Transcript Presentation to Valerie Mcniven

Risk Formulation: The Key to
Risk Management Planning
Dr Caroline Logan
Consultant Specialist Clinical Psychologist
in Risk Assessment and Management, Mersey Care NHT Trust
& Board Member, Risk Management Authority
www.RMAscotland.gov.uk
With thanks …
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Introduction
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Your decisions are likely to be regarded as
acceptable if you can demonstrate that …
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You and your staff conformed to the relevant Trust/locality
policies and procedures and national guidelines
You used the best information available, you tried to obtain
the information you did not possess, and you used
empirically-based methods of evaluating the information you
had
You can account for your decisions and chosen courses of
action, and you documented your decision-making
appropriately
You informed the most appropriate people of your concerns
You took all reasonable steps to try to manage risk
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Overview
Introduction
1. A model of risk assessment and risk management
2. Structured professional judgement and risk formulation
3. A short case study
4. The way forward in risk management planning
Conclusions
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1.
Model
Risk assessment is …
• An estimation of risk potential based on our
understanding of the presence and relevance of certain
conditions that we assume to be risk factors
• Result: Risk formulation
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1.
Model contd/...
Risk management is …
• Action taken to prevent the harmful outcomes thought
possible by anticipating what these outcomes might
look like (scenario planning)
• Implementation of continuous ongoing action designed
to monitor risk and respond appropriately to early
warning signs of a relapse to violence
• Creating a traceable route from risk assessment to risk
management
• Result: A written plan of action
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1.
Model contd/...
A plan of action providing …
• A traceable route from risk assessment to risk
management and back again … and again and again
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A risk management plan is a live document, relevant to a
specified time period, and should be updated
Practice in respect of risk management is stratified
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Target triggers or destabilising factors first – ensure security
as a priority
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1.
Model contd/...
Risk of harm to others …
• The proximal cause of violence is a decision to act
violently
• The decision is influenced by a host of psychological,
social, biological, and contextual factors including …
– Mental and personality disorder
– Exposure to violent models, attitudes that condone violence,
criminal peers
– Neurological insult, genetic/hormonal abnormality
– As well as proximal triggers (e.g., provocation, anger,
intoxication)
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1.
Model contd/...
• But risk is context-specific ...
– We can never know a person’s risk for violence
– We merely estimate risk on the basis of our knowledge of
various relevant individual (internal) and situational
(external) factors and how they relate to one another
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1.
Model contd/...
So, what do we need to make robust
decisions about risk?
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1.
Model contd/...
• Need a decision-making framework that…
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Promotes consistency between clinicians
Can facilitate communication between parties
Identifies outcomes of interest
Takes the individual patient into account
Takes all relevant risk factors into account
Takes protective factors into account
Is flexible
That links risk assessment to risk management
– And, overall, is reviewable, accountable, & transparent
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1.
Model contd/...
Because the reality is …
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Often concern about risks in multiple domains
Over varying time scales
Where risks are often linked
Risk of reoffending per se is often not a priority
Therefore, a framework for understanding risk
assessment and management is essential to help
practitioners select the most relevant information
quickly
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1.
Model contd/...
Therefore, there is a need for both …
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A framework for understanding risk
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AND tools that you can use to make complex
decisions about certain risks as evidence-based,
accountable and transparent as possible
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1.
Model contd/...
Framework?
• Clarity about what we mean by risk assessment
(definition)
• Clarity about what we want to prevent (focus)
• An understanding of what can make violence or sexual
violence happen (knowledge)
• A judgement about what’s relevant in this case
(experience)
• Leading to a risk formulation (skill)
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1.
Model contd/...
Framework contd/…
• Directly resulting in a time-specific plan of action that
will …
– Limit the role of risk factors in generating harmful outcomes and
– (Ideally) enhance the role of protective factors in inhibiting
harmful outcomes
• Which will in turn inform risk assessment and
subsequent management (an individual plan)
• Back to assessment and management, over and over
again (a dynamic, flexible plan)
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1.
Model contd/...
Frame clinical judgement about risk in
this way:
Under what conditions and over
what time period might what
kind of risk occur?
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2.
Structured professional
judgement & risk formulation
Features of structured professional judgement tools
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Tools are for use in key risk areas
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Violence, sexual violence, etc.
They make very much more explicit the operation of
this framework based on empirical evidence
Prevention not prediction is the objective of their use
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2.
SPJ & risk
formulation contd/…
Features of structured professional judgement tools
contd/…
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Rely on clinical expertise with a structured
application
Rational and empirical selection of risk factors
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Based on review of scientific (empirically-based) and
professional literatures
Not sample-specific - broad-based applicability and
generalisability
Inclusion of most potentially relevant risk factors
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2.
SPJ & risk
formulation contd/…
Plus the facility to identify …
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Critical risk factors
Strengths (or protective factors) increasingly relevant
Idiographic (or signature) risk or protective factors
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Facilitating flexibility and case-specific considerations
Practice of shared risk formulations and
multidisciplinary collaboration encouraged
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Supports professional judgement
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2.
SPJ & risk
formulation contd/…
Structured Professional Judgement (SPJ)
approaches …
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Offer practice guidelines …
For specific behaviours (e.g., violence, sexual
violence, stalking/harassment, domestic violence,
self-harm/suicide, self-neglect, victimisation, etc) …
Across a range of populations (adults, young people,
service users with cognitive impairment, etc)
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2.
SPJ & risk
formulation contd/…
How does SPJ work?
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2.
SPJ & risk
formulation contd/…
Step one:
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Collate relevant information
Personal, social and forensic history
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Using multiple methods
Using multiple sources
Considering multiple domains of functioning
Updating old/out-of-date information on risk factors
Documenting information reviewed
Evaluating the adequacy of information reviewed
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2.
SPJ & risk
formulation contd/…
Step two:
Identify those risk factors that are present in the
case presently being assessed
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NB. Numbers are NOT involved
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2.
SPJ & risk
formulation contd/…
Step three:
Make a professional judgement about the
relevance of those risk factors to this individual’s
violent conduct
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2.
SPJ & risk
formulation contd/…
Broadly, a risk formulation is an analysis of ...
• Specific risks (e.g., sexual violence, violence, stalking,
domestic violence, etc)
• Offending and other linked behaviour leading to
identification of relevant risk factors, highlighting critical
and signature risk factors and protective factors
• Interactions between risk factors over time
– Including short-term triggers
• Taking into account possible future circumstances
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2.
SPJ & risk
formulation contd/…
Specifically …
Consider the different models of formulation:
• Therapeutic formulations (CBT, CAT, SFT, etc)
– However, such formulations offer little guidance for decisionmaking about the offending process or the future
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2.
SPJ & risk
formulation contd/…
Specifically …
• (Offending) behaviour formulations
– Antecedents – Behaviour – Consequences (ABC)
• Limited to specific behaviours
– Predisposing, Precipitating, Perpetuating, and
Protective (PPPP or 4Ps)
• More comprehensive but also complex
– Motivators (or Drivers), Destabilisers, (Dis)inhibitors
(or 3Ds)
• Also comprehensive but complex
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2.
SPJ & risk
formulation contd/…
Step four: Risk scenario planning
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Scenarios are ‘possible futures’
Consider more than one
In constructing scenarios, consider:
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nature of future harm
severity of future harm
imminence
frequency or duration
likelihood that harm will actually occur
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2.
SPJ & risk
formulation contd/…
Step five: Risk management strategies
– Treatment:
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Supervision:
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what restrictions on activity, movement, association, or
communication are indicated?
Monitoring:
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treatment strategies relevant to risk management;
treatment priorities
identification and detection of (early) warning signs,
indicators of change in risk
Victim safety planning:
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what steps could be taken to enhance the security of the
victim?
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2.
SPJ & risk
formulation contd/…
Step six: Summary Judgments
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Prioritisation – case, treatment / management needs
Need for immediate action & on what?
Risk of serious harm (impact)
Range of risks indicated (e.g., harm, self-harm/
suicide, self-neglect, victimisation)
Frequency of review, and review of what?
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Inc. the sell-by date of the report
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2.
SPJ & risk
formulation contd/…
Process revisited with formulation
1. Gather information
2. Rate presence of risk factors
2a. Ask WHY did these offences/behaviours happen?
3. Rate relevance of risk factors
3a. Establish whether and how relevant risk factors cluster
or coalesce
4. Determine 2+ future scenarios
4a. Identify critical risk factors
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2.
SPJ & risk
formulation contd/…
Process contd/…
4b. 4P/3D table – why and how will offences/ behaviours
happen in the future
5a. Consider blue sky risk management options –
treatment, supervision, monitoring, victim safety
planning ALL linked to relevant risk factors and risk
formulation
5b. Consider essential risk management options from
those examined above
6. Summary judgements
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A SHORT CASE STUDY
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3.
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Way forward in risk
management planning
Collaboration
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Differentiate between predisposing factors and
precipitating or trigger factors
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With colleagues and with the client
And think about motivation
Think about factors that maintain offending behaviour
Pay attention to protective factors or strengths for their
role as offence inhibitors and as a way of gaining
collaboration
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3.
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Way forward in risk
management planning contd/…
Attend to risks in multiple areas: consider the bigger
picture
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Make revisions to individual risk factors and risk
formulation on the basis of effective – ineffective – risk
management
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Harm, self-harm, suicide, self-neglect, victimisation, self-neglect
Risk assessment and management is an iterative process
If possible, measure effective (effectiveness of) risk
management
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Multiple administrations of short-term assessments
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3.
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The way forward in risk
management planning contd/…
Protect the victims of offenders
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Target hardening
Aim for transparent risk assessment and risk
management planning over time
Be realistic!
Measuring prevented violence as a novel research
objective
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3.
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The way forward in risk
management planning contd/…
A note on writing:
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Attend to grammar – avoid sloppy writing – makes your
thinking look sloppy
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“Failure to proofread is like preparing a magnificent dinner
and forgetting to set the table, so that the wretched guests
have to scramble for the food with their hands.”
Jessica Mitford, The Making of a
Muckraker, 1979; p22
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3.
The way forward in risk
management planning contd/…
RMA Risk Management Standards
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Collaborative working
Risk assessment
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The foundation of risk management
Planning
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To achieve clarity about objectives, to maintain proportionality,
to coordinate action
Risk management strategies
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How to actually achieve risk management objectives
Resulting in a preventative action plan and a contingency
action plan
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3.
The way forward in risk
management planning contd/…
RMA Risk Management Standards
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contd/…
Accommodation and community management
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Essential
Responding to change
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7.
A dynamic process
Organisational
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Risk management needs resources and skills!
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Conclusions
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Prevention rather than prediction
Tools exist to give structure to your clinical judgement
The framework for clinical risk assessment is
applicable whatever the circumstance
Risk
assessment
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Risk formulation
Risk
management
Contact Information:
Dr Caroline Logan
Psychological Services Directorate
Ashworth Hospital
Parkbourn
Maghull
Liverpool L31 1HW
Tel: 0151 471 2420
E-mail: [email protected]
web: www.rmascotland.gov.uk
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