Tips for involving service users in mental health assessments

By Jeremy Dixon

In one of my first jobs as a mental health social worker I used to visit the office of the local crisis team. There was a poster in the staffroom of a pair of handcuffed fists with the caption, “have you done your risk assessment?” The poster was aimed at building contractors but had been put on the wall as a joke. The joke was that risk assessment had come to play a major role in mental health assessments and that staff worried that they may be scapegoated if they failed to complete one and something went wrong with their case.

Much of the research into risk assessment within social work has focussed on the ways in which workers understand and manage risk. Less has been written about the way in which service users themselves interact with these processes. I first became interested in this issue when working as a social worker in a medium secure unit with mentally disordered offenders. I noticed that within these settings staff often talked amongst themselves about the risks that they thought that a mentally disordered offender might pose to themselves or others but often struggled to talk to offenders about this. I began to wonder how mentally disordered offenders themselves understood their own risk and what they felt about risk assessment practices. My subsequent research into the views of nineteen mentally disordered offenders, “Mentally disordered offenders’ views of ‘their’ risk assessment and management plans”, has examined this.

Few service users saw their risk assessments
Research by John Langan and Vivien Lindow in 2004, “Living with Risk: mental health service user involvement in risk assessment and management”, found that mental health service users were often unaware that mental health staff were carrying out risk assessments about them. By contrast, the majority of mentally disordered offenders that I interviewed were aware that they were judged to have posed a serious risk to others and were being supervised because of this. Whilst most were aware that risk assessments about them existed, few had seen the assessments or knew what was in them. Most stated that these assessments had not been openly shared with them. In addition, they were often unclear about which professionals had responsibility for assessing and reviewing their risk, and how judgements were made. Mentally disordered offenders involved in my research were aware that their behaviours had been categorised as ‘high’ or ‘low’ risk by mental health staff. However, they believed that these categories reflected the judgments of staff rather than being based on standardised processes.

Benefits of collaboration
Whilst my research was conducted with mentally disordered offenders, it has relevance for social workers placed within community mental health services. Department of Health guidance issued in 2007, “Best practice in managing risk: principles and evidence for practice in the assessment and management of risk to self and others in mental health services”, states that risk assessments should be put together collaboratively with service users and should be based on “warmth, empathy and a sense of trust”. My findings indicate a need for mental health staff to ensure that the basis on which they make risk assessments is clear. My research also indicates some of the benefits of greater collaboration between mental health professionals and mentally disordered offenders in the process of risk assessment. In cases where offenders had been involved in identifying and monitoring risks they had a much stronger sense of engagement in and understanding of the process. In addition, they felt more able to highlight future risks, and were clearer about what they should do if they occurred. This did not mean that they always agreed with the way that staff had interpreted events, but differences of opinion became more transparent in such cases.

Tips to improve social work practice
In my view, mental health social workers can take a number of simple steps to improve their practice. I would recommend that:
• Service users are asked about their views of their own risks at the time at which they are first assessed.
• That they are helped to draw up their own assessment of risks once their mental health is stable.
• That service user and staff accounts of risk are incorporated into one document so that differences in perception are made explicit.
• That service users are given a copy of their risk assessment and that the rationale behind it is explained to them by their key worker.
• That risk assessments are regularly reviewed at care programme approach meetings and that service user and staff comments are recorded in these document.