risk & recoverybehavioural and developmental psychiatry clinical academic group (cag) aims to...
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Risk & Recovery Behavioural and Developmental Psychiatry Clinical Academic Group (CAG)
Aims
•To describe “HCR20 & Recovery” group
•To suggest that this is one way of implementing the “Recovery Model” in forensic services.
•This is EMPOWERING to patients.
•We empower them by being TRANSPARENT about risk.
•It is also a way to assist them in TAKING RESPONSIBILITY for (a) their discharge from security and (b) managing their own risk factors for violence
•We teach them about how we assess risk
•Help them to develop skills at self-management of risk.
Amory Clarke, PhD, Clinical PsychologistSouth London & Maudsley NHS Foundation Trust Forensic Mental Health Services
22 August 2014
Scottish Prison Service College, Polmont
Involving service users in their own HCR-20 – The HCR-20 Risk & Recovery Programme in Forensic Psychiatry
Risk & Recovery Behavioural and Developmental Psychiatry Clinical Academic Group (CAG)
Aims
•To describe “HCR20 & Recovery” group
•To suggest that this is one way of implementing the “Recovery Model” in forensic services.
•This is EMPOWERING to patients.
•We empower them by being TRANSPARENT about risk.
•It is also a way to assist them in TAKING RESPONSIBILITY for (a) their discharge from security and (b) managing their own risk factors for violence
•We teach them about how we assess risk
•Help them to develop skills at self-management of risk.
A. Good ideaB. Bad IdeaC. Not sure
Before I being let me ask:
Service users should complete their own HCR-20.(By “complete” I mean code their responses and provide evidence for their coding as an alternative to professional coding.)
Risk & Recovery Behavioural and Developmental Psychiatry Clinical Academic Group (CAG)
Aims
•To describe “HCR20 & Recovery” group
•To suggest that this is one way of implementing the “Recovery Model” in forensic services.
•This is EMPOWERING to patients.
•We empower them by being TRANSPARENT about risk.
•It is also a way to assist them in TAKING RESPONSIBILITY for (a) their discharge from security and (b) managing their own risk factors for violence
•We teach them about how we assess risk
•Help them to develop skills at self-management of risk.
•I am going to discuss how we implemented having service users complete their own HCR-20s.
•Brief exploration recovery principles within forensic services
•I am going to present practical suggestions for implementing the recovery model into forensic services
•I am going to describe how we implemented this programme across three levels of security.
•I am going to present research data
Aims of this talk
Risk & Recovery
Aims
•To describe “HCR20 & Recovery” group
•To suggest that this is one way of implementing the “Recovery Model” in forensic services.
•This is EMPOWERING to patients.
•We empower them by being TRANSPARENT about risk.
•It is also a way to assist them in TAKING RESPONSIBILITY for (a) their discharge from security and (b) managing their own risk factors for violence
•We teach them about how we assess risk and to attain FLUENCY WITH THE HCR20 so that they can use it as a tool just as we do.
•Final Goal is self-management of risk.
• Policy and guidelines• Theory• Practice• Research• Future directions• Parallel complementary developments
Risk & Recovery Behavioural and Developmental Psychiatry Clinical Academic Group (CAG)
Aims
•To describe “HCR20 & Recovery” group
•To suggest that this is one way of implementing the “Recovery Model” in forensic services.
•This is EMPOWERING to patients.
•We empower them by being TRANSPARENT about risk.
•It is also a way to assist them in TAKING RESPONSIBILITY for (a) their discharge from security and (b) managing their own risk factors for violence
•We teach them about how we assess risk
•Help them to develop skills at self-management of risk.
•The recovery model takes a positive approach:•In many respect it draws on “positive psychology”•It tries to focus on health over pathology•What is right over what is wrong•Strengths over weakness•It sees possibilities, rather than constraints•It view service users as active, rather then passive, participants•It emphasizes hope and the the future to can better.•The Recovery model is an alternative to the disability model and the medical model.
What is the “Recovery Model”
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HCR-20 Risk & Recovery Programme
Risk assessment is a central task in forensic psychiatry
Recovery is an important for the way we think about our work.
ASSUMPTION: Risk assessment and recovery do not naturally fit together
I WILL ARGUE THE OPPOSITE: The recovery model does fit within forensic psychiatry
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Guidelines
Recent guidelines from the Department of Health* and the Royal College of Psychiatrists** recommend integrating recovery principles into risk management:
•Best practice point 4: Risk management must be built on a recognition of theservice user’s strengths and should emphasise recovery.
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*Best Practice in Managing Risk (Department of Health, 2007)
**Giving up the Culture of Blame: Risk Assessment and Risk Management in Psychiatric Practice (Morgan, 2007)
Given that SLAM has been identified as a mental health service that is actively putting recovery approaches to care into practice…
I am going to describe one approach that we have been using in forensic mental health services at SLAM to do this.
NICE GuidelinesSpecifically, in these guidelines relating to Anti-Social Personality Disorder the HCR-20 is cited as a tool to be used for:
•Risk management
•Directing staff to: ‘explore treatment options in an atmosphere of hope and optimism’
•Explaining that recovery is possible and attainable; and to build a trusting relationship
•Promote engagement with patients with a recovery orientated and collaborative approach
•For example, ASPD, Schizophrenia, and more generally acutely ill patients in hospital (NICE 2007; 2009a; 2009b).
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What is recovery?
Definition of Recovery I
“A deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness. Recovery involves the development of a new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness” (Anthony, 1993).
This definition does not work from a forensic service user point of view!
This definition does not work from a “responsivity” point of view (Andrews & Bonta, 2010) point of view.
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Recovery Star Ten Step Ladder Of Change
MacKeith & Burns, Mental Health Providers Forumhttp://www.mhpf.org.uk/recoveryStar.asp
Definition of Recovery II
Stuck (pre-contemplation)“leave me alone! there is no problem!”
Accepting help (contemplation)“I want someone else to sort things out”
Believing (preparation)“I can make a difference. It’s up to me as well”
Learning (action)“I’m learning how to do this”
Self – Reliance (maintenance)“I can manage without help”
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“No one in this room looks mentally ill – so why are you still in hospital?” – Correct answer: RISK!
“If you can manage your own risk then we don’t have to!”
“Our beds are expensive and we WANT – believe it or not - to move you on”
“One way of doing this is to teach you how we assess risk - the HCR-20”
Knowledge is power. We want to give the power back to you.
Definition of Recovery III
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•One of the most researched and validated violence risk tools
•Widely used in the UK and internationally - “the HCR-20 [is] becoming the de facto standard within medium security”*
•It has been translated into 19 different languages. There have been over 50 evaluations of it’s validity across approximately a dozen countries.
•Easy to understand
•Provides structure and focus for their time in hospital
•SLAM Trust policy! – No HCR-20 = no leave.
*Khiroya et al - Violence risk assessments in medium secure units (Psychiatric Bullitin 2009)
Why the HCR-20?
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HCR-20
HISTORICAL CLINICAL RISK
PastStatic
Gained from notes10 items
PresentDynamic Variables
As observed5 items
FutureSpeculativeProjected5 items
Structure of the HCR-20
Step 1 - Rate the Items
Step 2 – Feared Scenarios
Step 3 – Management Strategies
Step 4 – Risk Level (high/medium/low)
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•Regular weekly one hour session
•Open to all patients and staff
•Voluntary attendance
•Run by two facilitators (psychologist & psychiatrist) providing pro-social modelling.
•We encourage dissenting opinions!
•Encourage regular attendees to describe the HCR-20 to new members of the group (service users and staff)
Format of the HCR-20 & Recovery Group
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History & Development of the Group
•Now running on all of our wards across our service.
•We use a simplified, abridged, version of the manual (version 2).
•However, anyone we wants a full copy of the HCR-20 manual is given one.
•We mixed medium and low secure, open forensic rehab, and community patients.
•It was an open ended group.
•Certificates given based on taking a test
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History & Development of the Group
• Start with short fictional cases with short (2-3 sentences for each item)
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Short fictional cases:
• 2-3 sentences for each item)
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History & Development of the Group
• After we do the short fictional cases we go into more detail. •Longer fictional cases•The we get more detailed an look at cases in the news: Sword attacker
•Real cases, the group participants (voluntary only)• Real HCR-20’s provoked the most interest and engagement. •We then role play
•Ward review•MHRT, •Parole hearings, •Manager’s hearings
•Goal: Fluency with the HCR20. •We achieved the fluency goals to a remarkable degree.
)
BBC: Sword attacker's release condemned
29 June, 2002• A parishioner at a church where a man attacked the congregation with a
samurai sword has condemned his early release from a secure mental hospital.
• Schizophrenic Mr ES was detained indefinitely after attacking worshippers in Thornton Heath because he believed they were demons.
• In June 2000 an Old Bailey jury found Glasgow-born ES not guilty through insanity of attempted murder, but ordered him to be detained indefinitely at a psychiatric hospital under the Mental Health Act.
• But the 29-year-old was released from hospital in March of this year, and has since been living in a hostel in the local area, being monitored by a public protection panel.
• The Daily Mail and the Sun went much further than the BBC in demagogueing this case.
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•An individual agrees beforehand for the group to review their HCR-20 (often prior to a CPA or MHRT)
•We rate each item, encouraging debate and discussion
•We encourage candid feedback from peers
•We use a democratic voting system to make final decision
•Encourage discussion on what they can do to improve particular scores
•We warn them that this is not the final draft
•We often have to come back the following week – following a CPA - and explain why the MDT rated the risk more conservatively and what needs to be done to reduce score
Real HCR-20s in the group
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We tell them:
•The HCR-20 is one of the most widely used risk assessment tools in the world
•If you attend this group regularly you will have the necessary skills to be able to stand up for yourself in CPAs, and at MHRTs.
•If you have all “No’s” in the C and R items – you will be discharged!
•Knowledge is power and this group will empower you to take more control of your discharge.
•The goal posts do not move!
Current Structure of the Group II
Risk & Recovery Behavioural and Developmental Psychiatry Clinical Academic Group (CAG)
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Step 1: The above table. Step 2: Worst case scenariosStep 3: Risk ManagementStep 4: Rate the overall risk
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Current Structure of the Group III
•Focus on the “Clinical” and “Risk” items
•This is partly for confidentiality purposes but also because we cannot change the past.
•This is also a way to say that their past behaviours are not the only way they are judged.
•We invite them to discuss the Historical items if they wish to.
•Step 2 (Feared Scenarios) is based on the idea that past behaviour is the best predictor of future behaviour.
•Step 3 (Risk management strategies) can be an opportunity for creative thinking and collaboration.
•The purpose of risk assessment is risk management
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Certificates are awarded based on testing
MULTIPLE CHOICE QUESTIONS: Circle the best answer for each of the following: The HCR-20 is rated using -
a) 5 itemb) 20 itemsc) 32 items
According to the HCR-20 definition of violence, which of the following are NOT counted as violence -
a) Threatening to punch a member of nursing staffb) Calling a member of nursing staff “a bitch”c) Kicking another patient who is annoying youd) None of the above
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Certificate of Completion
Three levels of certificates awarded:
1.Basic understanding of the HCR-202.Excellent understanding of the HCR-203. HCR-20 Expert
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CORE PRINCIPLE: Transparency
We have taken a position of complete transparency.
Service Users can have copies of the complete manual
Copies of their completed HCR-20.
We encourage them to disagree with us and then we try listen to what they have to say.
We encourage them to “show us the evidence.”
We aspire to being non-defensive, that is, admitting when we are wrong.
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CORE PRINCIPLE: Empowerment
We try to empower the service users as much as possible with their knowledge and use of the HCR-20
We see this approach as a way to shift them from having an External to an Internal locus of control .
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CORE PRINCIPLE: Taking Responsibility
We try to shift the responsibility for their risk from use to them.
We want them to improve their self control skills.
If they can manage their risk then we do not have to.
Observed Outcomes
•Adheres to the “spirit” of the Recovery Model
•It is well attended by patients, sometimes 20 participants.
•The participants get very interested in the HCR-20 case studies and can get quite passionate.
•It appears to increase their sense of self-efficacy
•It appears to empower them by giving the knowledge (“Knowledge is Power”) about risk
•Provides hope that they can change and progress
•Patients and staff work towards an objective common goal of expedited, safe discharge.
•Risk management is imporvedRisk & Recovery
Observed Outcomes II
•It puts control back in their hands.
•It increases collaboration particularly around risk management.
•It gives them a choice.
•The goal post do not move
•This approach to the HCR-20 structures how they understand risk assessment and risk management.
•It puts staff in a position where they can be coaches rather than experts.
•They see peers with ‘good’ HCR-20’s moving on – showing that it works.
•Some have even come back to the group, after discharge, to help others and provide positive role modelling
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Research
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•non-randomised between groups experimental study (N=96)
•group attendees compared to matched patients not attending at two MSUs.
•time period is May 2009 to December 2011.
•differences in HCR20 scores over 18 month period for anyone who attended at least 10 times.
•This was not retrospective because of method
Research
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. Case Register Information System (CRIS)It has prior ethical approval for research.Essentially it key word searches our medical recordsThis was not a retrospective study because of CRISCRIS eliminates recall bias
Aim of the study:
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(1) does this new intervention effectively reduced participants’ HCR-20 C, R, or Total scores? and (2) are there specific factors which correlate with a reduction in HCR-20 scores?
Using a quasi-experimental design, data from 96 adult male inpatients who were detained in one of two south London MSUs between 2008 – 2012
All inpatients were diagnosed with a psychotic disorder
Findings from ANCOVA analyses:
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. • Total HCR-20, and Clinical subscale scores did not significantly decrease. • However, Risk Management subscale scores did significantly decrease when impulsivity was controlled for.
Most often asked question or statement: We are teaching service users to manipulate?
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. I do not see this as a valid concern. We are looking at what they DO not what they say.
To they: TALK THE TALK
Or can they:WALK THE WALK
Most often asked question: It seems you are teaching the service users how to manipulate the HCR-20?
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History Items: Past BehavioursClinical Items: Current BehavioursRisk Items: Future Behaviours, based on the premise that past behavoiur is the best predictor of future behaviour.
Risk assessment is not so much about Prediction as it is about Risk Management
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. Past behavoiur is the best predictor of future behaviour.
Mark Twain
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. History does not exactly repeat itself.But it does have a certain rhythm.
Service User Involvement• The right for Service Users or representatives to be involved in the
planning and development of services (NHS Constitution, 2009)
• Users of health and social care services and their carers should expect to be involved, not only in individual care planning, but also in the development, provision and monitoring of services.
• Still a lack of SU involvement in actual facilitation of clinical interventions
• Complements South London and Maudsley’s Recovery College
The Role of Service User Co-facilitators Risk & Recovery Programme Psychosis Clinical Academic Group (CAG)
Practical Issues• Needing to realistically adapt to accommodate for SU
consultants – Printing out worksheets/manual – Memory issues,
– Anxiety in groups/mental health issues, • Time keeping• Preparation for sessions • Disclosure of SU experience• Need for ‘careful’ recruitment SU co-facilitators• Extra training and debriefing recommended
The Role of Service User Co-facilitators Risk & Recovery Programme
Reflections on SU involvement• Pros and cons of Service User involvement
– He took it very seriously– He appeared to be using it instrumentally, that is mainly for the purpose
of his parole hearing– Practically it was difficult
The Role of Service User Co-facilitators Risk & Recovery Programme
The Future
•Basic (ongoing/rolling) and advanced (time-limited) groups
•Basic - Open-structure vs Advanced - Manualised
•Ideally develop Patient-led groups
•New instruments: HCR-20 v3 / SAPROF / START
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The Challenge of the HCR20 v3
• HCR20 v3 is more complex.• Part of the beauty of version 2 is its simplicity. • Version 2 has four steps• Version 3 has seven• However version 3 has better, sharper,
definitions.
Historical
Scale
H1. History of Problems with Violence
H3. Problems with Personal Relationships
H3a. Intimate Relationships
H3b. Non-intimate Relationships
H4. Problems with Employment
H6. Major Mental DisorderGeneral (e.g. chronic)Psychotic (e.g. positive sx)Major Mood Other (e.g. executive)
H5. Problems with Substance Use
H2. History of Problems With Other Antisocial Behavior
H7. Personality Disorder (w/ Antagonism; Dominance)H8. Traumatic ExperiencesVictimization/TraumaAdverse Childrearing Experiences
H9. Problem with Violent Attitudes
H10. Problems with Treatment or Supervision Response
Clinical
Scale
C1. Recent Problems with Insight
Problems with Insight into Mental Disorder
Problems with Insight into Violence Risk
Problems with Insight into Need for Treatment
C3. Recent Problems With Symptoms of Major Mental Illness
Symptoms of Psychotic Disorders
Symptoms of Major Mood Disorders
Symptoms of Other Major Mental Disorders
C2. Recent Problems with Violent Ideation or Intent
C5. Recent Problems with Treatment or Supervision Response
C5a. Problems with Compliance
C5b. Problems with Non-responsiveness
C4. Recent Problems With Instability
AffectiveBehaviouralCogntive
Risk Management Scale
R1. Future Problems With Professional Services and Plans
R3. Future Problems With Personal Support
R2. Future Problems With Living Situation
R5. Future Problems With Stress or Coping
R4. Future Problems With Treatment or Supervision
R4a. Problems with Compliance (e.g. little motivation
R4b. Problems with Responsiveness (e.g. no improvement in adjustment despite treatment.
PCL-R psychopathy (H7 from v2 has been removed.
In some ways it is helpful H7: Psychopathy has been removed in v3
I think we can adapt HCR-20v3
Transition from HCR20v2 to v3
New Developments in England Personalised Budgets
•Personal budgets have been introduced by councils into mental health services throughout England. •This is a process where the service user has a say in how the huge sums on money provided for their care, are spent.•A Personal Budget is a sum of money allocated as a result of an assessment of needs. •This gives the service user the chance to have more control over how support is provided.•A Personal Budget is not extra money, but a different way of making the ‘social care’ element of the funding for them available.•By April 2013, all councils in England and Wales should be offering Personal Budgets to all those who are eligible to receive support, including people with mental health needs.
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Personalised Budgets
•This is a powerful way to do risk management.•Where people require longer-term support, such as forensic services, it is designed and delivered with the service user to meet their individual needs and preferences, . •
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Risk & Recovery Behavioural and Developmental Psychiatry Clinical Academic Group (CAG)
Aims
•To describe “HCR20 & Recovery” group
•To suggest that this is one way of implementing the “Recovery Model” in forensic services.
•This is EMPOWERING to patients.
•We empower them by being TRANSPARENT about risk.
•It is also a way to assist them in TAKING RESPONSIBILITY for (a) their discharge from security and (b) managing their own risk factors for violence
•We teach them about how we assess risk
•Help them to develop skills at self-management of risk.
A. Good ideaB. Bad IdeaC. Not sure
Returning to the question I asked initially:
Service users should complete their own HCR-20.(By “complete” I mean code their responses and provide evidence for their coding as an alternative to MPT coding.)
Questions
Risk & Recovery Behavioural and Developmental Psychiatry Clinical Academic Group (CAG)
Contact Details
Dr Amory ClarkeClinical Psychologist
South London and Maudsley NHS Foundation Trust
Psychosis Clinical Academic Group (CAG)