Risk management

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Chapter 12 Risk management

Psychiatric risks (chiefly violence to self or other) are manifestations of suffering, and addressing the suffering is the primary way psychiatrists and other mental health care workers should address risk.1

Risk management in a mental health setting is the task of minimising the likelihood of an adverse outcome whilst maintaining a focus on good treatment.

The quote below first appears at the beginning of the book, but it is useful to cite it again here as the message is very important.

Much medical effort goes into managing the risks of complications of disease processes rather than managing the symptoms of the disease itself. Hypertension is the classic example, with no symptoms but plenty of treatments, all aiming to reduce the risk of complications such as strokes and myocardial infarctions. Psychiatry’s misfortune has been to choose diseases where the complications … are homicide, suicide or reduced capacity for self-care and vulnerability.2

This problem becomes the nub of risk management within mental health. On the one hand clinicians try to treat the illness whilst at the same time managing the risk which is often a complication of the disease process rather than a symptom of the disease itself.

Given the examples that have been worked through in this book, it will be apparent by now that risk management is a combination of all the processes that have been described so far. The task now is to combine them into a whole and ensure that the effectiveness of the risk management can be evaluated.

Risk management on its own is meaningless. It is only when it is incorporated into the treatment of the patient’s illness with a focus on recovery that it develops meaning. Before considering anything else, consider the illness. Sometimes in mental health there is no choice but to live with high risk whilst instituting appropriate treatment for the illness. This is no different to any branch of medicine. A pitfall in risk management for clinicians is instituting containment to reduce the risk which does not necessarily improve the outcome for the illness and which may also generate other risks.

EXAMPLE

A common example would be the risk-avoidant clinician with a very low threshold for admission to hospital who unwittingly creates dependence in his or her patients. The dependence created may lead to deterioration of the illness, possibly to chronicity and to further risk.

Trying to incorporate clinical management into risk management tends to lead to an approach in which the illness takes secondary importance. It is more effective to incorporate risk management into clinical management.

Risk management starts from the beginning of the first assessment and continues until the patient is discharged. It involves a series of decisions, some small and some large, made with the patient and often their family over the course of their path through mental health services.

The clinician does not need to predict behaviour in the next 5 years or even 6 months, but only until the next outpatient appointment or home visit by the community psychiatric nurse.3

Imminence and level of risk is assessed during each meeting with the patient and is guided by the risk management plan. (For inpatient settings, this may be formally undertaken on a daily basis but in an outpatient setting, this should occur each time the patient is seen.)

As well as routine management of clinical risk, good risk management should also be able to cover the following situations:

• calculated risk-taking when the level of risk will remain high

• situations in which staff anxiety will remain high

• situations in which it may be contraindicated to reduce the level of risk

• situations in which the proposed management is counterintuitive.

EXAMPLE

The classical situation in which these bullet points arise is when a management plan for a patient with chronic suicidality is first implemented. The plan will often encourage a focus of the patient taking more responsibility for themself whilst continuing to get support from the mental health service. If the self-harming behaviour (e.g. cutting) has been reinforced by frequent long admissions to hospital or by extra phone calls, the shift of focus may cause an escalation of self-harming behaviour in the short term. This should be anticipated and discussed with the patient who will be encouraged to utilise distress tolerance techniques that they will have been learning within their individual and/or group therapy. Nonetheless, there is a real risk of cutting becoming deeper, the patient feeling rejected, and the family being more concerned. The intuitive response is to not create more distress for the patient, which in the short term would help but in the long term would be negligent. Clinician anxiety during these times is often high. (See also the example of Sally, page 115.)

Risk management can be separated into two parts: management of the risk in the here and now and planning for the future. In practice, the two parts tend not to be divided as the management of the current situation should also be future oriented. A risk management plan can be used as a ‘decision support tool’4 both in the acute situation to facilitate immediate intervention as well as for implementing interventions over a longer period.

The tasks of risk management (after the assessment is complete)

1. Decide which treatment option to take and which risk(s) should be managed.

2. Managing risk factors in the context of illness.

3. Managing any other contextual matters.

4. Managing the potential consequences (risk mitigation).

5. Communicate the plan to the patient, other clinicians involved and others involved in the patient’s care.

6. Document, document, document.

7. Implementation.

8. Review and evaluation.

1 Treatment options and risk

This will occur after the assessment and may involve the risk/benefit analysis (see Chapter 10).

2 Managing the risk factors (specific strategies)

To recap:

Likelihood = static risk factors + dynamic risk factors

Once the decision has been made to follow a particular course of action, and the risk/benefit analysis has been documented, the management of the risk factors can be considered. This is no different to routine clinical practice.

The management of both the static and the dynamic risk factors is one which is discussed amongst the treatment team, the patient and family. The focus of trying to reduce the likelihood of the event occurring will invariably focus more on the dynamic factors as the static factors will not change. There is no rank order for predictors. The only change which may occur with the static factors is the patient’s adaptation to them. ‘The value for the clinician is in the interaction of the factors.’5

How frequently the risk factors are reviewed will be dependent on the setting. In services in which levels of risk are used, there should be a schedule for formal reviews to be undertaken whilst other services will determine the frequency of reviews dependent on clinical judgment. In either case, the process will be the same: a review of the risk factors. In services in which standardised rating scales are used, there will be specific risk factors which are reviewed on a regular basis. In those services in which structured clinical judgment is used without standardised rating scales, those risk factors specific to the patient will have been identified and can be considered individually. Some clinicians use simple scales — present, partially present or absent — whilst others may wish to review the efficacy of the interventions.

This step is usually indistinguishable from good clinical management of the disease process. As well as treating and managing risk factors, assessment and interventions for the early warning signs (EWS), triggers and relapse indicators should be undertaken. The aim of looking forward is to anticipate repetition of the context.6 This is the stage when the patterns which were identified as making the risk behaviour more likely are managed. This step is the central task of risk management.

EWS and triggers which may make the risk behaviour more likely are not the same as risk factors. EWS are often more subtle signs, such as irritability, loss of self-care, pre-occupation, etc. These will often be noticed by others before the patient notices them. Developing an awareness of precursors of the risk factors makes the likelihood of early intervention more possible. There will often be overlap between the risk factors, EWS and triggers. In practice it does not matter where they are documented as long as interventions are developed.

Identification of early warning signs (EWS)

Example 1

Chris is a patient with bipolar affective disorder. He usually presents with episodes of mania but has had two episodes of major depressive disorder. He enjoys the early stages of his manic episodes as he has more energy, feels invulnerable and has lots of creative ideas which he would like to incorporate into his business. Because these ideas have not been thought through, when he has implemented them, the business has often lost large amounts of money. Most of his admissions for mania have occurred several weeks into a relapse and have necessitated involuntary admission. His wife notices the early warning signs of a relapse long before Chris does. She notices that he does not sleep well, that he becomes sexually demanding and that he takes a greater interest in fitness than is usually the case for him.

Example 2

John is a patient with schizophrenia, paranoid type. During previous episodes of illness he has hit members of the public for no reason that was immediately apparent. His parents, with whom John lives, have noticed early warning signs of John relapsing into illness and also being more likely to become violent. He withdraws into his room, becomes less communicative and tends not to join them at mealtimes. He begins to pick arguments with his father.

Example 3 — clinical example

Sally is a 24-year-old woman with BPD. Over the last 3 years, she has made repeated superficial cuts to both her forearms at times of distress. Her family have been very concerned that these are attempts at suicide, and on 12 occasions she has had admissions to hospital. Sally has become very close with two of the nurses on the ward.

In recent weeks, as a result of a review of her treatment, education for Sally and her family, and the implementation of dialectical behaviour therapy (DBT), Sally has agreed to utilise some different techniques to try and change the pattern of behaviour. Even though Sally and her family realise that this will be difficult, and that she may actually find herself cutting more frequently for a period of time, she says that she won’t. In fact, much to her distress over the next 3 weeks, she does cut herself more frequently and it is only when she is able to identify how much she misses the two nurses on the ward within her individual therapy, and with her family declining to take her to the ED after each episode, that the frequency of her cutting diminishes dramatically.

Summary of specific strategies

Consideration will need to be given to the threshold for and imminence of the risk behaviour occurring. The concepts of signature risk signs (page 20), critical risk factors (page 20) and risk scenarios (page 34) will help in this regard. For example, if an impulsive patient has a history of being violent with little obvious provocation, violence may always be close by. For other patients, it may take immense provocation for them to become violent.

Sometimes it may be necessary to put short-term measures in place to reduce acute risk whilst waiting for the illness to settle.

A risk management plan will always complement and be a component of a fuller clinical treatment/management plan. The risk documentation should be placed in the patient’s file in such a way that it is easily accessible for all clinicians and written in such a way so that the risk factors, early warning signs and relapse indicators can be cross-checked against the patient’s mental state and external circumstances on the day that they are seen. Working with the patient and their family so that they all have copies of the risk and treatment plans makes this easier. This will also go a long way to increasing the likelihood of the management plan being feasible, the patient having better support and being less likely to be exposed to destabilising influences. These latter three factors rate highly in the Historical/Clinical/Risk Management 20-item (HCR 20) scale7

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