Care and Treatment Planning/CPA in The State Hospital: violence risk assessment and management planning: how you can make a difference

Before we start… Evaluation Your feedback is invaluable as it help us identify what we are doing well and what we can develop and improve upon We will be comparing pre- and post-training evaluation forms to see whether we have met our aims and objectives We would appreciate it if you could complete the evaluation forms and return them to us – thank you!

Overview of training Aims and objectives Background to violence risk assessment and management planning in TSH – why do we do it? The violence risk assessment and management planning process – how do we do it? Violence risk assessment and management planning – what and how you can contribute Using the Violence Risk Assessment and Management Plan Profile (VRAMP)

Aims and objectives Have a general overview of the process of violence risk assessment and management planning within TSH Be able to identify and pass on to the clinical team information you know about a patient that would be relevant for their risk assessment and management plan To know about the violence risk assessment and management plan profile (VRAMP) and be able to use it in your care and treatment of patients

Background to violence risk assessment and management planning in TSH – why do we do it?

Why do we assess risk of violence…? Exercise: In pairs, consider why we assess risk of violence in TSH. Why would the following groups of people think risk assessment was important? The clinical team? Scottish ministers? The public? Patients? Why would risk assessment be important for you in your job?

Legislation and political drivers In the past… Individuals who committed acts of violence were not properly assessed Individuals who were risky were not properly managed Staff who were noticing issues indicative of increasing risk of violence struggled to be heard – poor documentation and lines of communication

Legislation and political drivers cont. As a result… Offenders repeated patterns of offending - including violence with significant harm Several high profile cases

Legislation and political drivers cont.

Legislation and political drivers cont. Memorandum of Procedure (MoP) Care Programme Approach (CPA) Risk Management Authority (RMA) Mental Health (Care and Treatment) (Scotland) Act 2003 Multi Agency Public Protection Arrangements (MAPPA) High profile cases where things have gone wrong – e.g. MWC inquiry (Mr L and Mr M)

Lessons learnt… Violence risk assessment and management planning should be… Systematic using standardised tools for assessing risk Consistent and use standardised documentation Based on comprehensive and detailed information about the patients background, treatment and progress Multi-disciplinary All staff involved in patient’s care and treatment should be aware of the assessment and management plan and should highlight areas of concern – it is everyone’s responsibility Information should be shared between disciplines and agencies

The violence risk assessment and management planning process – how do we do it?

Care and treatment planning in TSH How violence risk assessment and management planning used to be done in TSH… No agreed format across the hospital for reviewing patients (care and treatment planning) No agreed formal assessment of future risk of violence Risk assessment and management planning not always linked with care and treatment planning Different practices and documentation were used by different clinical teams

Care and treatment planning in TSH The new Care and Treatment Planning process and documentation… All wards are now following the same process and using the same documentation This meets the requirements for CPA Aim is for all patients to have a completed violence risk assessment and management plan which is reviewed regularly by the clinical team Violence risk assessment and management planning is now part of the care and treatment planning process The Violence Risk Assessment and Management Profile (VRAMP) forms part of the care and treatment plan

Violence risk assessment and management planning Violence risk assessment and management planning involves: RISK ASSESSMENT (RISK FACTORS) - Assessing an individual’s risk of committing a violent act by looking for evidence of established risk factors which have been shown in research to be linked with future violence FORMULATION - Considering how these risk factors are relevant for the individual being assessed and understanding why an offence happened SCENARIO PLANNING - Making an assessment of the likelihood of future violence and the circumstances that this is likely to occur WARNING SIGNS - Identifying warning signs that would indicate an increase in the risk of violence RISK MANAGEMENT PLANNING - Developing strategies to manage this risk - including intervention and treatment, monitoring, supervision and victim safety planning

Thinking about risk… Exercise: Imagine a situation where you are driving in adverse weather and have a car accident… In 3 groups: What factors would make driving in adverse weather risky (risk assessment)? Why did the accident happen (formulation)? What might happen in the future (scenario planning)?

Thinking about risk…cont. What signs would indicate that the risk was increasing (warning signs)? What could you do to reduce the risk or minimise the harm (risk management planning)?

Violence risk assessment and management planning Violence risk assessment and management planning involves: RISK ASSESSMENT (RISK FACTORS) - Assessing an individual’s risk of committing a violent act by looking for evidence of established risk factors which have been shown in research to be linked with future violence FORMULATION - Considering how these risk factors are relevant for the individual being assessed and understanding why an offence happened SCENARIO PLANNING - Making an assessment of the likelihood of future violence and the circumstances that this is likely to occur WARNING SIGNS - Identifying warning signs that would indicate an increase in the risk of violence RISK MANAGEMENT PLANNING - Developing strategies to manage this risk - including intervention and treatment, monitoring, supervision and victim safety planning

Violence risk assessment in TSH – risk factors In TSH the risk assessment tool most commonly used is the HCR-20 The HCR-20 is a structured clinical judgment tool used to assess risk of violence. Other tools are available to assess different types of violence (e.g. sexual violence, stalking, spousal violence) The HCR-20 defines violence as… “actual, attempted, or threatened harm to a person or persons” The HCR-20 contains 20 items (or risk factors) 10 Historical items 5 Clinical items 5 Risk Management items

Violence risk assessment in TSH cont. Clinical teams collect evidence of the various risk factors identified in the HCR-20 for the patient being assessed. The evidence is presented in a draft evidence document and discussed by the clinical team The clinical team decide whether there is evidence that the item is present (rating of definite, possible or no evidence) The evidence in the HCR-20 evidence document for the C and R items is updated and reviewed every year

The HCR-20 Historical items: Previous violence Young age at first violent incident Relationship instability Employment problems Substance use problems Major mental illness Psychopathy Early maladjustment Personality disorder Prior supervision failure

The HCR-20 cont. Clinical items 1. Lack of insight 2. Negative attitudes 3. Active symptoms of major mental illness 4. Impulsivity 5. Unresponsive to treatment

The HCR-20 cont. Risk Management items: 1. Plans lack feasibility 2. Exposure to destabilizers 3. Lack of personal support 4. Noncompliance with remediation attempts 5. Stress

Violence risk assessment and management planning – what and how you can contribute

Contributing to the risk assessment Nursing and PARS staff spend a significant amount of time in contact and interacting with patients It is therefore likely that you will know things about your patient or have observed things which would be useful evidence for the risk assessment

Contributing to the risk assessment – what do you know? Exercise: In two groups think about the Clinical and Risk Management items of the HCR-20 What information could nursing or PARS staff have through their contact with patients that would be evidence for or against the presence and relevance of these items? How would you have obtained this information?

BEST – Index (scale - items) How the best Index links with the C&R items of the HCR-20 (Walker & Kettles) BEST – Index (scale - items) HCR-20 Risk – 2, 3, 4, 5, 6, 7; Insight – 1, 2, 3, 15,16, 17, 18, 19, 20 H1 – previous violence Insight – 1, 2, 3, 15, 16, 17, 18, 19, 20; Work and Rec – 1, 2, 3, 4, 5 H4 – employment problems Risk – 19; Insight - 1, 2, 3; Empathy – 1, 2, 3, 14 H5 – substance use problems Risk – 20; Insight – 1, 2, 3, 5, 16, 17, 18, 19 H6 – major mental illness Insight – 1, 2, 3; Empathy – 1, 3, 14 C1 – lack of insight Insight – 15, 16, 19; Empathy – 1, 3, 14, 19 C2 – negative attitudes Risk – 2, 3, 19, 20; Insight – 1, 2, 15, 20; Work and Rec – 1 C3 – active symptoms of MMI Insight – 16, 17, 18, 19, 20; Work and Rec – 1, 2, 4, 5 C4 – impulsivity Insight – 16, 17, 18 C5 – unresponsiveness to Tx Insight – 19 R4 – noncompliance with remediation attempts

Violence risk assessment and management planning Violence risk assessment and management planning involves: RISK ASSESSMENT (RISK FACTORS) - Assessing an individual’s risk of committing a violent act by looking for evidence of established risk factors which have been shown in research to be linked with future violence FORMULATION - Considering how these risk factors are relevant for the individual being assessed and understanding why an offence happened SCENARIO PLANNING - Making an assessment of the likelihood of future violence and the circumstances that this is likely to occur WARNING SIGNS - Identifying warning signs that would indicate an increase in the risk of violence RISK MANAGEMENT PLANNING - Developing strategies to manage this risk - including intervention and treatment, monitoring, supervision and victim safety planning

Understanding a person’s offending behaviour Why do people commit offences? People commit offences for different reasons – the same type of offence may be motivated by very different reasons…

Understanding a person’s offending behaviour cont. Offender A – Serious Physical Assault At the time of the offence…they are intoxicated, become involved in an argument…unable to manage their anger they lash out at victim… Offender B – Serious Physical Assault At the time of the offence…they have been a victim of domestic abuse for a number of years…unable to cope any longer, they retaliate and assault their partner…

Understanding a person’s offending behaviour cont Understanding a person’s offending behaviour cont. What might we find in TSH? Some external motivators for offending may be controlled by the security of TSH Some internal motivators for offending may remain but they may be expressed or evident in different ways in the different environment of TSH Within the TSH we may see offence-related behaviours: these behaviours are similar to past offending behaviour in that they are driven by similar motivators and indicate an increase in risk of violence.

Understanding a person’s offending behaviour cont Understanding a person’s offending behaviour cont. What might we find in TSH? cont. Observed behaviours in TSH Offence information Noted to drink excessive amounts of milk. Causes other patients to become annoyed with him when none left for teas/coffees. [Motivation: delusional beliefs.] Index offence involved stabbing family member whom he believed was trying to poison him with an out of date carton of milk. Psychosis includes delusional beliefs and a belief that drinking milk will make him God. Noted to be reluctant to engage with keyworker. Also became extremely angry when she advised him that outing has had to be rescheduled. [Motivation: negative attitudes towards females.] Index offence involved murder of girlfriend. Extensive history of physical abuse towards intimate partner. Reporting to select members of staff that he is being targeted by other patients on the ward; bullied and made to buy tobacco, confectionary. [Motivation: need for control and to assert self.] Index offence involved significant control and violence. Extensive history of childhood sexual abuse.

Understanding a person’s offending behaviour cont. Understanding a person’s offence helps us to make sense of behaviours we might see in TSH and think about how these link with risk of violence Understanding a person’s past offending behaviour is crucial for effective violence risk assessment and management: It helps us think about what violence that individual may perpetrate in the future and how this might come about It highlights potential warning signs that could indicate increasing risk of violence It can also help identify areas for intervention

What we might find in TSH – motivating factors and offence-related behaviours. Exercise: Think of a patient you know and their offence Describe their background to your group Describe their offence in as much detail as possible Ask your group to predict what kinds of behaviour you might see in this person in TSH

Information about a person’s offences In order to be able to identify offence-related behaviours, we need to… Know details about an individual’s past offending behaviour Understand why an individual’s past offending behaviour occurred (the formulation) Information on patients offending can be found in the… File review Case summary HCR-20 evidence document

How do you communicate what you know? If you observe something which you think may be related to an individual’s risk of violence and/or important for the risk assessment and management plan it is essential that you pass this on effectively The next step is to make sure the clinical team gets the information so it can be incorporated into the risk assessment – you may also want to discuss it with a colleague or line manager If writing notes or a report – make sure this is accurate and descriptive Try to avoid phrases like “sexually inappropriate” or “abusive” – we need details!

Using the Violence Risk Assessment and Management Plan Profile (VRAMP)

Violence risk assessment and management planning Violence risk assessment and management planning involves: RISK ASSESSMENT (RISK FACTORS) - Assessing an individual’s risk of committing a violent act by looking for evidence of established risk factors which have been shown in research to be linked with future violence FORMULATION - Considering how these risk factors are relevant for the individual being assessed and understanding why an offence happened SCENARIO PLANNING - Making an assessment of the likelihood of future violence and the circumstances that this is likely to occur WARNING SIGNS - Identifying warning signs that would indicate an increase in the risk of violence RISK MANAGEMENT PLANNING - Developing strategies to manage this risk - including intervention and treatment, monitoring, supervision and victim safety planning

The Violence Risk Assessment and Management Profile (VRAMP) The VRAMP can be found within the care and treatment/CPA plan The VRAMP includes: Summary of risk factors Formulation of offending behaviour Scenario planning Warning signs Recommendations for risk management strategies

Using the VRAMP Exercise Spend some time reading Adam Brown’s case summary. Whilst reading this think about: What might be the important factors in Adam’s background Why Adam committed the offence What Adam might be like in TSH

Using the VRAMP cont. The clinical team have completed a risk assessment and prepared a VRAMP for Adam Brown. Spend some time reading over the VRAMP. What would you be looking out for in his behaviour in TSH that would indicate increasing risk of violence?

Using the VRAMP cont. Now spend some time reviewing reports about Adam’s current functioning and presentation in the hospital. 1. Is there anything standing out in the reports that concerns you? Why? 2. Is there anything you would like to find out more about or investigate further? How would you do this? 3. Is there anything that you would want to pass on to the clinical team? What would you tell them?

What will you do differently…? What have you taken from today’s training… Take a few minutes to think about what you will do differently when you return to your ward or department. What changes will you make to your practice? What responsibilities do you have in relation to violence risk assessment and management planning?

Aims and objectives Have we covered our aims and objectives…? Have a general overview of the process of violence risk assessment and management planning within TSH Be able to identify and pass on to the clinical team information you know about a patient that would be relevant for their risk assessment and management plan To know about the violence risk assessment and management plan profile (VRAMP) and be able to use it in your care and treatment of patients

Before we finish… Evaluation Your feedback is invaluable as it help us identify what we are doing well and what we can develop and improve upon We will be comparing pre- and post-training evaluation forms to see whether we have met our aims and objectives We would appreciate it if you could complete the evaluation forms and return them to us – thank you!

Trainee Forensic Psychologist Specialist Psychological Practitioner Care and Treatment Planning/CPA in The State Hospital: violence risk assessment and management planning: how you can make a difference 2009 Clare Neil Trainee Forensic Psychologist Claire Hamill Specialist Psychological Practitioner