Clinical risk assessment of individuals

Pavilion conference: December 1999

I would like to begin by briefly explaining to those who may not know what Respond is. We are a voluntary sector organisation, core funded by the Department of Health, whose primary aim is to provide psychotherapy and counselling to people with learning disabilities who are victims and/or perpetrators of sexual abuse.

Based in central London, we provide individual work to around thirty clients per week. We also run a number of psychotherapy groups - a women's group, a men's group, and a group for adolescents with learning disabilities who have been abused and who are now displaying worrying sexualised behaviour. We run a number of parallel services for professionals and carers around issues of learning disability and sexual abuse - various training courses, supervision and consultancy services, and a helpline primarily for people with learning disabilities, but also for people without disabilities to use.

We began, like so many other agencies, as a victim only organisation. There was something comforting about this early position, allowing us, as it did, to occupy a fairly well defined place in terms of having permission to feel good about the fact that we only worked with the "good victims", and left the messiness of the "bad perpetrators" to others. While it may have been a comfortable place to be, there was something about this position that was not quite real, particularly given our increasing efforts to view our clients in a unified, non-split way. T

he growing recognition that people are not neatly packaged into good or bad, victim or perpetrator, but are often a demanding mixture of both, led us on to develop treatment models that could cater for abused, abuser and those that are both. Looking back on it some years down the line, the provision of forensic risk assessments was very far from our minds, but has, over the years, become an important part of our service, drawing together as it does the psychotherapeutic and investigative arms of our work. Before moving on to consider some of the ethical dilemmas inherent in practising Risk Assessments, it may be useful to briefly describe the Risk Assessment as we practice it. A client is referred to us by, in the main, Health Authorities, Social Services or Probation.

The reasons for referral are varied - a sexual offence may have been committed, there may be concerns about sexual practices in the toilet at the day centre, a keyworker in the group home may have concerns about the sexual content of his conversations with his client. We consider the referral, and say "no" to a number of them, for reasons that I'll outline later in this talk. If we agree that there is a compelling need for a Risk Assessment, we will then ask the referrer to gather as much background information as possible on the client, including childhood, family history, employment history, any psychology or psychiatry assessments that may have been conducted. Armed with this, we will, then convene a professionals meeting to discuss the history to the case, and the current areas of concern.

When referring a client for a risk assessment the explicit question may be: "This man or woman is, we think, a risk to others - please find out more." But the implicit question, the sub text, may be one or more of a combination of other, equally valid questions: · As a housing association we have decided to stop denying the fact that over fifty per cent of the clients we house are sexually dangerous. Are we right? · The parents of our clients do not trust us. We need to be seen to use another expert. It doesn't matter too much what you say - as long as you say something and you are not us.

· We know the risk, we know why he is abusing others and we know how it should be managed. Give us permission to do it. · We are all exhausted from working with this client. For a couple of hours a week for three months, spend some time with him and give us a rest. Clients may often not just be clients - they may also be personifications of difficulties in an organisation. This must make us view our assessments as having dual roles. Primarily they exist to assess the client, to take an in-depth look at the intrapsychic world of the client, to consider his or her history and to explore the reasons why sexual acting out has become such a feature of someone's identity.

But as important is the need to look at the world outside the client too. Our Risk Assessment process must also look at the environment in which the client is housed, where they receive day care or where they work. Is it a setting that is able to understand this client, can it provide safety and containment at all times, are there gaps in the safety net? To reach answers to these questions, it is necessary to have a dialogue with those who work with the client. Not just to seek pragmatic answers to pragmatic questions, but also to explore the less tangible areas.

How does this client make people feel? Is the team feeling split in two - are half feeling worried, anxious, concerned about the client, while the other half of the team feel secure with him, as if something is being blown out of proportion. Both reactions will be there for a reason, and can tell us much about what clients project into those around them and, perhaps, can tell us much about pre-existing family dynamics. Once there has been an opportunity to discuss these questions, the therapist will then meet with the client him or herself for a maximum of twelve sessions.

Each lasts just under an hour, all are at the same time and the same place each week. All sessions take place at our clinical base in London. We ask a lot of the network bringing the client to us, but, I feel, quite rightly. If it is supposedly impossible for a service to bring a client to us for twelve sessions, this must tell us something about the organisation's capacity to deal with demands on it, and its ability to enact any recommendations we make at the end of the three months of clinical work. Just as the client may not just be a client - the reports supplied to us may not just be reports - they may be all sorts of things - historical documents telling us much about the role of people with learning disabilities in society, fragments of family history or, as they so often are, statements about the ethical, political or clinical viewpoint of the professional who wrote them.

At Respond we ask for copies of as many written reports as possible before seeing the client. Just as it is interesting to consider which professionals are able to attend a liaison meeting and which are not, and what meaning is conveyed by the absences, it is useful to think about which parts of the client's life are not covered by reports, and why - whether it be schooling, employment or early childhood. Does the referrer who has been asked to collate the reports value some areas above others, and, consciously or unconsciously, put more effort into gathering information about the client's forties than their teens?

When the written information is with us, we tend to regard it fairly cynically, often with good reason. One example I would like to share is a client referred to us around eighteen months ago who came with a diagnosis of personality disorder. He had been referred as part of a court order, with the diagnosis as part of the pre sentence report. One of our first jobs of work was to think about this diagnosis. Three of us, myself, the therapist who was due to work with the client, and the consultant psychologist supervising the piece of work, shared our puzzlement over this diagnosis, which, for reasons we found it hard to classify, did not seem to fit in with what else we knew about him.

At this stage we were mostly speaking in terms of gut feelings. More to put our own minds at rest rather than anything else, we decided to try to trace back the origins of the diagnosis. It did not take us long. All reports alluding to this man over the past five years featured the term "personality disorder". Six years ago, however, the diagnosis was non existent. We found a draft report written by a trainee psychologist who have seen the patient for a one off assessment. Her report was a very tentative one, and one suggestion she made was that it might be worth investigating whether there might be any evidence of a personality disorder, although she herself in her assessment had not found sufficient evidence to make such a diagnosis. Two months later the suggestion found its way into a social workers' care plan about the client, but without its tentative framing. It became, for the first time, written as a fact, without any qualification. It did not take long for it to become a permanent feature of biographies of this client in all manner of reports. On one level there was a huge mystery about this man that all those who came into contact with him were very aware of.

Not surprising then that a diagnosis such as personality disorder soon came to serve to absorb some of the mystery, to the point where it was part of a pre-sentence report in a court of law. Appalling as this example of professional "Chinese whispers" may be, it is not an isolated one. A similar process can often be played out around the level of learning disability. We have been referred clients who, in the original referral letter are described as having mild learning disabilities, in the minutes of their case conference are described as having moderate learning disabilities and in their psychology assessment it is stated that they may have severe learning disabilities.

IQ tests certainly cannot tell us all we need to know about the different levels of functioning in our clients, but they are often one of the measures we recommend is tested following the risk assessment - if only to clarify what level of learning disability the client actually has. In conducting a Risk Assessment the therapist will struggle with a whole range of ethical considerations. Confidentiality is high on the list, and will no doubt occupy many people's thoughts throughout today's conference. The ethical role of the therapist conducting the assessment also needs careful consideration, particularly in such areas as how much to push the client, using psychotherapeutic skills in what is, over all, not a psychotherapeutic piece of work. The issue, too, of working with sexual fantasy - one of the most difficult areas to explore, enmeshed, as it is, with the client's sense of himself as a private and sexual being. How far should we explore this within what is not, after all, long term therapy. The process I am describing here is a twel

ve session one, and we must always be mindful of the dangers of dismantling people's carefully erected defences if there is not time to think about what could take their place. Consent is another important issue to consider. When I am asked to see a client for individual psychotherapy, one of the questions that will be foremost in my mind is whether this client is knowingly consenting to come. The lives of our clients are so often defined by compliance and a need to agree to the wishes of those charged with their care that it can often be difficult to form an objective view on this.

If it is clear that a client is genuinely confused about why he is here and what he is here for, I would recommend that his team do some more work with him before we are ready to conduct a meaningful psychotherapy assessment. When Risk is being assessed, it can be even less of an even playing field. We have not yet met the client who is attending a Risk Assessment because he truly believes it will help him. There are usually all sorts of subtle and not so subtle conditions in place to get the client to us. Given all of that, it is vital that in the first session we are explaining to clients what the conditions of the assessment are - that all sessions will be tape recorded, that sessions will be written up and that eventually there will be a written report that will be seen and discussed by others.

If, at the end of the day, the client does not consent to this process, we cannot proceed with the piece of work and would, instead, advise the referring team on alternative methods of ascertaining the client's risk. It may be useful to say something about the ways in which our therapists engage with clients in order to build as comprehensive as possible a picture of their life history, and their level of risk. Our Risk Assessment process draws on our psychotherapy process. One of the things to know about the psychotherapy we practice is that it is informed predominantly by psychoanalytic thinking. It seeks to provide a space in which clients can think about not just the experience of abuse they have experienced or the abuse they are perpetrating upon others, but also other areas of their life that this experience has touched.

For one client the thing she may wish to talk most about is not how their key worker raped them, but more about how they've always felt like they don't properly fit into every day living situations. Another client, referred because of being abused by his grandfather, will instead need to talk about how he never has enough money, or has never had a proper job, or feels upset whenever people on television talk about having lots of money. Our job is not to jolt the client back onto the "right agenda", but, instead, to make links with these presenting issues and the underlying losses, abuses and traumas they have lived through.

Often in the course of working with a client for two to three years it is, thus, not just the trauma of abuse that needs to be worked with, it is also the trauma of having a learning disability itself. What Professor Sheila Hollins calls the three central conflicts that are addressed by long term psychotherapeutic work - a: the disability itself, what it feels like to be different from the majority of the world, what it felt like to not be the longed for child; b: sexuality - the effect of one's sexuality representing something complex and unknowable to the rest of the world, and how this can become something intricately internalised. C: mortality - like sexuality and disability, something we as a society are not good at talking with our clients about.

The experience of being born and the experience of losing others and dying oneself. Professor Hollins regards the exploration of these conflicts as being key to a worthwhile psychotherapeutic process. I would also extend these conflicts to being useful in formulating a risk assessment. It is important not to isolate anything. The experience of hurting others through sexual aggression will rarely be found to be a behaviour in and of itself that does not have its roots in earlier trauma. It is rare for clients to think about their sexual behaviour in isolation from the rest of themselves, and in thinking about their selves it is necessary to think about the disabled bits of themselves.

The Risk Assessment must then accommodate explorations of disability, the primary organic deficit and what Valerie Sinason calls the "secondary handicap" - a construction which can be described as a defence against trauma. Sometimes the trauma of being abused, sometimes the trauma of disability. The more we are able to consider these issues with our clients, the less restricted our formulations will be, and the more useful our recommendations will be in terms of long term risk management. This issue is of equal importance when working with clients who do not use words. We have yet to meet a client who does not communicate, and when words are not the primary source of communication we need to adapt our vocabulary to use silence, dolls, drawing and movement. By definition, the work is slower, more gradual, and we need to adjust our sights accordingly. In working with one young man who did not use words I knew that compiling a full history of his life would be impossible.

There was very little documentation on his short life against which I could test out what he communicated. And yet, without words, he was able to convey more clearly to me his early childhood than many clients whose words flow effortlessly. Using a dolls house, he managed to let me know which of the dolls was mum and dad, which of the dolls were his brothers and sisters and which of the dolls, the smallest and most fragile looking one, was him. Over a number of weeks he managed to act out various scenarios in the house, culminating in an appalling display of violence that almost resulted in the dolls house being smashed in two.

For the first time this young man had managed to tell a part of his story. For him it was the most important part - how he himself had been abused, and with what degree of accompanying violence. No risk assessment should be viewed as the answer - the solution to a client's problems in sexual acting out. Risk Assessments are snapshots - polaroids of how this client is right now. If done well, they will also provide information as to the client's history as well. But the information will be different in a year's time. We would hope that the recommendations that we make concerning treatment, residential placement, employment and other options have been acted on.

We would further hope that the recommendations would have effected change in the internal as well as the external world of the client. Once a Risk Assessment has been conducted we often recommend that a similar process be undertaken in twelve months time, and regularly thereafter to ensure that the change experienced within the client is being reflected in he outside world.

Risk Assessments are powerful documents, covering as they do such issues as one to one monitoring. Ethically we need to be able to review all such statements in the light of newer evidence. I have spoken mostly about a tightly constructed Risk Assessment process, and I would like to mention how the assessment process can also overlap into treatment services. Providing, as we do, psychotherapeutic treatment for perpetrators of sexual abuse who have learning disabilities, the issue of new information about dangerous situations is one that often taxes our thinking.

Although it is useful to have thorough policies on disclosure of information in treatment, it is important to remember that every case will be different, and a service will need to have some flexibility around its boundaries and its policies. This highlights some of the difficulties in practising psychotherapy for victims and perpetrators of sexual abuse who have learning disabilities in purely private practice, outside of the containing structure of an organisation. At Respond we are fortunate in being able to use a team approach when faced with dilemmas about confidentiality and disclosure. For example, when a client lets me know that they are feeling particularly vulnerable to hurting other people in their group home, it can be helpful for me to be able to say that someone else from within Respond will be able to talk to someone from my client's support network to ensure that people are aware of how vulnerable my client is feeling.

This helps ensure that the issue of danger is being acknowledged and worked with, while also retaining some sense of the therapeutic relationship being protected. Without that sense of the whole organisation being a safe container, it can be difficult for clients to forge a trusting therapeutic alliance with their therapist. One of the most interesting parts of this process of assessing risk is looking back over what has actually been achieved with our recommendations. We end with a written report and another professionals meeting to discuss the findings of the assessment. In those cases where the recommendations have, in the main, been followed, it appears that services have been able to achieve a higher degree of safety for their clients. In talking to them a year or two years down the line, one of the key elements that has been useful has been the ability to view the sexual acting out behaviour as, in most cases, a symptom of some underlying trauma.

People do not just do things for the sake of doing them, and we are often called in to think with a team about the function of the sexual symptom, not just for the client, but also for the team - what it represents, and what life may be like for them once it has been worked through. Certainly the cases for whom things appear to have been worked through or are being worked through are those where, at some level, split thinking has been addressed. The capacity of our clients to instil in teams a polarised set of reactions is enormous, and meaningful progress can rarely be made while the split persists.

To address this requires much work and commitment, and it is often that we may be recommending individual or group treatment for the client, as well as some kind of on going parallel process for the team in which their dynamics can also be looked at and talked about. Viewing the effects of sexual trauma whether the client is a victim or a perpetrator of both must be a core aim of a risk assessment. I would like to end with the view that it is not just the effects upon the client that must be examined in order to produce effective risk management strategies, it is also the effect upon the support network that must be carefully considered.