How involved are mental health service users in risk assessment and risk management where they are considered to pose a possible risk to other people? One mental health trust set out to answer this question by interviewing 17 service users, 16 relatives and 56 professionals.1
Many service users were aware of the risks that they could pose to other people when experiencing psychosis and wanted help to reduce this. But some users were still not aware that professionals perceived them to pose a risk to other people. Indeed, some could not be asked if they wanted to take part in the study because they did not know that staff considered them to pose a risk.
Service user involvement was variable and depended upon individual professional initiative, but there were a few examples where service users were fully involved in risk assessment. However, most did not know that assessing and managing risk was an integral part of the workers’ role.
Most workers said that they discussed risk with service users. In terms of assessment, professionals most commonly used their own mental checklist based upon professional experience or a simple tick box checklist. Where more formal risk assessments were done, service users were rarely given copies.
Effective risk assessment and management depends upon accurate information but there were instances of staff not knowing about risk behaviours (for example, that someone heard voices suggesting they harm themselves) or where accounts were conflicting or inaccurate. One said: “He’s been accused of going to stab a staff member. I was present and it was very half-hearted. It was with one of our table knives and he came in waving it. There was no way he was going to stick it in him. But that’s gone down as an attempted stabbing.”
The study showed the aspects of a person’s life that may increase their chances of experiencing a psychotic breakdown. This is often called a “trigger”, which can hopefully be managed or ameliorated to reduce risk. Yet some people had so many triggers such as poverty, substance misuse, or experiencing discrimination or racism that a much wider focus than the individual was crucial.
Little use was made of advocates, and users did not have a full picture of the different services such as self-help groups that were available. Some service users made positive comments about staff (“I really feel that she understands me and I do feel that she’s on my side”) while a minority saw no need for them to be involved in their lives. However, good relationships take time and there was dissatisfaction with staff turnover especially of psychiatrists in out-patient clinics.
The research shows that while nearly all workers and relatives believed medication to be the lesser of two evils, some service users found taking it so distressing that it became the greater evil. Unexpectedly, some service users did not want to use supported housing because of previous bad experiences or because they wanted more independence.
The report suggests that a willingness to take appropriate risks; to talk honestly about risk; to look holistically at all aspects of a person’s life, including other harms they may be experiencing such as racism or trauma; and to make them feel more involved in the process of care planning will enable more effective and collaborative risk management.
1 Joan Langan and Vivien Lindow, Living with Risk: Mental Health Service User Involvement in Risk Assessment and Management, Policy Press, 2004
Joan Langan is lecturer, school for policy studies, University of Bristol.