Risk assessment and safety planning or risk management are central components of mental health practioners' roles. A recovery orientated-approach to care has implications for safety management practices and requires mental health services to resolve the tension between supporting self-determination, choice and positive risk taking within medico-legal requirements and duty of care. Managing risk in a manner that supports an individual’s recovery and autonomy can be challenging and requires practitioners to think about risk not as something to be eliminated from people's lives but as opportunities for personal growth and development. At the same time, positive risk must be balanced with the client's and publics' right to be protected from negative outcomes.
At the end of this sub-unit, you will be able to:
To work in a recovery oriented way with risk, practitioners need to be mindful that all risks can never be completely eliminated from the person's life. Hence, practitioners need to engage with the risks posed rather than seeking to control or eliminate them all. Practitioners also need to support people experiencing mental health problems to take decisions that involve an element of risk. In keeping with the recovery principles, practitioners need to work collaboratively with the person to identify factors influencing risk, protective factors and strategies to help the person remain safe, whilst supporting them to grow and develop personally.
Several terms have been used to describe a positive risk approach, including ‘responsible risk-taking’ ‘positive risk-taking’, ‘positive risk-management’ and ‘creative risk-taking’. Morgan (2011: 6) defines positive risk as “weighing up the potential benefits and harms of exercising one choice of action over another. Identifying the potential risks involved (i.e. good risk assessment), and developing plans and actions (i.e. support for safety) that reflect the positive potentials and stated priorities of the service user (i.e. a strengths approach). It involves using ‘available’ resources and support to achieve the desired outcomes, and to minimise the potential harmful outcomes.”
It is important to remember that the term ‘positive’ relates to the desired outcome of enhanced growth and personal development and not to the risk itself.
Recovery-based risk assessment practice
Read the ‘Implementing Recovery through Organisational Change’ (IMROC) briefing document which sets out a critical perspective on current risk assessment and management practices and suggests ways these could be changed in order to facilitate a recovery-based approach.
Answer the following questions based on the IMROC briefing document:
What organisation-level factors that might influence the adoption of ‘safety planning’ approach as opposed to traditional risk assessment and risk management approaches by mental health professionals?
What clinician-level factors might influence mental health professionals’ willingness to adopt a risk-taking approach when working collaboratively with service users?
Critical perspective on the language of ‘risk’
There are numerous barriers to practitioner's communicating with service users about risk or safety issue, including fears about negative reactions from service users, differences in perceptions of risk and differences in the use of language.
Watch this service user narrative in which a critical perspective is offered on the language of ‘risk’ versus the language of ‘safety’ in interactions between mental health professionals and service users.
Answer the following reflective questions:
Thinking about this service user narrative, summarise why Andy finds the use of the word ‘risk’ stigmatising in interactions with mental health professionals?
Application of Best Practice Principles
In order to support collaborative decision making within recovery orientated mental health practice and enable service users to actively participate; make informed decisions; and take responsibility and control over their own lives, a fundamental shift in thinking around the meaning of risk and risk taking is required.
Read Higgins, A., Morrisey, J., Doyle, L., Bailey, J & Gill, A. (2015). Best Practice Principles for Risk Assessment and Safety Planning for Nurses in Mental Health Services’. Dublin: Health Services Executive
Watch the video case study about John
Reflect on the ‘Best Practice Principles for Risk Assessment and Safety Planning’ report and on John’s video case study. Answer the following questions in relation to how you might approach risk management and safety planning for John in a way that promotes autonomy and recovery.
Using the framework in the Best Practice Guidelines (risks to self, risks to others, risk from others and iatrogenic risks), what risks do you consider might be relevant when working with John?
What might be the differences and similarities between John’s perceptions of any risks he is facing and a clinician’s views?
What steps would you take to engage and work collaboratively with John to assess and manage risk/safety?
What strengths, abilities and protective factors can you identify from John’s case study that may help support John’s safety?
In this section we have considered risk assessment and safety management strategies that facilitate recovery- and strengths-based approaches. The importance of communication, language and power relations in the risk assessment process was highlighted through the service user narrative. This narrative underlines the importance of approaching risk assessment or safety planning in a non-judgemental way and underscores how the use of stigmatising language can negatively impact on the therapeutic relationship and service user's experiences of care. Methods for managing risk and safety planning in a positive, non-stigmatising way were presented.
The best practice principles underpinning the process of risk assessment and safety planning are: supportive collaborative decisions making; assessment of risk through talking and using tools; exploring risk and protective factors; working towards and promoting positive risk taking; and involving and working with others in formulating a safety care plan. All of these principles are embedded in a commitment to therapeutic engagement. Risk assessment and safety planning is an ongoing process that involves: making clinical judgments in collaboration with others (MDT, service user and family); identifying risks, triggers and protective factors; and developing safety plans that promotes the positive potential and wellbeing of the person. Working with risk involves balancing the person's right to self determination with duty of care within the parameters of professional, legal and ethical responsibilities.
Higgins, A., Morrisey, J., Doyle, L., Bailey, J. and Gill, A. (2015). Best Practice Principles for Risk Assessment and Safety Planning for Nurses in Mental Health Services Dublin: Health Services Executive.
Langan, J. and Lindow, V. (2004). Mental health service users and their involvement in risk assessment and management. Bristol: Joseph Rowntree Foundation/Policy Press
Morgan, S. (2004). Strengths-based practice. Openmind 126: pp. 16-17.
Morgan, S. (2011). Positive Risk-Taking. Practical ways of working with risk. A Practice Based Evidence production for Hampshire Partnership NHS Foundation Trust.
Slade, (2009). The contribution of mental health services to recovery, Journal of Mental Health 18: pp. 367-371.
Stickley, T. and Felton, A. (2006). Promoting recovery through therapeutic risk taking. Mental Health Practice 9(8): pp.26-30.
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