Self-Harm and Violence

Towards Best Practice in Managing Risk in Mental Health Services

Richard Whittington, Caroline Logan, Richard Whittington, Caroline Logan

• Publisher: Wiley
• Year: 2011
• Print ISBN:
  9780470746066
  9780470746073
• eBook ISBN:
  9781119996224
• Edition: 1
• Topic: Psicologia
• Subtopic: Psicologia clinica

Self-Harm and Violence: Towards Best Practice in Managing Risk in Mental Health Services presents the first exploration of the most effective clinical practice techniques relating to the management of risk in mental health care settings.

• Based on the Department of Health's Best Practice in Managing Risk guidance document, which was developed over a 12-month period in consultation with a national expert advisory group
• Features contributions from many members of the group that drew up the Best Practice document – all leading theoreticians and practitioners in their particular fields – and embeds the principles laid out in the guidelines in real world practice
• Reveals how contemporary risk management is a multidisciplinary and collaborative enterprise in which practitioners from different professions need to engage with each other in order to achieve success

1

Introduction

Richard Whittington and Caroline Logan

The idea of ‘risk’ has begun to prevail in many areas of life over the past two decades (Gardner, 2009). Mental health services in particular find their activities increasingly dominated by the view that risks such as violence and self-harm can be calculated, predicted and managed. Service users, in turn, increasingly find their personal experiences of distress to be framed in terms of the risk they may present to themselves and to society as a whole. Such an emphasis on risk could have benefits. For instance, by encouraging more comprehensive treatment plans that take into account undesirable as well as desirable outcomes, service users can be liberated from unnecessary restrictions at an earlier stage in their recovery. On the other hand, and more negatively, the emphasis on risk can be seen as just another phase in the long history of the stigmatization routinely faced by people with mental health problems based on an exaggerated, largely false, sense of their dangerousness; fears about risk then limit rather than energize progress. Ultimately, however, the discourse of risk is here to stay in mental health services and the challenge for practitioners is to try to use it creatively and fairly – and safely – in their therapeutic work. This book is an attempt to help with that process by examining the personal experience of service users, carers and staff, the research evidence and the practice dilemmas that arise frequently in relation to risk decision-making in mental health services. By looking at these issues from several different perspectives, we hope to move forward the debate about what exactly is meant by risk in this context and, furthermore, what are the best ways of ‘doing’ risk management in mental health services when working with the problems of self-harm and violence.

Managing such risks as these in mental health services is a highly charged topic and ideas about the right way forward are hotly contested. There are many and varied debates about what constitutes risk and how the right balance should be struck between risk management and treatment. There is also the question of power between service users and practitioners when a particular decision needs to be made involving users’ liberty or the use of coercion in care. There are also understandable anxieties about the reality of engaging service users in their own risk self-management. Working and living with risk is, almost by definition, stressful. Being responsible for decisions about risk can also be demanding and often troubling for both practitioners and service users and their carers. The potential for self-harm or violence is only one small part of the full range of a person’s potential needs and problems, but they are problems that tend to dominate the picture because they can generate far more anxiety and concern than any other aspect of care. At the same time, people with mental health problems are as entitled as anybody else to high quality services with an underlying philosophy that emphasizes a collaborative approach in all decisions about care and treatment. Getting the balance right in this area is exceedingly challenging, but at the same time extremely important.

This book has grown from the work of an expert panel convened by the English Department of Health in 2006 to set out the key principles that should underpin risk management in mental health services. Self-neglect and personal vulnerability were included as relevant risks alongside the ‘headline’ risks of self-harm and violence. The panel represented a wide range of views, including those of service users, carers, professional organizations, academics and the police. Together, they were asked to devise a ‘best practice’ guideline for staff faced with the task of managing these various risks in mental health services. There had been growing attempts within government to systematize and improve approaches to risk in mental health services in this way in the early years of the new millennium and the proposed ‘best practice’ guidance was part of this overall initiative. Other efforts included preparation for the revised 2008 Mental Health Act, reform of the 20-year-old Care Programme Approach, and dissemination of the Seven Steps to Patient Safety guide (National Patient Safety Agency, 2008). The urgency of the problem was emphasized by two violent incidents in London in 2004 where people with very recent service contact acted violently with fatal consequences. In one of these incidents, a man with a diagnosis of paranoid schizophrenia discharged himself from the hospital where he had been resident for 18 months following a stabbing incident. The next day, he attacked and killed a man cycling through a London park. In the second incident, a mother killed her child shortly after being visited at home by her health visitor. These were both tragic, high-profile cases where something had clearly gone wrong. Their occurrence indicated a systems failure in that both mental health services and other agencies had failed to detect the risk of imminent violence. It seemed clear that some practitioners working in mental health services were still not properly equipped to assess and manage the risky behaviours they encountered and that the time was right for a statement of basic principles and some guidance on tools that could support effective assessment and decision-making in this area.

Inevitably, there was much debate in preparing the Best Practice document. There was, for instance, an awareness of the potential over-use of the concept of risk. There was passionate debate already around the Mental Health Act and changes to the scope for compulsory treatment. Risk was seen as part of good quality care rather than as something separate or specialized. But at some point in formulating guidance, a consensus must be reached and clear ideas put forward to those who have to make the decisions. Therefore, the process of developing the guidance required, first, a systematic review of the evidence in the various risk domains (violence, self-harm, etc.) and the generation of an expert consensus view about the principles of clinical risk assessment and management practice. Then, a systematic (and independent) examination of a range of risk assessment tools was prepared, including information about their technical performance, clinical efficacy and effectiveness, cost and utility. Eventually, a collective view was achieved and a range of recommendations were made, including a set of 16 best practice principles. These principles are set out in full elsewhere (see Chapter 8, Box 1), but they can be encapsulated in six core areas (see Leitner and Barr, Chapter 4):

• clinical decisions should be based on established research evidence;
• clinicians should proactively engage with clients as partners in care;
• risk management should be flexible, dynamic and responsive;
• careful forward planning should be integral to the clinical process;
• care should be multidisciplinary but well coordinated; and
• structural, procedural and organizational factors should be addressed in addition to individual (client-specific) factors.

In sum, the guidance – entitled Best Practice in Managing Risk – was designed to improve effectiveness in mental health care, especially in relation to clinical risk, and to be an instrument for quality assurance for practitioners, the services they work for and the service users and carers with whom they work. Nothing radically new was being put forward here – the basic tenets of good mental health practice were being crystallized and restated in the new context of risk management as they seemed to have been lost in some settings over time. Since production of the guideline, the basic vision of mental health services has been revisited again in the New Horizons strategy (Department of Health, 2009) and many of the messages remain the same around issues of, for instance, personal control in care and recovery through involvement in developing personal care plans.

Therefore, consensus is vital in establishing policies and providing formal guidance to staff on what constitutes best practice. However, improving practice for the future also relies on debate and on contesting ideas about what works and what is desirable or acceptable. This is where this book moves on from the work of the guidance. Here, especially in the first three sections of this volume, there is scope for competing voices. Each of these voices has space within the book to develop their argument for consideration by the reader. It is crucial, for instance, to get the balance right between care and risk management. Safety is, of course, central to effective care, but most clinicians from every discipline are motivated by a desire to help people achieve wellbeing and recovery, rather than to act purely as a risk management agent whose relations with the service user are framed entirely in terms of risk. Many of the views here are probably incompatible with each other, but we believe the creative tension between them contributes to new thinking on these important topics. In the final section, the book builds on the original project to develop 16 principles of best practice in managing risk. Such principles are meaningless unless they can be translated into better practice in real settings, and the final section considers the specific challenges of implementation. Overall, the book aims to take the next step after developing the idea of best practice in risk management by contextualizing the principles contained within the original guidance and testing their application to real-world settings.

Two key themes emerging from the chapters that follow are particularly worth highlighting. First, several contributors are concerned with the issue of positive risk management; how can practitioners retain a sense of optimism when working with service users and avoid the temptation to take as few risks as possible in the hope of avoiding personal and professional criticism? The stakes are always high when working with clients who are violent or who self-harm – very occasionally things can go seriously wrong and this can have major consequences for everyone involved, including the practitioners who took the key decisions. Imagining these painful consequences if things go wrong is an inevitable part of the process of risk decision-making and practitioners deserve maximum support when deciding to go beyond the risk-averse mindset of ‘safety at all costs’. Several of the chapters that follow recognize this dilemma and the consequences it can have for the ongoing therapeutic relationship. However, they try to explore some ways in which positive approaches to working with risk can be justified, developed and sustained.

Secondly, there is much discussion here about the continuing struggle to develop a philosophy of care and risk management with a real commitment to collaboration at its core. For centuries, the experience of receiving mental health care has been one in which the recipients of the service feel estranged from the system and the passive target of allegedly therapeutic interventions – an abusive feeling at worst. More recently, the notions of collaboration and shared decision-making have become popular in the rhetoric of mental health but, to date, it has been little more than just rhetoric – many service users still report feeling uninvolved and unengaged, their fears and preferences ignored or patronized. Perhaps inevitably, this can lead to a passive and even reluctant compliance with risk management plans and, in the worst case scenario, a dangerous disengagement from services and potentially increased risk leading to more imposed risk management and even less talk of collaboration. Consequently, advocates of collaborative care can be accused of naivety when some service users are seen to be beyond the pale in terms of partnership and engagement in realistic decision-making. It is clear that we still have some way to go to change the mindset of many mental health staff to one in which real collaboration is the starting point for developing risk management plans rather than an add-on or token gesture. However, while it is realistic for practitioners to question the potential for collaboration in some situations, they have a duty to ask themselves if their reluctance to work with other service users in decision-making is truly because of that person’s incapacity or if, in fact, it may be more to do with the practitioner’s worldview. Are they, for instance, becoming cynical about the scope for change and meaningful clinical engagement, perhaps due to excessive workload or poor supervision? How much of this reluctance to work collaboratively is really to do with the service user?

Elsewhere, one of us (Logan, ) has highlighted the major challenges faced by mental health services working with people with a personality disorder, and many of these challenges can also be seen when working with the linked problems of self-harm and violence. For instance, as mentioned above, sometimes practitioners lose their capacity for therapeutic optimism and stop believing that a particular service user can change in a positive direction. Similarly, the public and the government can expect too much from services in terms of their capacity to manage risk effectively and at all times, perhaps because these services have in the past promised to do so thus inflating expectations to an unrealistic level and dooming themselves to failure. Inadequate resources will always be an element of this problem, especially in the economic future we are currently facing. In both these areas of practice, there is the real danger of clinging to risk assessment tools based on an ill-founded belief in their seemingly scientific qualities, credibility and simplicity – that the tool will make the decision for the practitioner rather than aid what is ultimately his or her decision-making responsibility. Finally, as with the management of all complex mental health problems, where diverse agencies are responsible for various aspects of care and treatment, there is the scope for poor communication, unclear relationships and risky people disappearing in the gaps between agency boundaries. These challenges are not going to disappear any time soon. However, it was these problems of pessimism and unrealistic thinking, over-reliance on tools, inconsistent decision-making and poor communication that drove the development of what became the Best Practice guidance and what has since become this book.

Many of the contributors to the book participated in the debates surrounding the development of the Best Practice document or are now leading on the implementation into practice of the principles set out in the document. Together, they have a wide range of experience in thinking about the notion of risk in this area, conducting risk management in real-world mental health settings, living with a label of risk and making everyday practice reflect best practice in the full range of mental health professions. They combine theoretical, research and personal knowledge with a wealth of practical skills in care and management. Further, they emphasize the collaborative and recovery-focused nature of modern risk management – working with the service user, building on strengths – but trying at the same time to remain aware throughout of the realities of mental health care.

In the forthcoming pages, there is much discussion about the evolving evidence base, for violence and self-harm as well as clinical risk assessment and management, and how this can be incorporated into designing and delivering services in ways that can make a real difference to their efficacy and to the experience of service users. Some chapters explicitly deal with the relevant evidence base, most acknowledging appropriately that there are still worrying gaps in what we know. However, while the ‘science’ of structured risk assessment tools and specific interventions (particularly cognitive–behavioural therapy and pharmacological interventions) is quite advanced and sophisticated, it does not capture the service user experience. Much of this experience is mediated via the dynamic relationship with the practitioner and the subtle aspects of this relationship, which can be crucial in underpinning an effective therapeutic alliance, are still poorly understood and very difficult to study using approaches valued in the traditional research methods hierarchy. Consequently, most of the contributors draw on the evidence base available to them in relation to their topic, but also draw on sound clinical and real-life experience to fill the gaps.

The book is structured into four sections. The four themes of personal experience, research evidence, practice and implementation run through most of the chapters, but are prioritized in different ways in each section. We have tried to move from the direct experience of service users and carers, through some of the relevant research evidence, to explore some key aspects of clinical practice. The final section then looks at ways in which a variety of trusts have attempted to implement the principles of best practice in this area.

In the first section, ‘Experience’, Kay Sheldon (Chapter 2) and Sally Luxton (Chapter 3) write about their personal experiences as a service user and a carer, respectively, involved in the process of risk management. Both acknowledge that there is good work going on, but their personal experience on the receiving end indicates that we are still a very long way from achieving best practice (i.e., collaborative care) in this area. Hence, the title of this book, which emphasizes movement towards, rather than arrival at, best practice in current services.

In the second section, ‘Evidence’, there is an attempt to examine and, where possible, to summarize research evidence as it relates to the problems with which we are concerned. In Chapter 4, Maria Leitner and Wally Barr use a systematic review approach to tackle the voluminous literature from around the world on the management of self-harm. In Chapter 5 Richard Whittington, James McGuire, Tilman Steinert and Beverley Quinn provide an overview of key points from the even more vast literature relating to violence risk management. Then, in Chapter 6, Kirsten Windfuhr and Nicola Swinson complement these two reviews by drawing conclusions from the UK National Confidential Inquiry on Suicide and Homicide, which underpins much policy in this area in England and Wales. Finally, in this section, and building on the experiences outlined in Chapter 2, Helen Gilburt (Chapter 7) examines the emerging evidence base relating to service user involvement in risk management decision-making.

Both personal experience and research evidence should provide the raw material for improving practice and moving it towards best practice. Therefore, the third section is concerned explicitly with ‘Practice’ and considers various aspects from a number of angles. The first two chapters are pitched at the national policy level. In Chapter 8, Caroline Logan, Norbert Nedopil and Thomas Wolf look at the growing desire around the world to articulate the principles of best practice and the consistency that is emerging across different countries. Ben Thomas (Chapter 9) works from a national policy perspective to emphasize the role that organizations, as well as individual practitioners, play in embedding best practice into their everyday endeavours. Then, the other three chapters in this section take a detailed look at what might be called the mechanics of practice. Caroline Logan, Rajan Nathan and Andrew Brown (Chapter 10) discuss the core skill, often implicit rather than explicit, of formulation and argue for its centrality in the bridge between risk assessment and risk management. In Chapter 11, Paul Clifford examines the idea, often celebrated but very difficult to implement, of positive risk management, the capacity for both service user and clinician to be cautiously creative in working with risk. Richard Whitehead, Ged Carney and Beth Greenhill (Chapter 12) then conclude this section by discussing an example of implementing positive risk management with one particular client group, namely, people with learning difficulties.

The final section is made up of a collection of case studies in which clinicians describe their efforts to move towards best practice in managing risk in four English mental health t...

Table of contents

• Cover
• Title Page
• Copyright
• Contributors
• Foreword
• Preface
• Chapter 1: Introduction
• Part I: Experience
• Part II: Evidence
• Part III: Practice
• Part IV: Implementation
• Glossary
• Index