Breaking the cycle of risk behaviour

by Chris Raven
risk-averse perspective in mental health is unethical when it denies service users the range of experience that others take for granted. Ethically, the question to consider is whether people receiving treatment from mental health services have the same right as everyone else to learn from making mistakes. A risk-averse perspective may actually increase risk through eliciting two dangerous responses from practitioners. In the first response, control is immediately taken away from an individual until a perceived crisis has passed. Although there may be situations where this approach would be appropriate, these are not the norm. There are always opportunities to discuss risk with service users, to try to find safe or harm-minimising solutions to difficult situations and to incorporate their skills, views and abilities into any crisis management plan. However, media reporting of tragedies which implies that homicides and suicides are always preventable creates a climate in which mental health workers are more likely to respond to risk in restrictive and paternalistic ways. Concern for personal professional status can then take precedence over ethical practice. Such defensive practice actually increases risk by robbing service users of opportunities to develop their own coping strategies or learn how to manage their own behaviour. Once the crisis is over and levels of supervision reduced, the same risks may recur because nothing has fundamentally changed. The second reactive response occurs when the service users behaviour or past history is so anxiety-provoking that practitioners avoid engaging with them altogether. Services can be reluctant to take responsibility for 'difficult' cases, with protracted games of 'patient tennis' between services trying to refer the service user to each other. This too is unethical because of the increased potential for the service user to fall through the net and the reduced opportunities for services to communicate and work collaboratively with complex cases. When the so-called 'risky' service user is finally allocated, services can spend more time protecting themselves from things going wrong than offering a therapeutic service and opportunities for the service user to develop their own coping strategies. The assessment of risk of harm to self or others is an essential element of working in mental health. But it could be instructive for practitioners to consider whether the focus of their last risk assessment was a therapeutic exercise, a paper exercise or to protect their registration and to avoid a potential serious incident investigation. Removing choice results in dependency, lack of self-esteem and stigmatisation. Cautious practitioners disempower not only their service users but also themselves by limiting the scope of positive therapeutic work.

A systemic context

Organisational intolerance of risk has been strengthened by disproportionate reporting of rare but fatal incidents involving people experiencing severe mental distress.1 Media calls for such a thing never to happen again and insistence that an individual professional must be to blame promotes unreal expectations that all service users might either become assailants or come to harm in some way, and that mental health services have a duty to prevent this. Government reinforces this culture through a focus on legislation, concentrating on superficial measurements of practice and a tick-box mentality, where the completion of a task is more important then the quality of work undertaken. As greater focus is placed on striving to reduce risk, but with diminishing tools and resources to achieve this, practice inevitably becomes defensive and risky, as workers spend more time watching their backs. This has two fundamental implications for the quality of therapeutic work. The first is the perception by practitioners that they will be held accountable, and even punished, for the behaviour of service users. Service users can therefore be seen as a threat to services rather than as individuals in need of support and understanding. The second is a steady deterioration in the quality of risk assessments, and of clinical work generally, as the organisation becomes focused on how many rather than how well. If the best predictor of future risk behaviour is past behaviour, then why are many risk assessments superficial and generalised? Statements such as 'risk of aggression when unwell' and 'history of past suicide attempts' reveal nothing of the individual service users experience or circumstances during incidents of past risk behaviour. The only alternative is to wade through their notes in an attempt to apply some level of context to the raised concerns (or maybe even ask the person concerned!).

Ethical solutions

1. Taylor, P.J. and Gunn, J. (1999) Homicides by people with mental illness: myth and reality, British Journal of Psychiatry 174: 914. 2. Ryan, T. (1993) Therapeutic risks in mental health nursing, Nursing Standard 7(24): 314. 3. Morgan, S. (2004) Strengths-based practice, Openmind 126. 4. Morgan, S. (2004) Positive risk-taking: an idea whose time has come, Health Care Risk Report 10(10): 1819.

The answer must lie in reclaiming risk assessment as a therapeutic tool.2 Risk assessment should be considered a proactive therapeutic exercise that can free up practice rather then condense it into generic responses. Senior management can lead in this by reassuring frontline staff they are accountable for the quality of their work rather than the behaviour of service users. This would shift the focus from preventing all risk behaviour to a focus on well-formulated risk management plans that take into account the perspective of the service user. Consulting with service users should be crucial to risk assessment, and understanding the context surrounding past, present and potential risk behaviour should be paramount. We can also ask about the skills and resources service users have applied in past crisis situations on occasions when they did not engage in risk behaviour. In this way, we can assist them in building on existing coping strategies and in developing new skills for managing stressful situations, while reducing the risk of dependency and disempowerment created by services.3 The careful weighing up of the pros and cons of positive risk taking within a properly formulated risk assessment should justify a proactive and supportive approach to risk management.4 This requires acceptance of a number of assumptions: The service user is central to the formation of risk assessments and management plans, and is encouraged to contribute and take on an appropriate level of responsibility for their behaviour. Practitioners are mindful of the impact of risk assessments on the service user's self-esteem, life opportunities and the future involvement of services. Risk is not necessarily negative and in many situations it is an empowering activity. Being told something is too risky is removing choice and the opportunity to grow and develop.4 Despite past behaviour being a strong indicator of potential future behaviour, the service user is still regarded as being able to learn, grow and develop, and is therefore not denied any opportunity to break the cycle of risk behaviour.

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