Self-Harm and Violence E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 750

Veröffentlichungsjahr: 2011

Beschreibung

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

Leseprobe

Contents

Cover

Title Page

Copyright

Contributors

Foreword

Preface

Chapter 1: Introduction

Part I: Experience

Chapter 2: Service Users: Experiences of Risk and Risk Management

Introduction

Experiences and Views

Six Questions

Getting Involved: A Personal Perspective

Rights as Human Beings

Information as Evidence

What Needs to Change?

A Future: Light at the End of the Tunnel

Call for Change: A Manifesto

Acknowledgements

Chapter 3: Carers: Experiences of Risk and Risk Management

Our Story

Collaborative Working

Carer Perspective: What Helps?

Family Work

What Hinders Collaborative Working?

The Service User’s Perspective

Top Tips for Carers

Conclusions

Part II: Evidence

Chapter 4: Understanding and Managing Self-Harm in Mental Health Services

Synopsis

Introduction

Evidence-Based Risk Prediction

Evidence-Based Risk Assessment

Evidence-Based Intervention

A Way Forward

Chapter 5: Understanding and Managing Violence in Mental Health Services

Introduction

The Concept of Aggression

Violent Acts: Individual or Culture?

How Does Childhood Aggression Relate to Adult Aggression?

What Psychological Factors Make Violence More or Less Likely to Happen?

What is the Relationship between Violence and Mental Disorder?

Are People with Mental Health Problems More Likely to be Aggressive than the Rest of the Population?

What are the Most Effective Ways of Judging the Risk of Violence?

What Role does Pharmacotherapy Play in Treating Violent Behaviour?

How Effective are Psychological Interventions for Violent Behaviour?

How Important are Engagement and Collaboration in the Risk Management Process?

Conclusion

Chapter 6: Suicide and Homicide by People with Mental Illness: A National Overview

Introduction

How the Inquiry was Established

How Does the Inquiry Work?

Suicide Inquiry Findings

Homicide Inquiry Findings

Recommendations

Future Directions

Acknowledgements

Chapter 7: Evidence and Principles for Service User Involvement in Risk Management

Introduction

Introduction to User Involvement

User Involvement and Risk Management

Implementation of User Involvement

Conclusion

Part III: Practice

Chapter 8: Guidelines and Standards for Managing Risk in Mental Health Services

Introduction

Evidence-Based Practice and the Role of Clinical Guidelines

Standards and Guidance in Clinical Risk Assessment and Management: An International Perspective

Implementing Best Practice in Managing Risk

Conclusions

Chapter 9: Organizations, Corporate Governance and Risk Management

Introduction

Embedding Best Practice

Partnership Working

Organizational Culture

Assessing, Preventing and Managing Harmful Behaviours: The Size of the Problem

The Corporate Manslaughter and Corporate Homicide Act 2007

The Role of the National Patient Safety Agency

Integrated Risk Management in Organizations

Achieving Integrated Risk Management

The NHS Litigation Authority

The Role of the Care Quality Commission

Review of Mental Health Services

Organizational Characteristics that Influence the Capacity to Deliver Effective Risk Management

Clinical Guidelines and Risk Management

Conclusion

Chapter 10: Formulation in Clinical Risk Assessment and Management

Introduction

Clinical Risk Assessment and Management: An Overview

General Principles of Clinical Formulation

Risk Formulation in Practice

Concluding Comments on Risk Formulation

Case Study

Final Conclusions

Chapter 11: Evidence and Principles for Positive Risk Management

Introduction

Assessing Risk

Taking Positive Risk Decisions

Recording and Communicating Risk Decisions in the Care or Support Plan

Positive Organizational Risk Management

Conclusion

Chapter 12: Encouraging Positive Risk Management: Supporting Decisions by People with Learning Disabilities Using a Human Rights-Based Approach

Introduction and Background

A HRBA to Positive Risk Management

Moving from Assessment to Risk Management for ‘A Life Like Any Other’

The Transition to ‘A Life Like Any Other’: Obstacles, Challenges and Solutions to Delivering the HR-JRAMP

Conclusion

Part IV: Implementation

Introduction to Case Studies

Chapter 13: Case Study 1:A Four-Step Model of Implementation

Introduction

The Case Study Context

The Step-by-Step Stages to Implementation

Case Vignette

Challenges and Facilitators

Conclusions and Recommendations

Chapter 14: Case Study 2:Narrowing the Gap between Policy and Practice

Governance

The Use of the Best Practice in Managing Risk Implementation Toolkit

Development of the Clinical Risk Policy

Training Strategy

Lessons from SUIs

Risk Management and Review Panels

The Recovery Approach

Audit of Practice

Summary and Conclusions

Chapter 15: Case Study 3:Learning from Experience – Using Clinical Risk Data to Influence and Shape Clinical Services

Introduction

The Local Context

Next Steps

Conclusions

Chapter 16: Case Study 4: From Ticking Boxes to Effective Risk Management

Service Context

Historical Factors and Major Influences for Change

Case Example: Evidence of the Need for Change

Factors Supporting the Need for Change: Further Discussion

Policy Development and Implementation: Achieving Improved Practice?

What We Have Learnt: Ticking Boxes or Effective Processes?

Chapter 17: Conclusions

A Route Map

Conclusions

Glossary

Index

This edition first published 2011 © 2011 John Wiley & Sons, Ltd.

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Library of Congress Cataloging-in-Publication Data

Self-harm and violence : towards best practice in managing risk in mental health services / edited by Richard Whittington and Caroline Logan. p. ; cm. Includes bibliographical references and index. ISBN 978-0-470-74607-3 (cloth) – ISBN 978-0-470-74606-6 (pbk.) 1. Violence in psychiatric hospitals–Prevention. 2. Mental health facilities–Risk management. 3. Psychotherapy patients. 4. Violence in psychiatric hospitals–Prevention. 5. Parasuicide–Prevention. I. Whittington, Richard (Richard Charles) II. Logan, Caroline. [DNLM: 1. Self-Injurious Behavior–prevention & control. 2. Mental Health Services–organization & administration. 3. Mentally Ill Persons–psychology. 4. Organizational Case Studies. 5. Risk Management. 6. Violence–prevention & control. WM 165] RC439.4.S45 2011 616.85′82–dc22 2010042190

A catalogue record for this book is available from the British Library.

This book is published in the following electronic formats: ePDF 9781119991182; Wiley Online Library 9781119991175

Contributors

Dr Wally Barr is a Senior Research Fellow in the Health and Community Care Research Unit at the University of Liverpool, where he has worked since 1997. He holds a BSc from the University of London and an MA and PhD from the University of Manchester. Wally’s past experience has included training in both mental health nursing (RMN) and social work (CQSW). Before joining the Health and Community Care Research Unit, Wally worked for several years as a mental health social worker in a community mental health team, and until recently also practiced as a sessional out-of-hours approved social worker (ASW) under the 1983 Mental Health Act. Wally’s main areas of research interest are self-harm, and suicidal and violent behaviour. He is currently working with colleagues on a programme of studies being conducted for the Mersey Forensic Psychiatry Research Group, as well as research evaluating newly developed counselling services for people with sight loss and people with personality disorder. He is also is a member of the research team developing evidence-based guidelines for the prevention of violence in mental health settings.

Andrew Brown is a Forensic Nurse Consultant currently working within SaFE Partnership CBU, Mersey Care NHS Trust. He fulfils the Lead Nurse and Research Lead roles for that service and is an Honorary Research Fellow at the University of Liverpool. His clinical work incorporates the completion of assessments and formulation of personality disorder and risk. In addition to providing cognitive behavioural therapy for psychosis and personality disorder, he is also working as part of a team trying to develop mentalization-based approaches within Mersey Care NHS Trust. He contributed to the Best Practice in Managing Risk guidance 2007 and continues his work to implement these guidelines within his CBU. He has research interests that encompass all aspects of medium secure care provision, with particular interest in personality disorder, auditory hallucinations and dissociation. He is currently reading for a PhD at the University of Liverpool.

Roy Butterworth is a Practice Development Nurse and professional lead for nursing within the Secure Mental Health Service, Lancashire Care NHS Foundation Trust. His previous roles have included ward and service management and Senior Nurse for Professional Development. Having acquired a Masters in Business Administration in 2000 he has continued to lead on a broad range of service and Trust-wide change initiatives, including the development of a network of effective aggression management instructors. Roy has utilized risk assessment approaches in the management of seclusion and medicine administration. In 2003 he recognized a lack of clear risk management performance criteria for registered nurses, which led to the design of competence frameworks contributing to a service-wide Preceptorship Portfolio. His work has been recognized within the Trust ‘Excellence in clinical practice awards’ on two consecutive years. He has written a number of chapters and articles as well as contributing to national and international conferences, on various change management and service development initiatives, and to the Department of Health’s mental health policy implementation guide. More recently he attained a Masters in Psychosocial Interventions for Psychosis and is currently exploring service development options towards a multidisciplinary – recovery oriented approach to embracing psychosocial interventions in medium secure care.

Ged Carney is a Registered Learning Disability Nurse and holds a combined honours health/psychology degree. He has 28 years of experience in a variety of settings with people who have learning disabilities and complex needs. He has considerable experience of planning, designing and implementing future plans for people who have lived in institutional settings, including those at risk of offending and with negative reputations. Ged is known for his work with people who have challenging behaviour. He has extensive knowledge, skills and ability with regard to the development of risk assessment and management plans for people who have a learning disability. He currently works as a nurse at the Rebuild Clinical Business Unit, which is part of Mersey Care NHS Trust. He is a member of the Human Rights working group at Olive Mount.

Dr Paul Clifford is a clinical psychologist, Director of FACE Recording and Measurement Systems and Honorary Senior Lecturer at University College London. Paul began developing the FACE suite of assessment and care planning tools in 1990, and has been running national-level research and development programmes for over 20 years, focusing on the creation of clinical, risk and outcome measurement tools for use in mental health and community care. He was the first Programme Coordinator for Severe Mental Illness at the Sainsbury Centre for Mental Health from 1985 to 1990, he ran Department of Health development programmes in mental health information and outcome measurement systems from 1990 to 1995, and, in 1995, he became the first Director of CORE, the British Psychological Society’s Centre for Outcomes, Research and Effectiveness. Paul is now responsible for the scientific and clinical programmes at FACE. This work includes the further development and updating of FACE tools, outcomes benchmarking, resource allocation programmes and overseeing developments of the FACE toolsets across health and social care. The FACE tools include a widely used suite of risk assessment guides for adult mental health services, older people’s mental health services, child and adolescent mental health services, learning disability, perinatal and substance misuse services.

Dr Louise Fountain is a Consultant Clinical and Forensic Psychologist working in adult mental health in a secondary care psychological therapy service. Originally from Northern Ireland, she completed a degree in psychology at the University of Exeter in 1978 and went on to train as a clinical psychologist at Queens University Belfast, qualifying in 1982. She worked in the field of adult mental health in a number of posts in Leicester, Norwich and Salisbury until an opportunity arose in 1999, which allowed for the development of an interest in community forensic practice. She undertook an MSc in Applied Forensic Psychology, followed by a doctorate in Clinical Psychology, researching the assessment of risk of violence in a community mental health setting. She worked in a community forensic service for ten years before taking on more management responsibilities and moving back to general adult mental health. Involvement in the area of risk has continued and developed, however, in both service-related – with involvement in the Best Practice guidance and its implementation within her NHS Trust – and clinical settings, in which the regular, frequent assessment and management of risk with consultation and supervision is an ongoing and fundamental aspect of practice.

Phil Garnham was Head of Nursing Development at Oxleas NHS Foundation Trust at the time of writing and is now a Forensic Nurse Consultant. He has worked in the field of mental health care for over 26 years, with 17 of those in forensic mental health. He has a masters degree in counselling and psychotherapy, has published several journal articles and contributed a chapter entitled ‘Managing the Psychiatric Intensive Care Unit’ to the second edition of Psychiatric Intensive Care by Beer and colleagues. Phil is an Honorary Lecturer at the University of Greenwich and at the Centre for Health and Social Care Research, Canterbury Christchurch University. He is also an external examiner for the Institute of Psychiatry short course programme and was Chair of the Royal College of Nursing’s National Forensic Forum for four years.

Dr Helen Gilburt is post-doctoral research worker in the Department of Addiction at the Institute of Psychiatry in London. She started her career as a biological scientist but, after experiencing mental health problems at university, has forged a career in mental health services research. Joining the Institute of Psychiatry in 2005, she has worked on a number of projects including a national study of innovative care provision in acute inpatient psychiatric services, the implementation of the recovery model in community mental health services, and most recently, developing assertive outreach for people with alcohol dependence. She has a particular interest in the added value of facilitating service user involvement for care provision, service development, and research itself.

Dr Beth Greenhill is a clinical psychologist working with adults with learning disabilities in the Rebuild Clinical Business Unit at Olive Mount in Mersey Care NHS Trust. Beth has worked in the Liverpool Team at Olive Mount for eight years and has drawn heavily on her learning from, and experiences with, service users and team colleagues in her contribution to her chapter. Clinically, Beth works therapeutically within a Cognitive Analytic Therapy (CAT) framework, offering direct therapy and ‘relationally informed’ systemic support to service users on the complex care pathway and their staff teams. Indeed, she is about to finish her CAT practitioner training. Beth has particular experience and interest in working with women who have experienced trauma and whose responses to trauma are labelled as ‘complex’. Beth also has a strong personal, political and professional interest in human rights and equality issues. She is project lead for the ‘Human Rights in Healthcare Project’ within Mersey Care’s Learning Disability Services.

Dr Devendra Hansjee MRCPsych, is the Associate Specialist Psychiatrist for the Bromley Assertive Community Treatment (ACT) Team in Oxleas NHS Foundation Trust. This team serves a group of clients who have a wide range of complex social and mental health needs. In his three years with the ACT Team, he has gained extensive experience in assessing and managing risk across both inpatient and community settings. He is a proponent of community-based psychiatric care and is committed to helping service users to achieve their full potential during their journey towards recovery.

Kate Hunt is a Consultant Clinical and Forensic Psychologist in the NHS. She is currently the Professional Lead for Psychology and Psychological Therapies in Acute and Crisis Services in Sussex Partnership NHS Foundation Trust, and has a lead role in clinical risk assessment and management across all care groups within the Trust. She was a member of the expert reference group in the recent Department of Health Best Practice in Managing Risk guidance and a member of the recent National Task Force on the Health Aspects of Violence against Women and Children. She is currently a member of the National Collaborating Centre for Mental Health Guideline Development Group for Self-Harm: Longer Term Management, and a member of the National Steering Group for Multiagency Risk Assessment Conferences (MARACs). Kate Hunt is a chartered clinical and a chartered forensic psychologist.

Dr Lorna Jellicoe-Jones is currently Head of Secure Psychological Services at Guild Lodge Secure Services, Lancashire Care Foundation Trust. Lorna qualified as a clinical psychologist in 1997 after a number of years working in voluntary sector mental health projects, including MIND, with the Eating Disorders Association and with young people’s mental health projects. Her specialist areas of interest are women in secure services, personality disorder, self-injury and multidisciplinary team working. On qualifying, Lorna worked for three years in the Women’s Services at Ashworth Hospital, after which she moved to Guild Lodge. Lorna has led on the development of the Psychological Services team at Guild Lodge and on various clinical and service initiatives, including self-injury and Trust and service strategy, the development of gender-sensitive secure women’s services, risk policy and training and the establishment of specialist forensic personality disorder teams and networks. Lorna has maintained an active interest in research and has supervised and contributed to projects on trauma and psychosis, sexual offending, the management of challenging behaviour and engaging service users within secure services. A current focus of her work is on developing service user involvement in risk assessment and management and increasing multidisciplinary involvement in psychological service provision.

Dr Maria Leitner is currently Research Director of a company carrying out both medical and veterinary research and also holds an honorary Senior Research Fellow post at the University of Liverpool. Previous posts include five years as Research Director of the School of Health Sciences at Liverpool University and two years as a Manager and Senior Reviewer at the NHS Centre for Reviews and Dissemination, University of York. Maria’s research background includes a BA in Experimental Psychology and Philosophy from the University of Oxford and a PhD in quantitative genetics from the University of Sheffield. In line with this diverse background, her primary research interests lie in the quantitative analysis of large-scale population datasets. Current interests in relation to human health issues include the use of systematic reviews in promoting evidence-based health care; prevention, intervention and risk assessment in the context of violent behaviour; and the epidemiology and prevention of suicidal and self-harming behaviour.

Dr Caroline Logan is a Consultant Forensic Clinical Psychologist in Greater Manchester West Mental Health NHS Foundation Trust and an Honorary Research Fellow at the University of Manchester, positions she has held since August 2009. She contributed to the development of the Best Practice in Managing Risk guidance while working as a Consultant Specialist Clinical Psychologist in the Secure Psychological Services based at Ashworth Hospital, part of Mersey Care NHS Trust. She has worked in forensic mental health services for 15 years, working directly with clients who are a risk to themselves and to others and, in various consultancy roles, with the multidisciplinary teams and the health and criminal justice organizations that look after and manage them. Caroline serves on the editorial board of the International Journal of Forensic Mental Health and is an associate editor of Legal and Criminological Psychology and the Journal of Forensic Psychiatry and Psychology. She also has ongoing research interests in the areas of personality disorder, including psychopathy, and risk and has a special interest in gender issues in offending. Caroline is both a clinical psychologist and a forensic psychologist, and has a DPhil in experimental psychology.

Mark Love is Senior Team Leader, Occupational Therapist at Guild Lodge Medium and Low Secure Services, Lancashire Care Foundation NHS Trust. After completing a fine arts degree in 1985, Mark worked as a technical instructor at Whittingham Psychiatric Hospital. In 1996, he qualified as an Occupational Therapist and commenced his first clinical post at the Rowan High Dependency Unit, Whittingham Hospital. Since 1999, he has worked as a Senior Team Leader in the Occupational Therapy department at Guild Lodge. Mark has undertaken various training courses, including psychosocial interventions with psychoses (at Manchester University in 2000), as well as cognitive rehabilitation and motivational interviewing. One of his roles within the Occupational Therapy department has been the setting up of a comprehensive range of activities as part of the treatment programme for service users – this has included coping with psychoses, anger and anxiety management, as well as social skills training. He is involved in the Risk Working Group, offering an occupational therapy perspective on the risk pathway at Guild Lodge. Mark continues to facilitate in-house training to students and staff on risk assessment and management, as well as lecturing at Salford University on the Occupational Therapy degree course.

Sally Luxton has brought up three children, and has been the primary carer on her own for her son, her youngest child, who became ill with schizophrenia when he was 17 years old. He is now 31. For the past eight years, Sally has worked as an associate trainer in the training department of Avon and Wiltshire Partnership Mental Health Trust. Together with service users and clinicians, she has developed and delivered training to staff. Training includes Working Collaboratively with Risk, CPA and Care Pathways, Working in Partnership with Families and Carers and Mental Health Awareness. Sally also teaches on the three-year pre-registration mental health nursing degree at the University of the West of England, has worked with Rethink and been engaged in other work in the mental health field, all promoting the importance of working together with families and carers.

Prof. James McGuire is Professor of Forensic Clinical Psychology and Director of the Doctorate in Clinical Psychology Programme at the University of Liverpool. He also holds an honorary post as Consultant Clinical Psychologist in Mersey Care NHS Trust. He worked for some years in a high security hospital and has carried out psycho-legal work involving assessment of individuals for Youth Court, Crown Court and for hearings of the Mental Health Review Tribunal, Parole Board and Criminal Cases Review Commission. He has conducted research in probation services, prisons, and other settings on aspects of psychosocial rehabilitation with offenders and has written or edited 13 books and numerous other publications on this and related issues. Professor McGuire serves on the editorial boards of four journals, and has contributed to a Guideline Development Group for the National Institute of Clinical Excellence (NICE) on Antisocial Personality Disorder. In addition, he has been involved in a range of consultative work or staff training with criminal justice agencies in the United Kingdom, Sweden, Finland, Romania, Canada, Australia, Hong Kong and Fiji.

Patrick McKee is currently the head of practice and clinical quality development for the Avon and Wiltshire Mental Health Trust. He holds a dual qualification in nursing, with 30 years’ experience in mental health. He trained initially in Northern Ireland, qualifying as a Registered Mental Health Nurse in 1983. Patrick moved to England in 1984, working in a number of mental health fields including drugs and alcohol, acute care, rehabilitation and later as a ward manager in an interim psychiatric intensive care, low security facility in London. Patrick moved into senior clinical managerial roles from 1990 onwards running both inpatient and community services. In 1999, he completed a BSc (Hons) in Health and Community Studies, which led to a role as associate nurse director for quality development. This eventually led to a seven-year period as Director of governance and nursing with the Avon and Wiltshire Mental Health Partnership Trust providing professional leadership for a large nursing workforce. In 2008, Patrick embarked on a new career as head of practice and quality development, with a central role in developing new and innovative clinical services. One of the founder members of the Care Programme Approach Association (CPAA), he has been involved in the development of care planning and clinical risk processes. He is currently leading his Trust’s plans for the introduction of a system for payment by results, including the introduction of care clusters and clinical outcome measures.

Jane Moore is Head of Clinical Audit and Research at Oxleas NHS Foundation Trust. She has worked in the field of health care quality for over 15 years, with a background in psychology and academic research. She has a masters degree in ‘Evaluation of Clinical Practice’, has published several journal articles, and has a special interest in change management theory and its application. Jane has advised on several national audits, and recently spent a year working for the local quality improvement team at the Healthcare Quality Improvement Partnership (HQIP), which is a national body established to promote and support clinical audit.

Dr Rajan Nathan is a Consultant Forensic Psychiatrist in Mersey Care NHS Trust and an Honorary Senior Research Fellow at the University of Liverpool. He qualified in medicine in 1992 and the following year commenced psychiatric training, culminating in the appointment to a consultant post in 2001. As a post-doctoral research fellow, the focus of his research was the assessment of serious violence and the developmental antecedents of violence. He was awarded a doctorate in 2007. Alongside his clinical commitments, largely in the area of forensic personality disorder, he has continued to conduct research in the forensic field. He has led service development in the area of forensic personality disorder.

Prof. Dr Norbert Nedopil is Head of the Department of Forensic Psychiatry at the University of Munich, Germany, having previously been Professor and Head of the Department of Forensic Psychiatry at the University of Würzburg. Norbert studied medicine and psychology at the University of Munich, graduating in 1974. Between 1977 and 1984, he held a residency at the psychiatric hospital of the University of Munich, specializing in psychopharmacology, schizophrenia research and sleep research. He has specialized in forensic psychiatry since 1984. Norbert’s special interests are psychiatric assessment, human aggression, treating mentally disordered offenders, predicting recidivism and a range of ethical and legal issues pertaining to psychiatry. Norbert is the author or editor of seven books and more than 200 scientific papers.

Beverley Quinn is a Registered Psychiatric Nurse and holds a BSc (Hons) in neuroscience and a BSc (Hons) in psychosocial interventions in psychosis, as well as a diploma in mental health nursing. She has seven years’ experience of working within both inpatient and forensic psychiatric services. She is currently working at the Scott Clinic, part of Mersey Care NHS Trust, which is a medium secure psychiatric unit. The unit emphasizes working with clientele using a psychosocial intervention framework, utilizing therapeutic and cognitive behavioural therapeutic techniques, as well as traditional interventions to aid recovery. Bev currently has a dual role in the Scott Clinic, where she is involved in research projects in collaboration with the University of Liverpool and also works on the wards within the unit as a psychiatric nurse.

Claire Riding is Case Manager for the North West Secure Commissioning Team. Claire qualified as a Mental Health Nurse in March 1997 and took up her first post at the Chesterton Unit at Winwick Hospital (later changed to Hollins Park Hospital). She completed a BSc in Personality Disorder and Mental Health at Liverpool John Moores University in 1999, before moving to Guild Lodge medium secure unit in August 2000 to take up the post of Team Leader. Shortly afterwards, Claire led a project to open the unit’s first women-only ward, and in 2002 completed an MSc in Forensic Behavioural Science at the University of Liverpool. Her dissertation focused on women suffering from psychopathic disorder. Claire then enjoyed a series of promotions, from ward manager to Flow and Capacity Manager, and finally Modern Matron, managing four clinical areas within the unit. She is currently on secondment as a Case Manager with the North West Specialized Commissioning Team.

Kay Sheldon has received a range of mental health services including inpatient care under the Mental Health Act. She has been involved with a wide range of service user initiatives either as an ‘involved’ service user herself or by developing opportunities for others. She has been a Mental Health Act Commissioner and a member of the Mental Health Act Commission board. In the latter capacity, she helped to develop an involvement strategy for the organization, which included setting up a Service User Reference Panel of people with either current or recent experience of being detained under the Mental Health Act. She is currently a Commissioner – board member – with the Care Quality Commission, the new health and social care regulator. Kay also has a background in advocacy and user-led research. For example, she was the founding chairman of a local user-controlled advocacy project and has worked as a user/survivor researcher with the Mental Health Foundation. Other voluntary sector experience includes being a trustee with MIND, having previously been co-chair of MIND Link, MIND’s user/survivor network. Kay also writes and undertakes some training and consultancy work.

Prof. Tilman Steinert is a senior doctor in acute psychiatry in Weissenau, Germany, and an extraordinary professor at Ulm University. He was born in 1957 and went to school in Stuttgart, Germany. He studied medicine at Ulm University from 1976 to 1984, interrupted by 16 months of civil service, undertaken in place of national service as a conscientious objector. In 1984, he finished his dissertation on psychiatry in Nazi Germany. He has been a psychiatrist since 1990, and a neurologist and a psychotherapist since 1991. In 1997, he achieved his habilitation with several articles and books on violence and schizophrenia (Aggression bei psychisch Kranken (Aggression in Mentally Ill People); Aggression und Gewalt bei Schizophrenie (Aggression and Violence in Schizophrenia); Basiswissen: Umgang mit Gewalt in der Psychiatrie (Basic Knowledge: Management of Violence in Clinical Psychiatry)). In the same year, he founded the German Working Group for the Prevention of Violence and Coercion in Psychiatry, of which he is still the leader today. In 2007, he was commissioned by the German Association of Psychiatry and Psychotherapy to develop guidelines for the management of aggressive and violent behaviour, which was eventually published in 2009 (Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde: Praxisleitlinien in Psychiatrie und Psychotherapie (German Association for Psychiatry and Psychotherapy: Guidelines in Psychiatry and Psychotherapy)). Since 2008, he has belonged to the managerial board of the hospital group Zentrum für Psychiatrie Südwürttemberg with responsibility for general psychiatry and research. He has published four monographs and about 170 papers and book contributions in German and English, and is editor of the journal Psychiatrische Praxis.

Dr Geraldine Strathdee OBE, MRCPsych, is the Associate Medical Director for Mental Health for London and the Specialist Clinical Adviser on Mental Health to the Care Quality Commission. For over 15 years she has held senior roles in mental health policy and regulation at national and London regional levels in organizations that have included the Department of Health and the Healthcare Commission. She advises policy bodies internationally on mental health policy and service design. Her particular commitment is to the translation of policy and best practice guidelines into routine working practice. Clinically, she has worked in a wide range of inpatient and community services for people with complex and multiple needs, and is currently the Consultant Psychiatrist for the Bromley Assertive Community Treatment team, Oxleas NHS Foundation Trust. She is committed to providing services that enable service users to live in their own homes, develop their own self-management expertise to achieve recovery, while at the same time working with community agencies to achieve risk management, which maximizes service users’ chances of recovery and provides public protection.

Dr Nicola Swinson is a Consultant Forensic Psychiatrist at Guild Lodge, Lancashire Care NHS Foundation Trust and an Honorary Clinical Research Fellow at the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness at the University of Manchester. She graduated from the University of Glasgow with an MB ChB in 1999, having completed an intercalated degree in Biomedical Sciences and Psychology at University College London in 1997. She trained at the Maudsley Hospital, London until becoming a member of the Royal College of Psychiatrists in 2003. She then completed her higher specialist training in Forensic Psychiatry in the north west of England. She is currently studying for a PhD in personality disorder in perpetrators of homicide. She teaches on violence risk assessment and supervises both undergraduates and postgraduates on research projects and higher degrees. Her other research interests include violence risk assessment, suicide prevention, homicide and other aspects of forensic psychiatry.

Dr Ben Thomas is the Head of Mental Health and Learning Disabilities for the National Patient Safety Agency. He is currently on secondment to the Department of Health, England as the Director of Mental Health and Learning Disability Nursing in the Professional Leadership Team. He has held a number of senior clinical, managerial and academic positions both in the United Kingdom and Australia, where he was Chief Nurse at St Vincent’s Mental Health Service, St Georges Older Peoples’ Service and Associate Professor at the University of Melbourne. He was also a non-executive director for the Norwood Rehabilitation and Housing Association. Ben has served on a number of ministerial reviews and advisory committees to governments including Malaysia, South Korea, Australia and China.

Richard Whitehead is currently Head of Clinical Psychology for Rebuild Clinical Business Unit, which is based at Olive Mount and is part of Mersey Care NHS Trust. The psychology service works with learning disability, psychiatric rehabilitation, brain injury and Asperger syndrome services. Richard has worked in the NHS for over 24 years, working with people who have psychosis, personality disorder and forensic labels. His main focus over the last 12 years has been supporting people with a learning disability and complex needs into the community from secure settings. Richard is also Course Convener and honorary lecturer on the learning disability module in the Doctorate in Clinical Psychology course at the University of Liverpool. Over the last four years, the team at Olive Mount has developed practical tools for applying human rights-based approaches in learning disability services, in collaboration with the British Institute of Human Rights and the Department of Health. These have ranged from human rights-based risk assessment and management tools, benchmarking third sector providers on a range of human rights factors, to a ‘Standing up for my rights group’ for people who use services, and the development of Service User Consultants based on the co-production model.

Prof. Richard Whittington is Professor of Mental Health in the Institute of Psychology, Health and Society at the University of Liverpool and an Honorary Research Fellow at Mersey Care Mental Health NHS Trust. He has a PhD from the Institute of Psychiatry, London, and is a researcher and forensic psychologist with a particular research interest in the issues of violence, self-harm and mental health. He has a background in mental health nursing in intensive care and general acute settings. He is a member of the Liverpool Violence (LiVio) Research Group and was Chair of the European Violence in Psychiatry Research Group (EViPRG) from 2004 until 2009. He has published widely on psychological and social aspects of violence in both institutional and community settings, with a particular focus on the role of interaction in the generation of aggression and the use of coercive interventions. Other current research interests include the management of mental health problems in the youth justice system and the translation of complex evidence syntheses into useable decision–support guides. Together with Dr Caroline Logan, he led the team which produced the Best Practice in Managing Risk guidance in 2007.

Dr Kirsten Windfuhr is the Senior Project Manager and Research Fellow for the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, which forms part of the Centre for Suicide Prevention at the University of Manchester. She completed her PhD in Psychology at the University of York in 1999, having completed her BA at Hope College (in the United States) in 1995 with a double major in Psychology and German. Pursuing her interests in health care ethics, she also completed her MA in Health Care Ethics and Law at the University of Manchester in 2006. Dr Windfuhr’s research interests include the epidemiology and aetiology of suicidal behaviour and suicide prevention.

Dr Thomas Wolf is a judge. He studied law at Marburg University, and practised law thereafter. In 1980, he was appointed judge at the Land Hessen, and in 1983 appointed life-time judge. In 1984, he was promoted to doctor of law science, and between 1990 and 1993, he was scientific clerk at the German Constitutional Court. In 1998, Thomas became chair judge at Marburg Regional Court, dealing with all cases of release both from prison and forensic hospital. Thomas is the director of the Führungsaufsichtsstelle Marburg (surveillance over released prisoners and mentally-ill offenders), author of a scientific commentary on the law of execution, and has published many of his court decisions in German law journals. He is a permanent lecturer at the German Judge Academy and teaches at many other institutions and meetings. He is a member of the scientific board of German journals on matters of execution (Der Deutsche Rechtspfleger) and on forensic psychiatry (Zeitschrift für Psychiatrie, Psychologie und Kriminologie, edited by Kröber, Saß et al.).

Foreword

Safety is at the centre of all good health care. However, in mental health, safety can be particularly sensitive and challenging. The autonomy and rights of service users have to be considered alongside risk to the public. A good therapeutic relationship must, therefore, include both sympathetic support and objective assessment of risk.

In the last decade, there have been a number of initiatives that are intended to make mental health services safer. Assertive outreach teams, for example, now provide intensive care in the community to people who may drift away from care, putting themselves and others at risk. Also, more acceptable treatments, both modern drugs and psychological therapies, are more widely available. The Care Programme Approach has recently been revised to align it more closely to the management of risk. And, to back up these changes, the Mental Health Act has been amended in various ways.

We know from the work of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness that staff have often found it difficult to recognize risk in cases where a suicide or a homicide occurs. There are complex reasons for this, to do with our training as frontline professionals, the relationships we try to make with service users and the inherent difficulties in understanding and positively managing risk as part of a collaborative venture.

This book offers a positive message and practical guidance on what can be done to improve our understanding of risk and what we can usefully do to manage it. It is unrealistic to expect services to prevent all incidents of harm to self and others, but the clinical management of risk can always be strengthened, with benefits to service users and their families, to the public and to the public perception of mental health services.

Louis ApplebyNational Clinical Director for Health and Criminal JusticeMay 2010

Preface

In this book, we offer a view about risk – what it feels like to be a person at risk of harming themselves or others or the close relative of such a person, what risk is and what it is not, how to understand risk in individuals and in the organizations in which they are cared for, and ultimately, how to try to manage risk using the least restrictive methods possible. It has taken us around two years to bring this book together, to gather the views that follow and to shape them into a collective whole that communicates one key message: the basis for risk management is an understanding about the risks posed by an individual interacting with his or her environment and the other people encountered within it. Consequently, this book endeavours both to enhance understanding about self-harm and violence and to offer practical solutions to the management of individuals and the organizations tasked with managing them.

Why have we put this book together? Because it is our view that despite a very great deal of research on the subject of risk assessment, we still do not know enough about what it feels like to be on the receiving end of risk management plans, what positive risk management really looks like and how it can be achieved, what a risk formulation is and how organizations can improve the way they think collectively about risk and its management. All these topics are addressed in this book by practitioners, researchers, managers, service users and carers who are in a position to offer an expert view on their area of interest or experience.

This book follows on from the publication in 2007 by the Department of Health of the document, 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 (Department of Health, 2007). The authors of this guidance – all of whom have contributed to chapters in this book – were moved by the experience of putting the guidance together and, subsequently, in 2008, of implementing it in mental health trusts across England. We were moved by the experiences of service users and carers who were consulted on the development of the guidance and by the frequent fears and frustrations of practitioners and managers uncertain about what to do with their risky clients. This book is intended as a way of channelling their experiences into something that might be useful for practitioners and managers, service users and their carers, all grappling with risk and its safe, effective, transparent and, ultimately, proportionate management.

Work began in earnest on this book in November 2008 when many of the authors were brought together in a writer’s workshop, which took place over two days at Albert Dock, Liverpool. At this workshop, the purpose of the book was discussed and individual chapters were planned. In the 12 months that followed, chapters were written and edited, reviewed and updated, in a process notable for the patience of the authors with the tiresome obsession with detail shown by the book’s two editors. Consequently, in the last few months, this volume has come together into what we hope is a coherent whole – a guide to the entire clinical risk assessment and management process that complements and enhances the original Best Practice guidance, and reinforces the view that something good can come out of doing something positive about risk. It is our hope that you will agree that this objective has been met.

Our most heartfelt thanks go to the contributors to this book. We are grateful to you for your time and patience and for the vital information you have distilled and communicated so well in the pages that follow. We must also thank Janet Davies of the Department of Health who had faith in us to deliver the Best Practice guidance and who has supported our work in the delivery of this book. Our thanks also go to Dawn Fleming, who for the period during which the Best Practice guidance was prepared, was assistant to Ms Davies. The contribution is also gratefully acknowledged of all the members of the Best Practice National Mental Health Risk Management Programme ‘Risk Assessment and Management Tools and Methods’ Expert Advisory Group, as well as all the other experts – by training or experience – consulted in the process of the development of the guidance, its revision and in the preparation of this book. In addition, we must thank both the University of Liverpool and Mersey Care NHS Trust for supporting the development of the Best Practice guidance and the preparation of this book in many different ways. The support of Greater Manchester West Mental Health NHS Foundation Trust is gratefully acknowledged by Caroline Logan, in particular, the support given by Drs Adrian West and Josanne Holloway, for allowing her the time to complete her work on this book since she joined them from Mersey Care NHS Trust in August 2009. Finally, we wish to express our gratitude to Sarah Davidson whose contribution over these last few months, getting this manuscript organized and ready for Wiley and generally not missing a thing, has been invaluable.

Richard Whittington and Caroline LoganMay 2010

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; andstructural, 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.