[Content Warning: Discussion of suicide, suicidal ideation, and iatrogenic harm]
Positive risk-taking, also known as ‘therapeutic risk-taking’, is a risk management concept used in numerous health and social care service interventions and practices. It is based on the understanding that “risk” is an immutable part of life, and cannot be entirely eradicated, nor should it be, as taking certain risks can lead to positive outcomes and personal growth which may otherwise have been inaccessible. Within mental health care, moving away from overly risk averse practices is a deliberate act which recognises that when mental health practitioners are too risk averse, they restrict patient freedom; choice; potential for growth; and, for some, recovery [1]. “Positive risks” in this sense are actions or inactions, taken in the service of recovery/growth/empowerment/autonomy/etc with the knowledge that they hold some risk. To give a fictitious example; Mr A is on an inpatient ward following a suicide attempt. Despite the fact that Mr A is improving and expressing wishes to go for a walk alone to enjoy the good weather, staff are concerned that if they allow Mr A leave without supervision, he may attempt suicide again. To protect Mr A they decide he should not be allowed to leave, which he finds deeply upsetting and impacts on his recovery and discharge. If the staff had conducted a risk assessment with Mr A which weighed his wishes and goals against the potential risk, and considered that eventually Mr A will need to be able to do things alone, they may have decided that allowing him to take short walks alone was a positive risk, as it would be in line with Mr A’s wishes, respect his choices, and contribute to a future in which Mr A is independent again.
Theoretically, “positive risks” are considered shared decisions made between both clinician and patient (and sometimes family/carers) with the patient's wishes, needs, and goals leading the decisions. Unfortunately, in practice, this is frequently not the case, as research finds that only 38% of outpatients, 50% of inpatients, and 10% of carers/families are involved in the creation of their risk management plans [2-4]. Anecdotally, positive risk-taking appears to be an intervention extremely vulnerable to misuse, and is often included in people’s risk management plans without their knowledge or consent. Patient/survivor accounts detail times people in vulnerable positions have been forced to take risks (discharged against their will, left to cope alone during crisis, had care removed, etc) due to the belief of clinicians that such actions will allow patients to become more responsible, learn to manage their own risk, and eventually reduce their service use:
“In the last few years I have been left in high risk situations, because of the misuse of enforced positive risk taking. [...] As a person with a severe and enduring mental health disability I realise I need to take some responsibility for reasonable risks in my daily life, but there are times that I simply can’t be responsible for my own safety. In these situations there is no joint decision making between myself and professionals. Being told it’s my choice to suicide when desperately asking for help in a life threatening situation as per my crisis plan is totally inappropriate and not one bit therapeutic. It seems to be shorthand for “We don’t give a fuck.” Surely, services should not withhold support and care when I’m at serious risk of harm under the guise of it being in my best interests, to teach my badly behaved personality a lesson, as a way of tapering care to somehow facilitate resilience, or in a way to avoid blame. You’re actually gambling with my life. It’s scary! Positive risk taking – positive for who? It’s no good promoting recovery if I’m dead!”[5]
“I was told repeatedly that if I wanted to kill myself it was my decision to make. [The psychiatrist] stated very matter-of-factly that his only priority was to ensure that his back was covered legally, and that if I were to kill myself, he felt he could justify his decision to allow me to do so in a coroner’s inquest. I was told that ‘some psychiatrists would play it safe and section you to keep you alive’, but he felt that wasn’t best for me because he wanted me to ‘take some responsibility’. [...] Discharging someone with expressed suicidal intent is the equivalent of discharging someone in the middle of a heart attack, there is nothing positive about positive risk taking, you’re gambling with people’s lives.”[6]
Overly risk averse practice is criticised for being coercive, restrictive, disempowering and removing patient choice. Positive risk-taking which is forced upon someone (termed “coercive risk-taking” by some patients/survivors) is just as coercive, restrictive, disempowering, and removes just as much patient choice as overly risk averse practice. Swapping out one practice for the other does nothing to increase autonomy if patients are still not included in decisions about their own lives. Despite this quite obvious reality, many clinicians appear to believe that positive risk-taking is inherently person-centred and empowering: failing to consider there is nothing empowering about being compelled to take risks you are not comfortable with or feel able to safely manage. There is no consideration that being forced to cope alone during a crisis can be experienced as deeply traumatising, and can have long term effects on a person’s engagement and trust in services; and work to increase thoughts and feelings of hopelessness, worthlessness, and suicidal ideation[7]:
“[T]he trauma I have been caused as a result of [services] withholding care is immense. I will not subject myself to this abuse any longer and now do not engage with them at all. There is no help for people like me."[8]
Interestingly, although positive risk-taking is now recommended practice by the Department of Health, and an expected clinical capability in numerous mental health professions[9], there are conflicting accounts of its safety, efficacy, and professional understanding of the concept. Some papers suggest that positive risk taking is under-researched and not well understood in practice [10-12], while others suggest the opposite [13]. Either way, despite the repeated assertions that positive risk-taking is not a negligent position [14], I have been unable to find any research which considers how it may be misused, and how to safeguard against the possibility that it could be used as an excuse to neglect.
Given the evidential inconsistencies, I was curious about the directed use of positive risk-taking in mental health services, and what, if any, evidence NHS mental health service policy is based on. As such, I submitted FOI requests to all 56 NHS mental health trusts in England requesting their risk assessment/management policies. It was certainly eye opening reading through them all (but I’ll save many of those observations for a later blog). Coventry and Warwickshire Partnership NHS Trust refused to provide their risk management policy, and Derbyshire Healthcare NHS Foundation Trust and Nottinghamshire Healthcare NHS Foundation Trust both stated that they do not have trust-wide risk management policies. 91% of the risk management policies provided explicitly highlight the importance and/or necessity of a positive risk-taking approach. Given that positive risk-taking is a planned action or inaction in service of patient recovery/empowerment/increased wellbeing, it would be reasonable to consider it a clinical “intervention” (as it is a deliberate decision designed to result in an outcome)[15]. Unless in very specific circumstances (such as certain treatment under the Mental Capacity Act or Mental Health Act), clinicians must seek and be provided with consent to carry out interventions on/with patients. Positive risk-taking is not excluded from this legal and ethical requirement. Despite this, only 12% of the policies directly state that active elements of risk management plans, including the implementation of positive risk-taking, require patient consent. Most give absolutely no instruction for staff to even consider patient views in terms of positive risk taking, or any indication that staff should seek consent to move forward with such an intervention. Berkshire Healthcare NHS Foundation Trust has a “positive risk panel” which clinicians can refer cases to when there is a disagreement about the proposed course of action. Their guidelines state that patients and carers cannot attend these panels, and there is no obligation for staff to even inform patients that they will be discussed at one.
While some of the policies did not provide references, most had a short reference section for the practices they directed. In regards to the references provided for positive risk-taking, there were several which came up over and over again [16-18]. I read each of these documents and followed the references provided within them, in an attempt at tracing back to the roots of positive risk-taking in current day mental health services. It can be seen in the following (simplified) diagram:
Several lines of investigation ended because I reached a document which did not provide further specific references for positive risk-taking, and the final three (Carson, Bleach, Mind) ended because I was unable to locate the documents in question. Overall, however, it is clear that current day positive risk-taking in mental health services is based on professional and clinical opinion, rather than more robust forms of evidence, such as randomised controlled trials (RCT). While this is not necessarily a bad thing, it is interesting to look at whose opinions are being centred and platformed. One name appears repeatedly throughout the literature: Steve Morgan. Steve Morgan runs a consultancy service called Practice Based Evidence, which, amongst other things, provides positive risk-taking training to organisations such as NHS trusts and social services [19]. His name appears repeatedly throughout NHS risk management policies and positive risk-taking protocols for other organisations. Google his name and you will also find masses of references to his training programmes across the country. On his blog, Steve Morgan credits himself with initiating the concept of positive risk-taking in 1994 [20,21], and has written and taught extensively on the subject since the 1990s.
In reading his early work, it is interesting to see that the narrative is focused on reducing the then widely held belief that people experiencing mental illness were dangerous and posed a risk to the general public. The idea of positive risk-taking appears initially to have been formed from the perspective of ‘risking’ caring for mental health patients in the community, mingled with the desire to reduce clinical paternalism surrounding patients who “worried” clinicians with their risk to themselves. In one of Steve Morgan’s earliest books (“Helping relationships in mental health”) he explicitly states that positive risk-taking is not something to be done to a person, but a collaboration between clinician-patient which forwards the wishes and goals of the patient [22]:
“By far the most empowering aspect of positive risk taking is for the practitioner to let go of the ‘professional expert’ role and actually ask the service user what it is they want. They may not always know, partly due to the constant experience of having power removed and being told what is best for them. On these occasions it may be the responsibility of the practitioner to suggest options and to create choices, but definitely not to take the decisions.” (page 122, underlining mine)
However, fast forward eight years to 2004 and we can see a dramatic shift in this person-centred, collaborative ethos. In one of his most frequently cited papers [23], Steve Morgan discusses positive risk-taking in terms of withdrawing care from people; “tolerating” risk; boundary setting; and ensuring people are not becoming dependent on services. The paper provides ten points on ‘how to take positive risks’. Not a single one of these points mentions consent, or even collaboration with the person whose safety is being risked. This is very much the foundation of coercive modern day positive risk-taking - a means to withhold care:
“It can occasionally be distinguished between its short- and long-term differences, whereby short-term heightened risk may need to be tolerated and managed, for longer term positive gains. It can be about explicit setting of boundaries, to contain situations that are developing into potentially dangerous circumstances for all involved. It can be about taking the risk of withdrawing services that are inappropriate to needs, or have created a dependency on contact that serves no therapeutic value.”[24]
This seemingly small shift in language is so significant in terms of how positive risk-taking is utilised and conceptualised in services. I found it interesting that Steve Morgan’s earlier, patient-centred works are not cited by mental health services in their risk management policies, rather it is the later, collaboration-free, coercive, neo-paternalistic [25] ideas and phrases which have been latched onto. For a service desperate to discharge, offroll, and reduce patient numbers, what could be better than an intervention which allows staff to rid themselves of their legal responsibilities and duty of care under the guise of patient empowerment and recovery. On top of that, given that coercive positive risk-taking appears heavily focused on patients labelled with personality disorder, staff have the perfect intervention to rid themselves of the patients they dislike and want to avoid [26,27], in the name of promoting self-responsibility and autonomy.
These exact principles, and even Steve Morgan’s exact words, can be found littered across NHS mental health service policies:
“[...] enhanced observations can sometimes reduce a person’s responsibility for their own wellbeing and create conditions for reckless behaviour. Or hospitalisation can convey to a person that professionals feel they are incapable of looking after themselves, thus reducing self efficacy. The Trust recognises that optimal care for people with a diagnosis of BPD+ often means offering the patient care plans that “play the long game”, that strategically hold back from short term risk reduction (or the appearance of short term risk reduction) in order to achieve long term gains or reduce long term harms. This is therapeutic risk taking. The Trust supports well considered, well documented therapeutic risk taking according to the principles of this protocol, and will continue to support such risk taking even when tragic events occur.” [28] (Tees, Esk and Wear Valleys NHS Foundation Trust)
“[...] this may involve holding back from short-term risk reduction interventions in order to facilitate the longer-term goal of enabling the individual to develop their own ways of managing their risks. This therapeutic (or positive) risk-taking process is there to support the individual in improving their ability to manage distress and develop better coping strategies, and to foster a sense of responsibility in the individual for their own well-being, thus aiming to increase self-efficacy and be more recovery focused.” [29] (South West Yorkshire Partnership NHS Foundation Trust)
“positive risk taking could involve making a decision not to admit someone to an inpatient ward, or to discharge a patient who has had recent episodes of self-harm, because the risks of them being on a ward (e.g. an escalation in their self-harming) outweigh the risks posed if they are treated in the community. In these circumstances effective management of the short term risks could lead to longer term gains for the patient.” [30] (Rotherham, Doncaster and South Humber NHS Foundation Trust)
“Of particular importance is the need for clinicians to feel supported in taking clinically indicated risks, especially around reducing admissions to hospital. This is important; although admissions to hospital might reduce risk in the short term, often they have a counter-therapeutic effect fostering dependency, and causing further harm by increasing the long-term risk. [...] The inevitability of serious untoward incidents must be recognised in the relationship between senior management and clinical staff, so staff feel confident to take short-term positive risks to achieve longer-term positive outcomes.” [31] (Mersey Care NHS Foundation Trust)
There are two strong themes running through these quotes and the risk management policies in general: the promotion of positive risk-taking as a means of reducing service use; and the clinical defensiveness surrounding the recognition that removing care from someone in need could potentially cost their life. No evidence exists to support the enforced withholding of care as an effective clinical intervention, particularly in crisis situations. A mounting pile of evidence exists, however, which describes the immense harm experienced by people when they have care withheld [32-43]. When considering this, together with the running themes in the policies, you can see the weighing up of the personal benefits to staff/financial benefits to services that come with excluding patients, with the possibility that these patients may die. Multiple policies explicitly state that trusts acknowledge this risk, and accept it. Thus, it's clear to see who is truly benefitting from these interventions, and it isn't the patients.
In February 2021 a deeply concerning and unusual Regulation 28 Report to Prevent Future Deaths (PFD) was produced by senior coroner, Dr Fiona Wilcox, into the death of Valeria Muñoz Biggs [44]. While I have not conducted a long-term systematic review of PFDs which look at mental health related deaths, I have personally read through hundreds, and this was the first I found which explicitly mentioned positive risk-taking as a contributory factor in someone’s death. The concerns laid out by Dr Wilcox, which were directed to West London NHS Trust, specifically noted that the trust had a concerning “culture by senior staff of positive risk taking in relation to suicidality” and that this was in fact so significant, legally the coroner was obliged to produce a PFD report to highlight that this could lead to further deaths. I believe this finding merely scratches the surface of the harms and deaths caused by a misuse of positive risk-taking, and given the criticism frequently directed at coroners in regards to their lack of willingness to make critical findings, this culture in West London NHS Trust must have been extremely significant for it to have been noted. That same culture is described nationwide by patients, survivors and families.
Positive risk-taking is an intervention which holds a very real risk of clinical misuse, with potentially fatal outcomes for patients. There is a desperate need for evaluation of the understanding and utilisation of positive risk-taking interventions in mental health services, particularly its use in crisis situations; its use with people at long-term high risk of self-harm and suicide; and its use with people labelled with a personality disorder diagnosis. There is an additional need for studies which consider its misuse, and potential for misuse, and focus on how mental health professionals, patients, and family members/carers can recognise and safeguard against this. Within services it seems there is also an immediate requirement for conversations to be had about patient consent and what constitutes an “intervention”. Given that positive risk-taking falls within the definition of a clinical intervention, mental health trusts must take steps to ensure their staff are adhering to their legal responsibilities regarding patient consent when considering positive risk-taking.
As previously noted, moving from overly risk averse practice cannot encourage autonomy, responsibility, empowerment, and personal growth if the new practice is just as coercive, restrictive, disempowering, and removes just as much patient choice as the previous practices. Abandoning people when they need support can traumatise, remove hope, encourage negative self-perceptions, and increase risk of harm and death. We deserve actual empowering interventions which truly provide patient choice, not to be told we are being empowered as we are left to die.
Wren
If any mental health professionals reading this would like to begin to make changes in their Trust, please consider downloading and sharing this Patient Safety Briefing, co-produced by Dr Ahmad Khouja (TEWV Medical Director) and Ellie (Service User) in 2021.
References
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