The Journal of Mental Health Training Education and Practice

Felton, Anne; Wright, Nicola

2018 The Journal of Mental Health Training Education and Practice

doi: 10.1108/JMHTEP-11-2017-0061

Callaghan, Patrick; Grundy, Andrew

2018 The Journal of Mental Health Training Education and Practice

doi: 10.1108/JMHTEP-04-2017-0027

PurposeThe purpose of this paper is to examine empirical, epistemological and conceptual challenges and clinical narratives in the application of risk assessment and management in mental health.Design/methodology/approachThe authors used a narrative review of empirical, conceptual and clinical literature.FindingsThe worldwide prevalence of violence in mental health settings remains high. Risk assessment and management approaches, while well intentioned as an attempt to reduce harm and increase people’s safety, have negligible effect on both. They are invariably individual centric, ignore wider environmental, societal and behavioural influences that foment violence and have a stigmatising effect on people using mental health services. They also reinforce the myth that people who are mentally unwell threaten society and that through current risk assessment and management approaches, we can minimise this threat.Research limitations/implicationsThere is a need to reconsider the study and application of violence risk assessment in mental health.Practical implicationsThe practice of risk assessment and management in mental health is marred by an overuse of risk assessment measures that are limited in their predictive efficacy. As a result, they have little value in preventing, reducing and/or managing harm. The language of risk punishes and stigmatises service users and reinforces the image of menace. An alternative language of safety may nourish and protect. A collaborative approach to safety assessment based upon recovery-focussed principles and practices may fuse professionals and service users’ horizons. Combining service users’ self-perception, professionals’ sound clinical judgement, assisted by electronically derived risk algorithms and followed by evidence-based risk management interventions, may lessen the threat to service users, reduce harm and transform the practice of violence risk assessment and management.Social implicationsRisk appraisals discriminate against the small number of people who have a mental illness and are risky, an example of preventive detention that is ethically questionable. On the basis of the limitations of the predictive efficacy of actuarial measures, it is ethically dubious to subject people to interventions with limited benefits. Risk assessment processes tend to reinforce stigma by classifying individuals as risky, sanctioning society’s prejudices and fear through scientific authority.Originality/valueThe increasing focus on risk assessment and management to tackle violence in mental health is fraught with empirical, conceptual and practical concerns; the authors have suggested ways in which these concerns can be addressed without compromising people’s safety.

Newton-Howes, Giles

2018 The Journal of Mental Health Training Education and Practice

doi: 10.1108/JMHTEP-04-2017-0030

PurposeThe purpose of this paper is to review the perceptions of risk from the viewpoint of the psychiatrist, in the context of the expectations of patients, staff and society.Design/methodology/approachThe paper is a reflection on clinical practice and narrative review of the literature.FindingsThere are significant problems in the prediction of risk, to do with the difficulty in attempting to predict any low prevalence outcome. Additional complications relate to societal expectations and the legal frameworks within which mental health is practiced. The evidence related to poor outcomes, such as suicide is very complex, occasionally appears contradictory, and caution is required in application. The paradigm of recovery provides a way forward in the assessment and management of risk that moves away from any pretence of future prediction and aims to engage with service users and their families in a supportive and complimentary way.Practical implicationsUse of a recovery framework, with a focus on need, as opposed to risk, would appear to benefit patients, carers and those delivering service.Originality/valueThis viewpoint enables a broader gestalt of the literature in the context of day-to-day clinical practice. This prevents the limitation of only examining the (largely) epidemiological literature, or just commenting on one clinician’s practice. It provides for a conceptualization of a way to move forward in the consideration of risk.

Crowe, Sally; Deane, Frank

2018 The Journal of Mental Health Training Education and Practice

doi: 10.1108/JMHTEP-05-2017-0039

PurposeThe purpose of this paper is to investigate the relationships between clinicians’ and managers’ risk aversion and a range of variables related to the implementation of the Collaborative Recovery Model (CRM). Positive risk taking is an integral component of the recovery process. Clinicians’ risk aversion has the potential to negatively impact on their implementation of recovery-oriented practices. The CRM provides an evidence-based framework to assist consumers to participate in the recovery process. However, there is a need for research to clarify the factors related to recovery that have impact on managers’ and clinicians’ risk aversion, and ultimately on implementation of recovery practices.Design/methodology/approachA cross-sectional survey assessed clinicians’ (n=174) and managers’ (n=48) risk aversion and their self-reported learning experiences, commitment to using CRM, goal setting attitudes and CRM implementation behaviour.FindingsClinicians who reported more risk aversion were significantly more likely to report positive attitudes towards goal setting. Stepwise regression revealed that training experiences, goal setting attitudes and commitment to CRM significantly predicted an increase in CRM implementation. Over and above this, risk aversion predicted a small but significant increase in the self-reported use of CRM. Managers experienced significantly less risk aversion than clinicians, with a negative relationship between risk aversion and commitment to CRM principles.Originality/valueThis paper suggests that clinicians’ risk aversion impacts upon their implementation of the CRM, with managers less risk averse than clinicians.

Morrissey, Jean; Doyle, Louise; Higgins, Agnes

2018 The Journal of Mental Health Training Education and Practice

doi: 10.1108/JMHTEP-03-2017-0017

PurposeThe purpose of this paper is to examine the discourses that shape nurses’ understanding of self-harm and explore strategies for working with people who self-harm in a relational and a recovery-oriented manner.Design/methodology/approachSelf-harm is a relatively common experience for a cohort of people who present to the mental health services and is, therefore, a phenomenon that mental health nurses will be familiar with. Traditionally, however, mental health nurses’ responses to people who self-harm have been largely framed by a risk adverse and biomedical discourse which positions self-harm as a “symptom” of a diagnosed mental illness, most often borderline personality disorder.FindingsThis has led to the development of largely unhelpful strategies to eliminate self-harm, often in the absence of real therapeutic engagement, which can have negative outcomes for the person. Attitudes towards those who self-harm amongst mental health nurses can also be problematic, particularly when those who hurt themselves are perceived to be attention seeking and beyond help. This, in turn, has a negative impact on treatment outcomes and future help-seeking intentions.Research limitations/implicationsDespite some deficiencies in how mental health nurses respond to people who self-harm, it is widely recognised that they have an important role to play in self-harm prevention reduction and harm minimisation.Practical implicationsBy moving the focus of practice away from the traditional concept of “risk” towards co-constructed collaborative safety planning, mental health nurses can respond in a more embodied individualised and sensitive manner to those who self-harm.Originality/valueThis paper adds further knowledge and understanding to assist nurses’ understanding and working with people who self-harm in a relational and a recovery-oriented manner.

Clarke, Charlotte Laura; Titterton, Mike; Wilcockson, Jane; Reed, Jane; Moyle, Wendy; Klein, Barbara; Marais, Sandra; Cook, Glenda

2018 The Journal of Mental Health Training Education and Practice

doi: 10.1108/JMHTEP-12-2016-0060

PurposeThe purpose of this paper is to explore the experience of older people and their sense of developing wellbeing, including consideration of the strategies they employ to respond to perceived risk.Design/methodology/approachAn Appreciative Inquiry study was used, which collected data with 58 participants in focus group and individual interviews. Interviews focussed on ways in which older people in South Africa, Australia, Germany and the UK understand and seek to maintain wellbeing.FindingsThe changing time horizons of older people lead to perceptions of risk and concerns that embrace societal as well as individual concerns. Often, this leads to a sense of societal responsibility and desire for social change, which is frustrated by a perceived exclusion from participation in society.Social implicationsIn mental health practice and education, it is imperative to embrace the shift from ageist concerns (with later life viewed as risky and tragic in itself) towards a greater sensitivity for older people’s resilience, the strategies they deploy to maintain this, and their desire for more control and respect for their potential to contribute to society.Originality/valueVariation in time horizons leads to changes in temporal accounting, which may be under-utilised by society. Consequently, societies may not recognise and support the resilience of older people to the detriment of older people as individuals and to the wider society.

Felton, Anne; Stickley, Theo

2018 The Journal of Mental Health Training Education and Practice

doi: 10.1108/JMHTEP-06-2017-0043

PurposeThe assessment and management of risk is central to contemporary mental health practice. The emergence of recovery has contributed to demands for more service user centred approaches to risk. The purpose of this paper is to examine the potential of narrative as a framework for understanding risk and safety in mental health care.Design/methodology/approachNarrative theory is adopted to structure a debate examining the potential role of a narrative approach to risk assessment and inform future practice.FindingsThere is a danger that even within services, people with mental health problems are understood in terms of their riskiness perpetuating an image of service users as “dangerous others”. This is confounded by a disconnection with individual context in the risk assessment process. Narrative centralizes the persons’ subjective experience and provides a contemporaneous self-account of their identity. This situates risk within a context and creates possibility for greater understanding of coping, strengths and resilience.Originality/valueThere has been a call for new ways of working with risk in mental health which facilitate safety and recovery. There is limited examination of what this might actually look like. This paper presents narrative as an approach that may achieve these aims.