Group cohesiveness

Within a mental health team, there is likely to be more than one clinician involved in the care of a patient and even if there is only one clinician directly involved, the patient’s care will be discussed in a MDT format. The cohesiveness or otherwise of the staff group can have a large bearing on risk management. Group cohesiveness can break down for several different reasons, such as weak leadership or one clinician holding a grudge against another. Any psychological process affecting an individual clinician can also affect the MDT as a group. As is the case with individual staff, the capacity of the group to think and reflect may be impaired in a setting of risk and perceived danger.¹

For example, if the psychiatric registrar is anxious about the care of the patient, this may make other clinicians anxious and the whole team becomes risk-avoidant. This will then need to be managed as a team problem. Conversely, if the MDT is supportive, anxiety will be lower and the risk thermostat for the team will be set differently.

Another influence on group decision-making is the concept of ‘groupthink’.^{2, 3} Groupthink is a type of thought exhibited by group members who try to minimise conflict and reach consensus without critically testing, analysing and evaluating ideas. Individual creativity, uniqueness and independent thinking are lost in the pursuit of group cohesiveness. During groupthink, members of the group avoid promoting viewpoints outside the comfort zone of consensus thinking. Groupthink may cause groups to make hasty, irrational decisions where individual doubts are set aside for fear of upsetting the group’s balance. Groupthink is more likely to occur in situations in which there is directive leadership, the group perceive themselves as being under stress from external threats or where there are excessive difficulties in the decision-making tasks. Moral dilemmas are also likely to invoke groupthink.

Difficult risk decisions often have to be made when a group feels threatened or when there are moral dilemmas. Groupthink should be considered if risk management in the MDT is problematic. It is likely that groupthink occurs not infrequently in MDT settings and should be considered as a cause of poor decision-making even when the MDT feels cohesive.

Clinicians as custodians

Inpatient mental health services are often given the task of being custodians of patients and ensuring that they cannot leave. The conflict between being custodial and trying to be therapeutic at the same time can create tension and anxiety which may challenge group cohesiveness. It is possible for the requirements of custodial care to become paramount in the minds of staff and when this occurs, a power differential will be created in which therapeutic relationships cannot occur. The capacity to explore risk issues with patients is then substantially decreased and any information which is gathered may well be compromised by the power differential which is present.

Clinicians perceiving patients as hostile

When some clinicians perceive a patient as being hostile and ‘negative’ and other clinicians perceive the same patient as being helpless and a victim of their circumstances, tension will be set up within the staff group. This is sometimes diagnosed as the patient ‘splitting’, which may be correct; for example, ‘the manipulative patient’, but any tension or conflict within the staff group needs to be recognised as well. The classical scenario is of an inpatient who ‘threatens’ to self-harm on the ward. It is not unusual for some clinicians to feel that the patient is fully in control of their actions and to say that they are just manipulating the situation to get attention, and for other clinicians to say that the patient can’t help their feelings. In these situations, risk assessment can be sabotaged by dissenting clinicians.

A more problematic scenario is one in which there is group solidarity against one particular patient who becomes the perceived enemy. In some units, there may be subtle processes set up to avoid admitting new patients, thereby avoiding the risk. If there are clinicians who want to admit the patient, they may well be ostracised and group cohesiveness goes out the window.

It almost goes without saying that the team leader needs to have good skills in risk assessment and management in order to not to have to rely on his/her authority. Being able to model best practice and create a climate in which risk assessment is seen as being core business is vital.⁴

All of these questions should be in the mind of the team leader and there should be sufficient time for the team to reflect on these issues.

In summary, utilising collective judgment is likely to improve the quality of the risk assessment as long as the ‘collective judgment’ is not distorted by pathological processes working within the group.⁵

See Murphy’s Risk Assessment As Collective Clinical Judgment (2002)⁶ for a more detailed discussion of this topic.

Exercise 1 — level of risk changing over time

Alison is 45 years old and is suffering from a major depressive disorder with current suicidal intent. She has made one attempt at suicide in the past. Her treatment for previous episodes of depression has included hospitalisation, ECT and prophylactic antidepressants. Her very supportive family is coming to the end of their capacity to cope with her suicidal depression and asks for your help. You want to admit her to

hospital because you feel that her suicidal intent is acute. You know that if you admit her to hospital, she will be taking the last available bed and this is the beginning of the weekend.

As you read this, consider where your risk thermostat is set. What are the factors that have influenced its setting? Identify the systemic components which may affect your risk management. Possible answers to this exercise appear in Appendix 3.

(The management of these issues will be covered in Part 2.)

Other systemic issues which will have a bearing on risk assessment and management include:

Some of the bullet points above are related to organisational issues and are beyond the direct influence of individual clinicians. Nonetheless, it is important to recognise the influences which these systemic issues may have on risk management of individual or groups of patients. Part 4, advanced skills, explores some of the organisational issues and is primarily written for senior clinical staff. For individual clinicians, however, it is vital to remember to include others (not least the patient and their families) in the assessment and management of risk and not to feel that there is no-one else involved in the management of it. Remember, nearly all clinicians work in a team and have many other resources available to assist in developing and implementing risk management and treatment plans.