The needs of older people are rarely considered outside of their age-related ailments. Community services remain geared towards the younger generation more specifically children and young people, while older people’s needs tend to be looked at peripherally. A question that springs to mind is how risk is assessed in an older person with mental health issues.
A starting point could be to look at a definition of risk. Risk can be defined as ‘the possibility of beneficial and harmful outcomes and the likelihood of their occurrence in a stated timescale’ (Alberg et al in Titternon, 2005). Risk is also a common feature in assessment frameworks by agencies and policies in social care and health. Hence the need to attach significance to risk issues in several public inquiries. However, these seem to be primarily related to child death inquiries where risk assessment and risk management are seen as the ongoing needed requirements to improve best practice. Most available research studies of risk and older people seem to focus on falls and other everyday risks they might encounter when seeking to return home after a hospital admission.
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Langan & Lindlaw (2004) comment that mental health service users have become increasingly defined in terms of risk and dangerousness, despite consistent research evidence that their contribution to violence in society is minimal. They further stipulate that continued focus upon risk means that there is a danger that people so defined will be excluded from decision-making about their lives. This could be related to theory and research evidence that suggests that although older people with mental health needs are at increased risk of admission to long-term care, staff tend not to be well informed about their mental health needs (Nicholls, 2006). This could be related with mental health issues coexisting with other medical conditions in later life, leading to this client group being commonly treated in mainstream settings rather than mental health related institutions.
In regards to legislation and policy that incorporates risk assessment, we have the NHS and Community Care Act (1990) which spells out the duty to assess those in need of community care services. More specifically to risk related interventions, these should be the least restrictive and clients ought to be encouraged to use their own resources or develop new ones as per Mental Health Act (1983), Mental Capacity Act (2005) and Safeguarding Adults. Moreover in context of the National Service Framework for Older People (2001) ‘person-centred care’ is key, where the aim is for older people to be treated as individuals and receive appropriate and timely packages of care which meets their needs as individuals, regardless of health and social services boundaries (DH, 2001). The No Secrets guidance (2000) encourages services users to have greater control of their lives by being given the opportunity to take and manage risks. There is also the Risk and Choice Framework (2007) which provides guidance on risk assessment and tools.
However, current policy and legislation seems to hold long-held ageist assumptions about capacity and capability. For instance, the NSF for Older People (2001) and Essence of Care (2003) require service providers to ensure that care for this client group is fully integrated and holistic in nature. Hence the intended use of the FACS (Fair Access to Care Services) criteria to ensure equality. Yet, these eligibility criteria can prevent an important focus on an older person’s biography in terms of the strengths and abilities they gained over their transitional experiences. In this instance, policy relating to risk assessment needs to consider the impact of age and life course stage.
Moreover, has concluded by McDonald (2010) legislation alone will not change the way in which professionals respond to older people and further analysis is needed in regards to the factors that influence decision making in the context of risk.
Through our lifespan risk can be perceived as beneficial and part of everyday life as it enables learning and understanding. However, one cannot dismiss the negative consequences of risk and subsequently the need for it to, at times be monitored and restricted. Thus risk assessment becomes a significant element of many frameworks.
Risk assessment has been defined as ‘the process of estimating and evaluating risk, understood as the possibility of beneficial and harmful outcomes and the likelihood of their occurrence in a stated timescale’ (Titterton, 2005: 83).
In that context, such process should look at a situation or decision, identify the risk and qualify/rate it in terms of likelihood, harmfulness or even low, medium or high risk. Thus, a risk assessment will only identify the probability of harm a risk may have to the related client and others. Subsequently, intervention strategies should aim at reducing harm. Irrespective of this a risk assessment cannot prevent risk (Hope and Sparks, 2000) and most models of risk assessment recognise that it is not possible to eliminate risk, despite the pressure on public authorities to adopt defensive risk management (Power, 2004).
This defensive risk management is perhaps in response to some of the high profile cases dominated in the media over the recent years, which has directed the focus of community care policy to minimise risk. Also the government current emphasis on risk when it comes to mental health related incidents/cases conveys a highly misleading message to the public which in turns seems to contribute to the defensive nature found in the professionals that carry assessment and are meant to support this client group.
As commented in the Health Select Committee (2000) the current “blame culture” risks driving away much needed staff from mental health services. The parallel concern becomes what are acceptable risks and how these might conflict with the agenda of person-centred assessments and user empowerment. As put in Carr (2011) defensive risk management or risk-aversive practice may result in service users not being adequately supported to make choices and take control, hence being put at risk.
Risk assessment is not only about negative labelling with adverse consequences. It has the value of promoting safety and, where necessary, identify appropriate intervention and support for service users. The methods most used in assessing risk in social work are: actuarial and clinical methods. Adams, Dominelli and Payne (2009) state that the actuarial method involves statistical calculations of probability where an individual’s behaviour is predicted on the basis of known behaviour of other in similar circumstances; clinical assessment employs diagnostic techniques relating to personality factors and situational factors relevant to the risk behaviour and the interaction between the two. This latter is the more familiar method in social work practice. Both methods have limitations in terms of generalising behaviour (actuarial method) and risk assessment being a subjective process (clinical methods), i.e. influenced by assessor’s background, values and beliefs. As such, it is central for professionals to be aware of the limitations of risk assessment tools.
Thus far, risk and its assessment seem to vary which reinforces the need for partnership and collaborative working as a way forward in integrating health and social care to provide a person centred support to mental health service users. Alaszewski and Alaszewski (2002) found that users, families and professionals had differing views about risk and safety. Nicholls (2006) refers to the Green Paper on Independence, Well-Being and Choice, which found that service users believe that professionals are too concerned about risk, and that this gets in the way of enabling service users to do what they want to do.
In relation to older people, the Single Assessment Process stipulates the need for a coordinated approach by which health and social care organisations work together to ensure person-centred, effective and coordinated care planning (Nicholls, 2006). This entails sharing information, trusting one another’s judgement, reducing duplication, and together ensuring that the range and complexity of an older person’s needs are properly identified and addressed in accordance with their wishes and preferences.
Such collaborative working between professionals and service users can address potential conflict, evaluate strengths, needs and risk where the effectiveness of intervention is likely to be improved and the outcomes for service users more positive (Adams, Dominelli and Payne, 2009).
The implications for social work practice is that the needs for service users with mental health issues frequently cross organisational and professional boundaries. For example, professionals working with older people with mental health issues are more than likely to work alongside a range of practitioners from different health and social care disciplines and organisations. Thus, one needs to consider how organisational cultures may impact or influence on how risk is perceived as subsequently assess. As put by Neil et al (2009, p.18) risk decision making is often complicated by the fact that the person or group taking the decision in not always the person or group affected by the risk.
Waterson (1999) further suggests that professionals and users tend to disagree on the levels of risk, not least because risk is subjective and can apply to environments as well as to people. Alaszewski and Manthorpe (1998) equally argue that risk is perceived differently by different professionals and allocating blame is one of the main concerns of public enquiries into failures of community care interventions.
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As current society develops into a culture of blame and risk-aversion, there is an emphasis on the need to minimise uncertainty about risks and attribute individual culpability. As put by Parton (1998) ‘blaming society’ is now more concerned with risk avoidance and defensive practice than with professional expertise and welfare development. This defensive form of social work in risk assessment put at risk effective and open collaborative and partnership working. Today’s dominance of individual accountability (or culpability) might make social work lose sight of their traditional values where service users are meant to be empowered to make informed decisions about the risks they are prepared to take and the support they feel they might need. As stated in Carr (2011) practitioners are less able to engage with individuals to identify safeguarding issues and enable positive risk tasking. As a result issues of discrimination, inequality and anti-oppressive practice start emerging with a client group that is already vulnerable.
Both stigma and discrimination against older people is further accentuated by a diagnosis of mental health. It is reported that older people with mental health needs are at greater risk of abuse than other groups of older people (Nicholls, 2006). In regards to risk assessment, literature stresses the need for mental health service users to be included in that process, to have choice and opportunities to take risks towards maintaining their independence and self-determination, as put by Lawson (1996: 55) ‘risk taking is choosing whether or not to act to achieve beneficial results in an awareness of potential harms’.
As mentioned before risk taking is part of life, but too often for older people the presence of an element of risk results in the prescription of care solutions or admission to residential care which may not be the older people’s own wishes. For example, in placement experience when older clients were admitted to hospital the local authority primary goal was to ensure clients remained at home for as long as possible however the package of care was delivered in accordance with the local authority’s interpretation of these client’s needs such as dictating bedtime routines and dismissing the need for social interaction. In this instance, the risk assessment tended to focus on the worker’s interpretation of perceived need. This could relate to the findings of Langan & Lindlaw (2004) study where service user involvement in risk assessment was variable and depended upon individual professional initiative. The concern here is that being overpreoccupied with risk can be to the detriment of assessing needs suggesting a primary concern with organisational procedures and resource-allocation over service user’s wellbeing. As put by Munro (2002) social work should be much more than minimising risk, it should be about maximising welfare. Carr (2011) further suggests that this also impacts of practitioners’ ability to engage with service user to enable positive risk-taking, leaving clients unsupported in taking control.
Discrimination may also occur has a result of the level of risk attributed to a service user. Whereby over-estimation can lead to unwarranted labels and under-estimation lead to inappropriate service provision and/or risk to others (Langan & Lindlaw, 2004). Inflexible labelling is both unhelpful and often stigmatising. As found in research, people with mental health problems are a far greater risk to themselves than they are to the general population and while there are instances where intervention is required this should not be done in a way that pigeonholes this client group as if the category of “dangerousness” (Tew, 2011) is solely related to mental heath issues.
In an attempt to answer the initial question, of how risk is assessed in an older person with mental health issues, risk assessment of older people with mental health issues is more likely to take place in crisis situations. Hence interventions might be more reactive rather than proactive, where professionals’ focuses on weaknesses and inabilities rather than strengths and abilities. Professionals may ‘play safe’ by minimising risk at the expense of user empowerment.
To better understand how risk, strengths and difficulties are assessed in regards to risk assessment in older people with mental health needs (and other mental health service users) we need to put it in the context of current political and social perception. The latter being significant given that research into causes and effects of mental health in older people are limited, also there is limited research on how mental health service users manage risk. Therefore, it is essential that risk assessment moves from a “one-size fit all” approach or a sort of tick-box exercise to being an inclusive process where the individual involved brings expert knowledge that needs to be incorporated into the assessment of risk. As found in Langan and Lindlaw (2004) few service users were fully involved in risk assessment. Similarly, Stalker (2003) makes reference to the omission from research of services users who are perceived to be at risk or a risk. Littlechild & Hawley (2010) suggest that little is known about how social workers actually assess risk and that judgements made by individual professionals can vary when using the same risk assessment tools. Petch (2001) adds that overemphasising the importance of accurate risk assessment may lead to misleading conclusions about the level of risk posed by someone and as such expose this group to unnecessary restrictions.
From some of the literature review and research available risk can be viewed as a social construction, perception of risk differs between professionals (and service users) and society has its own normative views on risk and it’s overtly concerned with the consequences of risk behaviour in relation to mental health. Moreover, the role of the media in shaping and, one could argue, amplifying some of these concerns must also be acknowledged. Nonetheless, this does not make risk inexistent. The key seems to be for the needs and risk of mental health service users to be assessed from a holistic approach, avoiding judgements, placing the service user at the centre and valuing their perspective as a contributing expert while at the same time recognise that risk is contextual as well as its fluid, i.e. risk can change.
Risk assessments need to be comprehensive and build on a bigger picture of the service user by drawing on their strengths and aspirations. Tew (2011) reiterated that the dominant discourse around risk tends to pathologise service users where social and environmental context is not considered. Also that this leads to a paternalistic practice where service user’s needs are provided for without considering their rights.
The concept of ‘risk’ is complex, making its assessment challenging. This is reflected in the different ideas and approaches to risk assessment as well as the inkling that we are moving to a risk dominated society. As a result, the attitudes and behaviours of such society are weighed in policy and practice in relation to service users with mental health issues whereby isolated incidents involving people with mental health issues become exaggerated to generate perceptions that such client group are inherently dangerous and need to be controlled and confided (Gould 2010). Undisputedly, it is a major challenge to get the right balance when making difficult risk decisions.
On the other hand, risk assessments are needed to improve the validity and reliability of decision making particularly where there may be concerns about an individual’s capacity to make informed judgements. However, risk can never be eliminated altogether, and occasionally decisions will be made in good faith, on the best evidence available.
As proposed by Stalker (2003) more studies are needed to address the complex nature of risk as well as positive-risk taking in regards to service users with mental health needs. This in addition to the need for research to include services users perspectives as well as other variables such as race and gender.
In regards to older people, if as a social group they tend to be institutionally marginalised then it might be equally easy to negate the views of people with mental health problems who equally challenge society’s assumptions of capability in regards to managing risk. Risk assessment is central to social work practice; however it must not depersonalise the service user and merely identify them through a compilation of risk variables. Additionally the discourse around risk assessment needs to move from a concern about risk adversity to a probability of negative and positive risks. Equally antagonistic is the use of the term “dangerousness” to define vulnerable service users. Such language can impact on collaborative and partnership work between professionals and service users. Moreover, as put in Tew (2011) the ongoing rituals of risk assessment may impact further on service user’s sense of self and undermine their capability to manage risky situations. Also, as stated in Petch (2001) there will always be people in the community who pose risk, whether or not they suffer from mental health, and singling out or blaming a particular group of professionals will not change this.
Thus, a risk assessment is made on a balance of probabilities rather than exact conclusions. While striving for uniformity within risk assessment is a move towards equity, flexibility is also important given the subjective contexts of risk and mental health needs. People’s lives involve many changing and interrelated variables which will always create some difficulty in balancing risk assessment. In the end, life cannot be without risk and risk-taking is part of the process that makes us who we are, complex beings.
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