Occupational therapy risk assessment in forensic mental health practice: an exploration.
Forensic occupational therapists are one of the members of the
multidisciplinary team who participate in the risk assessment process.
However, the forensic occupational therapy risk assessment literature is
largely descriptive and experience based, with little empirical
This study investigated forensic occupational therapists' ideas about risk assessment and what risks they assess. A qualitative approach, using three focus groups of therapists working in different forensic settings, provided the data. The analysis of the data found that four themes emerged: risk perceptions and interpretations, fundamental information, risk behaviours and occupations, and environments.
These themes support a number of aspects of risk assessment in the forensic occupational therapy literature and could be categorised under the components of the person, the environment and occupational performance and participation. There was, however, limited evidence in the literature and in this study about the risks associated with occupations and about client-centred approaches to risk assessment. Further research of these aspects, and a comparison between forensic occupational therapy risk assessment and multidisciplinary risk assessment, is recommended.
Key words: Forensic mental health, risk assessment.
Mental health (Practice)
Occupational therapy (Standards)
Occupational therapy (Practice)
Psychiatric services (Management)
|Publication:||Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 College of Occupational Therapists Ltd. ISSN: 0308-0226|
|Issue:||Date: Dec, 2009 Source Volume: 72 Source Issue: 12|
|Topic:||Event Code: 200 Management dynamics; 350 Product standards, safety, & recalls Computer Subject: Company business management|
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|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
There are guidelines for occupational therapy risk management, within which risk assessment is integrated (College of Occupational Therapists [COT] 2006). This provides a useful general framework for risk assessment because it includes identifying any hazards and potential risks, the potential for harm and what might be the consequences (COT 2006). Clinical risk assessments completed by various disciplines in 64 out of 67 forensic psychiatric units in the United Kingdom indicated no uniformity in the assessments used and inadequately developed tools, potentially causing a lack of continuity in care through the system (Kettles et al 2003). It was recommended that risk assessment should be standardised, drawing on a stronger research base for the current tools (Kettles et al 2003). This study was concerned with the specific requirements for occupational therapy risk assessment in forensic mental health settings.
Kettles (2004) used concept analysis to explore and evaluate the meaning of forensic risk, producing a modified version of Wood's definition (2001, cited in Kettles 2004, p491):
One aspect not included in the above statement, but noted in the Reed Report (Department of Health and Home Office 1991), is the individual's clinical condition and the circumstances that he or she is in at any given time, which can influence different forms and levels of risk. The process of risk assessment is therefore dynamic, varying across time and situations and between people (Crighton 1999). This reflects Scott's (1977) useful equation of offender + victim + circumstances = the offence.
The forensic occupational therapy literature has defined risk in a number of ways. Flood (1993) and Duncan (2008) used levels of dangerousness. Others have suggested that risk is the potential for physical and psychological harm to others and oneself (Chacksfield 1997, Rogowski 1997). However, Kettles (2004) did not include harm to oneself. The definition above, along with the possibility of risks being of different levels and changing across time and circumstances, as well as the clinical condition, including self-harm, is used as the basis for this study.
Risk assessment involves making a prediction, based on an evaluation of the potential of an individual carrying out risk behaviours (Blackburn 2000). Work by Crighton (1999), Kettles (2004) and COT (2006) includes the probability or prediction of how likely it is that harm will occur. The forensic occupational therapy literature implies that risks are assessed by therapists using information gained from patients and the multidisciplinary team to inform their clinical decisions. The crucial issue in any prediction is to make the correct prediction of risks, both because of the effects on human rights and moral issues, which could also lead to unnecessary public spending (Duncan 2008), and public safety issues. Thus, risk assessment is critical to effective practice, requiring a strong evidence base.
Occupational therapy and risk assessment
A study by Duncan et al (2003) identified forensic occupational therapy research priorities, highlighting the need for risk assessments for safety reasons and requiring the development of a specific tool. Risk assessment fell in the highest of three research priorities, but participants favoured this less strongly (Duncan et al 2003). The rationale to assess risk for safety is understandable, but does not fully justify the need for a forensic occupational therapy risk assessment.
There appears to be no specific model for risk assessment, but it is proposed here that risk assessment could be mapped using the concepts of person, environment, occupation and performance (PEOP) from models of practice (Baum and Christiansen 2005, Townsend and Polatajko 2007, Kielhofner 2008). The models have a common feature where the concepts of PEOP interact, thus the person performs by the act of doing an occupation in an environment (Baum and Christiansen 2005). The PEOP concepts defined by Baum and Christiansen (2005) have been used here to categorise the relevant literature.
The person includes the psychological, physiological, neurobehavioural, cognitive and spiritual factors (Baum and Christiansen 2005). Aspects of risk assessment would include mental illness and insight (Neeson and Kelly 2003). Another risk is decreased motivation and sense of purpose, resulting from fear of isolation and rejection (Clarke 2003). A multidisciplinary postal survey about risk assessment of violent mentally disordered offenders in secure hospital environments suggested multiple personal factors: the person's psychosexual history or interest, his or her mood or post-traumatic stress disorder and his or her insight and trust in the therapeutic team (Cronin-Davis 1998). In addition, Rogowski (2002) highlighted patients' resentment at their detainment and feeling restricted or persecuted as factors increasing risk.
One aspect of the environment is the physical place for carrying out occupations (Baum and Christiansen 2005). This includes the therapeutic environments, such as craft rooms, workshops, kitchens and gardens, where patients may have access to tools, materials and equipment that could be used as weapons (Fairhead 1997, Seymour and Monks 1997, Taylor et al 1997). Self-harm and suicide can be attempted using tools and dangerous substances (McQue 2003) and patients can hide implements in the environment (Neeson and Kelly 2003).
Other aspects of the environment are cultural and social (Baum and Christiansen 2005). Clarke (2003) acknowledged that patients are in a subculture of people with mental illness and offending behaviour, who are cut off from society. Other risks are linked to how similar the context of therapy is to the offence and possible precipitants, such as the pressure of court appearances or tribunals and the presence of other patients (Rogowski 2002). For example, adding women to create mixed gender interventions changes the social environment, which requires particular attention to abused women and assessing risks arising from their difficulties in interacting with men (Harris 2003).
Occupation is what people want or need to do (Baum and Christiansen 2005). There were few references in the literature about potential risks that might be a part of specific occupations. Walsh and Ayres (2003) highlighted cookery sessions, where the therapist must be able to assess the client's tolerance to frustration. Alred (2003) wrote broadly of work rehabilitation and using 'safe risk-assessed interventions' (p50). Spybey and Morgan (2003) suggested that sustained engagement in creative activities requires taking relatively low risks. This extends to other occupations that may have higher risks, which require risk assessment.
Performance means the act of 'doing' an occupation (Baum and Christiansen 2005). The areas of risk include the possibility of self-harm, using information obtained about staff inappropriately or attempting to split and manipulate the team (Neeson and Kelly 2003). This behaviour relates to the types of relationship that the client develops with others (Joe 2003, Duncan 2008). A patient's response to frustrating tasks and difficult social situations can inform about his or her ability to perform in everyday stressful situations (Schindler 2000). Other aspects of performance have been suggested, such as interpersonal skills, the record of previous violence, the use of coping strategies, the risk of absconding, behaviour during leave and a patient's performance progress during peer group work (Cronin-Davis 1998). Occupation cannot be isolated from its performance, which risk assessment needs to reflect.
The concept of occupational performance and participation (Baum and Christiansen 2005) is about behaviours that are meaningful to the individual when participating in the home and community. They include working, playing and caring for their self and others (Baum and Christiansen 2005); examples of these occupations are above. The occupations in themselves may not pose a risk, but the combination of the person, the environment and the occupational performance and participation do so. This highlights all of the relevant information and the context for the potential performance of risk behaviours in occupational performance and participation.
In summary, the literature provides little empirical research on risk assessment, although Rogowski (2002), Neeson and Kelly (2003) and Duncan (2008) offer useful guidance. The existing literature has not met the recommendations of Kettles et al (2003) to standardise risk procedures. Applying PEOP to the literature about forensic occupational therapy risk assessment has highlighted a focus on the components of risk assessment. However, there is a limited discussion about occupations, suggesting that there is no holistic approach used to think through risk assessment. This study offers a useful starting point by investigating forensic occupational therapists' ideas about risk assessments and the risks that they assess.
Aim of the study
The aim of this study was to ascertain forensic occupational therapists' perspectives on the beliefs and considerations informing their risk assessments.
A qualitative method using three focus groups generated the data. This method enables a target audience, with common characteristics (in this case forensic occupational therapists), to share how they see, understand and value the specific topic (Krueger and Casey 2000).
Recruitment included occupational therapists from the first author's colleagues in a National Health Service (NHS) trust and a forensic occupational therapy research group. The first author anticipated that appropriate numbers for three focus groups would be available. Ultimately, eight therapists participated in small groups. The participants practised in a wide range of settings: local / low security, medium security and a young offenders' institute and category 'A' prison settings. The participants' job grades were varied, from junior to management grades. They had worked specifically in forensic mental health from between one month and just under 8.5 years. The age range was 26-50 years and the length of qualification was 2.5-20 years.
The Ethics Committees of an NHS trust and the University of East London approved the study. Each therapist gave written consent to participate. All identifying details have been changed, including names of services and participants.
The study used a traditional single category design with one target audience (Krueger and Casey 2000) of forensic occupational therapists. The first author acted as the moderator for each group, which lasted approximately 2 hours 30 minutes per group.
All groups received the same questioning route categories (see Table 1). The transition questions helped the participants to start thinking about general aspects of risk assessment. The key questions provided the main data for analysis specific to the study aim. There was a slight variation to the procedure of the transition questions for group three and the second and third groups received small prompts for the first transition question. This did not affect the data collected or the findings. All three groups received various comments or questions to clarify and expand upon a topic from the moderator.
Videotape recordings of the focus groups were made and were used only to distinguish who was talking, in order to make the transcribing of the tapes easier.
The long table approach was applied to analyse the transcripts of the videotapes (Krueger and Casey 2000). Four factors indicate the weight, and thus the importance of the data, in order to develop themes and categories. The factors are:
* Frequency: This is how often something is said, and is not necessarily the most important. A key insight may only be stated once.
* Specificity: More emphasis is given to comments that are specific and that provide more detail.
* Emotion: More weight is typically given when participants show more emotion, passion, enthusiasm and intensity in their answers.
* Extensiveness: This is how many different people make the same comment (Krueger and Casey 2000).
The long table approach facilitated systematic data analysis and was therefore a verifiable method. Each group transcript was printed on different coloured paper for coding. The four factors were applied to the answers in the analysis of each transcript, with a large sheet of paper laid out for each question. The data were checked for the answers that responded to a different issue than that asked and repeated answers were checked. Finally, a summary was produced of the groups' answers to each question. These summaries facilitated the comparison of themes and categories arising across all groups (Krueger and Casey 2000).
Rigour in data collection and analysis
All participants received a transcript of their focus group in order to verify the accuracy of the transcription. No changes were required from the feedback of three participants (one from each group). A peer examination determined the trustworthiness of the data (Lincoln and Guba 1985, Krefting 1991) by reviewing the analysis and all of the transcripts, and completing a debriefing session with the researcher. Minor changes were made to make category titles more explicit, to improve the description of theme three and to provide better support for one of the categories.
Findings and discussion
The findings and discussion have been combined for clarity. The analysis generated four themes, which are interrelated but have distinct implications for practice: risk perceptions and interpretations, fundamental information, risk behaviours and occupations, and environments. This study suggests that, in the forensic setting, risk assessment is a dynamic process, requiring occupational therapists to make ongoing judgements in collaboration with their colleagues.
Theme 1: Risk perceptions and interpretations
The forensic occupational therapists' perspectives and interpretations about risk assessment suggested a framework of their core ideas about risk, which underpinned and informed their assessment. This framework incorporated the dynamic nature of risk, contextual factors and professional differences in risk assessment. The PEOP concepts do not incorporate these aspects; however, they represent underlying assumptions about the therapists' risk assessment. The interaction of PEOP is a complex, contextualised and dynamic process (Baum and Christiansen 2005), which the therapists' risk assessment mirrors in this and the other themes.
All three focus groups identified that risks can change and are dynamic, with an increase and decrease in risks:
This is supported by Scott (1977), Department of Health and Home Office (1991), Crighton (1999) and COT (2006). The contextual aspects of risk assessment and an occupational therapist's view of potential risks in a specific environment may not be linked to the patient's past risk behaviours. Here, Gina's view does not support Scott's (1977) equation:
Context is, however, an aspect of risk that needs to be assessed (Rogowski 2002, Duncan 2008) and it suggests that this is a complex area that is particularly important for occupational therapy, requiring more rigorous exploration.
Perspectives on risk could have various interpretations. Even though only one therapist commented on this, it suggests that different disciplines may perceive risks differently from each other. For example:
It may be that the assessor has a different threshold for risks based on personal perspectives, previous experiences, position and responsibilities within the organisation or recent adverse events (Duncan 2008). Kettles et al (2003) support this to some degree, but a comparison of occupational therapists' and multidisciplinary teams' forensic risk assessments may clarify the degree to which the different perceptions affect a correct prediction of risk.
Different professionals' perception of risk suggests differing definitions of risk. Kettles' (2004) definition covered many aspects of risk behaviour. The participants in this study highlighted offending behaviour, but physical and psychological harm in forensic risk is implicit. There was not sufficient evidence to claim that therapists take a different perspective on defining risk.
The second focus group briefly mentioned actuarial (statistical) approaches to risk prediction. Gina mentioned two measures used by the multidisciplinary team, reflecting different perspectives on risk. Other participants did not highlight actuarial approaches.
Parker (2006) noted that the ability to explore risks is of paramount importance to success in the client-centred relationship. Taking a client-centred approach in the forensic context still requires risk assessments (Couldrick and Alred 2003). However, the groups did not discuss client-centred approaches to risk assessment. Duncan (2008) highlighted that a challenge is to apply the client-centred values of unconditional positive regard, empathy and congruence when therapists are faced with a client and his or her offence, such as sex offenders. This may have been a factor inhibiting discussion in the present study. Further research on the client-centred practice of risk assessment in forensic occupational therapy is required.
Theme 2: Fundamental information
For this study, fundamental information was identified as clinical information derived from the multidisciplinary team, informing the occupational therapists of relevant risks. This has two aspects: current information and historical information. As Nell stated, 'If we don't know what their background is then we don't know what it is we are looking out for and what to expect.' The dynamic aspect of risk assessment from the first theme reflects the current information that Josie considered for day-to-day decisions. She noted that the nurses' observations informed her risk assessment immediately before clinical contact. Sonia summed up the use of current and historical information:
The PEOP model can be used to organise these two categories from an occupational perspective. The person includes the client's mental state (Cronin-Davis 1998, Neeson and Kelly 2003); also, as Nell stated, 'factors that were involved in incidences in the past ... the triggers, their mental state', which incorporate historical and current information. The participants noted the psychiatric history included in 'historical information', but the literature did not include this.
Rogowski (2002) noted environmental triggers for historical and current risks; however, she did not specify these. She may have been referring to triggers that shape performance, which are based on personal interpretation, and that then become risk behaviours.
Occupational performance included the patient's offending history (Neeson and Kelly 2003). The participants did not specify the original index offence, as Seymour and Monks (1997) noted; however, this is a part of a patient's offending history. Duncan (2008) called historical and current information specifically related to offending 'security intelligence' (p524). This includes previous criminal convictions, past drug misuse and offences or incidences occurring during hospital admissions.
Also included in occupational performance are current and previous functioning, but the literature did not include these. However, the researcher's clinical experience indicates that functioning prior to admission would be part of an initial information-gathering process. Categorising risks according to PEOP suggests a relationship between offending history, functioning, mental health problems and risk, but further research is required about this.
There was no depth of discussion about ethnicity and culture in the focus groups. Only Chris commented that raising children in a family culture with lots of criminal activity would have an impact upon them. This would provide some historical information for patients with this kind of background. The literature does not consider what relationship these have to risk assessment, suggesting another area for study.
The findings so far suggest that the occupational therapists considered fundamental information and the context, along with personal and professional perspectives on risks. These interconnect in a dynamic way to inform the next two themes.
Theme 3: Risk behaviours and occupations
The categories in this theme include harm to others, self-harm, self-neglect, cognition, substance misuse, social behaviour and coping strategies. These are about potential risk behaviours occurring during occupational performance and participation (Baum and Christiansen 2005) in the forensic context. Some of these cross over with other areas of mental health. However, owing to the severity and level of risk to public safety, forensic practice relates to the following examples.
All three focus groups discussed harm to others, supported by Chacksfield (1997). Included were the use of weapons, sexual offences, arson and exploitation of others. Sally summed up a potential risk faced in gardening:
This is an example of the interaction between the concepts of the person, environment, occupation and performance in the model.
The participants also considered different forms of harm to others. The exploitation of those who are vulnerable can be evident and may be gender related. Sonia described the types of problem that can occur with women in a forensic setting:
The groups did not highlight that this factor may also occur between men, and between men and women. There are other sexual behaviour risks, because female occupational therapists may be a target for the patients' sexual advances (Seymour and Monks 1997):
Cronin-Davis (1998) found that only one therapist reported psychosexual interest and history in the risk assessment. However, Sniveley and Dressler (2005) argued that where patients are deprived of privacy and normal sexual behaviour is inhibited, there would be sexual tension, which has to be considered in any risk assessment. The conflict between security requirements and therapeutic considerations is a core aspect of forensic practice (Neeson and Kelly 2003, Duncan 2008), illustrated in work with sexual offenders. Risk assessment should include the 'staffing ratios, sex of patients, sex of therapist, previous index offences, environment and the equipment used' (Seymour and Monks 1997, p15). Compromising therapeutic aims may be required to ensure the safety of patients and staff.
Chris focused on the need for assessment when a paedophile patient is to go into the community and would possibly see or encounter children. Other behaviours that the occupational therapists identified were self-harming, such as head banging and self-cutting, and attempted suicide, such as hanging and overdosing. These behaviours also occur in general psychiatry; however, in the forensic setting, access to objects and substances is limited and many are classified as contraband items, so their use is monitored very carefully by staff in order to prevent risks. This reflects the first theme, highlighting different perspectives on risk.
Although not specific to forensic mental health, self-harm also has implications for risk assessment (Chacksfield 1997, Rogowski 2002). Chacksfield (2003) summarised the literature on the complex relationship between substance misuse and mental illness, which can increase the likelihood of violent behaviours. Sniveley and Dressler (2005) highlighted that 'some paints can be "sniffed" for an intoxicating effect' (p541) and McQue (2003) noted the potential of using substances for selfharm. This has a potential impact upon mental state and consequent risks. These may not affect occupational therapy environments and personnel directly, because substances need time to take effect. However, another area in the forensic organisation may experience the impact of risk behaviours. In the present study, all the participants supported a constant awareness of the surroundings, as highlighted by Lloyd (1995). Therefore, attention to detail in the therapists' risk assessment is required.
Chris valued using occupational therapy risk assessments, particularly in the community, such as with people who misused substances and increased their risk of relapse. However, in her experience, the multidisciplinary team had a different view from the occupational therapist:
Given differences of opinion such as this, it is appropriate that all the groups supported effective communication with the multidisciplinary team, where these matters could be discussed.
Theme 4: Environment
The categories in this theme about the environment included the occupational demands, opportunities and restrictions in a forensic environment, which linked closely with the use of materials, tools and equipment and occupational choices. Absconding was a key area of risk assessment owing to the community-based occupational therapy that was required.
Patients in therapeutic groups have demands, opportunities and restrictions placed upon them and all therapeutic work in the forensic setting is subject to security procedures. The security control of items affects everyone entering a forensic organisation (Duncan 2008). Although therapeutic occupations may not have inherent means of harming oneself or others, restricted access to tools and materials can limit occupational choices of the patients, increasing boredom and frustration:
Risk assessment in occupational therapy has to consider the interaction between materials, tools and equipment within the environment. All the focus groups regularly mentioned this because it was core to occupational therapy (Fairhead 1997, Taylor et al 1997, Sniveley and Dressler 2005). Environments have pressures and potential risks (Chacksfield 1997, Schindler 2000). Therefore, items used to perform occupations by patients can potentially be used as weapons or for self-harm (McQue 2003, Neeson and Kelly 2003). Sonia's description indicated the latter:
Risk assessment therefore requires a clear understanding and recording of potential risks in the environment in relation to each client. This is also required because it is ongoing, dynamic and not always accurate.
The participants also discussed risks and social interactions and 'how much people can tolerate that interaction ... ' (Sonia). The relationships developed could pose a risk in and out of the hospital, and so the therapist needs to monitor interactions during occupational therapy (Barton 2003). An awareness of subtle changes in relationships, with the development of cliques and groups, may indicate emerging risks, changing the social environment (Fairhead 1997, Sniveley and Dressler 2005).
Preparing for leave and discharge into the community environment is a major area for occupational therapists. This issue is crucial for public and patient safety, to avoid a repeat of the index offence (Rogowski 2002). All participants in this study considered absconding in their risk assessments. Nell shared the questions she used to identify absconding risks:
Nell highlighted that agreement for leave from the secure setting '... needs to be a team decision ... ', supported by the Department of Health (2007). Only one of the 30 occupational therapists considered absconding in their risk assessment in Cronin-Davis's (1998) study. The importance of assessing for potential absconding must not be underestimated.
This research suggests that forensic occupational therapists have a framework of beliefs about risks that underpins their assessment. They seek essential historical and current risk information from the multidisciplinary team, then consider risk behaviours associated with the core concepts in occupational therapy of occupational performance, participation and the environment.
Critique of the study
This study provides useful insights into forensic occupational therapists' risk assessments. However, occupational therapists working in maximum security hospitals, and other specialties such as with people with learning disabilities, were not included. The participants were predominantly senior therapists with experience spanning 2-8 years. Staff new to the forensic setting may have very different perspectives on risk. All three focus groups were asked the same questions, which provided continuity in the data collection. The mix of professional experience and research consistency provides some weight to the issues discussed and subsequently analysed, despite the low numbers in the study.
As a member check on the final themes was not completed, the trustworthiness of the analysis may be questioned, although peer checking mitigated this. This also helped to reduce any bias (Lincoln and Guba 1985, Krefting 1991), given the first author's immersion in the practice area as well as in all aspects of the research process. This may, however, have facilitated a better understanding of the subject matter. The focus groups were small, comprising two to three participants in each; ideally, five or six participants are suggested (Krueger and Casey 2000). Indeed, Hollis et al (2002) commented on focus groups with numbers lower than five, '... the range of experience will be less, but this might be a compromise for depth of experience' (p3).
This study has identified forensic occupational therapists' beliefs about, and the content of, risk assessments. Further research with forensic occupational therapists would verify and extend the findings. There is a lack of risk assessment of occupations and client-centred approaches to risk assessment. The application of person, environment, occupation and performance, when mapped to the literature and themes, reflects the dynamic nature of risk assessment.
This study has not covered risk management, perceived as a vital part of the practice strategy (COT 2006, Department of Health 2007). A comparison of forensic occupational therapy risk assessments is required with other occupational therapy practice areas and with multidisciplinary risk assessments. It will then be clearer as to whether a specific risk assessment tool for forensic occupational therapists should be developed.
* The person, environment, occupation and performance (PEOP) framework can be used to structure forensic occupational therapy risk assessments.
* Forensic occupational therapists have core ideas about risk that underpin and inform their assessment.
What the study has added
The content of and beliefs about risk assessments of some forensic occupational therapists are identified. When combined with PEOP, the literature and themes reflect the dynamic nature of this risk assessment.
The first author would like to give his thanks to the NHS trust, focus group participants and Karen Helbig, who made this study possible, and to Paul Hedges, for his timely comments and enduring patience. Also, thank you to Dr Wendy Bryant and the reviewers for their helpful suggestions.
Submitted: 26 April 2007.
Accepted: 26 October 2009.
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Corresponding author: Kevin Cordingley, Lecturer in Occupational Therapy, School of Health Sciences and Social Care, Mary Seacole Building, Brunel University, Uxbridge, Middlesex UB8 3PH. Email: firstname.lastname@example.org
Kevin Cordingley (1) and Susan Ryan (2)
(1) Brunel University, Uxbridge, Middlesex.
(2) The University of Newcastle, New South Wales, Australia.
... the clinical probability of a negative consequence, related specifically to the behaviour of those patients who are committed by law, or who are diverted from custody, to forensic settings and who have the potential to cause serious, physical and psychological harm to others. This includes those fear-inducing, impulsive, intimidating, manipulative and destructive behaviours that are displayed or have been known to be displayed ...
... risk assessment ... which is constantly moving and changing, given the mental state, environment ... therapeutic work ... (Sonia).
... just because they stabbed someone in the kitchen it doesn't necessarily mean they would go in the kitchen and stab someone (Gina).
... for us using the [basketball] hoop [is] good [for] physical activity lots of benefits for the lads, for the Head of Security it's an escape risk (Sally).
... we try and tie in psychiatric history ... make a match between when that deteriorated ... with the added framework of the offending behaviour ... looking for periods when they were functionally capable ... and what is the context of that ... their background will also feed into goal setting where they are going to go in terms of leisure, productivity and self-care (Sonia).
... if you are in a settled community group of people who are using gardening equipment it's not a huge issue, whereas for somebody ... who will lash out at somebody just [for] looking at you the wrong way ... That kind of degree of risk is much greater, [with] the nature of the tools that we use and what we do (Sally).
... women's interactions [and] their sexual roles [are considered], because a lot of them have been targeted or target other women in the unit. They form relationships that have implications for drug abuse, or fall into abusive and manipulative situations, not necessarily physically but sometimes sexually and financially as well (Sonia).
... we are aware of offenders who [are] rapists ... we are female therapists, we ... look at how they interact with us as women ... we have a role in our assessment of looking at how these people may generally deal with women ... when we take people out into the community and assess them, or see them in social settings with other women ... (Norma).
... [Multidisciplinary team members would state] 'well you shouldn't be going anywhere near a pub', and 'you know there shouldn't [be] any alcohol involved in the activity'. [Chris's response was] You know it doesn't seem realistic either ... it's a good opportunity ... to assess [their behaviour].
... for an OT it's the weighing up ... do you allow somebody to have the game 'word search' in their cell, because if they don't [have it] they smack their head against the wall constantly ... So it's ... looking at that aspect of the environment as well, so how we can make it meet their needs ... (Sally).
... the combination of being in the kitchen, beginning to vent some of her frustrations as she was talking [with] a knife in front of her, led to a very impulsive act [of cutting herself] ... it is that combination of factors, you provide the assessment [of] someone's susceptibility to [risks] in that environment given their present mental state (Sonia).
Absconding: Is it psychotically driven? Is it because they feel unsafe, bullied on the ward? Is it impulsive, is it planned? ... their mental state, whether people feel they are likely to abscond, what is [the] risk plan that we are taking. And if they are [going to abscond] what are they likely to do? (Nell).
Table 1. Questioning route Introductory question -- What experience or use have you had of any risk assessment? Transition questions -- What are the characteristics of risk assessment/s you have used or seen others use? (Participants list these to use in the main discussion.) -- When the word 'risk' is mentioned, what do you think of? Key -- Referring back to the characteristics of your risk assessment list, what other risks do you identify when thinking from a forensic occupational therapist's viewpoint? -- What is it that makes the above relevant to forensic occupational therapy? Ending -- Facilitator sums up discussion. -- Is there anything that has not been covered that you think should have been included? -- Feedback re: facilitator's presentation, the questions and presentation of material. -- Any changes suggested?
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