Abstract:In Britain there has been an increased emphasis on the use of risk assessments in mental health services over the past twenty years. Mentally disordered offenders subject to Section 41 of the Mental Health Act 1983 (England and Wales), are defined as posing a serious risk of harm to others. They are thus dealt with by forensic mental health services, which are often seen as specialists in risk assessments. This paper is based on original research in three mental health trusts in the South of England which was … Show more
“…Evidence also shows that patients are often unaware of risk assessments taking place, and that assessments overplay individual factors at the expense of structural, social or interactional issues . Contrasts in worker and patient assessments highlight that patients soften risk towards others and draw attention instead to vulnerability . Given the uncertainty around risk decisions, it has been noted that trust is central to engagement and communication between service users and workers …”
BackgroundCommunication and information sharing are considered crucial to recovery‐focused mental health services. Effective mental health care planning and coordination includes assessment and management of risk and safety.ObjectiveUsing data from our cross‐national mixed‐method study of care planning and coordination, we examined what patients, family members and workers say about risk assessment and management and explored the contents of care plans.DesignThematic analysis of qualitative research interviews (n = 117) with patients, family members and workers, across four English and two Welsh National Health Service sites. Care plans were reviewed (n = 33) using a structured template.FindingsParticipants have contrasting priorities in relation to risk. Patients see benefit in discussions about risk, but cast the process as a worker priority that may lead to loss of liberty. Relationships with workers are key to family members and patients; however, worker claims of involving people in the care planning process do not extend to risk assessment and management procedures for fear of causing upset. Workers locate risk as coming from the person rather than social or environmental factors, are risk averse and appear to prioritize the procedural aspects of assessment.ConclusionsDespite limitations, risk assessment is treated as legitimate work by professionals. Risk assessment practice operates as a type of fiction in which poor predictive ability and fear of consequences are accepted in the interests of normative certainty by all parties. As a consequence, risk adverse options are encouraged by workers and patients steered away from opportunities for ordinary risks thereby hindering the mobilization of their strengths and abilities.
“…Evidence also shows that patients are often unaware of risk assessments taking place, and that assessments overplay individual factors at the expense of structural, social or interactional issues . Contrasts in worker and patient assessments highlight that patients soften risk towards others and draw attention instead to vulnerability . Given the uncertainty around risk decisions, it has been noted that trust is central to engagement and communication between service users and workers …”
BackgroundCommunication and information sharing are considered crucial to recovery‐focused mental health services. Effective mental health care planning and coordination includes assessment and management of risk and safety.ObjectiveUsing data from our cross‐national mixed‐method study of care planning and coordination, we examined what patients, family members and workers say about risk assessment and management and explored the contents of care plans.DesignThematic analysis of qualitative research interviews (n = 117) with patients, family members and workers, across four English and two Welsh National Health Service sites. Care plans were reviewed (n = 33) using a structured template.FindingsParticipants have contrasting priorities in relation to risk. Patients see benefit in discussions about risk, but cast the process as a worker priority that may lead to loss of liberty. Relationships with workers are key to family members and patients; however, worker claims of involving people in the care planning process do not extend to risk assessment and management procedures for fear of causing upset. Workers locate risk as coming from the person rather than social or environmental factors, are risk averse and appear to prioritize the procedural aspects of assessment.ConclusionsDespite limitations, risk assessment is treated as legitimate work by professionals. Risk assessment practice operates as a type of fiction in which poor predictive ability and fear of consequences are accepted in the interests of normative certainty by all parties. As a consequence, risk adverse options are encouraged by workers and patients steered away from opportunities for ordinary risks thereby hindering the mobilization of their strengths and abilities.
“…Hence, it was acknowledged that staff perseverance and commitment with maintaining interpersonal relationships, in the light of disagreements, was helpful to keep dialogue open and enable a concerted management of risks (Brown & Calnan, ; Holley et al, ). This necessitated a patient awareness that risk management was a visible and approachable feature of their care, whereby patients spoke of the worthwhile, yet straightforward discussions with staff to transverse risks, accompanied by mutual cooperation, so compromises could be made (Coffey et al, ; Dixon, );“…I was quite happy with [compromises]…they are professionals…so I have to give it…out of respect” (Dixon, :672)…”
Accessible Summary
What is known about the subject?
Risk in psychiatry involves harm to self or others owing to mental health difficulties, for example iatrogenic effects of treatment, self‐harm, suicide and violence.
Risk management is a framework to minimize risks, comprising of risk assessment, generation of risk management plans and evaluation of interventions.
Literature has extensively explored risk management and presented a critique that its practices can lead to patient harm. However, there is a paucity of literature about what patients identify as helpful risk management practices, despite the potential for such patient views to ameliorate harm and improve mental health care.
What this paper adds to existing knowledge
Interpersonal relationships with clinicians, and communication that keeps patients involved and informed of management processes, were found to be central to beneficial risk management practices, while patients having agency and autonomy to influence their participation was also important.
Beneficial interpersonal relationships and connectivity in the form of patients’ wider community of support were found to be influential in aiding risk management. Meaningful relationships, and particularly peer support, that maintained personal and collective identities were prevalent in the literature.
What are the implications for practice?
Rendering risk management more visible and accessible in practice might cultivate an openness that promotes patient participation. This includes drawing on a wider network of support, for example the patient’s friends and family, as well as having advocacy utilizing peer support.
AbstractIntroductionMinimizing the harm that patients pose to themselves and others, due to mental health difficulties, is a central component of risk management in psychiatry. However, risk management itself can cause patient harm, but despite this and the potentially informative value of lived experience, little is known about what patients want or expect from risk management.AimTo review research and explore what patients consider beneficial in risk management practice.MethodA mixed studies systematic review utilizing PRISMA guidelines, alongside a convergent qualitative design to categorize findings.ResultsTwelve papers were identified, generating two categories of beneficial practices: interpersonal relationships and communication with clinicians; coupled with patient agency in their own risk management.DiscussionConnectivity appears important. Particularly patients feeling involved, and their voices being heard in both the identification of risks and then shaping risk management practice. Moreover, this included involvement of friends, family and peers to widen input and supportive networks beyond clinical relationships.Implications for PracticeRisk management needs to be an accessible part of care, which is more inclusive of patient views and needs. The latter might also be aided by drawing on the patient's wider community in order to provide more effective support and r...
“…However, if a person does not expect to receive any help, is mistrusting or is very depressed or ill, he/she might not want to talk about problems with prison staff. Dixon (2012) found that mentally ill prisoners did not view risk screening schedules as objective but rather as instruments of control, and emphasized the need to persuade staff that their risk had reduced. The prisoners in our study might have been more comfortable expressing problems to a doctor or nurse in the prisoner health study, which was known to be confidential.…”
Section: Why Do Long Sentences Predict Positive Assessments?mentioning
Substance abuse is viewed as one of the main factors (criminogenic needs) to be assessed and targeted in prison. Prison assessments of risk and needs are known to validly predict reoffending. However, there seems to be lacking research in how reliably the individual prisoner's problems, such as substance abuse, are represented in the assessments. In this study, we compare an independent medical health study (N=510) with in-prison assessments for the Eur J Crim Policy Res same persons to see whether some of the inmates' substance abuse disorders were overlooked in prison. We found that sentence plans (257) were in poor agreement with the health study (Kappa 0.315); they recognized only 65 % of all diagnoses. The risk and needs assessments (178) were in closer agreement with the health study, however, alcoholism diagnoses were recognized less accurately (Kappa 0.519) and less frequently (78 %) than drug diagnoses (Kappa 0.627, 87 %). The main factors predicting an assessment of substance abuse risks in prison, analysed through logistic regression were: longer stay in prison and one or more dependence diagnoses. We conclude that, a number of potentially criminogenic dependence problems remain unrecognized since some groups of prisoners are either completely left out from the more thorough instrument, the risk-and-needs assessment, or are not assessed thoroughly enough. This puts prisoners in unequal positions, since all interventions in prison are based on assessments. The study alerts us of the selectiveness of prisoner assessments in practical settings; the unrecognition of problems of shorter sentenced prisoners and prisoners with alcohol dependence.
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