Forensic patients’ views on risk management

Ms Gaby VojtDr Lisa Marshall

Prof Lindsay ThomsonDr Josie Williams

Funder: The State Hospitals Board

Overview

• Background• Methodology• Results and Interpretation• Limitations• Clinical Implications• Questions

Background

• Violence risk assessment and risk management as core issues in mental health and criminal justice system.

• Recent shift in research from risk prediction to risk prevention, i.e. risk management.

• The function of risk management is, essentially, to promote desistance.

• Paucity of research on the patients’ view of risk management (Greenhill & Whitehead, 2010).

• Langan & Lindows (2004): Mental health service users not involved in risk assessment nor management. Discussion about risk uncommon between service user and provider.

Methodology

IPA study with 25 male participants recruited across 3 risk settings.

Mean age 38.3 years (sd = 9.8), range: 24 – 58 years.

Focus• Understandings of violence• Perceptions of risk management• Incentives and barriers to treatment

uptake/adherence, i.e. risk management.

Emergent themesEmergent themes revealed a powerful ‘patient culture’

regarding:

• Understandings of violence– Lack of agency and lack of consistency

• Understandings of violence risk management within institutional settings– Artificiality of environment

• Reasons for Uptake/Adherence– ‘The nanny effect’ resulting in superficial engagement

Understandings of violence risk

• Perceptions of self as not ‘naturally violent’

• Violent behaviour linked to a ‘lack of agency’

• Internal factors: ‘being no well’ i.e. Mental illness/failure to take medication

• External factors: drugs and alcohol/other users, stressful and traumatic events (e.g. bereavement)

• Institutional factors: lack of agency/lack of consistency

Lack of agency

‘You cannae turn your head this way or that way coz they watch you and think what are you doing? You cannae be normal. All they can see you as is being a patient, they can’t see around that. You being on the ward means you’re still sick. You have problems, they cannae see around that. All they do is forcefeed you with their ideas about how you should behave, the way you should act so sometimes I don’t know who I am...’ (Scott, 47, medium)

Lack of consistency

‘They’re constantly watching you, constantly picking up on things, putting you under pressure to be a good wee boy. [...] being under pressure from the staff leads to being, leads to contempt. [...] they ask you to act like an adult but they treat you like a child sometimes. There’s never a balance, never any consistency.’ (Gordon, 37, low)

‘I hear staff talking about ‘oh, I’ve been on a night out, I was absolutely plastered, I couldnae fucking walk!’ and then they say tae you ‘what’re you gonna dae when you get out?’, ‘I’ll have a drink.’, ‘Oh, that’s no good, that’s no good’ just after saying that! So why are you different from me?’ (Chris, 37, high)

Understandings of violence risk management

• Fear of never getting out

• Artificiality – Regime of medication– Alcohol and drugs not available– Limitation of stressful events

Fear of never getting out

‘When you’re in jail and somebody says something to you, you need to hit them coz if you don’t you get looked at as a shitebag, you’ve got to stand up for yourself. In here nothing like that happens [...] because everybody wants get well and get oot. In jail you’re getting oot anyway [...] you’ve got a time. I’m in for 3 months and I punch somebody? That person’s not gonna charge me with anything so I’m gonna get out in 3 month’s time. In here if you punch somebody you do an extra two year, three year so naebody wants to fight in here. There’s nae drugs in here so naebody is fighting over drugs. Fights do happen but it’s maer from mental illness. ‘ (Stevie, 24, high)

‘The nanny effect’

‘Behave they say you need to behave yourself [...] just say nothing, just keep yourself on the straight and narrow. Eh, don’t say nothing to naebody. Just say please and thank you and all that and just keep out of trouble. That’s what they call ‘the nanny effect’ [...] Because it’s in my care plan so I need tae dae it. I need tae go along with what they’re saying.’ (Scott, 47, medium)

Reasons for uptake/adherence

• Need to be compliant‘You need tae be compliant with treatment, you need to go

your therapies, you need tae work with your psychologist, you need tae work with your doctor, and you need tae work with your staff and your your social workers, your key worker. To do what you need to do to get ootta here.’ (Chris, 37, high)

• Perceived consequence of non-adherence

Perceived consequences of non-adherence

‘[What would happen if you did not go to your groups and placements?] I’d be what some people class as unwell again. I’d be untrusting of people.’ (Glen, 40, medium).

‘[What would happen if you didn’t go?] It goes against you. They say you’re no trying to dae stuff or working with staff aw that kinda stuff. If you’re no working with staff, you don’t get out.’ (Scott, 47, medium)

Risk management: The bubble

‘There were some bits in [the] anger management group where they says to me ‘you’re walking down the street and somebody comes up and punches you in the face. What would you do?’ and my reaction was hit them back […] And they’re like that ‘you shouldnae do that’ […] But nobody takes a pelting [beating] outside […] Just because you’re a patient doesnae mean you don’t have the same feelings, the same reactions as a normal person outside […] in here, somebody can argue with you, and then that’s it. But outside, it’s a totally different ball game, somebody can argue with you and then stab you. So, how we deal with a situation in here doesnae mean tae say that situation is going to be the same outside […] What they preach in here is…you need tae try and teach what’s happening outside of here. In this place, it’s like a bubble, you know, it’s tough outside.’ (Chris, 37, high)

Superficial engagement with treatments

• Keeping your head down

‘[Do you feel like you’re involved in decisions about your future?] I know that I‘m involved basically if I keep my head down and don’t misbehave. You’re watching yourself all the time. [What’s that like?] Crap but they know that anyway. And that’s their problem with me, they’re saying I am a bit superficial but I need to be in this environment. I’ve just held back my tongue, held back and no say nothing.‘ (Joe, 30, high)

• Lack of interest

‘[Have you seen your risk management plan?] No, I wouldn’t want to coz I don’t need tae know, I just dae what I need to do coz I want to get out of here.’ (Leo, 30, medium)

Superficial engagement cont.

• Lack of control

‘Basically, my life is in other people’s hands now, my life’s been taken out of my hands, I might have a small say in whatever happens tae me, now and the future, but that really is just a small say. Everything’s decided for me from other people.’ (Glen, 40, medium)

• Lack of involvement

‘By the time you go in, they’ve already said this is what’s happening. And if you say ‘I’m no happy with that’, they basically say ‘well, just get on with it’ […] So you can only say ‘ok, that’s fine, nae bother’ even though you don’t like it.’ (Chris, 37, high)

Relationships to staff

‘The situation I’m in, I can’t not trust the staff [Which means?] which means is I have no choice, I have to trust the staff cos if I don’t trust the staff, then I would never move on. I would be trapped here forever.’ (Glen, 40, medium).

‘I wouldnae tell them nothing, they’re no my friends. I tell them what I must but I dinnae trust them.’ (Arthur, 47, low)

Positive understandings

‘You’re getting ready for going outside. Like of course they’re gonna be watching you just in case you make a mistake […] you don’t see any of that but you will be getting observed all the time. I don’t mind being assessed. [...] I feel like I am in control of it all, it’s good […] coz you don’t want to fall away just in case you take a relapse and you need to come back into hospital so I think its’ good these people see you.’ (John, 38, low)

Limitations• Biased recruitment.

• Sensitive topic.

• Verbal problems in expressing abstract concepts such as emotions and experiences.

• Semantics.

Clinical implications

• Best Practice in Managing Risk (2007): Risk management should be conducted in the spirit of collaboration. Relationship between service user and service provider as trusting as possible.

• ‘Talking Groups’

• Patient involvement in risk management plans

Questions?

• Follow our publications:– The clinical reality of implementing formal risk assessment and

management measures within high secure forensic care. Medicine, Science and the Law, 51 (4), 220 - 227.

– The predictive validity of the HCR-20 following clinical implementation: Does it work in practice? Journal of Forensic Psychiatry & Psychology, 24 (3), 371 – 385.

– The assessment of imminent inpatient aggression: a validation study of the DASA-IV in Scotland. Journal of Forensic Psychiatry & Psychology, 21 (5), 789 – 800.

• Gabriele.Vojt@rmascotland.gsi.gov.uk

Thank you