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A Collaborative Approach to Formulating Risk Management Plans in a Secure Unit for People With Intel


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Title: A Collaborative Approach to Formulating Risk Management Plans in a Secure Unit for People With Intel

A Collaborative Approach to Formulating Risk
Management Plans in a Secure Unit for People With
Intellectual Disabilities
Ms Louise Roberts, Forensic Clinical Psychology
MSc Student, Institute of Psychiatry Dr Anne
Sheeran, Consultant Clinical and Forensic
Psychologist, Tarentfort Centre Tarentfort
Centre Kent Forensic Psychiatry Service Forensic
Learning Disability Service Dartford,
Kent tarentfortcentre_at_kmpt.nhs.uk
  • Why Are We Using START?

The Tarentfort Centre
  • The Tarentfort Centre offers inpatient provision
    to male service users, aged 18 over with an
    Intellectual Disability (ID) whose offending
    behaviour and mental health needs require that
    they are detained under the Mental Health Act in
    secure conditions.
  • The service consists of an Acute Unit (10 beds)
    and a Rehabilitation Unit (10 beds).
  • Treatment, care and support is provided by
    multidisciplinary teams, conforming to the Care
    Programme Approach and the principles of Valuing

Assessing and Managing Risk
  • Within risk assessment tools there is a division
    between historical (or static) and dynamic
  • Historical static factors (such as gender or
    victim of child abuse) provide a vital foundation
    to assessing risk, but offer little guidance to
  • Historical factors also have limited ability to
    discriminate between individuals in forensic or
    inpatient settings (Ferguson et al., 2005 Serper
    et al., 2005).
  • There is restriction within current risk
    assessments to attend to dynamic factors
    (Nicholls et al., 2006).
  • Structured Professional Judgement (SPJ) schemes
    use actuarial scores and structured assessment to
    inform and support clinical decisions.
  • Actuarial variables are empirically derived (i.e.
    Violence Risk Appraisal Guide, Quinsey, Harris,
    Rice Cormier, 1998).
  • The use of SPJ tools in assessing and managing
    risks presented by inpatients has received
    growing empirical support.
  • By using dynamic actuarial variables we can use
    empirical research to guide our assessment of the
    aspects of the individual which changes over

The Use of Clinical Support Guides in ID
  • There has been increasing research in the area of
    assessing and managing risk, however research
    into risk assessments within ID populations is
    comparatively limited (Lindsay Beail, 2004).
  • Despite this, research into offenders with ID has
    grown over recent years, and there is preliminary
    evidence regarding the predictors of recidivism
    in this population (Lindsay, Elliot Astell,
  • While not designed specifically for use in this
    population, structured risk assessment tools such
    as the HCR-20, VRAG, and Matrix-2000-C have been
    shown to have discriminative and predictive
    validity when used with ID offenders (Lindsay et
    al., 2008).
  • Prevalence of acts such as arson and sex offences
    may be higher relative to other types of crimes
    in individuals with ID (Simpson Hogg, 2001),
    indicating that assessments tools primarily
    focused on the risk of violence to others, may
    not be as appropriate for this population as more
    comprehensive risk assessments.
  • It has also been argued that assessments for risk
    for violence to self and harm to others ought to
    be combined and considered in conjunction with
    each other (Hillbrand, 2001).

User-focused risk assessment
  • Valuing People (DoH, 2001) is a White Paper
    giving guidelines on improving the lives of
    individuals in England with intellectual
  • This government directive aims to improve
    recognition of individuals rights, social
    inclusion, choice in daily lives, and
    opportunities to be independent. This therefore
    forms a context within which work at Tarentfort
    is conducted.
  • By adopting a more comprehensive risk assessment
    that incorporates patient strengths, we are
    better equipped to meet these aims.
  • Person Centered Planning is a process of life
    planning for individuals whereby the individual
    is central and is comprehensively and fairly
    represented and involved in the management of
    their care (Felce, 2004).
  • Incorporating strengths in addition to risks, as
    well as enabling patients to contribute to their
    own assessment adheres and develops this approach
    (Parley, 2001).

Multidisciplinary approach
  • START is designed to integrate the ideas of a
    number of mental health specialists who work
    together as a team (Webster et al., 2004).
  • Department of Health Best Practices in Risk
    Management states that,
  • Risk management plans should be developed by a
    multidisciplinary and multi-agency teams
    operating in an open, democratic and transparent
    culture that embraces reflective practice
  • At the Tarentfort Centre a range of professionals
    collaborate as part of a Multidisciplinary Team
    (MDT), including psychologists, psychiatrists,
    social workers, occupational therapists, nurses,
    healthcare workers, doctors, speech and language
    therapists and other mental health professionals.
  • Approaching risk assessments using a
    multidisciplinary approach not only combines the
    skills and knowledge of different professions,
    but also promotes informed discussion, which is
    required for effective risk management (Webster,
    Muller-Isberner Fransson, 2002).

Forming Comprehensive Assessments of Risk
  • There have been substantial advances in assessing
    the risk of violence.
  • However, there are far fewer developments in
    assessing other possible negative outcomes.
  • Mental health professionals are often required to
    comment on an individuals risk to self, or
    inability to care for self.
  • Mental illness is associated with the individual
    being14 times more likely to become a victim of
    violent crime than to be arrested for one
  • Risk of suicide is significantly higher in
    individuals with a mental disorder
  • Is it therefore appropriate to focus efforts on
    assessing the risk of violence to others to the
    detriment or neglect of other risk

Best Practice in Managing Risk
  • Department of Health guidelines for the Best
    Practice in Managing Risk states that
  • Risk management must be built on a recognition
    of the service users strengths and should
    emphasise recovery
  • Many current risk assessments only focus on risk
    factors, without acknowledging protective
    factors. By doing this the individuals strengths
    cannot be fully recognised, and consequently the
    process of recovery may not be adequately
  • Risk management must always be based on
    awareness of the capacity for the service users
    risk level to change over time, and a recognition
    that each service user requires a consistent and
    individualised approach
  • Static, historical factors do not allow us to
    fully capture the potential for change over time
    in the individuals level of risk. By using
    dynamic tools we can more adequately address this

Strengths and Protective Factors
  • A comprehensive risk assessment designed to
    assist in the development of intervention
    strengths should take into account such positive
    features (Hart et al., 2003).
  • Risk assessments currently do not typically give
    consideration to patients strengths (Nicholls et
    al., 2006), and can stress risk factors to the
    extent that protective factors are neglected
    (Rogers, 2000).
  • In contrast START represents the potential to
    incorporate protective factors into the
    assessment of risk, and therefore guide
    therapeutic progress within risk management.
  • By doing this we are better able to follow a
    Person Centred Approach, as well as adhering to
    Valuing People.

  • What is it?

Short Term Assessment of Risk and Treatability
  • The Short Term Assessment of Risk and
    Treatability (START) is a new tool for assessing
    the risks presented to both self and others by
    mentally disordered individuals (Nicholls, Brink,
    Desmarais, Webster Martin, 2006).
  • It was developed with forensic mental health
    units and services in mind, and is intended for
    use with both inpatient facilities and outpatient
    services (Webster, Martin, Brink, Nicholls
    Middleton, 2004).
  • START has been shown to have concurrent validity
    and inter-rater reliability in a prospective
    validation study of a forensic psychiatric sample
    (Nicholls et al., 2006).
  • Evidence of a relationship between START scores
    and observed aggression has also been confirmed,
    as has high acceptability among staff regarding
    ease of use of the instrument (DoH, 2007).
  • However, as of yet, the use of START with ID
    samples has not been evaluated.

START Domains
  • The START is comprised of 7 overlapping risk
  • Risk to others
  • Self Harm
  • Suicide
  • Self-Neglect
  • Substance Abuse
  • Unauthorized Leave
  • Victimization

START Domains
  • These domains are all assessed according to
    dynamic risk factors, and are scored for both
    strengths and risks simultaneously.
  • Dynamic variables contribute greatly to the
    assessment of acute and short-term risk of
    violence (Gray, Snowdon McCulloch, 2004).
  • While historical factors are still of importance,
    START can be used to focus assessments of the
    factors of imminence.
  • In this way START does not need to supplant
    assessments such as the HCR-20, but can form a
    more dynamic assessment to contribute to
    short-term clinical assessment, for example
    replacing the need to continually reassess
    clinical and risk management factors of the

  • The START assessment is compromised of 20 items,
    with two further case specific items.
  • These 20 items are scored for both risks and
    strengths separately on a three-point scale from
    zero to two.
  • Social Skills - Poor social skills is associated
    with difficulty establishing and maintaining
    stable peer and therapeutic relationships
    (Andrews Bonta, 1995).
  • Relationships people who threatened violence
    felt threatened (Estroff Zimmer, 1994).
    Unstable or destructive relationships are risk
    factors for both violence and self-harm and
    suicide (Lipsey Derson, 1998 Vanderhoff
    Lynn, 2001).
  • Occupational Employment serves to both develop
    the constructive use of time, as well as to
    improve self esteem (Banks et al., 2001
    Charleston, Grossi Mank, 2001).

  • 4. Recreational Activities provide the
    opportunity to develop skills and build
    supportive social relationships with others
  • 5. Self-Care The ability to care for self
    has been stressed to be of particular importance
    by psychiatrists forming decisions regarding the
    admittance of individuals through psychiatric
    emergency services (Way Bans, 2001).
  • 6. Mental State The presence of psychosis is
    associated with higher rates of violence
    (Monahan, 1992), and particular types of delusion
    have also been correlated more highly with risk
    of violent behaviour (Swanson et al., 1996).
  • 7. Emotional State Emotional state impacts upon
    reason, decision making, actions, memory and
    attention (Dolan, 2002). Affective states are
    involved in the motivation of behaviour.

  • 8. Substance Use Research indicates a potential
    interaction between substance abuse and mental
    illness (Steadman et al., 1998). Dually diagnosed
    patients have twice the average readmission rate
    and longer lengths of stay in acute care (Hunt,
    Bergen Bashir, 2002).
  • 9. Impulse Control Impulsivity is a crucial
    aspect of antisocial personality and psychopathy
    (Hare, 2003).
  • 10. External Triggers the risk of antisocial
    and aggressive behaviour is increased by features
    of the larger social environment (Hodgins,
  • 11. Social Support Social support can act as a
    protective factor in the face of stressful life
    changes, helping the individual to manage and
    reduce stress (Webster et al., 2004).

  • 12. Material Resources The lack of material
    resources acts as a fundamental risk factor to
    disruptive, aggressive and violent behaviour
    (Hsieh Pugh, 1993).
  • 13. Attitudes Negative attitudes are a strong
    risk factor for a criminal lifestyle (Andrews
    Bonta, 1994), and have been associated with
    deviant behaviour in both the community and
    institutional settings (Quinsey et al., 1997
    Gendreau, Goggin Law, 1997).
  • 14. Medication Adherence There is a close
    association between medication non-compliance,
    deterioration in mental state, and readmission to
    hospital (Swartz et al., 1998).
  • 15. Rule Adherence The ability to adhere to
    rules is dependent upon a number of factors, and
    impacts on the individuals ability to engage in
    treatment and other means of progression (Webster
    et al., 2004).

  • 16. Conduct Extensive evidence supports the
    prediction of future violence from prior violent
    behaviour (Douglas Webster, 1999).
  • 17. Insight This remains a vital construct in
    day-to-day clinical practice (Vaz, Bejar
    Cassado, 2002).
  • 18. Plans Goal setting provides the map for
    the treatment plan (Reesal Lam, 2001).
    Effective, positive planning involves the
    capacity to make decisions that ensure the safety
    and well-being of the self and others (Webster et
    al., 2004).
  • 19. Coping This is important in regards to a
    both a risk of self-harm and suicide, and risk of
    harm to others (Mortensen, 1997). Coping may help
    individuals to manage or reduce stress and
    symptoms, therefore alleviating or reducing the
    impact of their risk factors (Webster et al.,
  • 20. Treatability This is dependent on a number
    of factors, including contextual issues, degree
    of insight, treatment readiness and treatment

Implementation of START
  • The Process

  • Consultant Psychologist already trained in SPJ
    attended training programme for START.
  • Whole day training programme devised for the
    first ward to implement START involved the
    whole MDT.
  • Training included theoretical background to risk
    assessment and management, the START itself, and
    group activities to conduct daily ratings and
    overall assessments of risks and strengths.
  • Subsequent training day for the second ward.
  • Further training sessions planned for new MDT

Daily Recording
  • Incident severity scales constructed to record in
    the seven areas, plus a section to record
  • Nursing and other staff add to these forms for
    each patient throughout each shift where
  • The forms are discussed in morning handover
    meetings with the whole MDT.

Incident Severity Scales
  • The daily Incident Severity forms were comprised
    from the 7 START areas in order to encompass the
    20 START items.
  • The forms consist of 14 areas of risk, 1 area for
    strengths, and 1 additional area for any other
  • Incidents are recorded according to item
    descriptors in each area, and are ticked
    according to time of occurrence (AM, PM or night)

START Interviews with Patients
  • Primary nurse and other members of the primary
    health care team interview the patient before the
    MDT START meeting.
  • The interview covers key areas related to
    patients views of their progress, their care and
    treatment, and their views of the future.
  • Structured but allows individual needs to be
  • Relies on good knowledge of the patient and
    relationship with staff not a questionnaire.

  • Quarterly START assessments for each patient (80
    per annum).
  • Initial assessment meetings convened subsequent
    reviews within CPA meetings and clinical team
  • Information collated from daily recording forms,
    interview, and MDT knowledge used to guide START
  • Risk management plans completed for factors such
    as access to activities, and also used to
    highlight treatment goals.

Integrating START
  • HCR-20/RSVP are standard for our patient group.
  • These are completed annually.
  • START requires good historical information too.
  • The information from the daily forms is used to
    complete the Trust CPA risk assessment document
    and included in clinical team meeting minutes.
  • This information also aids completion of HCR-20
    and RSVP.

Evaluating START
  • What Weve Found So Far

Responses to Training
  • All staff who attended training for START
    completed a feedback form regarding their views
    of the teaching and its content.
  • This revealed positive responses to training,
    with overall ratings ranging from Good to Very
  • Confidence in completing the START assessments
    was significantly associated with confidence in
    complete the daily Incident Severity forms.
  • Confidence in completing Incident Severity Scales
    was also significantly related to satisfaction
    with the outline of plans for risk.

Staff Views of Risk Assessments
  • A questionnaire was distributed to all staff
    before START was implemented, and again 4 months
  • This investigated staffs views regarding risk
    assessment and management, including what risks
    and strengths are pertinent to our client group
    at the Tarentfort Centre.
  • Preliminary results indicate a distinction
    between staff views on the Acute ward, as
    compared to the Rehab ward, which indicate
    significantly different views regarding the
    clinical relevance of risk assessments, in
    addition to the impact that risk management has
    on patients.

Predictive validity of START Findings so far
  • At present preliminary findings indicate a good
    correlation between predicted strengths (as
    indicated by scores from START assessments) and
    actual recorded strengths (from subsequent
    Incident Severity Scales).
  • It is of note that the correlation is currently
    higher for strengths than it is for risks
  • Does this reflect the management of risks and the
    encouragement of strengths?
  • Or may this reflect the nature of the Rehab ward?
  • Accuracy of incident recording is also of

Future Goals
  • What we aim to do with START

Whats Next?
  • - Continue to evaluate data
  • Develop standardised approach to interviewing
    patients prior to quarterly START assessments.
    Next training step interview workshop
  • Work towards including patients directly in START
    assessment meetings where appropriate
  • Whole day workshop for patients will include an
    exposition of START

Strengths of this Approach
  • Involves the whole MDT.
  • Flexible and translates directly into risk
    management plans for patients daily living.
  • Encourages recording of information and
    discussion amongst team.
  • Prevents patient risk assessment being frozen in
    time but also allows long term view.
  • Provides a means to illustrate change.
  • START daily forms will be used in relapse
    prevention groups and are also used in individual
    interventions when this is relevant.

  • From the ward perspective, START captures more
    behaviour specific information this is
    invaluable in accurate recording. kick-starts a
    robust risk orientated discussion every day at
    MDT handover
  • Ward Manager, Acute ward
  • Gives holistic picture of patient over the 3
    month period to enable comprehensive risk
    assessment and care plan to be developed The
    measurement scale will allow us to easily gauge
    improvements or relapses
  • Ward Manager, Rehab ward

..and Risks of this Approach
  • Emphasis on risks and strengths how to ensure
    that we do not lose sight of the whole person?
  • Collation of daily information if there is an
    Adult Protection event involving staff, there may
    be problems with confidentiality
  • Time allocation for MDT assessment meetings has
    proved more problematic than anticipated
  • Although other sources state that START
    assessments take less than 10 minutes (Nicholls
    et al. 2006), we have found it to take
    considerably longer.

  • Compiling first risk assessment after 3 months
    is very time consuming. Difficult to get
    appropriate staff together to do 3 monthly
  • Ward Manager, Rehab ward

What Do Patients Say?
  • About interviews for START
  • I think Id find it hard to speak to someone
    whos not in my care team.
  • Its all part of moving on, and understanding
    what youve done wrong.
  • About Risks and Strengths
  • Risk is where you do something quite serious.
    Strength is where you actively understand when
    you go wrong and you can correct it before you go

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