, she
had to ring the police many times as he kept knocking on her door and following her out of work and
phoning her. Seamus does not attend many of his appointments with the community team. Seamus
was asked to leave the hostel he was living in because he invited many people around to do drugs
and drink alcohol and they trashed the place. He was also not paying his rent. More recently he has
been sofa surfing or sometimes sleeping in the local park. Patrick’s friends all use a lot of drugs and
don’t tend to look out for him. He has no contact with his mother and sisters any more. Just a few
months prior to this his mother had been diagnosed with cancer and Seamus was very upset about
this – he overdosed on heroin the night after finding out. His mother tried to talk to him about things
but Seamus kept getting so angry with her that she told him to come back when he had calmed
down and he never did. Seamus sometimes speaks with his father but they often get into lots of
fights, verbal and physical. Seamus is not sure where his father is at the moment and thinks he
might be back in prions. Seamus does not believe that he needs any help or treatment.
Tools
• Videos
• Role plays
• Case Studies (Patrick and Seamus)
• Adapted / easy read HCR20 forms
• Traffic light system
• SLT involvement– Talking mats
• Relapse prevention plans: booklets, easy read, pictorial, audio, video
• Flash cards
Challenges• Flexibility of group structure and content
• Motivating service users to attend: those who see no need for recovery or change.
• Generalising & internalising the information
• Tick box exercise for some?
• Balance between education about HCR20 and personal experiences
• Another group?
Feedback from participants• ““To get information from staff”
• “Gain a shared understanding”
• “To help us to have a good life”
• “For staff to get to know us”
• “For us to get to know ourselves and our problem areas”
• “To have a plan to stick to”
• “Establish goals to work toward”
• “To help us to have empathy for others”
Feedback from participants
• “To help us to safely manage our risk”
• “To make progress”
• “To learn different methods of coping”
• “Reduce our risks for future freedom”
• “So I don’t re-offend”
• “To reduce my risk”
• “To know what my risks are”
• “To prevent my risks from happening again”
Risk clinics
Risk Clinics• 6 monthly meetings
• Similar process to CPA (invites sent out)
• Focus groups
• Planning centred around service user – Who attends
– Structure of meeting
– Materials
Materials
My Shared HCR20
Name:
The HCR20 is a risk assessment of violence.
This assessment looks at how likely someone will be violent again.
It also helps us to understand previous violence and to work out what management and interventions are needed.
Date Completed:
Signed
Risk reducers Risk enhancers
Telling the truth Keeping secrets
Talking about my feelings Not following rules
Thinking about consequences ‘manipulating’ people
Occupying myself with
activities
Not spotting my thinking errors
One to ones with staff Not managing my thinking errors
CBT diary sheets Letting problems build up
Doing my therapies Rejecting advice / support
Using my leaves Drugs
Listen to advice Alcohol
Following my plans Peer influence
Using EQUIP skills Misusing / missing medications
Having a ‘project’ or a challenge Not managing my money
Relapse prevention plan
My keeping well plan
• My plans for the future
To get discharged
• To see more of my family
• To get discharged
• To continue my voluntary job at….
This keeping well plan is to help me
to stay well, in control of my life and
to be able to live well in the
community. I believe that the areas I
need to continue to work on and that
have been a problem in the past are:
• Mental health
• Drugs and alcohol
• Hurting myself
• Arson & risk
A little about me:
Relapse prevention plan• Managing my mental health
Take responsibility for my health
Keep busy and do good things – having structure and a
reason for getting up is important and having a role will help
me to feel good about myself
Take medications
If I notice early warning signs I will speak to my team
Take control of my thoughts – avoid worry cycles but
manage the worries by problem solving
Managing my feelings better and not allowing them to build
up until they become unmanageable
I can now remind myself that I have had this before. I now
know what it is and can get help
Remind myself that my mind is playing tricks on me and that
it’s not real.
In the past, early warning signs that I am getting unwell have included:
Blaming myself for a lot of things and thinking over and
over about this.
Start feeling anxious and worried, leading to suspicious
thoughts, ruminating (thinking over and over) which
develops into paranoia.
Sleep less
Starting to think that everyone is against me
Stop taking medications
Start to think people are following me
Take more drugs to help cope at the time
Invite lots of people who I don’t know around to my house
so that I am not alone. This means I am partying harder
and taking more drugs and alcohol.
I stop leaving the house
I stop looking after myself, don’t shower or wash
Relapse prevention planI now use coping strategies that I have learnt including:
Stop and think
Remind myself of the consequences of committing more
crimes
Self-talk
Checking the evidence for and against
Spot my thinking errors
Talk to others about how I am feeling
Treat others with respect – how I would like to be treated
Make sure I am occupied and this will help structure my time
and make me feel good about myself
Use my self-soothe strategies (to make my feelings more
manageable)
Write in my CBT diaries
I no longer enjoy seeing people get hurt. I now feeling guilty I have hurt
someone because I think:
o That was my fault
o I should not have done that
o It’s wrong – breaking the law
o That person’s feelings are hurt
o That person might be physically hurt and need time off work
or worse
o Their family and friends will be upset
Managing my feelings
I sometimes have difficulty recognising my feelings. I find it
difficult to make myself feel better and so sometimes ask for
a lot of reassurance from others.
At other times I let my worries and feelings build up until the
situation seems unmanageable and sometimes I have hurt
myself, taken drugs to make things feel better, or hurt other
people.
Sometimes I think about something so much that I worry lots
and feel panicky about a situation before it happens
(anticipatory anxiety).
Relapse prevention planMy trigger situations
My trigger thoughts
My trigger feelings
Confused
Upset
Sad
Irritable
Tired
Vulnerable
Lonely
Rejected
Uncared for
Physical feelings – how I’m feeling in my body
Heart racing
Sweating
Clammy
Fidgety – can’t keep still
Relapse prevention planThe behaviours I want to stop My coping skills toolbox
Substance misuse RPP
My goals for substance use
The things I want to do / my life goals
Things that will help me to cope (healthy habits)
Tempting times
Coping strategies
Tempting People
Tempting Places
Tempting Items
Tempting Thoughts
Temping Feelings
Consequences of using drugs or alcohol again for me
What happens if I have a blip or change my goals?
Talking mats
FlashcardMy coping card
Listen to music
Watching TV
Doing my hobbies Relaxation
My coping card
Talk to people/staff
Good sleep
Positive self-talk
Advantages
• Completion rate 98%
• Feedback so far:– Sharing
• Nurse A: “I used to do the HCR20 myself when I was on nights. I worried that if anything went wrong I’d be held responsible as it was my name at the end…this way the risks feel shared between us all, there’s much more info on there too…I talk more to [service user name] about it… a richer assessment I’d say.”
• Service user A: “I never knew what they were saying about me …writing about me. I never knew what was in there and now I know and can have my say and make plans….”
– Opening risk discussions
– Goal setting
– Service user is central
Challenges
• Individualising the processes and documents
• Meeting targets
• Electronic systems
• Getting people together
• Process rather than a completed task eg
working toward formulations
• Application day to day
Q4 outcomes
• 97% nursing staff attended training session
• 25/25 patients offered risk assessment training session, group and shared HCR20
• 3 declined all of above
• Further 5 attended training but declined group and HCR20
• Of 17 who completed group, 14 now take part in their HCR20s– 1 x “I don’t need to; I know my risks already”
– 1 x declined involvement in “paper work”
– 1 x too stressful and so uses traffic lights for H,C,R
References & useful resources:• DHSSPS. May 2010. Promoting Quality Care: Good Practice Guidance on the
Assessment and Management of Risk in Mental Health and Learning Disability Services. Accessed on https://www.health-ni.gov.uk/sites/default/files/publications/dhssps/mhld-good-practice-guidance-2010.pdf
• Department of Health, June 2007. Best Practice in Management Risk: principles and evidence for best practice in the assessment and management of risk to self and others in mental health services. Nation Mental Health Risk Management Project.
• Douglas, K., Hart, S.D. Webster, C.D., and Belfrage, H. (2013) HCR-20 Assessing Risk for Violence (3rd ed.) Vancouver: Simon Fraser University
• http://www.merseycare.nhs.uk/managing_clinical_risk/default.asp
• Morgan, J.F 2007. Giving up the Culture of Blame: Risk assessment and risk management in psychiatric practice. Royal College of Psychiatrists
• NICE, 2015 Violence and aggression: short-term management in mental health, health and community settings. Accessed on https://www.nice.org.uk/guidance/ng10/chapter/1-Recommendations#anticipating-and-reducing-the-risk-of-violence-and-aggression-2
References & useful resources
• Langan, J. & Londow, V. 2014. Mental health service users
and their involvement in risk assessment and management.
Joseph Rowntree Foundation.
• Henagulph S, McIvor R, Clarke A. Risk and recovery group
for offenders with mental disorders. Psychiatr Serv.
2012;63:94–5
• Mann, B. 2012. Service users assessing their own risks. In
Quality Network for Forensic Mental Health services
Newsletter, Royal College of Psychiatrists
• Widgit symbols from www.widgit.com
