Assessing Risk

A Relational Approach

Stephen Blumenthal, Heather Wood, Andrew Williams

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9781351847803
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Assessing Risk: A Relational Approach offers the practitioner a novel framework for understanding the complex and subtle issues involved in assessing and managing risks related to violence and sexual offending. The authors draw on their considerable experience working with high risk individuals in assessment and treatment. They have for many years consulted to practitioners in forensic mental health services and the criminal justice system and taught renowned courses at the Tavistock and Portman NHS Foundation Trust.

This book outlines a comprehensive model of risk which draws on mainstream empirical research, threat assessment, developmental psychopathology, attachment theory, and a relational model derived from psychoanalysis. The framework incorporates intrapersonal and interpersonal dimensions and is designed to enhance the reader's capacity to make a thorough risk formulation. The approach highlights the significance of childhood development in understanding violent and sexually violent acts, and the complicated interpersonal processes involved in managing individuals who have a propensity to violent enactment. These dynamic processes between people impact on risk and risk perception, and can distort judgement if not recognised and understood.

Assessing Risk will be of practical use in enhancing the skills of professionals to assess and manage risk in a comprehensive and effective way, and will appeal to all those mental health and criminal justice practitioners working with risky individuals.

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Chapter 1

Introduction

On a day in 1819, the whaling boat Essex was struck by a whale, thousands of miles off the coast of South America. The 20 sailors on board clambered into life boats as their ship sank beneath the waves. They were as far from land as they could possibly be, with meagre supplies and only the most basic navigational equipment. The story was to inspire aspects of Herman Melville’s Moby Dick and is also used by the author Karen Thompson Walker (2013) to illustrate the way in which the generation of fear in the imagination provides the main impetus for the decisions we make. She describes how the nearest land was to be found at the Marquesa Islands, but the sailors had heard fearful tales about the islands being inhabited by cannibals. Another option was Hawaii, but the captain was concerned about storms which would sink them. The last option was the longest. It involved sailing 1,500 miles south in the hope of catching the winds which would take them to safety on the coast of South America.

The sailors faced the fear of being devoured by cannibals, swept away by a storm, or starving to death, and the fear they attended to most, writes Thompson Walker, would determine their fate. Their choice was both informative and tragic. The fear of cannibals was greatest, and so they decided to relinquish the closest option for the longest and most arduous journey with scant provisions which they knew would not last. Half of the men perished by the time they were picked up two months later, and had ironically resorted to cannibalism themselves. The men were driven by the most vivid and powerfully graphic fear. Had they been more systematic in their judgement and less at the mercy of their anxiety, they would almost certainly have survived. It turned out that there were no cannibals on the Marquesa Islands after all.

When we make a determination of risk, we do not have a retrospectoscope; that is, we do not have the benefit of hindsight at the time of making our assessment. We are not looking back, we are looking forward into an unknown future, and because of a shortage of facts there is plenty of room for imagination. Where there is scope for imagination, there is a fertile space for our fears to grow. Consequently, fear can be one of the most important influences on our assessments of risk and the way in which we manage high risk individuals. Practitioners in mental health services, social services and the criminal justice system are given the unenviable job of predicting what are essentially ‘unpredictable’ events. Moreover, we are expected to do so with an inadequate framework to undertake this momentous task. The potentially dangerous actions of those we assess and manage, which can cause us so much anxiety, are usually rare events and in the vast majority of cases our worries are not realised. But anxiety will always be central to the process of identifying, assessing and managing risk.

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A ‘good’ service is one which creates a sense of security in service users, practitioners and the public at large; it conveys a sense of confidence in its capacity to contain and minimise risks. This provides the safe setting in which high quality work can take place in reducing risk and improving quality of life for those we manage and treat. The framework we present in this book is a means of making sense of the complexity of human behaviour. We argue that recognising anxiety – the anxieties of service users, as well as the anxieties generated in the staff working with them – strengthens and improves our risk assessment and management. We can work more effectively if we recognise anxiety, than if we pretend it is not there and that we are completely in control. Whilst infallible risk prediction is an impossibility, we can do more to assess, contain and manage risk thoughtfully.

In this book we refer to acts which potentially violate the self or another human being by acting on the body in violent or sexually aggressive ways as ‘crossing the body barrier’. Violation in the form of violence and sexual abuse is ubiquitous. Millenniums of civilisation have not dented the tendency in us to infringe our neighbours’ rights through the transgression of boundaries. Psychoanalysis holds that there exists a conflict, a perennial tension, between the tendency towards the reining in of our impulses through the establishment of civil structures, and our underlying animalistic instincts towards aggression and sexuality. When there is a corruption or distortion of the human character, typically through negative developmental experiences, and in the context of genetic or neurobiological predisposition to poor impulse control or heightened aggression, such instincts can find dangerous expression in destructive behaviours towards our fellow humans. The way in which the most risky and the most vulnerable in our community are managed provides a yardstick for the level of civilisation of our society.

Practitioners involved in the care of dangerous people are given the authority to provide judgements about risk. What are the elements which draw us to conclude that a particular individual represents a risk either to themselves or to others? We begin the book by considering the flaws in human decision-making which make decisions about risk so unreliable, and thereby consider how these flaws may be addressed to orient the practitioner towards better decision-making. In an effort to counter the tendency for mental health and criminal justice professionals to make more or less random, subjective judgements about risk, and to standardise risk assessment procedures, risk decision-making has adopted the actuarial approach, which makes use of large scale research studies to identify various factors and their relation to the particular outcome variable, be that sexual or violent recidivism, self-harm or suicide. In the following chapter, we describe some of the limitations of an approach solely reliant on such actuarial measures and, conversely, the risks of an exclusive focus on subjective or ‘clinical’ intuition. Despite the widespread availability of these instruments, and substantial evidence that they outperform subjective clinical judgement, professionals who have the task of risk decision-making tend to avoid their use in favour of their own subjective opinion. Fortunately, the field of risk is moving in the direction of structured clinical judgement which attempts to integrate actuarial principles with sound clinical judgement.

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The majority of actions of violence we are called upon to assess and manage are impulsive and reactive. Threat assessment is a related field, which is concerned with targeted, planned acts of violence. People committing such behaviours may not necessarily have a history of violence, and consequently present a particular challenge to the assessor (Meloy et al., 2012). Although our principal concern here is with impulsive or reactive acts of violence or harm, insights from the field of threat assessment will be included where relevant. The model we propose here is a variant of structured clinical judgement (such as the HCR-20) and is designed to enhance this approach. We go beyond what we believe is an inherent weakness in this approach – namely the lack of an encompassing theoretical and practical framework to underpin the procedure and thereby to identify the meaning and the motives for the act. We do so by offering a more comprehensive model of risk than is often used, integrating mainstream empirical research, threat assessment, a theory of developmental psychopathology, attachment theory and a relational model derived from psychoanalysis.

We believe that part of the problem of ‘objective’, actuarial risk assessment is that it does not take account of context and applies a rational model to risk, which assumes that both the service user concerned and the individuals working with them will be inclined to act rationally or predictably. Risk is not an objective enterprise. We have stronger feelings about certain risks compared to others. Whilst death in a car accident is much more likely than being a victim of homicide, there is legitimately more fear of the latter and stronger feelings associated with it. A preventable homicide correctly absorbs more of our attention. What makes this task difficult is that our minds are not objective, but clouded by ordinary human subjectivity. How do we manage this? In this book, we aim to describe a method of taking charge of risk, via knowledge of human development, both conscious and unconscious processes, and a psychodynamic understanding of the professional relationship. Having a coherent model of understanding human relationships and risk allows us more mastery of these processes, and enables us to choose our route to safety, rather than being at sea in a storm.

A central principle we adopt is that the actions we habitually engage in have meaning. They are representative of character, and character itself is shaped by the adaptations we make in early childhood. Throughout this book, we provide plenty of illustrative examples, and we begin here with the case of Andy, the boy who raised the alarm no one heard.¹

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The boy who raised the alarm no one heard

Andy was 25 and was doing well in his career in the catering industry. He achieved a management position in which he had significant responsibility. Whilst working on a particularly big project providing the catering for a major national event in a large stadium, he planted a hoax bomb threat which he then ‘discovered’ saying, ‘There is a bomb in this stadium which will explode unless our demands are met’. He reported this to the director of operations, who, intuiting something suspicious on the basis of Andy’s evident excitement, asked him to write a statement from which he discerned that the handwriting on the bomb threat was identical to Andy’s. Andy’s presentation made his alarming and irrational behaviour perplexing. He was a good looking, intelligent young man who seemed to have the world at his feet. He said that he had ‘always kept things inside’ and found it hard to understand why he had acted in such a dangerous and self-destructive manner, which resulted in his losing his job, acquiring unwanted infamy through the national press, a criminal record, and so on. The closest he could get to an understanding was that it was to do with ‘unresolved grief issues’ from childhood which he had ‘kept all in’.

In his account of childhood, Andy reported that ‘everything seemed fine’ until his parents’ divorce at age 10 when his father left the family home. He remained living with his mother and recalled night terrors when he would wake up screaming for his father. His mother became severely emotionally unstable from this point, engaging in self-harming behaviour and being frequently admitted to hospital. She recorded details in a diary which he took a morbid interest in reading. He and his sister moved away after she deliberately burned down their home. He distanced himself from her, but his father would insist that he went to stay with her every second weekend because his father ‘needed the space’, and, alongside a sense of gratitude towards his father, feelings of resentment grew towards him as these weekends were a hateful, claustrophobic exposure to her serious disturbance. In a replica event to the index offence at age 12, Andy set a fire at school, raised the alarm by telling the teacher, and then admitted to causing it, which led to his suspension. He said that he wanted recognition for ‘saving the day’. This occurred shortly after his mother set the house on fire, and the weekend prior, he discovered his mother unconscious following an overdose and had to call an ambulance. He was furious with his father for exposing him to this unmanageable trauma. He experienced overwhelming feelings of guilt when she committed suicide when he was 14 because he sought to distance himself from her.

Andy said that the index offence was unplanned and impulsive. He recalled thinking that he would look ‘really good’ and that people would think that he ‘saved the day’. He fantasised about telling the director, and dreamed of his praise for his heroic actions. It emerged that in the briefing prior to the event, he experienced the director as being condescending in his criticism of the younger staff in the organisation, because of their reputation for not working hard enough and for being frivolous. The director questioned their capacity to do their jobs, and at a conscious level, he wanted to show that he could handle a high pressure situation and do his job well.

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Andy’s actions may have been impulsive and irrational, but they are not meaningless. Freud held that all aspects of the mind, conscious and unconscious, seek expression in the outside world. For the contents of the mind which do not cause us conflict this is straightforward. But thoughts, feelings and impulses which cause us conflict often find a more circuitous route to representation – something ‘leaks out’ from the unconscious in ways that we may be unaware of, often in actions rather than words. Andy was exposed to his mother’s severe disturbance, but no one heard him. He tried to raise the alarm by setting a fire and felt angry with authority, represented by his father, who would not listen. We may hypothesise that the director’s perceived condescension caused him to feel like the hated inferior and triggered feelings of resentment. He sought to be the hero, to ‘save the day’, and obtain praise from the father/director figure, whilst simultaneously expressing his fury about the perceived injustice. The offence signified the re-enactment of an earlier scene in his life which remained unresolved, bottled up, awaiting a trigger to re-emerge. He suppressed it because the feelings threatened to overwhelm him. But this suppression was simply a harbinger for a more dangerous repetition when he carried out a series of apparently bizarre actions.

Destructive actions are thus the tip of the iceberg, so to speak. They act as a compromise between expressing internal conflict and hiding it at the same time, what Freud (1953 [1900]) called a ‘compromise formation’. It is crucial in assessing and managing risk to understand that the enactment, in the form of the dangerous behaviour, has a dual role. It both expresses underlying conflict, but in such a way as to prevent the actor from knowing too much about that conflict. The idiom of person at risk is action, and this makes it important to identify where in the mind of the actor the violence resides. When a person’s mode of expression is action, it can be hard to know where that action originates from in the mind. Often when someone is asked why they have done something they will say, ‘I don’t know’, or will make up a plausible explanation. One purpose of the action may be to ‘get rid of’ any mental conflict, to get it out of the person’s system so that it does not have to be thought about. Yet it is not ‘got rid of’ because it has an enormous impact on others, who may have very strong feelings about what has been enacted, whether it is violence, sexual abuse or self-harm. It is not one-way traffic: individuals who act in destructive and risky ways stir up powerful feelings in us. We are pulled into an interaction, whether we like it or not.

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We describe key psychoanalytic concepts useful in risk assessment, including transference and the impact of working with challenging individuals, and the subject of attachment and development and its relation to violence and sexual offending. We stress the importance of our emotional responses to those in our care. Thinking in these terms can help us consider how our response to individuals who pose a risk often reflects something about their difficulties, and examining our own responses to them can be a useful source of information. The responses people suffering with interpersonal difficulties evoke can also shape the kind of institutions they are managed in, as well as societal attitudes towards them. We may find ourselves precipitously drawn into actions, such as being either excessively punitive, or turning a blind eye.

Risk assessment and risk management are primarily based upon sound formulation. Our formulation of an individual’s difficulties and risks is like a mini-theory and represents the best understanding we have at that time of the person we are working with, not just their behaviour. In this book we describe a number of issues that may contribute to this formulation or mini-theory. It requires a sound grounding in the base rates for the particular behaviour in question, using the actuarial method. We then consider the person’s history of attachments and how this history is manifest in the present, both in the service user’s interaction with other people and their interaction with the practitioner. The judgement we make regarding risk is derived from the formulation.

The sailors on the Essex were unable to think rationally about what posed the greatest risk and what would be their best option to maximise survival. The capacity to think clearly was lost, or at least seriously impaired. The system in which health, social services and criminal justice practitioners have to function has some parallels with being lost at sea. The threat of an enquiry if things go wrong can contribute to a culture of blame, in which one or a handful of practitioners are singled out. It is one of the challenges for a service to promote a culture of curiosity, a ‘culture of inquiry’ as opposed to a fear of ‘the enquiry’. Just as a persecuted state of mind arising from fear can lead to dangerous actions, it can also undermine our capacity to think and lead us to dangerous risk decision-making. The structure of a framework provides a ‘cradle of thought’ (Hobson, 2002), which lessens anxiety and allows us to see reality and make informed decisions about risk.

We do not have and never will have perfect systems for assessing risk. Individuals’ actions are subject to conscious choice, chance encounters, subtle reactions to external circumstances, and transient factors like intoxication or hunger. We are not claiming to offer an infallible approach to risk. Our aim is to show how some factors which have previously been the preserve of a psychoanalytic approach – issues about the meaning of actions, anxiety, the unconscious, and the relational dynamics evoked when working with risk – can be integrated into a thorough approach to risk to make that approach more comprehensive, and hence more reliable.

The framework for thinking about risk that we propose in this book is based on our work at the Portman Clinic over many years. The Clinic is a national centre for NHS outpatient psychotherapy, offering assessment and treatment to patients described as forensic or having antisocial personality disorders. We offer specialist assessment and treatment of people who are troubled by their delinquent, criminal or violent behaviour or sexual impulses which compel them to act in ways which distress or damage others or themselves. The three of us have developed our experience through assessing and treating people with these difficulties, and we are involved in teaching, training, service development and consultancy to others in the field working with similar patients. The ideas we offer here are suggestions for further thinking. They should not be taken to override the recommendations of your service about assessing risk. But we hope that they will supplement the approach you are used to using, and will enable you to work with individuals who pose a risk in a way that...

Table of contents

• Cover Page
• Assessing Risk
• Title
• Copyright
• Contents
• Acknowledgements
• Foreword
• 1 Introduction
• 2 Risky Assessment: Making Decisions About Risk
• 3 Key Psychodynamic Concepts in Understanding Risk
• 4 Relational Issues in Assessing and Managing Risk: The Compulsion to Repeat and the Professional Relationship
• 5 Developmental Aspects of Adult Enactment
• 6 a Relational Approach to Violence and Aggression
• 7 Understanding Deviant Sexual Behaviour and Sexual Offending
• 8 Female Offending and Risk
• 9 Personality Factors and Understanding the Offender
• 10 Psychopathy and Antisocial Personality Disorder
• 11 Self-Harm and Suicide
• 12 Assessment and Communication Skills
• 13 Institutional Dynamics and Risk
• 14 Formulating Risk: A Framework For Assessing and Managing Dangerousness
• References
• Index