Best Practice in Managing Risk
Principles and evidence for best practice in the assessment and management of risk to self and others in mental health services
Document prepared for theNational Mental Health Risk Management Programme
June 2007
DH InformatIon reaDer BoX
Policy EstatesHR/Workforce PerformanceManagement IM&TPlanning FinanceClinical PartnershipWorking
Document purpose BestPracticeGuidance
Gateway reference: 8079
title BestPracticeinManagingRisk
author DepartmentofHealth,NationalRiskManagementProgramme
Publication Date 14June2007
TargetAudience PCTCEs,SHACEs,CareTrustCEs,FoundationTrustCEs,DirectorsofPH,LocalAuthorityCEs,DirectorsofAdultSSs,AlliedHealthProfessionals,GPs,DirectorsofChildren’sSSs
Circulation list VoluntaryOrganisations/NDPBs
Description Thisframeworkisaguideformentalhealthprofessionalsworkingwithserviceuserstoassessrisk.Itunderpinsriskassessmentwithprinciplesofgoodpracticeforallmentalhealthsettingsandprovidesalistoftoolsofferingstructuretoriskmanagement.
Cross reference ReviewingtheCareProgrammeApproach2006
Superseded document N/A
action required None
timing None
Contact details DawnFlemingNationalRiskManagementProgrammeLondonDevelopmentCentre11-13CavendishSquare,LondonW1G0AN02073072431www.nimhe.csip.org.uk/risktools
for recipient’s use
Foreword by the National Director for Mental Health, Professor Louis Appleby 3
Executive summary 4
16 best practice points for effective risk management 5
Introduction 7
Fundamentals 9
Basicideasinriskmanagement 13
Workingwithserviceusersandcarers 21
Individualpracticeandteamworking 25
Appendix 1: Tools for supporting best practice 30
Preamble 30
Overview 32
Multiplerisks 33CRMT:ClinicalRiskManagementTool/WorkingwithRisk 33FACE:FunctionalAnalysisofCareEnvironments 34GRiST:GalateanRiskScreeningTool 35RAMAS:RiskAssessmentManagementandAuditSystems 36GIRAFFE:GenericIntegratedRiskAssessmentforForensicEnvironments 37START:Short-termAssessmentofRiskandTreatability 38
Riskofviolenceorsexualviolence,andantisocialoroffendingbehaviour 39HCR-20:HistoricalClinicalRisk-20 39PCL-R:PsychopathyChecklist-Revised 40PCL:SV:PsychopathyChecklist:ScreeningVersion 41STATIC-99 42SVR-20:SexualViolenceRisk-20 43VRAG:ViolenceRiskAppraisalGuide 44
1
Contents
BestPracticeinManagingRisk
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Riskofsuicideorself-harm 45ASIST:AppliedSuicideInterventionSkillsTraining 45BHS:BeckHopelessnessScale 46SADPERSONS 47SIS:SuicidalIntentScale 48SSI:ScaleforSuicideIdeation 49STORM:Skills-basedTrainingonRiskManagement 50
Appendix 2: Risk factors for violence and suicide 51
Appendix 3: 12 points to a safer service 54
Appendix 4: Glossary 56
Appendix 5: Methods used to develop this framework 59
Appendix 6: Acknowledgements 62
References 66
3
Safetyisatthecentreofallgoodhealthcare. Thisisparticularlyimportantinmentalhealthbutitisalsomoresensitiveandchallenging. Patientautonomyhastobeconsideredalongsidepublicsafety. Agoodtherapeuticrelationshipmustincludebothsympatheticsupportandobjectiveassessmentofrisk.
Inproducingthispracticalbestpracticeadvice,wewanttosupportservicesinadoptingamoresystematicapproachtoriskassessmentandmanagement–atindividualpractitioner,teamandorganisationallevel. Theaimistoembedriskmanagementinday-to-daypractice,inparticularaspartoftheCareProgrammeApproach(CPA).
WeknowthatanunacceptablenumberofpatientswhodiebysuicideorcommithomicidehavenotbeensubjecttoenhancedCPA,despiteindicationsofrisk. Wealsoknowthatstaffsometimesfeelunabletointervenetoreducerisk,feelingthattragediesareinevitable.
Thisdocumentoffersguidanceonwhatcanbedone. Itisunrealistictoexpectservicestopreventalldeaths,buttheclinicalmanagementofriskcanbestrengthened.
AtthemomentweareupdatingtheMentalHealthActtobringitinlinewithcommunity-basedpractice. Anewpower–supervisedcommunitytreatment–willbeintroducedtohelptoensurethathigh-riskandvulnerablepatientsreceivethetreatmentthattheyneedafterhospitaldischarge. Itisas importanttohavetherightlegalpowersasitistohavethebestclinicalpractice:botharepartofthevitaltaskofimprovingsafety.
Foreword by the National Director for Mental Health, Professor Louis Appleby
4
Thisframeworkdocumentisintendedtoguidementalhealthpractitionerswhoworkwithserviceuserstomanagetheriskofharm.Itsetsoutaframeworkofprinciplesthatshouldunderpinbestpracticeacrossallmentalhealthsettings,andprovidesalistoftoolsthatcanbeusedtostructuretheoftencomplexriskmanagementprocess.Thephilosophyunderpinningthisframeworkisonethatbalancescareneedsagainstriskneeds,andthatemphasises:
• positiveriskmanagement;
• collaborationwiththeserviceuserandothersinvolvedincare;
• theimportanceofrecognisingandbuildingontheserviceuser’sstrengths;and
• theorganisation’sroleinriskmanagementalongsidetheindividualpractitioner’s.
Organisations,careteamsandindividualpractitionersshouldbenchmarktheircurrentpracticeagainsttheprinciplessetouthere,andconsiderwaysofmovingtowardsembeddingtheseprinciplesindailypractice.Theyshouldalsoexaminethelistoftoolsgivenhereandconsiderhowtheirpracticecouldbeimprovedbyincorporatingoneormoreofthetoolsintotheirriskassessmentandriskmanagementpractice.
Executive summary
5
Summary
Introduction
1. Bestpracticeinvolvesmakingdecisionsbasedonknowledgeoftheresearchevidence,knowledgeoftheindividualserviceuserandtheirsocialcontext,knowledgeoftheserviceuser’sownexperience,andclinicaljudgement.
Fundamentals
2. Positiveriskmanagementaspartofacarefullyconstructedplanisarequiredcompetenceforallmentalhealthpractitioners.
3. Riskmanagementshouldbeconductedinaspiritofcollaborationandbasedonarelationshipbetweentheserviceuserandtheircarersthatisastrustingaspossible.
4. Riskmanagementmustbebuiltonarecognitionoftheserviceuser’sstrengthsandshouldemphasiserecovery.
5. Riskmanagementrequiresanorganisationalstrategyaswellaseffortsbytheindividualpractitioner.
Basic ideas in risk management
6. Riskmanagementinvolvesdevelopingflexiblestrategiesaimedatpreventinganynegativeeventfromoccurringor,ifthisisnotpossible,minimisingtheharmcaused.
7. Riskmanagementshouldtakeintoaccountthatriskcanbebothgeneralandspecific,andthatgoodmanagementcanreduceandpreventharm.
8. Knowledgeandunderstandingofmentalhealthlegislationisanimportantcomponentofriskmanagement.
9. Theriskmanagementplanshouldincludeasummaryofallrisksidentified,formulationsofthesituationsinwhichidentifiedrisksmayoccur,andactionstobetakenbypractitionersandtheserviceuserinresponsetocrisis.
16 best practice points for effective risk management
BestPracticeinManagingRisk
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10. Wheresuitabletoolsareavailable,riskmanagementshouldbebasedonassessmentusingthestructuredclinicaljudgementapproach.
11. Riskassessmentisintegraltodecidingonthemostappropriatelevelofriskmanagementandtherightkindofinterventionforaserviceuser.
Working with service users and carers
12. Allstaffinvolvedinriskmanagementmustbecapableofdemonstratingsensitivityandcompetenceinrelationtodiversityinrace,faith,age,gender,disabilityandsexualorientation.
13. Riskmanagementmustalwaysbebasedonawarenessofthecapacityfortheserviceuser’sriskleveltochangeovertime,andarecognitionthateachserviceuserrequiresaconsistentandindividualisedapproach.
Individual practice and team working
14. Riskmanagementplansshouldbedevelopedbymultidisciplinaryandmulti-agencyteamsoperatinginanopen,democraticandtransparentculturethatembracesreflectivepractice.
15. Allstaffinvolvedinriskmanagementshouldreceiverelevanttraining,whichshouldbeupdatedatleasteverythreeyears.
16. Ariskmanagementplanisonlyasgoodasthetimeandeffortputintocommunicatingitsfindingstoothers.
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Introduction
RiskmanagementisacorecomponentofmentalhealthcareandtheCareProgrammeApproach.Effectivecareincludesanawarenessofaperson’soverallneedsaswellasanawarenessofthedegreeofriskthattheymaypresenttothemselvesorothers.Manypractitionersmakedecisionseverydayabouthowtohelpaserviceusertomanagetheirpotentialforviolence,self-harm,suicideorself-neglect.Thisframeworkdocumentisintendedtoguidementalhealthpractitionersinmakingthesedecisionsandalsotoguidetheorganisationsthatemploythem.Theframeworkisbasedontheprinciplethatmodernriskassessmentshouldbestructured,evidence-basedandasconsistentaspossibleacrosssettingsandacrossserviceproviders.1,2,3Thisconsistencyisessentialforgoodcommunicationbetweenagenciesandpractitioners.Aconsistentapproachtoriskanditsmanagementwillenablebettercommunicationandwillcontributetoimprovedcare.Allserviceprovidersshouldhaveinplaceasetofpoliciesandproceduresrelatingtothemanagementofrisk,4,5andthisframeworkdocumentshouldbeusedtoinformthesepolicies.
Thisframeworkrelatestothreemainareasofrisk:violence(includingantisocialandoffendingbehaviour),self-harm/suicide,andself-neglect.Itaimstoanswerthisquestion:whatisbestpracticeforconductingriskmanagementintheseareas?Bestpracticeinvolvescombiningthehighestqualityevidencewithprofessionaljudgementaboutthepersonwhoisbeingassessed.ThemainprinciplesofbestpracticearesetouthereandAppendix1containsdetailedinformationonsometoolsthatcanguideriskdecision-making.Thesetoolsaredescribedbelowinordertohelppractitionerstodecidewhichofthemarebestsuitedtothesituationfacedbytheserviceuserswithwhomtheywork.
Best practice point 1:Bestpracticeinvolvesmakingdecisionsbasedonknowledgeoftheresearchevidence,knowledgeoftheindividualserviceuserandtheirsocialcontext,knowledgeoftheserviceuser’sownexperience,andclinicaljudgement.
Theprinciplessetouthereareapplicableinallmentalhealthcaresettings–fromcommunity-basedcare,includingcrisisintervention,assertiveoutreachandearlyinterventionservices,throughtohigh-securitycare.Guidanceabouttools,though,ismorecomplex.Someofthetoolslistedherearedesignedforspecialist(e.g.forensic)servicesandothersforgeneralservices.Somearedeliberatelydesignedtopredictrisk–ofteninspecificgroups–whileothersaredesignedtoaidtheclinicaljudgementofpractitionerswhoaretryingtogainanoverallviewoftheissues.
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Itisvitaltonotethatbothtypesoftoolcanonlycontributeoneelementtoabroaderoverallviewoftheriskspresentedbyaparticularindividual:theyshouldonlybeusedaspartofageneralclinicalassessmentconductedwiththeserviceuser.Andthefindingsoftool-basedassessmentsmustalwaysbecombinedwithinformationonmanyotheraspectsoftheserviceuser’slifeandcurrentsituation.Thetoolsarelistedherebecausetheywillsupporteffectiveandconsistentriskmanagementdecision-making.They are an aid to clinical decision-making, not a substitute for it.
Careteamsshouldconsiderhowtheirriskmanagementprocedurescouldbeimprovedbyintegratingtheprincipleshereandoneormoreofthetoolsintotheiroverallapproach.Byeffectivelycombiningresearchevidencewithclinicalexpertiseinacollaborativeapproach,caseteamswillbeimplementingthehigheststandardsofevidence-basedpractice.6
Fundamentals
Positive risk management
Decisionsaboutriskmanagementinvolveimprovingtheserviceuser’squalityoflifeandplansforrecovery,whileremainingawareofthesafetyneedsoftheserviceuser,theircarerandthepublic.7Positiveriskmanagementaspartofacarefullyconstructedplanisadesirablecompetenceforallmentalhealthpractitioners,andwillmakeriskmanagementmoreeffective.8,9Positiveriskmanagementcanbedevelopedbyusingacollaborativeapproach.10Over-defensivepracticeisbadpractice.Avoidingallpossiblerisksisnotgoodfortheserviceuserorsocietyinthelongterm,andcanbecounterproductive,creatingmoreproblemsthanitsolves. Anyrisk-relateddecisionislikelytobeacceptableif:
• itconformswithrelevantguidelines;
• itisbasedonthebestinformationavailable;
• itisdocumented;and
• therelevantpeopleareinformed.11
Aslongasadecisionisbasedonthebestevidence,informationandclinicaljudgementavailable,itwillbethebestdecisionthatcanbemadeatthetime.
Safety first
Giventhenatureofseverementalillness,therewillalwaysbecircumstancesinwhichdecisionsaboutthecareplanaregoingtobedominatedbyimmediateconcernsaboutthesafetyoftheserviceuserandothers.Lackofinsightand
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non-adherencetotreatmentplansthathavebeenputinplacetoreducepsychopathologicalsymptomsareparticularlychallengingaspectsoftherelationshipbetweentheserviceuserandthepractitioner.Psychopathologicalsymptomscanseriouslyimpactonaserviceuser’sabilitytocriticallyassesstheimplicationsofsomeoftheiractions,andthiscanresultinunpredictableandpotentiallydangerousbehaviour.Inthesesituations,practitionershavetotakedecisionsonbehalfofaserviceuserwiththeirbestinterestsinmind.TheuseoftheMentalHealthActmaywellbepartofthemostappropriateriskmanagementstrategyhere.Acollaborativeapproachbasedontheprinciplesofpositiveriskmanagementisstilltheaim,butclearlythiswillrequirespecialeffortsinthesesituations.
Best practice point 2:Positiveriskmanagementaspartofacarefullyconstructedplanisarequiredcompetenceforallmentalhealthpractitioners.
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Box 1: What is positive risk management?
Positiveriskmanagementmeansbeingawarethatriskcanneverbecompletelyeliminated,andawarethatmanagementplansinevitablyhavetoincludedecisionsthatcarrysomerisk.Thisshouldbeexplicitinthedecision-makingprocessandshouldbediscussedopenlywiththeserviceuser.
Positiveriskmanagementincludes:
• workingwiththeserviceusertoidentifywhatislikelytowork;
• payingattentiontotheviewsofcarersandothersaroundtheserviceuserwhendecidingaplanofaction;
• weighingupthepotentialbenefitsandharmsofchoosingoneactionoveranother;
• beingwillingtotakeadecisionthatinvolvesanelementofriskbecausethepotentialpositivebenefitsoutweightherisk;
• beingcleartoallinvolvedaboutthepotentialbenefitsandthepotentialrisks;
• developingplansandactionsthatsupportthepositivepotentialsandprioritiesstatedbytheserviceuser,andminimisetheriskstotheserviceuserorothers;
• ensuringthattheserviceuser,carerandotherswhomightbeaffectedarefullyinformedofthedecision,thereasonsforitandtheassociatedplans;and
• usingavailableresourcesandsupporttoachieveabalancebetweenafocusonachievingthedesiredoutcomesandminimisingthepotentialharmfuloutcome.
Anotherwayofthinkingaboutgooddecision-makingistoseeitassupporteddecision-making.Independence, choice and risk12hasthistosay:
“Thegoverningprinciplebehindgoodapproachestochoiceandriskisthatpeoplehavetherighttolivetheirlivestothefullaslongasthatdoesnotstopothersfromdoingthesame.Fearofsupportingpeopletotakereasonablerisksintheirdailylivescanpreventthemfromdoingthethingsthatmostpeopletakeforgranted.Whatneedstobeconsideredistheconsequenceofanactionandthelikelihoodofanyharmfromit.Bytakingaccountofthebenefitsintermsofindependence,well-beingandchoice,itshouldbepossibleforapersontohaveasupportplanwhichenablesthemtomanageidentifiedrisksandtolivetheirlivesinwayswhichbestsuitthem.”
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A collaborative approach to risk management
Aswithallaspectsofmentalhealthcare,thekeytoeffectiveriskmanagementisagoodrelationshipbetweentheserviceuserandallthoseinvolvedinprovidingtheircare.Athree-waycollaborationbetweentheserviceuser,carersandthecareteamcanoftenbeestablished,andthisrelationshipshouldbebasedonwarmth,empathyandasenseoftrust–withtheaimofinvolvingtheserviceuserinacollaborativeapproachtoplanningcare. Fullengagementissometimesnotpossible,butthepotentialforitshouldalwaysbeconsidered.Thismeansthattheprocessofriskmanagementshouldbeexplainedtoeverybodyinvolvedattheearliestopportunity.Thedevelopmentoftheriskmanagementplanitselfshouldbecarriedoutinanatmosphereofopennessandtransparency.If,forwhateverreason,theserviceuserisnotinvolvedinsomeelementofriskmanagement,thisshouldbedocumented.
Best practice point 3:Riskmanagementshouldbeconductedinaspiritofcollaborationandbasedonarelationshipbetweentheserviceuserandtheircarersthatisastrustingaspossible.
Recognising strengths and protective features
Riskmanagementworksbestwhenaserviceuser’sstrengthsarerecognisedalongsidethepossibleproblemsthattheymightencounterandwithwhichtheymightpresent.13Everytimeaproblemisidentified,astrategyshouldbesuggestedanddiscussed,buildingonthepositiveskillsoftheserviceuser.Theemphasisshouldalwaysbeonarecoveryapproachandonthenextstageindevelopingtheserviceuser’sabilitytocopewhentheyarefeelingvulnerableorhavingdifficultdemandsplacedonthem.
Best practice point 4:Riskmanagementmustbebuiltonarecognitionoftheserviceuser’sstrengthsandshouldemphasiserecovery.
Risk management at the organisational level
Riskmanagementisnotjusttheresponsibilityofindividualpractitioners.Organisationsmustadoptanintegratedriskmanagementapproachinwhichrisksaresystematicallyidentified,managedandreduced.TheframeworkgiveninSeven Steps to Patient Safetyshouldguidethedevelopmentofasafetyculturethatlearnsfromnegativeeventsandbuildsgoodpractice.5Thesevenstepsareto:
• buildasafetyculture;
• leadandsupportyourstaff;
• integrateyourriskmanagementactivity;
• promotereporting;
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• involveandcommunicatewithserviceusersandthepublic;
• learnfromandsharesafetylessons;and
• implementsolutionstopreventharm.
Servicesforpeopleatriskofsuicideandself-harmshouldalsobedesignedwiththe‘12Pointstoasaferservice’recommendationsinmind.14,15ThesepointsarelistedinAppendix3.
Best practice point 5:Riskmanagementrequiresanorganisationalstrategyaswellaseffortsbytheindividualpractitioner.
Figure 1: Positive and negative risk management cycles16
Defensive approach to risk
‘Negative events’
Increasingly defensive approach:
escalating risk
Negative experience for the service user
Disengagement from services
No strategy in place to manage risk positively
Defensive risk management
Collaborative approach to risk
Lower risk as strategies for
management are designed and acted upon
Open approach: engaging with the user in planning
for risk
Positive experience for the
service user
More engagement with the process
Greater collaboration with
services
Collaborative riskmanagement
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Basic ideas in risk management
Defining risk and risk management
Itisimportanttobeclearaboutthebasicideasunderpinningthenotionofrisk.Riskrelatestoanegativeevent(i.e.violence,self-harm/suicideorself-neglect) andcoversanumberofaspects.
• Howlikelyitisthattheeventwilloccur.
• Howsoonitisexpectedtooccur.
• Howseveretheoutcomewillbeifitdoesoccur.
Riskassessmentinvolvesworkingwiththeserviceusertohelpestimateeachoftheseaspects.Informationabouttheserviceuser’shistoryofviolence,self-harmorself-neglect,theirrelationshipsandanyrecentlossesorproblems,employmentandanyrecentdifficulties,housingissues,theirfamilyandthesupportthat’savailable,andtheirmoregeneralsocialcontactscouldallberelevant.Riskmanagementtheninvolvesdevelopingoneormoreflexiblestrategiesaimedatpreventingthenegativeeventfromoccurringor,ifthisisnotpossible,minimisingtheharmcaused.Riskmanagementmustincludeasetofactionplans,theallocationofeachaspectoftheplantoanidentifiedprofessionandadateforreview.
Best practice point 6:Riskmanagementinvolvesdevelopingflexiblestrategiesaimedatpreventinganynegativeeventfromoccurringor,ifthisisnotpossible,minimisingtheharmcaused.
Defining risk factors
Ariskfactorisapersonalcharacteristicorcircumstancethatislinkedtoanegativeeventandthateithercausesorfacilitatestheeventtooccur.Riskfactorscanbecategorisedinanumberofways.17
• Static factorsareunchangeable,e.g.ahistoryofchildabuseorsuicideattempts.
• Dynamic factors arethosethatchangeovertime,e.g.misuseofalcohol.Dynamicfactorscanbeaspectsoftheindividualoraspectsoftheirenvironmentandsocialcontext,suchastheattitudesoftheircarersorsocialdeprivation.Becausetheyarechangeable,thesefactorsaremoreamenabletomanagement.
• Dynamicriskfactorsthatarequitestableandchangeonlyslowlyarecalledstableorchronicriskfactors.
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• Thosefactorsthattendtochangerapidlyareknownasacute factorsortriggersand,astheydochangerapidly,theirinfluenceonthelevelofriskmaybeshort-lived.ThekeyriskfactorsidentifiedthroughresearchforviolenceandsuicidearegiveninAppendix2.
Particularsensitivityshouldbeexercisedwhendiscussinghistoricalfactorsfromearlierinthelifeoftheserviceuser.Therelevanceandaccuracyofthesemayneedtobeexplainedtotheserviceuser,anditispossiblethatcarersmaybeunawareofthesehistoricaleventsoroftheirsignificancesomanyyearson.
The purpose of risk management
Theaimofriskmanagementisfirsttoassessthelikelihoodofriskeventsandthentoworkwiththeserviceusertoidentifywaysofreducingthelikelihoodofthemoccurring.Riskmanagementshouldbebasedonaplantoreducetheriskofharmoccurringandincreasethepotentialforapositiveoutcome.Itisimportantthatcareteamsandtheserviceuserhaveaclearideaaboutwhatrisktheyareassessingandwhytheyarecarryingoutariskassessment.18Riskassessmentshouldbeusedtoidentifythecircumstancesinwhichaparticularharmfulbehaviourcouldpossiblytakeplace,andthisinformationcanthenbeusedtofocuseffortsandexpertiseondealingwiththemostrelevanttriggers.Ariskmanagementplanincludesanawarenessofthepotentialforchangesinthelevelofriskovertime.Thisrequiresaparticularemphasisonthedynamicfactorsoutlinedabove,aswellasattentiontoregularlyreviewrisksandtheirmanagement.
Best practice point 7:Riskmanagementshouldtakeintoaccountthatriskcanbebothgeneralandspecific,andthatgoodmanagementcanreduceandpreventharm.
Risk management and the Care Programme Approach
RiskmanagementispartoftheCareProgrammeApproach(CPA)andshouldbealignedcloselywithit.19TheCPAinvolvesidentifyingspecificinterventionsbasedonanindividual’ssupportneeds,takingintoaccountsafetyandriskissues.Careplansshouldbedrawnuptomeetalloftheserviceuser’sneeds,includingthoseneedsrelatingtorisk.Thiscreatesarecordedmanagementplanfortheelementsofrisktobothselfandothers.20Theoutcomeoftheriskassessmentshouldalsofeedbackintooverallclinicalmanagement,sinceEnhancedCPA(ratherthanStandard)shouldbeappliedincaseswherethereisanincreasedriskrelatedtomentalhealthproblemsofharmingoneselforothers.Thesestepshelptosupportthecontinuityofcare,whichisessentialforeffectiveriskmanagement.
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Risk management and the Mental Health Act
Giventhenatureofmentalhealthproblems,thereareoccasionswhereserviceshavetointervenewithouttheuser’sconsent:theMentalHealthActisusedregularlytomanageariskofharmtoselfandothers.Itshouldalwaysbeseenasalastresortanditisimportantthatserviceuserswhoneedtobetreatedunderconditionsofcompulsiongetthehelpthattheyneed.UsingtheActdoesnotremovetheneedfordiscussionwiththeserviceuser–itisstillnecessarytomaximisetheserviceuser’sautonomyasmuchaspossiblewithintherestrictions.AgoodknowledgeoftheAct–anditsassociatedCodeofPracticeandMemorandum–isessentialtogoodriskmanagementinmentalhealth.TheGovernmentiscurrentlyupdatingtheMentalHealthActandproposalsincludeintroducingsupervisedcommunitytreatmentwiththeaimofimprovingsafetyforpatientslivinginthecommunity,andabolishingthetreatabilitytestwiththeaimthatpatientswithpersonalitydisorderreceiveappropriateriskmanagement.
Best practice point 8:Knowledgeandunderstandingofmentalhealthlegislationisanimportant componentofriskmanagement.
Screening and prioritising cases
Serviceuserswillvaryinthedegreetowhichtheyneedaformalriskmanagementplan.Screeningforriskandneedsshouldbepartofaroutinementalhealthassessment,butisnotanendinitselfandshould,wherenecessary,leadtofurtheraction.Someserviceuserswillbeidentifiedasapriorityformorein-depthassessmentandinterventionasaresultofthisroutinescreening,orwillidentifythemselvesasinneed.Generalandforensicserviceshavedifferentdegreesofexperienceofworkingwithviolence,andsotheyshouldworktogethertoensurethattherightlevelofassessmentisconductedinallcases.Asecondopinionshouldbesoughtfromspecialistserviceswhenappropriate,forinstanceifaserviceuserhasahistoryofseriousviolence.
Duty of care to those who present a risk and others
Asabasicprinciple,allmentalhealthprofessionalsrecognisethatreducingtheriskofself-harm,suicideandself-neglectispartofthepractitioner’sfundamentaldutytotrytoimproveaserviceuser’squalityoflifeandrecovery.Thereisalsoaclearprofessionaldutyofcaretoaserviceuserwhopresentsahighriskofharmtootherswhenthisriskisduetoamentalhealthproblem–thisdutymayincludetacklingstigmaanddiscrimination.Thereisalsoadutyofcaretootherserviceusers,otherprofessionalsandwidersociety.Inmanycases,improvingaserviceuser’squalityoflifemayhavewiderbenefitsforothers,suchasreducingtherisktovulnerablegroupsofpotentialvictims,includingchildren.Thesegoalsaremost
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likelytobeachievedinthecontextofagoodrelationshipbetweentheserviceuserandthoseprovidingtheircare.
Box 2: Supplementary NICE guidance on the short-term management of self-harm21
Respect, understanding and choice Peoplewhohaveself-harmedshouldbetreatedwiththesamecare,respectandprivacyasanypatient.Inaddition,healthcareprofessionalsshouldtakefullaccountofthelikelydistressassociatedwithself-harm.
Triage Allpeoplewhohaveself-harmedshouldbeofferedapreliminarypsychosocialassessmentattriage(orattheinitialassessmentinprimaryorcommunitysettings)followinganactofself-harm.Assessmentshoulddetermineaperson’smentalcapacity,theirwillingnesstoremainforfurtherpsychosocialassessment,theirlevelofdistressandthepossiblepresenceofmentalillness.
Assessment of risk Allpeoplewhohaveself-harmedshouldbeassessedforrisk.Thisassessmentshouldincludeidentificationofthemainclinicalanddemographicfeaturesknowntobeassociatedwiththeriskoffurtherself-harmand/orsuicide,andidentificationofthekeypsychologicalcharacteristicsassociatedwithrisk–inparticulardepression,hopelessness–andcontinuingsuicidalintent.
Psychological, psychosocial, and pharmacological interventions Followingpsychosocialassessmentforpeoplewhohaveself-harmed,thedecisionaboutreferralforfurthertreatmentandhelpshouldbebaseduponacomprehensivepsychiatric,psychological,andsocialassessment,includinganassessmentofrisk,andshouldnotbedeterminedsolelyonthebasisofhavingself-harmed.
Thisguidanceisavailablefrom:www.nice.org.uk/guidance/CG16/quickrefguide/pdf/English
Planning risk management
Riskassessmentonlyhasapurposeifitenablesthecareteamandtheserviceusertodevelopaplanofactioninspecificareastomanagetherisksidentified.Thisplanshouldbedevelopedwiththeserviceuserandtheircarer,andshouldberegularlyreviewed.
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Risk formulation
Riskformulationisaprocessinwhichthepractitionerdecideshowtheriskmightbecomeacuteortriggered.22Itidentifiesanddescribespredisposing,precipitating,perpetuatingandprotectivefactors,andalsohowtheseinteracttoproducerisk.Thisformulationshouldbeagreedwiththeserviceuserandothersinvolvedintheircareinadvance,andshouldleadtoanindividualisedriskmanagementplan.Everyriskformulationshouldhaveattachedtoitaplanforwhattodowhenthewarningsignsbecomeapparent.Theplanshouldalsoincludemoregeneralaspectsofmanagement,suchasmonitoringarrangements,therapeuticinterventions,appropriateplacementsandemploymentneeds.
Best practice point 9:Theriskmanagementplanshouldincludeasummaryofallrisksidentified,formulationsofthesituationsinwhichidentifiedrisksmayoccur,andactionstobetakenbypractitionersandtheserviceuserinresponsetocrisis.
Figure 2: The risk management planning cycle
Risk assessment
Risk formulation: how does the risk become acute or triggered?
Specific risk management plan:
what to do when the warning signs are
apparent
Review dates
General risk management plan:
monitoring arrangements, etc.
Risk management
planning
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Types of risk assessment
Therearethreemainapproachestoriskassessment.
• Inthepast,riskassessmentwasanecdotalandinconsistent.Itwasbasedonlyonalargelyunstructured clinical approachwhereinformationobtainedinthecourseofanongoingclinicalassessmentwasconsidered.Thisinformationwasnotgatheredsystematically,andanyinformationconsideredrelevantwasnotenteredintotheformulationofriskinaconsistentandstandardisedway.
• Theactuarial approachtoriskassessmentfocusesonstaticriskfactorsthathavebeenshowntobestatisticallyassociatedwithincreasedriskinlargesamplesofpeople.Aformulaicapproachisusuallyused:anoverallscoreiscalculatedasanindicatorofpresumedriskoveraspecifictimeperiod,generallymeasuredinyears.Thisapproachshouldbeusedwithcautionwithindividualpatientsinclinicalpractice.Errorsarelikelytooccuriftoolsbasedonthisapproachareusedtopredictriskratherthantomanageit.Theyshouldonlybeusedasonepartofanoverallriskassessment.
• Structured clinical (or professional) judgementistheapproachthatoffersthemostpotentialwhereviolenceriskmanagementistheobjective.Thisapproachinvolvesthepractitionermakingajudgementaboutriskonthebasisofcombining:
– anassessmentofclearlydefinedfactorsderivedfromresearch;
– clinicalexperienceandknowledgeoftheserviceuser;and
– theserviceuser’sownviewoftheirexperience.
Best practice point 10:Wheresuitabletoolsareavailable,riskmanagementshouldbebasedonassessmentusing thestructuredclinicaljudgementapproach.
Alltool-basedassessmentsshouldbeconductedasonepartofathoroughandsystematicoverallclinicalassessment.Thisisparticularlyimportantwhenassessingtheriskofsuicideandself-harm,asthereiscurrentlynoinstrumentwithasufficientlystrongevidencebase.
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Structured risk assessment
Riskmanagementinmentalhealthcareshouldbestructured andconsistent.1Itshouldbeexplicittotheserviceuserandshouldinvolvetheserviceuser’sownpriorities.Itshouldalsoincludethestructuredclinicaljudgementoutlinedabove.Decisionsaboutcareandsecurityshouldnotbebasedsimplyonthelargelyunstructuredclinicalapproach,whichcouldbesubjecttopersonalbiasesabouttheserviceuserandmaymissimportantfactorssuchastheserviceuser’sstrengthsandresourcesortheviewsofthecarer.Thesebiasescouldleadtopoorjudgementswheretheriskiseitheroverestimatedorunderestimatedifkeyfactorsaremissed.Thisisespeciallytrueifthejudgementsaremadebyanindividualpractitioneraloneratherthanbyaclinicalteamworkingtogether.Ifitisnotcleartotheserviceuserthattheirriskisbeingassessed,theprincipleofengagementisbroken.
Providing care proportionate to risk
Afundamentalprincipleofmentalhealthcareisthatthelevelofsecuritytowhichaserviceuserissubjectedshouldbeasnon-restrictiveaspossibleandshouldbeproportionatetothedegreeofriskthattheyactuallypresentatthetime.20Riskassessmentcanbeintegraltodecidingontherightlevelofinterventionandsupportforaserviceuser.Whenitisdoneproperly–usingtheprinciplesofinvolvement,workingtogetherandindividualisedsupport–riskmanagementisempoweringratherthandisempoweringfortheserviceuser23andcanbeavitalpartofrecovery.
Best practice point 11:Riskassessmentisintegraltodecidingonthemostappropriatelevelofriskmanagementandtherightkindofinterventionforaserviceuser.
Embedding risk management in everyday practice
Theinformationthatinformsariskmanagementplancanbebasedonspecialinterviewsorreports,butriskmanagementisalsobasedonroutinepracticesinmentalhealthcare.Theseroutinepracticesincludeenhancedobservationandpreventingabscondingwherethisisappropriate.19Thinkingaboutandrecordingriskmanagementdecisionsisnotan‘add-on’topractice,butshouldproduceastructuredanddocumentedversionoftheclinicaljudgementsthatpractitionersmakeeveryday.Thisformalversionofeverydaypracticeshouldincreasetheconfidenceofpractitionerswhenmakingdecisions,especiallyiftheyareworkingcollaboratively.
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Box 3: A brief critique of three approaches to risk assessment
Unstructured clinical approach Sincethisisnotastructuredapproach,importantfactorsmaybemissed.Whilethisunstructuredapproachsometimesprovidesvitalinformation,itisnotafeatureofbestpracticeinplannedandformalriskmanagement.
Actuarial approach Thisapproachhasanumberoflimitations.First,ittendstoignoreriskfactorswhichdonotoccurcommonly.Second,thecapacityoftheactuarialtooltomake‘predictions’onlyapplieswhentheserviceuserbeingassessedcomesfromthepopulationforwhichthetoolwasdeveloped.Third,anemphasisonriskpredictionratherthanriskmanagementislessusefulforpractitionerstaskedwithplanningcare.Finally,theemphasisonunchangeablestaticriskfactorsinthisapproachseverelylimitstheusefulnessofdevelopingriskmanagementstrategiesthatarerobustyetflexible.SomeofthetoolslistedinAppendix1areactuarial,andtheselimitationsmustbeborneinmindwhenconsideringwhethertousetheminpractice.Theydonotprovideameasureofriskinanindividualserviceuserandshouldneverbeusedastheonlywayofevaluatingtherisksposedbyanindividualserviceuser.Actuarialtoolsusedontheirownalsocontradicttheprinciplesofdiversityandindividualisedworking.
Structured clinical judgement Basedonpractice-basedevidence,thisisthemosteffectiveapproachtoviolenceriskmanagement.Although,liketheactuarialtools,theseinstrumentsarederivedfromresearchevidence,theclinician’sdiscretionisseenasavitalelement–especiallyinrelationtoformulatingtheassessmentofriskandpreparingriskmanagementplansbasedontheriskfactorsidentified.Theeffectivenessofthesetoolscanbehardtotest,giventheirrangeofapplicationsandthedifficultyofmeasuringthepreventedharm.Giventheirresearchfocus,theymayalsoexcludeissuesthattheindividualserviceuserconsidersimportant–althoughmoststructuredclinicaljudgementtoolsofferpractitionerstheopportunitytoaddextrariskfactorsandconsiderationsasrequired.
Structuredassessmentisimportantinassessingsuiciderisk,buttherearenoinstrumentswithasatisfactoryevidencebase.Inthiscase,structuredassessmentmeansasystematicassessmentofkeyriskfactorsandmentalstateleadingtoaninformedclinicaljudgement.
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Working with service users and carers
Sharing decision-making
Eachstepintheprocessofdevelopingariskmanagementplanshouldbebasedondiscussionsbetweentheserviceuserandthoseinvolvedintheircare.Theserviceusershouldbeofferedtheopportunitytotakealeadroleinidentifyingtherisksfromtheirpointofview,drawingupplansfordealingwithdifficultsituations,andindicatingthesortofsupportthattheywouldprefer:serviceusersandcarersareofteninthebestpositiontocommentontherobustnessandpracticalityoftheplan.Theplanshouldincludenegotiatedandindividualisedadvancedecisionsonearlywarningsignsofarelapse,aswellaspreferredearlyinterventionsattimesofcrisis.3,4
“Riskmanagementcanincreaseauser’sawarenessoftheirownbehaviourandofhowothersviewthem.Thiscanenablethemtomanagetheirlivesandrelationshipsmoreeffectively.”
Auser’sview
Collaborative work with carers
Wherethereisacarerinvolved,theyareavitalsourceofsupportfortheserviceuserandmayalsobeakeypersoninhelpingtomanagetherisksidentified.24Practitionersshouldbesensitivetotherelationshipbetweentheserviceuserandthecarer,astheremayberiskswithinthisrelationshipanddifferentpointsofviewaboutthebestactionstobetaken.Ifthecarerisatrisk,theyshouldbeseenindividuallysothattheriskscanbeexploredandactionscanbeagreed.Thecarershouldreceiveenoughinformationinacomprehensibleformattoenablethemtoprovidethenecessarycare.24Thecarer’sworriesabouttheserviceusershouldalwaysbetakenseriously,evenifthecareteamislessconcerned.2Thecarershouldbeofferedanassessmentandshouldbehelpedtodevelopaplanformeetingtheirownspecificneeds.
Confidentiality and disclosure
Agenciesshouldhaveinplaceclearagreedpoliciesoninformation-sharing,whichadviseonthe‘needtoknow’.Ifsomeoneotherthantheserviceuserisatrisk,advicemustbesoughtfromthepolicepublicprotectionteamormulti-agencypublicprotectionarrangements(MAPPA)sothatanappropriatepublicprotectionplancanbeactivated.Therationaleforanydisclosurewithoutconsent,e.g.topreventharm,shouldbeclearlydocumented.
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Avoiding exclusion on the basis of negative risk
Socialinclusionshouldbeoneofthegoalsofanyriskmanagementplan,andstrategiestosupporttheserviceuserinachievingthisshouldbeidentified.Serviceusersarelikelytobeawareoftheirownriskandtowanthelp,butmayfinditdifficulttotalkaboutthisincaseitincreasesstigma.9Anyrisksidentifiedshouldnotbeoverstatedorneedlesslyusedtoexcludetheserviceuserfromservicesorcontactwithpeople;thiscontributestomythsaboutmentalhealthproblems,stigmaanddiscrimination.Unnecessaryexclusioncanbeavoidedbycarefullylinkingriskassessmenttoriskmanagement.Regularreassessmentcanprovideopportunitiesforinformation-sharingwiththeserviceuserandtheircarer,andcanestablishaforuminwhichrisk-relatedissuescanbeopenlydiscussed.
“Atrustingrelationshipbetweentheuserandtheircareco-ordinatoristhebestfoundationforsuccessfulriskmanagement.”
Auser’sview
Diversity
Clinicaljudgementisbasedonperceptionsthatcanbebiasedwithoutthepractitionerbeingaware.Thereforeallstaffinvolvedinriskassessmentmustbecapableofdemonstratinganappropriatelevelofculturalsensitivityandcompetence.3,4,25Thiscompetenceappliestodiversityintermsofrace,faith,age,gender,disabilityandsexualorientation.Assumptionsaboutanyoftheseaspectsmayinfluenceperceptionsofrisk.Thepractitionershouldreflectontheirassumptionsaboutpeoplefromdiversegroupswithinsocietyandthinkaboutanyjudgementsofriskthattheyaremakingaboutpeoplefromthesegroups. Someauthoritieshavearguedthatassumptionsaboutracecanhaveaninfluenceonjudgementsofrisk.25
Assumptionsaboutgendercanalsoframethewaythatriskisassessedinwomenandmen.Itisessentialtostayopen-mindedaboutthepotentialforviolenceandself-harmorsuicide–regardlessofraceandgender–andnottoexpectserviceuserstoconformtobasicstereotypes.4,26Othersocialgroupsaresometimesstigmatisedas‘always’difficultinsomeway(e.g.serviceuserswithapersonalitydisorderdiagnosisorsubstanceuseproblem).Structuredassessmentapproachesandanawarenessof relevantresearchontheuseofdifferentinstrumentswithdifferentgroupswillhelpwiththisaim.Practitionersshoulddrawupontheirownknowledgeofequalityissuesandontheequalityanddiversityresourceswithintheirorganisationforguidance;thiswillhelptosetthecontextforfairandrespectfuljudgementsofrisk.Reflectivepractice,clinicalsupervisionandateamapproacharealsocrucial.
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Best practice point 12:Allstaffinvolvedinriskassessmentmustbecapableofdemonstratingsensitivityandcompetenceinrelationtodiversityinrace,faith,age,gender,disabilityandsexualorientation.
Recognising the fluidity of risk
Riskcanchange–sometimesoververyshorttimescales.Bydefinition,dynamicfactorsfluctuateintheircontributiontotheoverallrisk.Giventhefluidityofrisk,onlythetoolsbasedonstructuredprofessionaljudgementareusefulinmonitoringchangeandengagementwiththeserviceuserandcarer.Sothereshouldbeanestablishedproceduretoformallyreviewtheassessmentofriskatregularintervals.
Howeverthesereviewsshouldnotberigidlylimitedtothesetimepoints.Itisimportantthattheprocedurehassomeflexibilitysothat,inparticularcircumstances,anearlierormoretimelyformalreviewcanbeundertaken.Thisalsoguardsagainsta‘tickbox’mentalityincompletingriskassessmentforms.Allpractitionersworkingwiththeserviceuserneedtobefamiliarwithpreviousriskassessmentssothattheycanbealerttochangesinthelevelofrisk.Particularattentionshouldbepaidtotherelationshipbetweensubstancemisuseandchangesintheriskofharmtoselforothers.27Itiscrucialthatserviceusersandcarershaveaccesstosomeonewhomtheycancontactinacrisisiftheneedarises,andthattheyaretakenseriouslyifthisoccurs.
Regular review
Whileremainingflexible,riskmanagementplansshouldincludescheduleddatesforreassessment,sothattheyarenotsimplyamendedasareactiontoacrisisorotherevents.Thesereviewrequirementsshouldbepartoftheriskmanagementplanandnotseparatefromit,andtheserviceuserandallthoseinvolvedintheircareshouldbeinvolvedinthisreview.Riskmanagementplansshouldalsoincludeaclearstatementofresponsibilityforcarryingoutspecifiedtasksintheplan,aswellasforreviewingthem.Fromdiscussionwiththeserviceuser,itisessentialtoanticipatewhatcircumstanceswouldtriggerareviewoutsidethenormaltimetable,aswellaswhichtimesofyearareparticularlydifficult.Thereshouldbescopefortheserviceuserorcarertorequest areview.Inaddition,theriskmanagementplanshouldberevisitedbeforeandduringtimeperiodsthatarerecognisedtobeassociatedwithincreasedrisk,forinstancepriortoleave,onreturnfromleaveandaroundthetimeofdischarge.19
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Box 4: Supplementary NICE guidance on the short-term management of violence3
Prediction Measurestoreducedisturbedorviolentbehaviourneedtobebasedoncomprehensiveriskassessmentandriskmanagement.Thereforementalhealthserviceprovidersshouldensurethatthereisafullriskmanagementstrategyforalltheirservices.
Working with service users Serviceusersidentifiedtobeatriskofdisturbedorviolentbehaviourshouldbegiventheopportunitytohavetheirneedsandwishesrecordedintheformofanadvanceddecision.Thisshouldfitwithinthecontextoftheiroverallcareandshouldclearlystatewhatintervention(s)theywouldandwouldnotwishtoreceive.Thisdocumentshouldbesubjecttoperiodicreview.
Risk assessment Riskassessmentshouldincludeastructuredandsensitiveinterviewwiththeserviceuserand,whereappropriate,withcarers.Effortsshouldbemadetoascertaintheserviceuser’sownviewsabouttheirtriggerfactors,earlywarningsignsofdisturbedorviolentbehaviourandothervulnerabilities,andthemanagementofthese.Sensitiveandtimelyfeedbackshouldcompletethisprocess.
Care plans Riskassessmentshouldbeusedtoestablishwhetheracareplanshouldincludespecificinterventionsfortheshort-termmanagementofdisturbedorviolentbehaviour.
Tools Actuarialtoolsandstructuredclinicaljudgementshouldbeusedinaconsistentwaytoassistriskassessment,althoughno‘goldstandard’toolcanberecommended.
Thisguidanceisavailablefrom:www.nice.org.uk/guidance/CG25/niceguidance/pdf/English
Recognising the individuality of risk
Eachserviceuserbehavesdifferentlywhentheybegintoneedsupport.Itisimportantforcareteamstoprioritisetheirrelationshipwiththeserviceusersothatpersonalsignsandtriggers(‘signatures’)canbeidentifiedbythoseinvolvedintheircareaswellasbytheserviceuserherorhimself.Thesesignsandtriggerswilloftenbeveryindividualtoeachserviceuser.Whentheyhavebeennotedandtheirrelevancetoriskhasbeenunderstood,theyshouldleadtointerventionasearlyaspossibleandshouldneverbeignored.2Advanceddecisionsareanimportantcomponentofdevelopingindividualisedandcollaborativecare.
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Best practice point 13:Riskmanagementmustalwaysbebasedonawarenessofthecapacityfortheserviceuser’sriskleveltochangeovertime,andarecognitionthateachserviceuserrequiresaconsistentandindividualisedapproach.
First contact with services
Whentheserviceuserhasafirstcrisisepisodeandhasnothadcontactwithmentalhealthservicesbefore,thefamily’s–andinparticularthemaincarer’s–contributiontoinformation-gatheringiscritical.Inthissituation,thecarerhasthemostknowledgeabouttheserviceuserandisavitalsourceofbothinformationandsupport.Butthiswillbeaparticularlydifficulttimeforthecareraswellasfortheserviceuser,andpractitionersmustacknowledgethiswhenworkingwithcarersatthistime.
“Thereisoftenadefensivenessfromstafftowardscarers.”Acarer’sview
Individual practice and team working
What should trusts be doing to manage risk?
Therearemanypracticalstepsthattrustsshouldbeconsideringintheareaofriskmanagement.Thesestepsinclude:
• keepingthephysicalenvironmentunderregularreview;
• conducting investigationsasrecommendedbyDepartmentofHealthguidance;
• learningfrominquiriesandreportsbytheNationalPatientSafetyAgencyandtheHealthcareCommission;and
• appointingseniorstafftooverseeclinicalriskmanagement.
Who should be doing risk management?
Riskmanagementiseveryone’sbusiness–includingtheserviceuser’s. Thecarerandthepractitionerwithwhomtheserviceuserworksareinthebestpositiontomakethemostimportantandrelevantcontributiontoriskmanagementplanning,butallofthoseinvolvedinprovidingcarehavearoletoplay.Anybodyinvolvedintool-basedriskassessmentmustknowtheirownstrengthsintermsoftheirpersonalcompetenciesandskills.Newlyqualifiedstaffshouldbeallocatedless
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complexcasesandcloselysupervised.Themoreformaltheriskassessment,thehigherthedegreeofpersonalcompetencyrequired.Allstaffshouldreceivesupervision–regardlessoftheirskills,competencyorexperience.SomeoftheinstrumentslistedinAppendix1requirespecialtrainingorspecificqualificationsasaconditionofusingthem,howeverriskmanagementismuchmorethanjusttheuseoftools.
“Ifapositiveandopenrelationshipexistsbetweentheuserandtheirkeyworker,riskmanagementcanbeapositiveprocessandavitalsteptowardsrecovery.”
Auser’sview
Sources of information
Avarietyofsourcesshouldbeusedforgettingholdofinformationonwhichtobasetheassessmentandmanagementplan.Thesesourcesmustincludeinterviewswiththeserviceuserandcarer,butcanalsodrawonreports,casenotesandtherelevanttoolslistedinAppendix1.23
Effective team work and partnerships
Thepractitionermaysometimesbeworkingalone,butinmostsituationsthebestriskassessmentsandthemosteffectivedecisionsaremadebyateamofexperiencedpractitionersinconsultationwiththeserviceuserandcarer.Decisionsandassessmentsshouldalsobebasedoncollaborationbetweenhealthandsocialcareagenciesinhospitalsandinthecommunity.1,20Insomecasestheyshouldbebasedoncollaborationbetweengeneralandspecialistservices.Thejudgementsmadeinariskassessmentshouldbemadeincollaborationwithothersinthemultidisciplinaryteamandwiththeserviceuserandcarer.Ininstanceswheretheriskseemshigh,theinvolvementofseniorcolleaguestoadviseandsupportmaybehelpful.
Careteamsshouldthinkaboutthewaythattheyoperateandcommunicate:effectivedecision-makingismorelikelyinanatmosphereofopennessandtransparency,whereallviewsarewelcomedandresponsibilityisshared.Teamsshouldconsiderthebestwayforthemtoresolvedisagreementsaboutadecision,toensurethatthebestdecisionsaremadeandthatteamcohesionispreserved.Teamsshouldalsobealerttogroupprocessessuchasthepressuretoconformandthepotentialforgroupstorecommendmoreriskycoursesofactionthananindividualwould.Whenworkingacrossagencies,acommonunderstandingandlanguageshouldbeestablishedfortheissuesthatwillbeaddressed.23
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Best practice point 14:Riskmanagementplansshouldbedevelopedbymultidisciplinaryandmulti-agencyteamsoperatinginanopen,democraticandtransparentculturethatembracesreflectivepractice.
Meetings
Thereshouldbeacleardiscussionabouttheriskmanagementplanataformalmeeting,whichtheserviceuserandtheircarershouldbeenabledtoattendthismultidisciplinarymeeting.Theissueofriskneedstobediscussedwithsensitivityatthismeetingand,sincetheserviceuserorcarermayfeelinhibitedinalargegroup,theyshouldbegivenanopportunitytomeetwithkeycliniciansbothbeforeandafterthemainmeeting.Theyshouldalsobeabletohavemeetingsseparatelyfromeachother.
“Thereisnothingworsethantokenism,andwecansmellitamileoff.”Acarer’sview
Training
Allpractitionersinvolvedinriskmanagement shouldreceiverelevanttraining,andthisshouldbeupdatedatleasteverythreeyears.Thistrainingdoesnothavetobeclassroom-basedbutshouldincludeattentionto:
• theindicatorsofrisk;
• theimportanceofidentifyinghigh-riskperiods;
• optionsforflexibleandrobustriskmanagement;
• waysofmaximisinginvolvement;
• communicationandtherapeuticrelationships;and
• relevantaspectsoftheMentalHealthAct.
Serviceusersandcarersshouldbeinvolvedindeliveringtrainingtopractitioners.Thetrainingshouldincludeanemphasisonanawarenessoflong-termclinicalandsocialneeds,aswellasknowledgeoftheperson’scurrentmentalconditionandanawarenessofhowriskchangesastheserviceuser’slevelofcarechanges(e.g.followingdischargeorwhenonleave).14
Best practice point 15:Allstaffinvolvedinriskmanagementshouldreceiverelevanttraining,whichshouldbeupdatedatleasteverythreeyears.
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Recording information
Allsignificantrisk-relateddecisions shouldberecorded,signedanddatedinsuitabledocumentation.Also,wheneveritisnotpossibletofollowanimportantprincipleofbestpractice,thereasonforthisshouldbedocumented,signedanddated.Theserviceuserandallthoseinvolvedintheircareshouldhavetheopportunitytocontributetothisdocumentationandshouldbeprovidedwithcopies.Thisinformationcanbeusedcollaborativelytoplanfuturecare.
Negativeandjudgementallabelsmustbeavoided,astheyareabarriertocollaboration.Awrittenrecordoftheriskmanagementplanallowspractitionerstotrackchangesinthelevelofriskandtonotefactorsthathavepreviouslybeenconsideredimportant.Thisisparticularlyimportantwhenpeoplehavecomplexneedsandareincontactwithseveralagencies.Documentationalsohelpstoprotectpractitionersintheeventofareview.
Standardised documentation
ThetoolslistedinAppendix1mayassistinthedevelopmentofastandardisedapproachtodocumentationwithinatrustorservice.Localriskassessmentproformasshouldbedesignedwithevidence-basedprinciplesinmind,statingclearandverifiableriskindicatorsandprovidingfreetextspaceforindividualopinions.28Whenharmhasoccurred,thedetailsshouldberecordedaspreciselyaspossible:
• Whathappened?
• Whatwerethecircumstances?
• Whatweretheconsequences?
• Howdoeswhathappenedrelatetomentalillness?
Serviceusers’viewsontheseissues,riskanditsfuturemanagementshouldbeincludedinthedocumentation.9Allrelevantinformationshouldalsoberecordedintheappropriatelocalformat(e.g.CPAdocumentation)andstoredconfidentially.Theprocessofdocumentationshouldnotbecomeabureaucraticendinitselfandshouldnotbeaimedatself-protection.Writtendocumentationmustbemanagedinaccordancewiththerelevantlegalstatutes(e.g.theDataProtectionActandtheFreedomofInformationAct).Ultimately,localriskinformationwillbestoredelectronicallyinthenationalConnectingforHealthsystemthatiscurrentlyunderconstruction.
Communication
Onceariskmanagementplanhasbeendevelopedorreviewed,itmustbecomealivedocumentandbecommunicatedtotheserviceuserandallofthoseinvolvedinprovidingtheircare:theriskmanagementplanhasnopurposeifitisnotshared
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betweentherelevantpartiesandusedasabasisforjointaction.Theserviceuser’sconsentforsharinginformationinthiswayshouldbesought,althoughthedutyofconfidentialitycanbeoverriddenifthereisaclearriskofharm.Thelocalpolicyoninformation-sharingshouldgovernthisprocess.
Best practice point 16:Ariskmanagementplanisonlyasgoodasthetimeandeffortputintocommunicatingitsfindingstoothers.
Decision-making in the real world
Decision-makingbyprofessionalsinvolvedinriskassessmentandriskmanagementiscomplexandisaffectedbymanyfactorsthatarespecifictothepractitionermakingthedecision,suchastheirpersonalvalues,theirownattitudetowardsrisk,theirworkloadandthetimethattheyhaveavailabletoaddressthemattersinhand.Itisimportantforprofessionalstobeawareofandreflectonthefactorsthatinfluencetheirdecision-making,toensurethattheirvaluesareenhancingtheprocessratherthandistortingit.Again,effectiveteamworking,individualsupervisionandgoodcommunicationwithotherswillallsupporttheseprocesses.Feedbackfromtheserviceuseronthisaspectofpracticeisausefulpartofreflectivepractice.
Learning from adverse incidents
Thingscangowrongevenwhenbestpracticehasbeenused.Ifthingsdogowrongordonotgoaccordingtoplanitisimportanttolearnwhy,includingidentifyinganymistakesthatweremade.29Learningfrom‘nearmisses’isvitaltoimprovingservices,5althoughnotalllessonslearnedwillrequirechangesinpractice–theymaynotnecessarilyleadtobetteroutcomes.Thecultureofanorganisationcanmakeallthedifferenceinensuringthatstafffeelabletobehonestaboutthedecisionsthattheyhavetaken,thebasisonwhichtheymadetheirdecisions,andhowthingsmighthavebeendonedifferentlyandbetter:lessonscanbelearnedand,wherenecessary,practicescanbe changedforthebetter.Trainingcouldalsobeimprovedasaresult.Itisimportanttorememberthatanydecisionislikelytobeacceptableifitconformedtorelevantguidelines,itwasbasedonthebestinformationavailable,itwasdocumentedandtherelevantpeoplewereinformed.11
Learning from good practice
Mostofourlearninginriskmanagementisbasedonlookingbackatadverseincidents.Itis vitallyimportant,though,toacknowledgethatdealingwithriskandmakingdecisionsispartofeverydaypractice,andpractitionersmaketherightdecisionmostofthetime.Everyrightdecisionhelpstopreventanadverseincident,somentalhealthorganisationsshouldsetupsystemsforsystematicallylearningfromgoodpracticeaswell.Thisshouldincludesharingexperiencesamongpractitionersandencouragingmultidisciplinaryandpeerreviewofclinicalpractice.
30
Preamble
Bestpracticeinthisarearelies,inpart,onaconsistentapproachtotheassessmentofriskwhenworkingwithanindividualserviceuser.Thisconsistentapproachcanbeimprovedbyusingtoolsandotherpackagesthathavebeendevelopedforthispurposeandwhichhavebeentestedinsomewayinrealmentalhealthcaresettings.Inthisappendixinformationisprovidedaboutaselectionofstructuredapproachesthatcanbeusedaspartofanoverallriskmanagementplanandwhichhavebeentested,atleasttosomeextent,inthisway.Mostofthesestructuredapproachesareriskassessmenttoolsorguidestoclinicaljudgement,butsomebroaderapproaches,suchastrainingprogrammes,havealsobeenincluded.Theyhavebeenselectedandevaluatedthroughaprocesscombiningsystematicreviewoftheresearchliteratureandextensiveconsultationwithexpertsinthisarea.
Whenthinkingaboutriskassessmenttools,twokeywarningsmustbeborneinmind.
Riskassessmenttoolsmustbeusedwithcaution.
Atoolcanonlycontributeonepartofanoverallviewoftheriskpresentedbyaparticularindividualataparticulartime.Toolsshouldonlyeverbeusedaspartofageneralclinicalassessmentconductedwithaserviceuser.Theresultsofthetool-basedassessmentmustalwaysbecombinedwithotherinformationonmanyaspectsoftheserviceuser’slifeandcurrentsituation.
Appendix 1: Tools for supporting best practice
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Figure 3: Risk assessment tools as one part of the overall clinical assessment process
The risk assessment tool
Many other aspects of the service user’s
life
The current situation
Clinical assessment
Choosingtherighttoolforthejobisacomplextask.
Thetoolslistedherehavebeendesignedwithavarietyofpurposesandwithavarietyofserviceusersinmind.Someareactuarialandothersprovidestructureforclinicaljudgements.Somehavebeenthrougharigorousprocessofscientificdevelopmentwhileothershavebeentestedwithregardtotheirutilityandacceptabilitytopractitioners.Bothapproacheshaveadvantagesanddisadvantageswhenunderpinninggoodpractice.Sometoolshavebuilt-inpromptsforthinkingaboutthemanagementofanyrisksthatareidentifiedwhileothersdonot.Thechoiceofaparticulartoolbyacareteammustbebasedonaconsiderationofalltherelevantfactorsandhowtheyrelatetotherangeofrisksencounteredbytheteaminpractice.
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SomeofthestructureforthissectionisadaptedfromtheScottishRiskManagementAuthority’sRisk Assessment Tools Evaluation Directory.Thisdirectory30providesinformationonawiderrangeofviolenceinstrumentsrelatingtocourtproceedingsandshouldbeconsultediffurtherinformationisneededinthisarea.
Overview
Page
Vio
lenc
e
Sexu
alv
iole
nce
Ant
isoc
iala
ndo
ffen
ding
be
havi
our
Self-
harm
/sui
cide
Self-
negl
ect/
vuln
erab
ility
Multiplerisks
CRMT 33 • • •FACE 34 • • •GRiST 35 • • • • •RAMAS 36 • • • • •GIRAFFE 37 • • • • •START 38 • • •Risk of violence, sexual violence, antisocial or offending behaviour
HCR-20 39 •PCL-R 40 •PCL:SV 41 •STATIC-99 42 •SVR-20 43 •VRAG 44 •Risk of self-harm or suicide
ASIST 45 •BHS 46 •SADPERSONS 47 •SIS 48 •SSI 49 •STORM 50 •
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Multiple risks
CRMT: Clinical Risk Management Tool/Working with Risk
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
• • •
Description TheCRMTisastructuredtemplatechecklistofrelevantriskandcontextualfactors.Thetoolincludesastructuredassessmentofsuicide,neglect,violenceandotherrisks(ratedas‘present’or‘absent’)andfreetextboxes(threepages)fordescriptionsofthecontextofriskfactors,positiveresources,riskmanagementconsiderations,opportunitiesforriskprevention,andriskmanagementoptions(short-andlong-term).Amodifiedversion(MST)isavailablewithtwolevels(screeningandcomprehensive),andthisversionisembeddedwithina‘WorkingwithRisk’trainingpackagewhichemphasisespositiveriskmanagement.
Depth Screeningandin-depth.
Setting Allmentalhealthservicesettings.
Practitioners Alllevels.
Riskmanagement
Thereisanemphasisonconsideringeffectivemanagementoncerisksareidentified.Guidanceonpositiveriskmanagementisprovidedinthemanualanddedicatedtrainingworkshopson‘WorkingwithRisk’.
Training ATrainer’sManualandaPractitioner’sManual,withoptionalconsultanttraininganddevelopmentfromPracticeBasedEvidence.
Cost Trainer’sManualfor£179andadditionalcopiesofthePractitionerManualfor£29.
Manual AvailablefromPavilionPublishing(01273623222orwww.pavpub.com).
Evidence Thereisnopublishedevidenceontooldevelopmentintermsofreliabilityorvaliditybecausetheemphasishasbeenontheclinicalutilityofthetool.Ithasbeenconstructedanddevelopedinresponsetofeedbackfromlargenumbersofpractitionersattendingtrainingworkshopsandpracticedevelopmentprojects.Inonepublishedstudy,themodifiedversionofthistoolwasthepreferredriskassessmenttoolwhencomparedagainstthreeothers.
Origin UK
Formats Paperonly
Contact SteveMorgan,PracticeBasedEvidence
Phone 07733105264
Email [email protected]
Website www.practicebasedevidence.com
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FACE: Functional Analysis of Care Environments
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
• • •
Description FACEisaportfolioofassessmenttoolsdesignedforadultandolderpeople’smentalhealthsettings.Itincludesbothscreeningandin-depthlevelsofassessmentandcontainsspecialistformsapplicabletoareassuchassubstanceuse,mentalcapacity,perinatalservicesandforensicservices.ThetoolsmeetbothCPAandHealthoftheNationOutcomeScalesrequirements.RiskisassessedusingtheFACERiskProfile.ThismaybeusedeitherasastandalonetoolorinconjunctionwithotherFACEorlocaltools.Fivesetsofriskindicatorsarecodedaspresentorabsentandthenajudgementofriskstatus(0–4)insevenareas(includingviolence,self-harmandself-neglect)ismade.Scopeforserviceuserandcarercollaborationisbuiltintothesystemthroughtailoredforms,includingfeedbackonservices(e.g.relationshipwithpsychiatrist).
Depth Screeningandin-depth.
Setting Allgeneralandforensicmentalhealthsettings.
Practitioners AnymentalhealthpractitionerwhohasattendedFACEtraining.
Riskmanagement
TheFACERiskProfilespecificallypromptsrecordingofactionsrecommendedorrequiredasaresultoftheassessment.
Training Oneday’strainingisrequired.
Cost Outrightpurchaseofthefullsystemcurrentlycostsapproximately£4,000perannum.Foramedium-sizedtrust,thecostoftheRiskProfileonlyis40%ofthis.
Manual Adetailedtrainingguideisavailable,includingstandardisedvignettes,promptsandguidance.
Evidence ThetoolhasbeendevelopedwithaUKmentalhealthsample.Thereisevidencethattheriskindicatorsetsareinternallyconsistentandthatratersagreewhencompletingthemindependently.Thereisalsoevidenceofgoodvalidity.
Origin UK
Formats Electronicandpaperformatsareavailable,includinganenterprisedatabaseimplementationwithalerts,plans,incidentrecords,aggregationsystems/benchmarkingfacilitiesandinterfacingcapabilitieswithothersystems.
Contact IntermationLtd,Nottingham
Phone 01159838788
Email [email protected]
Website www.facecode.com
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GRiST: Galatean Risk Screening Tool
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
• • • • •
Description GRiSTisadecisionsupportsystem,basedontheexpertiseofmultidisciplinarymentalhealthpractitioners,thatidentifiesdetailedinformationaboutallrisks.Whenfullydeveloped,itwillbeaweb-basedprogramforcollectinginformationandgeneratingriskquantifications,withfullexplanationsofhowtheseassessmentswerederived.Thecurrentversion(May2007)organisesquestionswithrapidscreeningonesfirst,whichdirecttheassessortomorein-depthonesifrequired.However,theunderlyingrepresentationofriskknowledgemakesiteasyfortheinformationtobecustomisedtoparticularclinicalrequirements.Free-textentryisallowedforeachoverallriskdomain,andtheelectronicversionenablesittoberecordedforanypieceofriskdata.
Depth Screeningandin-depth.
Setting Allmentalhealthservicesettings.
Practitioners Alllevels–versionstailoredforvariouslevelsofpractitionerexpertiseareunderdevelopment.
Riskmanagement
Thereisafreetextprompttoconsideractiontobetaken,butotherwisethereisnoguidanceonriskmanagement.
Training Notrequired,butreferencetoinformationonthewebsiteisadvised.
Cost Freetoserviceproviders,subjecttoacknowledgementandinternaluseonly.
Manual Notavailable,butinformationisavailableonthewebsite.
Evidence ThementalhealthexpertiseunderlyingGRiSThasbeenderivedfromextensiveinterviews,focusgroupsandindividualvalidationoveraperiodoffouryears.Therigorousmethodofdatacollectionandanalysishasbeendescribedandthereisevidenceofgoodfacevalidity.Thetoolisdesignedtomakeriskpredictions,butthereisnopublishedevidenceasyetonitsreliabilityorvalidity.
Origin UK
Formats Web-basedandpaper
Contact DrChristopherBuckingham,AstonUniversity
Phone 01212043450
Email [email protected]
Website www.galassify.org/grist
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RAMAS: Risk Assessment Management and Audit Systems
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
• • • • •
Description RAMASconsistsofaframeworkandasetofstructuredprofessionaljudgementtoolsdesignedtoimprovequalityandsafetyinmentalhealthcare.Thetoolsrelatetorisktoself,risktoothers,vulnerabilityandmentalhealthrisk.Broaderneedsareconsideredalongsidethoserelatedtorisk.Thereisalsoanemphasisondevelopingacommonrisklanguageacrosscaresettings,andthesystemmapsontotheCPA.Serviceusers,carersandvoluntaryagencieswereinvolvedinitsdevelopmentandtheframeworkincludesaserviceuser’scharter.
Depth Triageandin-depth/review.
Setting Allmentalhealthandsocialcaresettings.
Practitioners PractitionersandteamswishingtoadoptRAMASmustattendtraining(seebelow).
Riskmanagement
Thereisanemphasisonapartnershipapproachtoriskneedandresponsivity.
Training Threelevelsareavailable:Level1(Triage)–StartSafe,StaySafe(includesriskrecognitionandcommunicationandissuitableforallstaff);Level2–RiskandCareManagement(suitableforqualifiedpractitionersandmapsontotheCPA);andLevel3–TrainingtheTrainers(forexperiencedLevel2usersandriskmanagers).
Cost Seethewebsitebelow.
Manual Level1:Handbookavailable.Level2:Professionalmanualcomesaspartofthetrainingpackage.
Evidence TheriskassessmenttoolswithintheRAMASsystemhavebeendevelopedandtestedinUKmentalhealthsettings.Thereisevidenceofgoodinternalreliability,considerableconstructvalidityandsomeconcurrentvalidity.Intermsofclinicalutility,implementingRAMAShasbeenassociatedwithincreasedpractitionersatisfactionandthereisevidenceofgoodinteragencyagreementonriskratingsbetweencommunitymentalhealth,highsecureandprobationstaff.
Origin UK
Affiliation NHS;UniversityofSurrey;UniversityCollegeCork.
Formats Anelectronicversionisunderdevelopment.ItwillbesuitableforautomationthroughnationalpatientrecordsandcompatiblewiththeCPA.
Contact Seewebsite
Phone Seewebsite
Email [email protected];[email protected]
Website www.ramas.co.uk
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GIRAFFE: Generic Integrated Risk Assessment for Forensic Environments
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
• • • • •
Description GIRAFFEisariskassessmentsoftwaresuitearrangedinfunctionalmodules.These includeriskhistory,riskformulation,riskmonitoring,riskmanagement, riskhandoverandanadverseeventsrecorder.Thesystemenablesthecompilation,analysis,reportingandchartingofrisk-relatedinformationderivedfromawiderangeofsources,suchascasenotes,interviews,observationandquantitativemeasuresincludingdatafromotherrisktoolslistedhere.Whilethereisnodirectserviceuserinputtothesystem,itencouragesacollaborative/consultativeapproach.
Depth In-depth.
Setting GIRAFFEwasdevelopedinaforensicmentalhealthsettingbut isadaptabletootherforensicorsocialcaresettings.
Practitioners Itisintendedforcollaborativeusebyallmembersofthemultidisciplinaryteam.
Riskmanagement
Thereisastrongemphasisonanindividualisedapproachtoriskformulation,riskmanagementandreview.
Training Recommendedon-sitecascadetraining.
Cost Thesystemcanbepurchasedoutrightbuttheprojectmustbecontacteddirectlyforaquote.
Manual Thesystemincorporatesanelectronichelpmanualtogetherwithwebsiteinformation.Usersupportisoffered.
Evidence Thereisnoevidenceavailableontheclinicalutilityofthetool.
Origin UK
Formats Electronicwithtextual/graphical printouts/dumps
Contact JulianFuller,ProjectDirector,‘GiraffeOnline’,POBox35,Dawlish,DevonEX79DQ
Phone 01626864985
Email [email protected]
Website www.giraffeonline.co.uk
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START: Short-term Assessment of Risk and Treatability
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
• • •
Description STARTisariskassessmentandmanagementdecisionsupportsystemdevelopedinCanada.Itadoptsaglobalapproachtoriskbycoveringunauthorisedleave,substanceabuse,victimisationbyothersaswellasrisktoothers,self-harm,suicideandself-neglect.Theserviceuser’sstrengthsandrisksoneachof20dynamicfactorsareassessedonascaleof0–2.
Depth In-depth.
Setting Itwasdevelopedinaforensicpsychiatricsettingbutmaybeapplicableingeneralmentalhealthsettingsaswell.
Practitioners Practitionersfromanymentalhealthbackgroundcanusethetool,butattendanceatatrainingworkshopisrequired.
Riskmanagement
Thetoolisdesignedtoprovideguidanceonclinicalinterventionsandtoassesschangesovertime.
Training Contactbelowforfurtherinformation.
Cost Notknown.
Manual Amanualisavailable.
Evidence Thereispreliminaryevidenceofgoodinter-raterreliabilitywhencompletedbypractitionersfromdifferentprofessions,andevidenceofvaliditywithaconfirmedrelationshipbetweenSTARTscoresandobservedaggression.Intermsofclinicalutility,completiontakeslessthantenminutesonaverageandthereisevidenceofhighacceptabilityamongstaff(e.g.easeofuse).
Origin Canada
Formats Paperonly
Contact BritishColumbiaMentalHealthandAddictionServices,70ColonyFarmRoad,PostCoquitlam,BCV3C5X9Canada
Phone +16045247730
Email [email protected]
Website www.bcmhas.ca/Research/Research_START.htm
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Risk of violence or sexual violence, and antisocial or offending behaviour
HCR-20: Historical Clinical Risk-20
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
•
Description TheHCR-20isastructuredclinicaljudgementtool.Itconsistsof20items,dividingriskassessmentintothreecomponents:historicalfactors,clinicalfactorsandriskmanagementfactors.Theseareseenasinformingtheclinicianofrelevantissuesinaserviceuser’spasthistory,evaluatingthepresenceofcurrentdynamicissuesinrisk,andinformingthepractitioneroffutureriskmanagementrequirements.Eachitemiscodedonathree-pointscale(‘absent’,‘possiblypresent’or‘definitelypresent’).Timescalesforconductingtheassessmentarequiteflexibleandallowconsiderableleewayforindividualjudgement.Thereisgoodscopeforinvolvingtheserviceuserintheassessment.
Depth In-depth.
Setting Generalandforensicmentalhealthsettings,malesandfemales.
Practitioners Psychologyorrelateddegreeplusrelevanttestadministrationtraining.
Riskmanagement
Riskmanagementplanningisbuiltintothe‘R’componentofthetoolandthepublishercansupplyariskmanagementcompanionguideinadditiontothebasictool.
Training Specifictrainingrequirementsarenotstated.Thetestdeveloperandtrainedothersprovidetrainingsessionsinternationally.
Cost Currentlyapproximately£80start-upthenapproximately£2percodingsheet.Seepublisher’swebsitefordetails.Anewversionisplannedforpublicationshortly.
Manual Availablefromthepublisherforapproximately£20.
Evidence Whilenotdesignedasanactuarialtool,thereisaninternationalevidencebase(includingtheUK)whichsupportsanassociationbetweenthefindingsoftheHCR-20andsubsequentviolenceoverlongtimeperiodsinsamplesofbothforensicandgeneralmentalhealthserviceusers.
Origin Canada
Formats Paperonly
Contact PsychologicalAssessmentResourceInc.,16204NorthFloridaAvenue,Lutz,FL33549,USA
Phone +18003318378
Email Seewebsite
Website www.parinc.com
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PCL-R: Psychopathy Checklist-Revised
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
•
Description ThePCL-Rwasdesignedasanassessmenttoolfortheidentificationofpsychopathyinforensicpatients.Ithassubsequentlybeenusedwidelyasaviolencepredictiontool,butthetestauthorarguesthatanyassociationwiththepredictionofviolenceisviaapresumedlinkwithpsychopathyandviolenceratherthanadirectlinkbetweenPCL-Ritemsandthelikelihoodofaggression.Thetoolisa20-itemscalewithitemsscoredonthebasisofasemi-structuredinterviewandacollateralreviewoffile-basedinformation.Eachitemisscoredonathree-pointscalebasedonhowcloselytheraterjudgesaclient’scharacterconformstothescaleiteminquestion.
Depth In-depth.
Setting Primarilyforensicsettingsbutmaybeapplicabletoantisocialandoffendingbehaviouringeneralmentalhealthsettings.Usuallymalesonly;evidenceforitsclinicalutilitywithwomenismorelimited.
Practitioners Postgraduatequalificationinamentalhealthprofessionisrequired.
Riskmanagement
Noexplicitlinktoriskmanagementstrategiesisincorporatedintothetool.
Training Specifictrainingisrequired:seewww.hare.org
Cost Currentstart-upcostsareapproximately£225(paperformat)and£290(electronicformat),thenapproximately£2percodingsheet(£10eachifelectronic).Seepublisher’swebsitefordetails.
Manual Availablefrompublisher.
Evidence Theevidencebaseforthistoolisextensive.Thereisevidence(includingUKstudies)ofatleastamoderateassociationbetweenPCL-Rscoreandviolencepost-discharge. TheevidenceforalinkbetweenPCL-Rscoreandsexualviolencerecidivismislessstrong. Oneofthefactorsmakingupthetool(‘antisocialbehaviour’)ismorereliableinthisrespectthantheother(‘emotionaldetachment’).
Origin Canada
Formats Paperandelectronic
Contact Multi-HealthSystemsIncorporated,MHS(UK),9aKingfisherCourt,HambridgeRoad,Newbury,BerkshireRG145SJ
Phone 08456017603
Email [email protected]
Website www.mhs.com
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PCL:SV: Psychopathy Checklist: Screening Version
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
•
Description ThePCL:SVwasdevelopedtoprovideashorterformofthePCL-Rfortheassessmentofpsychopathyingeneralpsychiatricpopulations.Itisa12-itemscalewithitemsscoredonthebasisofasemi-structuredinterviewandreviewofcollateralfile-basedinformation.Eachitemisscoredonathree-pointscalebasedonhowcloselytheraterjudgesaclient’scharacterconformstothescaleiteminquestion.
Depth Screening.
Setting Generalandforensicmentalhealthsettings.
Practitioners Postgraduatequalificationinamentalhealthprofessionisrequired.
Riskmanagement
Noexplicitlinktoriskmanagementstrategiesisincorporatedintothetool.
Training Specifictrainingisrecommended:seewww.hare.org
Cost Currentlyapproximately£110start-upthenapproximately£1.60percodingsheet.Seepublisher’swebsitefordetails.
Manual Availablefrompublisher.
Evidence ThePCL:SVhasnotbeenasextensivelyevaluatedasthePCL-RandthebulkofavailableevidencederivesfromoutsidetheUK.AvailabledatasuggestmoderatetogoodassociationsbetweenPCL:SVscoresandaggressioninbothforensicandgeneralpsychiatricpopulations.
Origin Canada
Formats Paperonly
Contact Multi-HealthSystemsIncorporated,MHS(UK),9aKingfisherCourt,HambridgeRoad,Newbury,BerkshireRG145SJ
Phone 08456017603
Website www.mhs.com
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STATIC-99
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
•
Description TheSTATIC-99isanactuarialscaledevelopedspecificallytoassessthelong-termpotentialforsexualrecidivisminadultmalesexoffenders.Thetoolismadeupofaten-itemlist,witheachiteminvitinga‘yes/no’response.Onepointisgivenfora‘yes’responsetoeachofnineitems,withthreepointsgiventotheremainingitem(priorsexualoffences).Arevisedversion,theSTATIC-2002,remainsintheprocessofdevelopment.
Depth Screening.
Setting Forensicmentalhealth,males.
Practitioners Requiredqualificationsarenotspecified.
Riskmanagement
Asanactuarialtool,thescopeforactivelyguidingindividualisedriskmanagementplansislimited.
Training Trainingqualificationsnotspecified.
Cost Free.
Manual Noneavailable.Codingguidelinesareavailablefrom<ww2.ps-sp.gc.ca/publications/corrections/pdf/Static-99-coding-Rules_e.pdf>
Evidence TheevidencebaseforthistoolisrelativelysmallandwillsoonbecomeoutdatedwhentheSTATIC-2002becomesavailable.However,evidencefromanumberofstudiesinvariouscountries(includingtheUK)indicatelowtomoderateestimatesofthepredictivevalidityoftheSTATIC-99inpredictingsexualandnon-sexualviolentrecidivisminrapistsandchildmolesters.
Origin Canada/UK
Formats Paperonly
Contact Themainsourceisthefollowingpaper:HansonandThornton,2002.Thecorrespondingauthor’saddressis:DrAndrewHarris,SeniorResearchOfficer,CorrectionsDirectorate,SolicitorGeneralCanada,11thFloor,340LaurierAve.West,ONK1A0P8Canada
Phone USA+(613)9912033
Email [email protected]
Website www.sgc.gc.ca
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SVR-20: Sexual Violence Risk-20
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
•
Description TheSVR-20isastructuredclinicaljudgementtool.Itwasdesignedtoaddresstheriskofviolenceinsexoffendersandthereisgoodevidenceforitspsychometricpropertiesanditsefficacy.The20-itemscaleisdividedintothreeriskfactordomains:psychosocialadjustment,sexualoffencesandfutureplanning.Eachitemisratedonathree-pointscale(‘notpresent’,‘somewhatorpossiblypresent’or‘clearlypresent’)andthegeneralpatternobservedistakenintoaccountinevaluatingriskas‘low’‘medium’or‘high’.TheSVR-20hasbeenupdatedtotheRiskforSexualViolenceProtocol(RSVP).
Depth In-depth.
Setting Generalandforensicmentalhealthsettings,malesonlyalthoughtheRSVPmaybeusedwithwomen.
Practitioners Psychologyorrelateddegreeplusrelevanttestadministrationtraining.
Riskmanagement
TheaimoftheSVR-20–andtheRSVP–istohelpinthedevelopmentofriskmanagementplans.
Training Trainingrequired.
Cost Currentlyapproximately£60start-up,thenapproximately50ppercodingsheet.Seepublisher’swebsitefordetails.
Manual Availablefromthepublishersforapproximately£20.
Evidence AswiththeHCR-20,theSVR-20andtheRSVPwerenotdesignedasanactuarialtoolalthoughthereisgoodevidenceoftherelationshipbetweenSVR-20riskfactorsandtheriskofsexuallyviolentreoffending.
Origin Canada
Formats Paperonly
Contact PsychologicalAssessmentResourceInc.,16204NorthFloridaAvenue,Lutz,FL33549,USA
Phone +18003318378
Email Seewebsite
Website www.proactive-resolutions.com
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VRAG: Violence Risk Appraisal Guide
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
•
Description TheVRAGisanactuarialtoolmadeupof12items.OneoftheseitemsisthetotalscoreofthePCL-Rtool(seepage40)andtherestarebasedoninformationheldinclinicalfiles(e.g.psychosocialhistory).Thereisnorelianceoninterviewsorquestionnaires.All12itemsarescoredfrom–5to+12andthetotalscoresaredividedintonineequalriskgroupings.
Depth Screening.
Setting Forensicmentalhealthsettingsformales.Thereisaheavyrelianceonitemsrelatingtopreviousoffendingbehaviour.
Practitioners Qualifiedmentalhealthprofessionals.
Riskmanagement
Therearenospecificpromptsonriskmanagementstrategies.
Training Nospecificqualificationshavebeenset.
Cost Free.
Manual Notavailablebutmuchoftheworkisdescribedinthefollowingbook:Quinsey,V.L.,Harris,G.T.,Rice,M.E.,andCormier,C.A.,Violent offenders: Appraising and managing risk(SecondEdition),AmericanPsychologicalAssociation.Washington,DC,2006.
Evidence ThereisquiteextensiveevidencefromvariouscountriessupportingtheabilityoftheVRAGtopredictfutureviolencebyoffenders.Muchofthisisprovidedbythescale’sauthors.AsmallnumberofstudiesintheUKsupportmoderatelevelsofpredictiveaccuracy.
Origin Canada
Formats Paper
Contact ResearchDepartment,MHC,500ChurchSt.,PenetanguisheneONL9M1G3,Canada
Phone Notknown
Email [email protected]
Website www.mhcp-research.com/index.htm
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Risk of self-harm or suicide
ASIST: Applied Suicide Intervention Skills Training
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
•
Description ASISTisatrainingprogrammedevelopedinCanadathatisdesignedtopreparecaregiversfromawiderangeofsettingsinsuicide‘firstaid’.Itconsistsofatwo-daypackageonsuicideriskmanagementforcaregiverswhichisinteractive,intensiveandcloselyrelatedtopractice.Theaimistopreparecaregiverstorecogniseriskanddevelopskillstointervenetoreducetheimmediaterisk.Awarenessisraisedontheimportanceofattitudesinthisareaandtheresourcesavailablewithinlocalcommunities.TheprogrammehasbeenruninanumberofcountriesworldwideandhasbeenadoptedasanationalsuicideinterventiontrainingprogrammebytheScottishExecutive.
Depth In-depth.
Setting Allmentalhealthsettingsinwhichsuicide‘firstaid’wouldbeappropriate.
Practitioners Allpractitionersinthesesettings.
Riskmanagement
Thecourseincludeslearningaboutinterveningtopreventtheimmediateriskofsuicide.
Training See‘Description’above.
Cost Seewebsitebelow.Arangeofpaperandelectronicsupportingmaterialsareavailable.
Manual Approximately£15.
Evidence ASISThasbeenadoptedasanationalsuicideinterventiontrainingprogrammeinScotland.Forfurtherinformation,seethewebsitebelow.
Origin Canada
Formats Notapplicable
Contact LivingWorks,4303D11StreetSE,Calgary,ABT2G4X1,Canada
Phone +14032090242
Email [email protected]
Website www.livingworks.net
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BHS: Beck Hopelessness Scale
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
•
Description Thisisaself-reportscale,measuringanimportantsuicide/self-harmriskfactor,thattakeslessthantenminutestocomplete.Thereare20itemsassessingfeelingsaboutthefuture.Eachitemisatrue/falsestatementandscored0or1.Negativeresponsesoneachitemareaddedtogethertogiveatotalscoreoutof20.
Depth Screening.
Setting Generalandforensicmentalhealthsettings.
Practitioners Psychologyorrelateddegreeplusrelevanttestadministrationtraining.
Riskmanagement
Noexplicitlinktoriskmanagementstrategiesisincorporatedintothetool.
Training Generaltestadministrationtrainingisrequiredforpurchase.
Cost Approximately£70forastarterpack(manualand25forms),thenapproximately£1.50perform.
Manual Availablefromthepublisherfor£36.50.
Evidence Thereisanextensiveinternationalevidencebaseincludingtestingofthetool’sstructureandsupportforhopelessnessasariskfactorforcompletedsuicide.SomeoftheavailableevidenceisderivedfromtheUK.TheBHShasbeenfoundtocorrelatewellwithchangeinclinicalsymptomsinrandomisedcontrolledtrialsofinterventionsforhigh-riskorsuicidalpatients.
Origin USA
Formats Paperonlyforadministration,butelectronicanalysissoftwareisavailable
Contact HarcourtAssessment,HalleyCourt,JordanHill,OxfordOX28EJ
Phone 01865888188
Email [email protected]
Website www.harcourt-uk.com/
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SADPERSONS
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
•
Description Thisbrieftoolassessesthepresenceorabsenceoftenriskfactorsforsuicide,e.g.malegender,socialisolation.Eachfactorisrated1or2ifpresent.Riskmanagementisindicatedifcertaincut-offscoresareexceeded.Itisaverybriefinstrumentsoiseasytoadministerbutmakesalimitedcontributiontooverallassessment.
Depth Screening.
Setting ItwasdevelopedforAmericancommunitysettingsbuthasbeenusedinsecondarymentalhealthsettings.
Practitioners Originallydevelopedforseniormedicalstudentsasnoviceriskassessors.
Riskmanagement
Fromacommunityperspective,interventionssuchasfurtherevaluation/treatmentorimmediatehospitalisationarelinkedtospecificcut-offscores,butthesearenotrelevanttotheUKsetting.
Training Noinformationavailable.
Cost Notknown.
Manual Notavailablebutinformationcanbegainedfromtheoriginalsource(Patterson,W.etal.,Psychosomatics,24,1983:343–9)andamorerecentpaper(Roudebushetal.,Psychological Services,3,2006:137–41).
Evidence TheavailableevidenceisbasedonAmericansamplesandindicatesthatthetoolisadequateasonepartofanoverallassessment.Onereviewhascriticisedthelackofevidenceindicatingacceptablereliabilityandvalidity.ThereisalackofevidencebasedonUKsamples.
Origin USA
Formats Paperonly
Contact W.M.Patterson,SmolianClinic,Room210,DepartmentofPsychiatry,UniversityStation,Birmingham,AL15294,USA
Phone Notavailable
Email Notavailable
Website Notavailable
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SIS: Suicidal Intent Scale
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
•
Description Thisinterview-basedorself-administeredscalewasdesignedtoassesstheintentiontodieamongpeoplewhohaveattemptedsuicide.Ithas15itemsseparatedintocircumstancesrelatedtothesuicideattempt(e.g.presenceofasuicidenote)andself-reportitems(e.g.expectationsoffatality).Thefirstgroupofitemscanbecompletedretrospectivelyfromcasenotes.Eachitemisscoredonathree-pointscaleandcut-offsforseverityareprovided.Fiveadditionalitemsdonotcontributetotheoverallscore.Therearenospecificcut-offsandapositiveresponsetoanyitemshouldbeacauseforconcern.
Depth Screening.
Setting Generalandforensicmentalhealthsettings.
Practitioners Nolimitationsspecifiedintheoriginalsource(see‘Manual’below).
Riskmanagement
Noexplicitlinktoriskmanagementstrategiesisincorporatedintothetool.
Training Nonespecifiedintheoriginalsource.
Cost Nonespecifiedintheoriginalsource
Manual Notknownbutthesourceforthetoolis:Beck,A.,Schuyler,D.,andHerman,I.,‘Developmentofsuicideintentscales’,InBeck,A.,Reesnick,H.,andLettieri,D.(eds)The Prediction of Suicide,CharlesPress,Bowie,Maryland,USA,1974.
Evidence AnAmericanreview31concludedthattheSISscorewasnotariskfactorforcompletedsuicideoverseveralyearsamongin-patientshospitalisedforattemptedsuicide.ArecentUKstudy32concludedthatthescaleremainsvaluableasaclinicalaid.Otherstudieshavereportedsomeassociationsbetweentotalorsubscalescoresandsuicide-relatedoutcomes.
Origin USA
Formats Paperonly
Contact BeckInstituteforCognitiveTherapyandResearch, OneBelmontAvenue,Suite700,BalaCynwyd,PA19004-1610,USA
Phone USA+16106643020
Email [email protected]
Website beckinstitute.org/
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SSI: Scale for Suicide Ideation
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
•
Description Thisisa21-itemscalethatcanbeself-administeredorcompletedviaaninterviewinabouttenminutes.Itisdesignedtoassesstheintensityofaperson’sattitudeswithregardtosuicideandtheirbehavioursandplanstocompletesuicideduringthepastweek.Some19testitemsareeachratedbetween0and2andaddedtogethertoyieldatotalscorerangingfrom0–38.Twoadditionalitemsaskaboutprevioussuicideattemptsandtheseriousnessofintentinthemostrecentattempt.Thefirst5ofthe19itemsactasascreeningfilter.Whileahigherscoreisassociatedwithahigherrisk,therearenospecificcut-offs,andapositiveresponsetoanyitemshouldbeacauseforconcern.
Depth Screening.
Setting Generalandforensicmentalhealthsettings.
Practitioners Itmaybeadministeredandscoredbyallpractitionersbutrequiresspecialisttrainingforpurchaseandinterpretation.
Riskmanagement
Noexplicitlinktoriskmanagementstrategiesisincorporatedintothetool.
Training Generaltestadministrationtrainingisrequiredforpurchase.
Cost Approximately£70forastarterpack(manualand25forms),thenapproximately£1.50perform.
Manual Availablefromthepublisherfor£36.50.
Evidence AmajorAmericanreview31foundevidenceofanassociationbetweenscoresontheinterviewversionofthisscaleandcompletedsuicideinoutpatients.Nosuchevidencefortheself-reportversionlistedherewasreported.ThereisUKevidenceofsensitivitytochangeinaself-harminterventiontrial.Aself-reportversionhasbeenusedtodetectchangeinaUKtrial.
Origin USA
Formats Paperonlyforadministration,butelectronicanalysissoftwareisavailable
Contact HarcourtAssessment,HalleyCourt,JordanHill,OxfordOX28EJ
Phone 01865-888188
Email [email protected]
Website www.harcourt-uk.com/
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STORM: Skills-based Training on Risk Management
Violence Sexualviolence Antisocialandoffendingbehaviour
Self-harm/suicide
Self-neglect/vulnerability
•
Description STORMisasuicidepreventiontrainingpackageboughtaspartofanoverallsuicidepreventionstrategybyorganisationsorpartnershipsoforganisationsinstatutoryandvoluntarysectors.Itcanbedeliveredon-siteeitherinashortmodularformatoroveroneortwodays.Thepackagecoversassessment,crisismanagement,crisispreventionandproblem-solvingwhenworkingwithpotentiallysuicidalserviceusers.AChildren’s&YoungPerson’sversionisavailableaswellastheadultversion.Facilitatorsareprofessionals,non-professionalsorserviceuserswithrelevantexperiencewhohavebeentrainedtodeliverthepackageinacascademodel.
Depth In-depth.
Setting Designedforapplicationinanymentalcaresettingaswellasforsocialcareandcriminaljusticestaff.
Practitioners Suitableforallmentalhealthpractitioners.
Riskmanagement
Aspartofanoverallstrategy,themainemphasisisonriskmanagement.
Training See‘Description’above.
Cost Currently£1,500perfacilitatorbutcontactbelowforaquotation.
Manual Notapplicable
Evidence STORMhasbeengivenasanexampleofgoodpracticeinarecentreviewofprogressindeliveringontheNationalServiceFrameworkstandardrelatingtosuicide.
Origin UK
Formats Notapplicable
Contact GillLever-Green,STORMCo-ordinator,UniversityofManchester,RusholmeAcademicUnit,RusholmeHealthCentre,WalmerStreet,ManchesterM145NP
Phone 01612751869
Email [email protected]
Website www.medicine.manchester.ac.uk/storm/
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Thissectionprovidesabriefsummaryofthemainfactorsthathavebeenfoundtobeassociatedwithviolenceandsuicideintheresearchliterature.
Risk factors for violence
Demographic factors
• Male
• Youngage
• Sociallydisadvantagedneighbourhoods
• Lackofsocialsupport
• Employmentproblems
• Criminalpeergroup
Background history
• Childhoodmaltreatment
• Historyofviolence
• Firstviolentatyoungage
• Historyofchildhoodconductdisorder
• Historyofnon-violentcriminality
Clinical history
• Psychopathy
• Substanceabuse
• Personalitydisorder
• Schizophrenia
• Executivedysfunction
• Non-compliancewithtreatment
Appendix 2: Risk factors for violence and suicide
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Psychological and psychosocial factors
• Anger
• Impulsivity
• Suspiciousness
• Morbidjealousy
• Criminal/violentattitudes
• Commandhallucinations
• Lackofinsight
Current ‘context’
• Threatsofviolence
• Interpersonaldiscord/instability
• Availabilityofweapons
Ref:33,34,
Risk factors for suicide
Demographic factors
• Male
• Increasingage
• Lowsocioeconomicstatus
• Unmarried,separated,widowed
• Livingalone
• Unemployed
Background history
• Deliberateself-harm(especiallywithhighsuicideintent)
• Childhoodadversity(e.g.sexualabuse)
• Familyhistoryofsuicide
• Familyhistoryofmentalillness
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Clinical history
• Mentalillnessdiagnosis(e.g.depression,bipolardisorder,schizophrenia)
• Personalitydisorderdiagnosis(e.g.borderlinepersonalitydisorder)
• Physicalillness,especiallychronicconditionsand/orthoseassociatedwithpainandfunctionalimpairment(e.g.multiplesclerosis,malignancy,painsyndromes)
• Recentcontactwithpsychiatricservices
• Recentdischargefrompsychiatricin-patientfacility
Psychological and psychosocial factors
• Hopelessness
• Impulsiveness
• Lowself-esteem
• Lifeevent
• Relationshipinstability
• Lackofsocialsupport
Current ‘context’
• Suicidalideation
• Suicideplans
• Availabilityofmeans
• Lethalityofmeans
Ref:35,36
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TheNationalConfidentialInquiryintoSuicideandHomicidebyPeoplewithMentalIllness19hasdevelopedasetofrecommendationstoimprovepolicyandpracticeinmentalhealthcaresettings.These12pointsareintendedtobeusedasachecklistforlocalservicesandarethebasisofariskmanagementtoolkitwhichtheNationalInstituteforMentalHealthinEngland(NIMHE)iscurrentlymakingavailabletoservices.
The12pointsrecommend:
• stafftraininginthemanagementofrisk–bothsuicideandviolence–everythreeyears;
• allpatientswithseverementalillnessandahistoryofself-harmorviolencetoreceivethemostintensivelevelofcare;
• individualcareplanstospecifyactiontobetakenifpatientisnon-compliantorfailstoattend;
• promptaccesstoservicesforpeopleincrisisandfortheirfamilies;
• assertiveoutreachteamstopreventlossofcontactwithvulnerableandhigh-riskpatients;
• atypicalanti-psychoticmedicationtobeavailableforallpatientswithseverementalillnesswhoarenon-compliantwith‘typical’drugsbecauseofside-effects;
• strategyfordualdiagnosiscoveringtrainingonthemanagementofsubstancemisuse,jointworkingwithsubstancemisuseservices,andstaffwithspecificresponsibilitytodevelopthelocalservice;
• in-patientwardstoremoveorcoveralllikelyligaturepoints,includingallnon-collapsiblecurtainrails;
• follow-upwithinsevendaysofdischargefromhospitalforeveryonewithseverementalillnessorahistoryofself-harminthepreviousthreemonths;
• patientswithahistoryofself-harminthelastthreemonthstoreceivesuppliesofmedicationcoveringnomorethantwoweeks.;
Appendix 3: 12 Points to a safer service
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• localarrangementsforinformation-sharingwithcriminaljusticeagencies;and
• policyensuringpost-incident,multidisciplinarycasereviewandinformationtobegiventofamiliesofinvolvedpatients.
AfulleraccountoftheconclusionsthatsupporttheserecommendationsareavailableintheSafety Firstreport14:www.dh.gov.uk/assetRoot/04/05/82/43/04058243.pdf
56
Actuarial approach:Anapproachtoriskassessmentinvolvingtheuseofstatisticalmodels3toestimatethelikelihoodofariskeventsuchassuicideorharmtoothers.Actuarialassessments,though,dependonthepersonbeingassessedcomingfromthesamepopulationthatgeneratedthestatisticaldatausedtomaketheriskevaluation.Soaccuracyofassessmentsdependsonthesimilarityoftheindividualwiththispopulation.Riskfactorsmeasuredbyactuarialtoolsaregenerallystatic(unchangeable)–someoftheneweractuarialguidesincludedynamic(changeable)factorsalso.
Aggression:Adisposition,awillingnesstoinflictharm,regardlessofwhetherthisisbehaviourallyorverballyexpressedandregardlessofwhetherphysicalharmissustained.3
Assessment:Theprocessofgatheringinformationviapersonalinterviews,psychological/medicaltesting,reviewofcaserecordsandcontactwithcollateralinformantsforuseinmakingdecisions.30
High risk:Atermusedofaserviceuserwhopresentsariskofcommittinganactthatiseitherplannedorspontaneous,whichisverylikelytocauseseriousharm.Therearefew,ifany,protectivefactorstomitigateorreducethatrisk.Theserviceuserrequireslong-termriskmanagement,includingplannedsupervisionandclosemonitoring,and,whentheserviceuserhasthecapacitytorespond,intensiveandorganisedtreatment.30,37
Low risk:Atermusedofaserviceuserwhomayhavecaused,attemptedorthreatenedseriousharminthepastbutarepeatofsuchbehaviourisnotthoughtlikelybetweennowandthenextscheduledriskassessment.Theyarelikelytocooperatewellandcontributehelpfullytoriskmanagementplanningandtheymayrespondtotreatment.Inallprobablefuturescenariosinwhichriskmightbecomeanissue,asufficientnumberofprotectivefactors(e.g.ruleadherence,goodresponsetotreatment,trustingrelationshipswithstaff)tosupportongoingdesistancefromharmfulbehaviourcanbeidentified.30,37
Medium risk:Atermusedofaserviceuserwhoiscapableofcausingseriousharmbut,inthemostprobablefuturescenarios,therearesufficientprotectivefactorstomoderatethatrisk.Theserviceuserevidencesthecapacitytoengagewith,and
Appendix 4: Glossary
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occasionallytocontributehelpfullyto,plannedriskmanagementstrategiesandmayrespondtotreatment.Thisserviceusermaybecomehighriskintheabsenceoftheprotectivefactorsidentifiedinthisassessment.30,37
Protective factor:Anycircumstance,event,factororconsiderationwiththecapacitytopreventorreducetheseverityorlikelihoodofharmtoselforothers.30,37
Risk:Thenature,severity,imminence,frequency/durationandlikelihoodofharmtoselforothers.Ahazardthatistobeidentified,measuredandultimately,prevented.2
Risk factor:Aconditionorcharacteristicassumedtohavearelationshiptothepotentialtoharmanotherpersonorself.37
Risk formulation:Anexplanationofhowrisksinspecifiedareasariseinaparticularindividualgiventhepresenceandrelevanceofconditionsthatareassumedtoberiskfactorsforahazardousoutcomethatistobeprevented.Ariskformulationshouldaccountfortheroleofprotectivefactorsaswellasriskfactors.37
Risk management:Theactionstaken,onthebasisofariskassessment,thataredesignedtopreventorlimitundesirableoutcomes.Keyriskmanagementactivitiesaretreatment(e.g.psychologicalcare,medication),supervision(e.g.helpwithplanningdailyactivities,settingrestrictionsonalcoholuseorcontactwithunhelpfulothers,andsoon),monitoring(i.e.identifyingandlookingoutforearlywarningsignsofanincreaseinrisk,whichwouldtriggertreatmentorsupervisionactions),and,ifrelevant,victimsafetyplanning(e.g.helpingavictimofdomesticviolencetomakeherselfsafeinthefutureandknowbetterwhattodointheeventofperceivedthreat).37
Self-harm:Self-poisoningorself-injury,irrespectiveoftheapparentpurposeoftheact.21
Sexual violence:Actual,attemptedorthreatenedharmtoanotherpersonthatisdeliberateandnon-consentingandissexuallymotivated.3
Structured professional judgement:Anapproachtowardriskassessmentdevelopedoverthepastdecade.It involvesthepractitionermakingajudgementaboutriskonthebasisofcombininganassessmentofclearlydefinedfactorsderivedfromresearchwiththeuseoftheirclinicalexperienceandknowledgeoftheserviceuser.
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Violence:Actual,attemptedorthreatenedharmtoanotherpersonthatisdeliberateandnon-consenting.3
Vulnerability:Specificfactorsthatrelatetothelikelihoodofanindividualbeingvictimised,takenadvantageof,orexploitedbyothers.Vulnerableindividualsmaybesubjecttoverbalabuseorharassment,physicalorsexualabuseorintimidation,coercionintounwantedactsandbullying.Assessmentofvulnerabilitymayincludeconsiderationofmentalstate,physical/physiologicalconditions,psychologicalorsocialproblems,culturalorgenderissues.3
59
Theprinciplessectionofthisframeworkismadeupofconsensusstatementsbasedonconsultationwiththefollowinggroupsthroughgroupmeetings,groupinterviews,individualinterviewsandemailcontact:
• theNationalMentalHealthRiskManagementProgramme‘RiskAssessmentandManagementToolsandMethods’ExpertAdvisoryGroup(July2006–June2007)
• hospitalandcommunity-basedstaffworkingforMerseyCareNHSTrustandNorthEastWalesNHSTrustinadultmentalhealth,mediumsecurecareandhighsecurecare(August–October2006);
• serviceusersfromacrossEnglandaffiliatedtotheMentalHealthFoundationSurvivorResearchNetwork(March2007);
• carersaffiliatedtotheBathCarersGroup(March2007);and
• researchersandpractitionersfromIreland,theNetherlands,NorwayandTurkeyaffiliatedtotheEuropeanViolenceinPsychiatryResearchGroup(September2006).
Appendixwasdevelopedinthefollowingway.Themultiplerisktoolswereselected(1)followingconsultationwiththeExpertAdvisoryGrouponthebasis(2)thattheyhadevidenceofclinicalutility,reliabilityorvalidityfromatleastonepublishedstudyand(3)thattheyhadbeenimplementedinatleastoneUKmentalhealthtrust.
Thetoolsassessingrisktoothers(violence,antisocialandoffendingbehaviour)wereselectedbytheDepartmentofHealthtoreflectpolicyprioritiesandwereevaluatedwithreferencetoasystematicreviewonthistopic.Fulldetailsofthesearchstrategyareavailableintheprojectreporttogetherwithadetailedanalysisoftheevidencebase.38Insummary,theelectronicsearchterminFigure3wasappliedtoallmainhealthandcriminaljusticedatabases(includinggreyliterature)forpublicationsupto2006.Inaddition,41journalswerehand-searchedfrom1990to2003.Theresultingdatabaseofmorethan41,000citationswassearchedforempiricalstudiesofriskassessmentand662relevantstudieswereidentifiedevaluatingover200structuredriskassessmenttools.
Appendix 5: Methods used to develop this framework
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Figure 3: ‘Risk to others’ tools search term
(((Homicid*ORmurder*ORmanslaughter*ORinfanticid*ORparricid*ORassault*OR(bodilyAND(harmORassault))ORassail*ORbugger*ORsodom*ORmolest*ORpedophil*ORpaedophil*ORsadis*ORsadomasochis*ORsado-masochis*ORanger*ORcruel*ORrapist*OR(rape*ANDoffend*)ORphysicalabus*ORspouseabus*ORpartnerabus*ORsexualabus*)OR(((dangerous*AND(behavior*ORbehaviour*ORhistor*ORconduct*))orviolen*)AND(risk*ORpredict*ORanteced*ORassess*ORcause*ORreason*ORinterven*ORprevention*ORpreventing*ORcontrolling*ORmanage*ORtreatment*ORtreating*ORreduction*ORreducing*ORstop*ORmental*ORforensic*ORpsychiatric*ORoffend*ORAxis1ORAxis2ORcriminal*ORdetain*ORinsan*ORNGRIORretard*OR(learningdisab*ORlearning-disab*)ORacquit*))OR((childabus*ORelderabus*ORhostil*ORkilling*ORattack*ORaggress*)AND(mental*ORforensic*ORpsychiatric*ORoffend*ORaxis1ORaxis2ORcriminal*ORdetain*ORinsan*ORNGRIORretard*OR(learningdisab*ORlearning-disab*)ORacquit*ORdisorder*)))NOT(cancer*ORcancer[mh]ORtumo*ORtumour[mh]ORheart*ORheart[mh]))
Theself-harm and suicide toolswereselectedbyoneoftwomethods.
Thefirstmethodwastodrawonasystematicreview31fundedbytheAmericanNationalInstituteofMentalHealth(NIMH).Threeofthetoolsselectedwerethoseinthereviewwhichhadevidenceofpredictivevalidityfrommentalhealthsamples.EvidencerelatingtothesetoolsandanynewtoolspublishedsincecompletionoftheNIMHsearch(1998)wasthensoughtbysearchingadatabaseofsuicide-relatedliteratureconstructedforanotherproject.Toconstructthisdatabase,theelectronicsearchterminFigure4ahadbeenappliedtoawiderangeofsources(i.e.C2Spectr,CINAHL,Cochrane,CRIB,Dissertationabstracts,Econlit,Medline,NationalResearchRegister,Psychinfo,SocialSciencesAbstracts,andSocialSciencesIndex)andtheresultingdatabasecontainedmorethan23,000citations.Evidencerelatingtotoolsidentifiedinthesourcereview31wassoughtbyusingthenameofthetoolandthemainauthors.Thisevidencewasaddedtotheappraisalinthesourcereview.EvidencerelatingtonewtoolswassoughtusingtheterminFigure4b,andthreenewtoolsrelatingtoworking-ageadultsinsecondarycarewereidentifiedbutnoneofthesehadsufficientinformationavailable.
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Figure 4a: Suicide citations search term
suicid*ORselfharm*ORself-harm*OR(selfANDharm*)ORselfinjur*ORself-injur*OR(selfANDinjur*)ORselfpoison*ORself-poison*OR(selfANDpoison*)ORselfmutilat*ORself-mutilat*OR(selfANDmutilat*)ORselflacerat*ORself-lacerat*OR(selfANDlacerat*)ORselfcut*ORself-cut*OR(selfANDcut*)ORparasuicid*ORpara-suicid*OR((deliberat*Orintent*)ANDoverdos*)
Figure 4b: Suicide tools search term
riskANDassessmentAND(instrument*ORscale*ORmeasure*Ortool*)
Thesecondmethodwasthesameasthatforthemultiplerisktoolsabove,i.e.threeadditionaltoolswereselected(1)followingconsultationwiththeExpertAdvisoryGrouponthebasis(2)thattheyhadevidenceofclinicalutility,reliabilityorvalidityfromatleastonepublishedstudyand(3)thattheyhadbeenimplementedinatleastoneUKmentalhealthtrust.
Threetoolsspecifictoself-neglectwereinitiallyidentifiedthroughsystematicreviewbutweresubsequentlynotincludedduetocoverageofthisdimensionbythemultiplerisktools.
62
DrRichardWhittington UniversityofLiverpoolandMerseyCareNHSTrustDrWallyBarr UniversityofLiverpoolAndrewBrown MerseyCareNHSTrustDrMariaLeitner InfoTechUKResearchDrCarolineLogan MerseyCareNHSTrustandUniversityofLiverpoolDrRajanNathan MerseyCareNHSTrustandUniversityofLiverpool
TheprojectteamgratefullyacknowledgetheadviceprovidedbymembersoftheNationalMentalHealthRiskManagementProgramme‘RiskAssessmentandManagementToolsandMethods’ExpertAdvisoryGroup:
JanetDavies(Chair) ProgrammeLead,NationalMentalHealthRiskManagementProgramme
DawnFleming ProgrammeSupportManager,NationalMentalHealthRiskManagementProgramme
ProfessorSueBailey RoyalCollegeofPsychiatristsDrRichardBenson UniversityofGlamorganDrChristopherBuckingham AstonUniversityMadelineBucknell RAMASFoundationChrisBurrows MetropolitanPoliceServiceBurtBurton ManchesterMentalHealthandSocialCareTrustPhilChick WelshAssemblyDrPaulClifford FACERecordingandManagementSystemsDrMaireadDolan Bolton,SalfordandTraffordNHSTrustand
UniversityofManchesterDrMikeDoyle Bolton,SalfordandTraffordNHSTrustand
UniversityofManchesterDrLouiseFountain AvonandWiltshireMentalHealthPartnershipNHS
TrustProfessorLindaGask UniversityofManchesterCarolineGodleman DepartmentofHealthHughGriffiths DepartmentofHealthProfessorChrisHawley HertfordshirePartnershipNHSTrustandUniversity
ofHertfordshireKateHunt SussexPartnershipNHSTrustMikeJones NHSConnectingforHealthGillLever-Green UniversityofManchesterGavinMackintosh NHSConnectingforHealthProfessorTonyMaden WestLondonMentalHealthNHSTrustandImperial
CollegeLondon
Appendix 6: Acknowledgements
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ChrisMerchant NationalWorkforceProgrammeSteveMorgan PracticeBasedEvidenceDrMargaretO’Rourke RAMASFoundationandUniversityCollegeCorkInspectorMikePartridge MetropolitanPoliceServiceDrPaulRogers UniversityofGlamorganDrFrankRohricht QueenMaryUniversityofLondon,andEastLondon
andTheCityUniversityMentalHealthNHSTrustProfessorRobertSnowden CardiffUniversityDrBenThomas NationalPatientSafetyAgencyProfessorKathrynTyson DepartmentofHealthSueWaterhouse SussexPartnershipNHSTrust
Theprojectteamalsogratefullyacknowledgetheadviceprovidedbythefollowingadditionalexpertsconsultedinthedevelopmentoftheframework:
AlisonBaker MerseyCareNHSTrustDrSteveBarlow Newcastle,NorthTynesideandNorthumberland
MentalHealthNHSTrustDrVenkatBoyapati MerseyCareNHSTrustProfessorHulyaBilgin UniversityofIstanbul,TurkeyGillianCarlyle NorthEastWalesNHSTrustJonCarey Tees,EskandWearValleysNHSTrustBobCooper MerseyCareNHSTrustEmmaDavis ChooseLife,ScotlandDrMojcaDernovsek UniversityHospitalLjubljana,SloveniaPeterDisley MerseyCareNHSTrustAlisonDrage TrowbridgeRethinkCarers’GroupMichaelDrage TrowbridgeRethinkCarers’GroupLouDuhig TrowbridgeRethinkCarers’GroupAlisonFaulkner IndependentServiceUserConsultantFransFluttert UniversityofUtrecht,NetherlandsDrJulianFuller DevonPartnershipNHSTrustDrGillHolt MerseyCareNHSTrustSusanneGibbons CatholicUniversityofAmericaDrHelenGilburt MentalHealthFoundationSurvivorResearch
NetworkAudreyGachen MentalHealthFoundationSurvivorResearch
Network/MindinKingstonThomasGoodwin MerseyCareNHSTrustDorothyGould MentalHealthFoundationSurvivorResearch
NetworkSueImlack MentalHealthFoundationSurvivorResearch
NetworkDrGerardJansen UniversityofGroningen,NetherlandsDesJohnson MerseyCareNHSTrustJoeJohnson MerseyCareNHSTrust
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DebbieLand NorthEastWalesNHSTrustBrianLangshaw 5BoroughsPartnershipNHSTrustProfessorWilliamLauder UniversityofDundeeChrisLawton NorthEastWalesNHSTrustDrPeterLepping UniversityofWalesandNorthEastWalesNHSTrustSallyLuxton TrowbridgeRethinkCarers’GroupNeilMcBride MerseyCareNHSTrustProfessorJamesMcGuire UniversityofLiverpoolandMerseyCareNHSTrustKevinMcKenna HealthServiceExecutive,IrelandDavidMort 5BoroughsPartnershipNHSTrustProfessorHenkNijman RadboudUniversityNijmegen,NetherlandsDrStephenNoblett MerseyCareNHSTrustGeirOlsen HaukelandUniversityHospital,NorwayJulieOwen MerseyCareNHSTrustDrIanRogerson CheshireandWirralPartnershipNHSTrustSteveRose MerseyCareNHSTrustRolandvandeSande UniversityofProfessionalEducationUtrecht,
NetherlandsRuthSayers MentalHealthFoundationSurvivorResearch
NetworkKaySheldon MentalHealthFoundationSurvivorResearch
NetworkProfessorJohnSnowden UniversityofSydney,AustraliaDrBillStein GlasgowCaledonianUniversityAngelaSweeney MentalHealthFoundationSurvivorResearch
NetworkDrEdSilva MerseyCareNHSTrustGinaSmith AvonandWiltshireMentalHealthPartnershipNHS
TrustDrIndiraVinjamuri MerseyCareNHSTrust
RiskManagementAuthority,Scotland
65
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