Risk management during the transition from hospital to community care

Abstract

There is a dearth of research on risk management of violent patients during the phase of transition from hospital to community care. D ischarge can only be contemplated when identi® ed risk factors are managed and tested in non-secure environments. Therefore this process should proceed cautiously and over as protracted a period as circumstances allow. A gradated programme which caters for various levels of risk allows for the testing of measures within a relatively well controlled milieu. Initial measures would include anticipating and preparing for future living arrangements (especially accommodation, supervision, ® nances) and psychoeducation for the patient and care givers. Speci® c risk factors, such as co-morbidity (especially alcohol and substance abuse), and relationship dif® culties may need specialized or particular individual interventions. Increasingly cultural issues will have to be considered and incorporated into management plans.M ost clinicians contem plate the discharge of dif® cult and previously violent patients with trepidation. The clinical team is confronted with competing interests: the need to treat and return the individual to the com munity, and the necessity of protecting others from possible harm. Various other factors have to be considered, such as the requirem ents of relevant legislation, problems encountered during previous attem pts at rehabilitation, and the resources available in the region. Unfortunately, the m ilieu of secure units is generally far removed from the demands and realities patients will confront outside' (Prins, 1990; Tong & M acKay, 1959). There will always be a sm all nucleus of treatm entresistant psychotic individuals with im pressive histories of sym ptom-driven violence for whom inde® nite institutionalization is appropriate, even though their behaviour in hospital m ay be exemplary. Som e will only be allowed brief (albeit frequent) supervised forays into the local surrounds. But for most, risk m anagement will have progressed as a counterpoint to risk assessm ent such that their eventual re-integration into society becomes possible. This process begins on admission and continues throughout rehabilitation. The pre-discharge period, during which the recent m em ories of containm ent in a secure unit com bine with the patient' s impatience to leave, is an exquisitely sensitive (and often precarious) opportunity to achieve long-lasting therapeutic gains.A com plicating factor is that m ost patients possess little insight into their disorder (or behaviour that precipitated the adm ission), and have had to submit to treatment under varying degrees of coercion. Whether continued m onitoring and m anagem ent in the com munity should be enforced by resorting to legislative measures rem ains contro-

Outcome of clinical risk management in the Gloucester rehabilitation service

“…While most of the goals were in areas that were obviously linked to risk, for example targeting compliance, others reflected an awareness that areas that might not obviously link with risk (such as family work, drug changes targeting side-effects, art therapy concerned with childhood experiences) were all considered to be legitimate foci for risk management. In our experience, the danger of therapeutic nihilism resulting from the allocation of a 'high-risk' label (Kaliski, 1997) to a case does not appear to have been realised. The clinical approach reported in this paper was of holistic clinical management, based on comprehensive assessment of need.…”

Risk Management in Transitions Between Forensic Institutions and the Community: A Literature Review and an Introduction to a Milieu Treatment Approach

“…No single publication was found in this search of the literature that dealt with individually adopted and stepwise, criterion-based progression, either as case material or as introduction to this kind of methodology. The three works that were close to meeting the goals of this search may be grouped into two areas of interest: An eclectic approach in which the patients progress from high containment to relative freedom by designating each treatment unit to fulfill certain functions and security demands (Kaliski, 1997). The two other works deal with the implementation of intra-institutional functional skills assessment and training (Vess, 2001) and an approach to group role playing for violent psychiatric patients with coaching and feedback (Frey & Weller, 2000).…”

“…It is important to emphasize that the reason for presenting the ProLad was not the idea that it represents a new and basically different approach from those already used within the context of forensic psychiatry. The ProLad part of the article was instigated by the paucity of publications found in the present and previous reviews of the literature (Kaliski, 1997;Lindqvist & Skipworth, 2000;Vaughan & Done, 2000;Vess, 2001). The basic principles that the ProLad is built upon are well known and integrated in the clinical practice of many forensic and correctional facilities.…”

“…There has been little dispute about the fact that individually adopted and needs-based rehabilitation programs will profit from structuring patient progress in a criterion-based and stepwise manner as part of the risk management process. The main reasons for conducting the present review were the paucity of studies reported in recent reviews (Kaliski, 1997;Lindqvist & Skipworth, 2000;Vaughan & Done, 2000;Vess, 2001) and the need for an updating on the literature, particularly since previous reviews did not "pretend to be exhaustive systematic reviews" (Vaughan & Done, 2000, p. 374).…”