‘A Risky Business?
03.10.19: This week I returned to the Institute of Psychiatry, Psychology & Neurosciences (IOPPN), part of Kings College London to facilitate some training for mental health and forensic professionals on Risk Assessment and Management. This got me thinking about the important role of risk assessment and management when working in ‘frontline’ homeless services, and how we as professionals balance the need to assess risk (i.e. harm to self or harm to others) competently with the need to manage the identified risks in a way that doesn’t stigmatise, or unnecessarily restrict an individuals’ rights. Young people experiencing homelessness are often a ‘complex’ group, with many risks and vulnerabilities and exposed to a wide range of dangers and stresses (https://centrepoint.org.uk/youth-homelessness/the-effects/). Therefore, staff working day to day with our Centrepoint young people have to make decisions about risks constantly. Hence, ‘frontline’ work can be a ‘risky business’.
However, luckily for those working to mitigate the risks our homeless young people face, there is a wealth of psychological evidence that can inform our practice of risk assessment and management so that we can keep the young people who use our services safe. As part of my role as Centrepoint Lead for Psychologically Informed Environments (PIE), I have also been working with Senior Housing and Support staff this week reviewing and updating Centrepoint’s Risk Assessment and Management processes to ensure that they are PIE informed and reflect the latest evidence base.
Specifically, the Department of Health (2007) argued that ‘Best Practice in Managing Risk’ (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/478595/best-practice-managing-risk-cover-webtagged.pdf) should adopt what is known as a ‘Structured Professional Judgement’ or an ‘SPJ’ approach to risk. This combines the wealth of research evidence about risk issues that exists, with a professional’s clinical judgement, and is known to be the most efficient and effective way to conduct risk assessment and management to prevent harm. An ‘SPJ’ type approach argues for a step by step approach to the identification and assessment of risk (considering evidence based factors known to increase risks), followed by the bringing together of those risk factors into a clear ‘risk formulation’ or ‘narrative’ outlining why an individual may be a risk from others or to others.
This formulation considers or outlines what are the ‘presenting’ risks for that individual young person might be, such as risk of harm from (or to) others, risk of harm to self through mental health issues, physical neglect or substance use as well as other issues such as criminal exploitation (e.g. https://centrepoint.org.uk/media/3425/escaping-the-trap.pdf). The formulation then links the evidence based risk factors identified for that specific young person, by considering whether they may be ‘predisposing’ (i.e. early life experiences / background), ‘precipitating’ (i.e. specific triggers that increase an identified risk), ‘perpetuating’ (i.e. issues that keep the identified risks live and current) or ‘protective’ (i.e. strengths or resources that a young person has that can reduce the presenting risk). In this way, every young person’s issues are uniquely considered and reflected upon to tell their individual ‘story’.
Such an individual specific formulation, then leads to the most critical step in the process; the development of clear risk management plan to address the identified risk factors through monitoring, supervision, intervention(s) and victim safety planning considerations. This essentially means what can we do to build upon that young persons’ strengths and what can we do to minimise their exposure (or manage any exposure) to their risks or vulnerabilities. Finally, and most importantly, this risk management plan is then communicated as appropriate to all those involved in the young person’s care to ensure that partnership and joined up working to support that young person occurs.
A PIE approach would also argue that co-production or collaboration in any risk assessment and management process is key, something also highlighted by the DOH (2007) guidelines and by Kirkbride (2017), in her book on counselling young people. Hence, ‘risk’ is not an issue that should be avoided in our discussions with the young people we work with. We know our homeless young people can be vulnerable, and we have a duty of care to them whilst they are in our services. Discussing and identifying together with young people what risks they may be facing and how they, and staff, can work together to manage these risks and keep them safe is critical. When done sensitively, and considering person-centred counselling principles (e.g. Rogers, 1967) such as empathy, non-judgement and unconditional positive regard, such discussions can help build therapeutic relationships between young people and staff. Being honest about what you fear, need or can do to support an individual builds trust, and isn’t about stigmatising our young people. Dealing with ‘risks’ is a normal part of life; we all have risks in we encounter day to day, which we learn to manage to navigate the wider world (e.g. looking before we cross a road, not drinking too much, or ensuring we have the emotional support we need if we have a challenging day) In the same way, getting a young person involved in understanding their own risks can increase their motivation to engage in activities or interventions to decrease that risk (e.g. education, training, employment, help to address mental health or substance use issues). Moreover, having clear boundaries with young people, clearly related to why they need to be in place to keep them safe, can build therapeutic relationships and support them to learn to manage their own behaviour and risks. Risk assessment and management should therefore be a supportive process, all with the ultimate goal of allowing that young person to reach their potential.
Whilst it may not be appropriate for Centrepoint to adopt a specific ‘SPJ’ tool per se, and in fact there isn’t a specific ‘risk tool’ developed for young homeless people that we could easily adopt ‘off the shelf’, adopting the principles of the SPJ process in our existing risk assessment and management process represents best practice in this area. Consequently, PIE (and ‘SPJ’) informed Risk Assessment and Management training will also be part of Centrepoint’s training offer to all our staff moving forward. This enables us as an organisation to continue to ensure that we can support our ‘frontline’ staff to make the best decisions they can about the young people in their service, and make risk decisions a less ‘risky business’…