Risk & Recovery

Pat AbbottConsultant Rehabilitation Psychiatrist

Mersey Care NHS Trust/Ashworth Hospital

Recovery

• ‘Living a satisfying, hopeful & contributing life, even with the limitations caused by the illness’

• Anthony, 1993

Recovery

• Re-establishment of a positive identity…which incorporates illness, but retains a core positive sense of self

• Shepherd et al., 2008

• Restoring the balance from illness towards other, more positive aspects of life

“Real Life”

“Patienthood”

Recovery Paradigm

• Set of ideas & values based upon hope, self determination & personal fulfilment for people with mental illness

• Key underlying principle in MH services in Australia, NZ, US, Ireland, Scotland Shepherd et al., 2008

• Increasing influence in England & Wales NIMH 2004, DoH 2006, 2007, Sainsbury Centre, RCPsych/BPS, CSIP 2008

• Not without its critics Stanton, 2008; Lemonsky, 2008; Fernando, 2008; Pembroke, 2008

Recovery-oriented Practice

• ‘Identifies & builds upon each individual’s assets, strengths, & areas of health & competence to support the person in managing his or her condition while regaining a meaningful, constructive, sense of membership in the broader community’

Davidson et al., 2006

• Civil-rights based definition – can encompass those with severe disability/risk

Risk & Recovery

• Risk is one of the ‘Top Ten Concerns’ about Recovery in relation to mental health system transformation

• Tension between autonomy & self-determination & need to minimise risk

• Risks to service users, potential victims & professionals in devolving risk taking to individual service users

Davidson et al., 2006

Autonomy & Risk

• individual’s right to autonomy & self determination may be compromised when individual is known to present a risk to others, whose rights & civil liberties must also be considered

Thomas & Bracken, 1999

Risk & Recovery

• Risk of self-harm, self-neglect & victimisation more common than risk to others RCPsych, Morgan, 2008

• Right of vulnerable individuals to be protected may over-ride right to autonomy if they lack capacity to make a particular decision

• But risks tend to cluster Nicholls et al, 2006

• CMHTs large number of risk v recovery decisions every day

How does risk fit in with Recovery-oriented practice?

• One of many other aspects of the person’s life• Collaborative working• Supporting personal responsibility• Fostering understanding and awareness of

aspects of person’s life which may increase risks

• Providing safeguards which are supportive and proportionate

Risk to Others

• Treatment Adherence• Substance misuse

National Confidential Inquiry, DoH, 2001

• But acknowledgement of the evidence that positive lifestyle factors such as personal support, stable relationships, employment, reducing stress have beneficial effect upon reducing risk HCR20, Webster et al., 1995

Other support for positive lifestyle as means to reduce risk

• Schizophrenia & violence: reoffending reduced by stable relationships, employment & mixing with non-criminogenic peers Mullen, 2006

• Employment & education important factors in reducing relapse & reoffending in mentally disordered offenders & recidivism in prisoners Simon, 1999; Gilligan, 1996; Social Exclusion Unit. 2002

• Good Lives Model: strengths based approach to reducing risk/achieving a positive lifestyle

Mann & Stewart, 2003

What about when things go wrong?

• Culture preoccupied with risk to others in UK, especially England

• Influenced by homicide inquiries

• Australia, NZ, USA & Scotland less preoccupation with risk

RCPsych, Morgan, 2009

Organisations & Teams

• Health of the organisation & staff as well as the people using the services

Repper, 2008

• Organisational culture which supports broader focus than just clinical recovery

Lloyd, 2008

• Culture of expectation, purpose & hope Roberts et al.,2008

The wider system

• Government’s commitment to choice, empowerment & social inclusion difficult to reconcile with equal commitment to public protection in an increasingly risk averse society Mezey & Eastman, 2009

• Political imperative to manage risk to public will invariably trump service users’ preferences when the two conflict Holloway, 2007

• Need for a ‘critical dialogue’ about decision-making in high risk situations Copeland & Mead, 2008

First steps to Recovery…

• May need to be coercive

• Involuntary admission• Enforced treatment• Restrictive

management (seclusion, restraint)

• Very limited autonomy & choice

Example 1: James

• 10 years in a high secure hospital• Serious impulsive violence, only partial response to

medication• Enforced medication, seclusion, restraint, special

observations (3/4:1)• Building relationships & trust• Gradual reintroduction to contact with others• Now re-established contact with family, accepted by

RSU, upholstery, gym, shopping

Example 1: James

• ‘I need to stay on these tablets, they do make a difference – I used to stop them in the past & I ended up in big trouble – you know that!

I know when I start getting thoughts about people I’ve got to stay out of the way…

I’m going to live in my own flat, near the family – I’m already making the furniture…I’ll carry on going to a workshop when I’m out…’

Recovery & Risk

• Understand own story• Motivation • Understand & take control of own illness (including

using medication well) as far as they are able to..• Strategies for managing stress & avoiding de-stabilisers with supports built in as needed• Positive steps to develop a productive lifestyle

(relationships, education, work, creativity)

Recovery for everyone?

• How do we make recovery meaningful for those who need longer term restrictive support?

• What about the people who lack capacity to take responsibility for many of their decisions & actions?

• Need for ‘compassionate paternalism’ in extreme situations? Dorkins et al., 2008

Example 2: Max

• Second HSH admission• Treatment resistant schizophrenia &

dysexecutive cognitive difficulties – complex psychopathology , impulsive

• Cut fellow resident’s throat in hostel readmitted to HSH – cut peer’s throat in workshop when mental state appeared stable

• No aggression for 6 years

Example 2: Max

• Does not have capacity to manage own risk• Requires high levels of restriction• ‘Come on Doctor, I haven’t done anything for 7

years, I’ve done my time now & I need to get on with my life, live in a flat, get a girlfriend’

• Still potentially grave risk of life threatening violence if particular symptom cluster were to recur & he responded impulsively to this

Example 2: Max

• How do we maintain hope for the future?• Which of his life choices can we support?• Football, handicrafts, garden access• Catering, trips to see his mother, trips out to

restaurants, unescorted grounds access• Close work with MSU team

Recovery & Risk

• Coercive intervention may be necessary step towards recovery for some people

• ‘How is what we are doing contributing to this person’s recovery?’ Different way of thinking about what we are already doing

• Forensic & other high risk service users may have most to gain by social inclusion & recovery Mezey & Eastman 2009

• Should be no ‘recovery free zones’ in services Roberts et al., 2008

Recovery for clinicians

• Could a more recovery-oriented system reduce perception that clinicians are responsible for all aspects of service users’ lives & reduce blame culture?

• ‘Fundamental shift towards sharing both power & responsibility’ Jacobson & Curtis, 2000

• But signs of healthy move away from preoccupation with predicting risk towards quality clinical services Mullen, 2004, Mossman, 2006,

Thank You

Pat.Abbott@merseycare.nhs.uk