Risk Formulation: The Key to Risk Management Planning

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Risk Formulation The Key to Risk Management
Planning

• Dr Caroline Logan
• Consultant Specialist Clinical Psychologist
• in Risk Assessment and Management, Mersey Care
  NHT Trust
• Board Member, Risk Management Authority

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With thanks
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Introduction

• Your decisions are likely to be regarded as
  acceptable if you can demonstrate that
• You and your staff conformed to the relevant
  Trust/locality policies and procedures and
  national guidelines
• You used the best information available, you
  tried to obtain the information you did not
  possess, and you used empirically-based methods
  of evaluating the information you had
• You can account for your decisions and chosen
  courses of action, and you documented your
  decision-making appropriately
• You informed the most appropriate people of your
  concerns
• You took all reasonable steps to try to manage
  risk

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Overview

• Introduction
• A model of risk assessment and risk management
• Structured professional judgement and risk
  formulation
• A short case study
• The way forward in risk management planning
• Conclusions

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Model

• Risk assessment is
• An estimation of risk potential based on our
  understanding of the presence and relevance of
  certain conditions that we assume to be risk
  factors
• Result Risk formulation

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Model contd/...

• Risk management is
• Action taken to prevent the harmful outcomes
  thought possible by anticipating what these
  outcomes might look like (scenario planning)
• Implementation of continuous ongoing action
  designed to monitor risk and respond
  appropriately to early warning signs of a relapse
  to violence
• Creating a traceable route from risk assessment
  to risk management
• Result A written plan of action

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1. Model contd/...

• A plan of action providing
• A traceable route from risk assessment to risk
  management and back again and again and again
• A risk management plan is a live document,
  relevant to a specified time period, and should
  be updated
• Practice in respect of risk management is
  stratified
• Target triggers or destabilising factors first
  ensure security as a priority

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Model contd/...

• Risk of harm to others
• The proximal cause of violence is a decision to
  act violently
• The decision is influenced by a host of
  psychological, social, biological, and contextual
  factors including
• Mental and personality disorder
• Exposure to violent models, attitudes that
  condone violence, criminal peers
• Neurological insult, genetic/hormonal abnormality
  
• As well as proximal triggers (e.g., provocation,
  anger, intoxication)

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Model contd/...

• But risk is context-specific ...
• We can never know a persons risk for violence
• We merely estimate risk on the basis of our
  knowledge of various relevant individual
  (internal) and situational (external) factors and
  how they relate to one another

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1. Model contd/...

• So, what do we need to make robust decisions
  about risk?

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1. Model contd/...

• Need a decision-making framework that
• Promotes consistency between clinicians
• Can facilitate communication between parties
• Identifies outcomes of interest
• Takes the individual patient into account
• Takes all relevant risk factors into account
• Takes protective factors into account
• Is flexible
• That links risk assessment to risk management
• And, overall, is reviewable, accountable,
  transparent

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1. Model contd/...

• Because the reality is
• Often concern about risks in multiple domains
• Over varying time scales
• Where risks are often linked
• Risk of reoffending per se is often not a
  priority
• Therefore, a framework for understanding risk
  assessment and management is essential to help
  practitioners select the most relevant
  information quickly

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1. Model contd/...

• Therefore, there is a need for both
• A framework for understanding risk
• AND tools that you can use to make complex
  decisions about certain risks as evidence-based,
  accountable and transparent as possible

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1. Model contd/...

• Framework?
• Clarity about what we mean by risk assessment
  (definition)
• Clarity about what we want to prevent (focus)
• An understanding of what can make violence or
  sexual violence happen (knowledge)
• A judgement about whats relevant in this case
  (experience)
• Leading to a risk formulation (skill)

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1. Model contd/...

• Framework contd/
• Directly resulting in a time-specific plan of
  action that will
• Limit the role of risk factors in generating
  harmful outcomes and
• (Ideally) enhance the role of protective factors
  in inhibiting harmful outcomes
• Which will in turn inform risk assessment and
  subsequent management (an individual plan)
• Back to assessment and management, over and over
  again (a dynamic, flexible plan)

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1. Model contd/...

• Frame clinical judgement about risk in this way
• Under what conditions and over
• what time period might what
• kind of risk occur?

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Structured professional judgement risk
formulation

• Features of structured professional judgement
  tools
• Tools are for use in key risk areas
• Violence, sexual violence, etc.
• They make very much more explicit the operation
  of this framework based on empirical evidence
• Prevention not prediction is the objective of
  their use

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SPJ risk formulation contd/

• Features of structured professional judgement
  tools contd/
• Rely on clinical expertise with a structured
  application
• Rational and empirical selection of risk factors
• Based on review of scientific (empirically-based)
  and professional literatures
• Not sample-specific - broad-based applicability
  and generalisability
• Inclusion of most potentially relevant risk
  factors

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SPJ risk formulation contd/

• Plus the facility to identify
• Critical risk factors
• Strengths (or protective factors) increasingly
  relevant
• Idiographic (or signature) risk or protective
  factors
• Facilitating flexibility and case-specific
  considerations
• Practice of shared risk formulations and
  multidisciplinary collaboration encouraged
• Supports professional judgement

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SPJ risk formulation contd/

• Structured Professional Judgement (SPJ)
  approaches
• Offer practice guidelines
• For specific behaviours (e.g., violence, sexual
  violence, stalking/harassment, domestic violence,
  self-harm/suicide, self-neglect, victimisation,
  etc)
• Across a range of populations (adults, young
  people, service users with cognitive impairment,
  etc)

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SPJ risk formulation contd/

• How does SPJ work?

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SPJ risk formulation contd/

• Step one
• Collate relevant information
• Personal, social and forensic history
• Using multiple methods
• Using multiple sources
• Considering multiple domains of functioning
• Updating old/out-of-date information on risk
  factors
• Documenting information reviewed
• Evaluating the adequacy of information reviewed

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SPJ risk formulation contd/

• Step two
• Identify those risk factors that are present in
  the case presently being assessed
• NB. Numbers are NOT involved

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SPJ risk formulation contd/

• Step three
• Make a professional judgement about the
  relevance of those risk factors to this
  individuals violent conduct

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(SHARED) RISK FORMULATION (ideally, 2
knowledgeable practitioners)
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SPJ risk formulation contd/

• Broadly, a risk formulation is an analysis of ...
• Specific risks (e.g., sexual violence, violence,
  stalking, domestic violence, etc)
• Offending and other linked behaviour leading to
  identification of relevant risk factors,
  highlighting critical and signature risk factors
  and protective factors
• Interactions between risk factors over time
• Including short-term triggers
• Taking into account possible future circumstances

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SPJ risk formulation contd/

• Specifically
• Consider the different models of formulation
• Therapeutic formulations (CBT, CAT, SFT, etc)
• However, such formulations offer little guidance
  for decision-making about the offending process
  or the future

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SPJ risk formulation contd/

• Specifically
• (Offending) behaviour formulations
• Antecedents Behaviour Consequences (ABC)
• Limited to specific behaviours
• Predisposing, Precipitating, Perpetuating, and
  Protective (PPPP or 4Ps)
• More comprehensive but also complex
• Motivators (or Drivers), Destabilisers,
  (Dis)inhibitors (or 3Ds)
• Also comprehensive but complex

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SPJ risk formulation contd/

• Step four Risk scenario planning
• Scenarios are possible futures
• Consider more than one
• In constructing scenarios, consider
• nature of future harm
• severity of future harm
• imminence
• frequency or duration
• likelihood that harm will actually occur

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SPJ risk formulation contd/

• Step five Risk management strategies
• Treatment
• treatment strategies relevant to risk management
  treatment priorities
• Supervision
• what restrictions on activity, movement,
  association, or communication are indicated?
• Monitoring
• identification and detection of (early) warning
  signs, indicators of change in risk
• Victim safety planning
• what steps could be taken to enhance the security
  of the victim?

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SPJ risk formulation contd/

• Step six Summary Judgments
• Prioritisation case, treatment / management
  needs
• Need for immediate action on what?
• Risk of serious harm (impact)
• Range of risks indicated (e.g., harm, self-harm/
  suicide, self-neglect, victimisation)
• Frequency of review, and review of what?
• Inc. the sell-by date of the report

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SPJ risk formulation contd/

• Process revisited with formulation
• Gather information
• Rate presence of risk factors
• 2a. Ask WHY did these offences/behaviours
  happen?
• 3. Rate relevance of risk factors
• 3a. Establish whether and how relevant risk
  factors cluster
• or coalesce
• 4. Determine 2 future scenarios
• 4a. Identify critical risk factors

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SPJ risk formulation contd/

• Process contd/
• 4b. 4P/3D table why and how will offences/
  behaviours
• happen in the future
• 5a. Consider blue sky risk management options
• treatment, supervision, monitoring, victim
  safety
• planning ALL linked to relevant risk factors
  and risk
• formulation
• 5b. Consider essential risk management options
  from
• those examined above
• 6. Summary judgements

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• A SHORT CASE STUDY

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Way forward in risk management planning

• Collaboration
• With colleagues and with the client
• Differentiate between predisposing factors and
  precipitating or trigger factors
• And think about motivation
• Think about factors that maintain offending
  behaviour
• Pay attention to protective factors or strengths
  for their role as offence inhibitors and as a way
  of gaining collaboration

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Way forward in risk management planning contd/

• Attend to risks in multiple areas consider the
  bigger picture
• Harm, self-harm, suicide, self-neglect,
  victimisation, self-neglect
• Make revisions to individual risk factors and
  risk formulation on the basis of effective
  ineffective risk management
• Risk assessment and management is an iterative
  process
• If possible, measure effective (effectiveness of)
  risk management
• Multiple administrations of short-term
  assessments

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The way forward in risk management planning
contd/

• Protect the victims of offenders
• Target hardening
• Aim for transparent risk assessment and risk
  management planning over time
• Be realistic!
• Measuring prevented violence as a novel research
  objective

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The way forward in risk management planning
contd/

• A note on writing
• Attend to grammar avoid sloppy writing makes
  your thinking look sloppy
• Failure to proofread is like preparing a
  magnificent dinner and forgetting to set the
  table, so that the wretched guests have to
  scramble for the food with their hands.
• Jessica Mitford,
  The Making of a
• 
  Muckraker, 1979 p22

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The way forward in risk management planning
contd/

• RMA Risk Management Standards
• Collaborative working
• Risk assessment
• The foundation of risk management
• Planning
• To achieve clarity about objectives, to maintain
  proportionality, to coordinate action
• Risk management strategies
• How to actually achieve risk management
  objectives
• Resulting in a preventative action plan and a
  contingency action plan

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The way forward in risk management planning
contd/

• RMA Risk Management Standards contd/
• Accommodation and community management
• Essential
• Responding to change
• A dynamic process
• Organisational
• Risk management needs resources and skills!

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Conclusions

• Prevention rather than prediction
• Tools exist to give structure to your clinical
  judgement
• The framework for clinical risk assessment is
  applicable whatever the circumstance

Risk assessment
Risk management
Risk formulation
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Contact Information

• Dr Caroline Logan
• Psychological Services Directorate
• Ashworth Hospital
• Parkbourn
• Maghull
• Liverpool L31 1HW
• Tel [phone]
• E-mail caroline.logan_at_merseycare.nhs.uk
• web www.rmascotland.gov.uk