Evaluating the use of the collaborative dynamic risk ... · assessment process and circles tool...

Evaluating the use of thecollaborative dynamic risk

assessment process and 'circles' toolfrom a ward staff perspective

Jessica Neil

Commissioned by Dr. Alex Brooks and Dr. Kerry Hinsby

Service Evaluation Project Staff perceptions of the collaborative dynamic risk assessment

Prepared on the Leeds D.Clin.Psychol. Programme, 2017 2

Table of Contents1.Background .................................................................................................................... 3

1.1 Risk assessment of violence...................................................................................... 3

1.2 Risk formulation and dynamic risk factors ............................................................... 4

1.3 Newsam Centre ......................................................................................................... 5

1.4 Research question and aims ...................................................................................... 5

2. Methodology .................................................................................................................. 6

2.1 Design ....................................................................................................................... 6

2.2 Recruitment............................................................................................................... 6

2.3 Ethics......................................................................................................................... 7

2.5 Analysis..................................................................................................................... 7

2.6 Quality checks........................................................................................................... 7

2.7 Reflexivity................................................................................................................. 8

3. Results ............................................................................................................................ 8

3.1 Previous experience: ................................................................................................. 8

3.2 Initial thoughts ........................................................................................................ 10

3.4 Limitations .............................................................................................................. 12

3.5 Improvements: ........................................................................................................ 13

3.6 Improving confidence and competence .................................................................. 13

3.7 Impact on staff ........................................................................................................ 14

3.9 Challenges for service users.................................................................................... 17

4. Discussion..................................................................................................................... 17

4.1 Previous experience of risk assessment vs. the dynamic collaborative process and

the circles tool ............................................................................................................... 17

4.2 Ward staffs’ perceptions of the collaborative dynamic risk assessment process and

the circles tool ............................................................................................................... 18

4.3 Recommendations for improvements ..................................................................... 20

4.4 Perceived Impact..................................................................................................... 21

4.5 Limitations .............................................................................................................. 21

5. Conclusion ................................................................................................................... 22

5.1 Summary ................................................................................................................. 22

5.2 Recommendations................................................................................................... 22

5.3 Dissemination ......................................................................................................... 23

References ........................................................................................................................ 24

Appendices....................................................................................................................... 26



1. Background

1.1 Assessment of risk of violence

Violence risk assessment has always been a central focus and a key responsibility for

forensic mental health services (Cooke & Michie, 2013). However, the way this has been

done has shifted over time (Singh & Fazel, 2010). Risk assessment has moved through

different phases; from unstructured professional judgement to actuarial measurement of

risk and then to structured professional judgement. Forensic services moved away from

using unstructured professional judgement because of the lack of evidence base, as well

as the lack of transparency, utility and replicability (Quinsey et al, 1998). There was a

shift to using actuarial measures of risk, so to bring structure and reliability to clinical

decisions. These measures or instruments make a prediction based on the statistics of

others; they categorise people into groups and use an algorithm to provide a risk rating.

These measures give the illusion of certainty, yet they do not take into consideration other

influences or individual difference. Actuarial measures are able to tell us what factors

make someone risky but cannot tell us why. Consequently, there was a shift towards

another phase of risk assessment, called structured professional judgement.

Structured professional judgement (SPJ) incorporates both clinical judgement and a

structured measurement of risk factors. SPJ instruments look at specific risk factors for

violence and then allows the clinician to judge how these risk factors relate specifically to

the individual being assessed (Cooke & Michie, 2013). Instruments such as the Historical

Clinical Risk Management 20 (HCR-20), are now widely used across forensic mental

health services as a common form of risk assessment (Douglas, 2014). Structure is

applied through a fixed number (20-30) of operationally defined risk factors, which the

clinician must judge and rate based on an explicit coding system for each risk factor

(Douglas, Blanchard & Hendry, 2013). They include historical, clinical and risk

management factors, which are usually rated using a three level system (not present,

possibly or partially present, definitely present). From this, the clinician assigns whether



someone is high, medium or low risk based on the number of risk factors present and the

anticipated level of intervention required to mitigate risk (Douglas, 2014). SPJ

instruments can provide some information about risk processes, yet there is still a focus

on the risk rating which is primarily based on historical factors.

1.2 Risk formulation and dynamic risk factors

To move from assessment to intervention we need to be able to understand the

complexity of how an individual relates to particular risk factors and to do this we need to

think psychologically rather than statistically (Douglas, Blanchard & Hendry, 2013) Risk

formulation looks beyond whether someone is ‘risky’ or not and focuses on the risk

process and how the risk factors are relevant to the individual and their risk of future

violence (Douglas, Blanchard & Hendry, 2013). It seeks to explain why a risk factor is

pertinent for that individual, to provide a richer understanding than a categorical risk

rating. Douglas & Skeem (2005) have proposed that what is missing from current risk

assessment processes and tools is the inclusion of dynamic risk factors. They describe

that dynamic risk factors are changeable over time and it is these factors that we need to

understand and formulate to obtain an understanding of risk that can be used to inform

intervention. To explain this further, they differentiate between risk status and risk state.

Risk status is based on static risk factors, assigning the individual a fixed categorical risk

status (e.g. high, medium or low risk) that doesn’t allow for risk to change over time

(Douglas & Skeem, 2005). Two individuals may both have a high risk status but this

doesn’t account for the fact that for each individuals risk will fluctuate over time and this

changeability is not captured by risk status. On the other hand, risk state compromises of

dynamic (changeable) risk factors and focuses on individual variability in violence

potential (Skeem & Mulvey, 2002). Risk assessment is now the process of making day to

day decisions to prevent risk of violence. To do this we need to understand what

aggravates or mitigates risk for the individual, rather than relying on a context-free

prediction of dangerousness (Skeem, Mulvey & Lidz, 2000). Thus, the next phase in risk

assessment needs to incorporate dynamic risk factors and we need to develop ways to



assess changeable aspects of risk and interventions which target these dynamic aspects so

to reduce violence.

1.3 Newsam Centre

The adult low secure forensic service in Leeds is based at the Newsam Centre and

provides inpatient, outpatient and community outreach to the local area. The low secure

inpatient service consists of 3 wards; one female unit, one male assessment and treatment

unit and one male treatment and recovery unit. The psychology team at the Newsam

Centre have created a collaborative risk assessment process and ‘circles’ tool (see

appendix 1) based on the dynamic risk factors proposed by Douglas & Skeem (2005).

Service requirements are that every individual must have a risk assessment and the Leeds

service currently use the HCR-20. However, several of the inpatient staff have been using

the collaborative dynamic risk assessment process (CD-RAP) and the circles tool that has

been created, in addition to the HCR-20.

1.4 Research question and aims

This service evaluation project was commissioned by Dr. Alex Brooks and Dr. Kerry

Hinsby, who both work at the forensic service at the Newsam Centre and have developed

the CD-RAP and the circles tool. The overall aim of the project was to gather staff’s

opinions and experiences of participating in the CD-RAP and using the circles tool.

Furthermore to develop recommendations for how both the process and tool could be

improved to benefit both the staff and the service users.

The aims of the project were:

To understand the inpatient staff’s previous experience of risk assessment and

how this compares to the dynamic collaborative process and the circles tool.

To understand the strengths and limits of the current use of the collaborative risk

assessment process and circles tool, from the ward staff’s perspective.



To gather ideas from the inpatient staff about how the collaborative risk

assessment process and circles tool could be improved.

To gain an understanding of how the inpatient staff perceive the impact of the

collaborative risk assessment process and circles tool on both themselves and the

service users.

2. Methodology

2.1 Design

Semi-structured interviews were conducted with clinicians working within the low secure

forensic inpatient service in Leeds (see appendix 2 for interview schedule). A qualitative

method was chosen because of the explorative nature of the aims of the project.

Qualitative methods are used to investigate meaning and inquire about how people

experience events and make sense of the world (Willig, 2008). Quantitative methods

would restrict the participants’ experience into predetermined and fixed categories,

whereas using a qualitative method allows for a richer, deeper understanding to be

captured (Willig, 2008). As the research question looks to explore the experiences and

perspectives of the staff team, it comes from a phenomenological position, which is

suited to a qualitative approach. Semi-structured interviews allow for a detailed

exploration of the experiences of the staff team. An alternative method would have been

to use focus groups, however, there were only a limited number of potential participants

and this may have limited the richness of the data as people may have been quieter in a

group than in interviews.

2.2 Recruitment

All inpatient staff members (across 3 wards) that had used the CD-RAP and circles tool at

least once were invited to take part in the study (n=15). To recruit, the commissioner sent

out an email to explain the study, with my details attached. The clinicians that wanted to

take part, then emailed me to arrange a meeting. 8 clinicians agreed to take part in the



project and of these 6 were from the psychology team and 2 were nurses. An information

sheet was provided before the interview began and informed consent was gained (see

appendix 3).

2.3 Ethics

University of Leeds School of Medicine Research Ethics Committee provided ethical

approval for the project on 13/03/2017 (see appendix 4). The Leeds and Yorkshire

Foundation Partnership Trust Research and Development department also granted

approval for this project (see appendix 5).

2.5 Analysis

The interviews were recorded using a Dictaphone and on average lasted 20-30 minutes.

The researcher then transcribed the interviews and then data was then analysed using

thematic analysis (see Braun & Clark, 2006). A description of the thematic analysos

process can be found in Appendix Thematic analysis is a qualitative method used to

“recognise and organise patterns in content and meaning in qualitative data” (Willig,

2008, p.57). It is a useful method to provide rich descriptive summaries of data that is

accessible to the reader (Braun & Clarke, 2006). Therefore, it is suitable to an evaluation

project of this nature and size.

2.6 Quality checks

Themes from the analysis were discussed with the SEP commissioner, alongside the

illustrative quotes. In addition, the themes and quotes were discussed with two other

trainee psychologists to ensure coherence. Finally, some data from the transcriptions are

given in the results section (see figures 2 & 3) to evidence how themes were developed.



2.7 Reflexivity

As a qualitative researcher, I acknowledge my own position and the potential bias I may

bring to this project. I am a psychologist in clinical training, which means that I will have

an investment in psychological formulation and working collaboratively. Furthermore,

this way of working is in line with my professional values. Therefore, during the analysis

of the data I needed to maintain my stance as a researcher and use quality checks to

ensure credibility of the themes.

3. Results

For the thematic analysis, I will be looking at themes for each question as these relate to

the different strands of the project. I will then bring these together within the discussion.

3.1 Previous experience:

Theme: The checklist approach

All clinicians reported that their previous experience of risk assessment was

predominately from using a structured assessment tool, such as the HCR-20. Clinicians

described the process as going through a ‘checklist’, particularly focusing on historical

factors and giving someone a fixed risk rating.

Theme: Service user as a passive recipient

The second theme within previous experience was that of the service user being the

passive recipient of the risk assessment. For some clinicians they had tried to involve

service users in the process of completing the checklist but found that often people did

not want to participate and that it felt like a paper exercise that the person didn’t have any

say in. Most of the time the assessment was done without the service user present, based

on historical notes and documentation and then the individual was told what the results

were and what restrictions this meant would be placed on them.



Figure 1: Thematic Map developed from the data (a more detailed version is in

appendix 7)



3.2 Initial thoughts

Theme: Optimistic Trepidation

For all of the clinicians there was a real sense of holding both enthusiasm and anxiety

about introducing the collaborative process and using the circles tool. This was a very

different process than the ‘traditional’ risk assessments that they had been used to,

therefore there was fear of the unknown and the uncertainty of how it would look and feel

to do. However, this was coupled with positive feelings about doing something

collaborative and broader than the structured assessments. There was an undercurrent of

the idea ‘making sense’ to them and this fuelling their enthusiasm to use the collaborative

process and tool.

Theme: Value Synonymy

One of the strongest reasons for positivity towards the collaborative process and tool was

that it matched the clinician’s values. Not only did it make theoretical sense to the

clinicians, but it also was aligned with their values which reinforced their enthusiasm for

using it.

3.3 Strengths

Main Theme: Being on the same page

Sub-theme: Shared resource

For all of the clinicians, there was a strength in the shared focus and task of looking at the

circles sheet and trying to fill it in. Having something concrete to focus was reported to

ease the pressure and allowed the service user to direct the conversation in the way that

they felt most comfortable with. The resource being shared rather than being held by the

professional was also seen as a physical act of working collaboratively, where the service

user could actively be more involved in the process.



Figure 2: Map showing themes and quotations for experience and strengths and

limits



Sub-theme: Knowledge sharing

One of the most common strengths of using the circles tool reported by clinicians was

that it helped to increase the service user’s insight and self-awareness. The circles tool

allows the clinician to make links between the different factors and provides a rationale

for how this impacts their mental health and offending. These links are then explained

and physically drawn out for the service user to take in. Clinicians reported that this

allowed for individuals to understand themselves more and to see the bigger picture of

what will be taken into account when decisions are being made.

Sub-theme: Normalising

There was a recurrent comment that the circles tool is grounded in empirical evidence,

which contributed to a theme around normalising risk. Several clinicians commented that

they would explain to the service user the evidence and rationale behind the circles tool

and that this would help to normalise risk, as a set of changeable factors that can affect

everyone. This was seen as moving away from blaming the individual.

3.4 Limitations

Main Theme: Individual Differences

Sub-theme: Service user ability

One of the over-arching difficulties named by 7 out of 8 clinicians was regarding a

service user’s ability to engage in the process and assessment. This included the service

user lacking insight, the service user cognitively struggling with the process as well as the

service user being in the right place (for example; being actively paranoid).

Sub-theme: Language

Over half of the clinicians reported that the language used to label the circles on the

assessment sheet had proven a difficulty in assessments they had been part of. Some of

the language such as ‘psychotic thinking’ was seen to be offensive or did not have a



shared meaning with the individual’s experience and this created a rupture during the

assessment process.

3.5 Improvements:

Main Theme: Expanding its reach

Sub-theme: Making it adaptable

Clinicians reported that being able to adapt the circles tool would be beneficial and there

were different suggestions about how this could be done. One way was to have different

versions of the circles for different factors e.g. a female specific one or one that was

adapted for people with learning disabilities. Another suggestion was to have a blank

circle to be able to have some flexibility with the factors and make it more individualised.

A common suggestion was being able to change the language or to have prompts on the

circles to help broaden out meanings and understandings.

Theme: Embedding it in the culture

The importance of having the process and theoretical understandings embedded in the

culture of the service was emphasised. Clinicians suggested that they would like the

process to be taken on board all across of the service, so that it would feel more integral

to people’s care and not just a standalone assessment that may be lost in translation to

other parts of the service or was over-ridden by more longstanding ways of thinking or

assessing someone.

3.6 Improving confidence and competence

Main Theme: Knowledge and learning

Sub-theme: Theoretical understanding

The clinicians stated that what helped both their confidence and competence was

understanding the theory, evidence and rationale behind the dynamic risk assessment



process and the circles tool. This was then strongly emphasised as a possible factor in

why disciplines outside of psychology, may not be as confident using it as they are may

not have this theoretical understanding. It was suggested that increasing knowledge about

the psychological theory and evidence would help to improve confidence and competence

throughout the multi-disciplinary team.

Sub-theme: Training

For all of the clinicians interviewed, more training regarding the collaborative process

and using the circles tool was strongly emphasised as a way to increase both confidence

and competence. This was often suggested as being conducted through watching other

(more experienced) clinicians doing it so to get experiential training rather than just

didactic teaching on it. There was another suggestion about using role play to practice the

skills and one clinician suggested that a peer supervision space may be beneficial to bring

together ideas and experiences and to learn from one another.

3.7 Impact on staff

Theme: Holistic thinking

Several clinicians reported that using the collaborative risk assessment process had

positively changed the way they thought about risk. They reported that it had broadened

how they understood risk, by seeing it as a changeable concept that is moderated by

various factors. It was suggested that by seeing it as ‘dynamic’ it allowed different

viewpoints to be acknowledged and therefore reinforced not to take reported facts as the

‘gospel truth’.

Theme: Increased confidence

A strong theme was increased confidence in talking about risk. It was suggested that

using the collaborative process and understanding the dynamic factors in the circles tool,

gave the clinicians an amenable way to talk about risk with an individual. It helped to

break down the concept, to normalise it and to provide a way to talk about risk not being



Figure 3: Map showing themes and quotations for improvements and impact



stuck. This increased clinicians’ confidence in discussing risk and made it feel less

daunting as a process.

3.8 Impact on service users

Main Theme: Empowerment

Sub-theme: Treating people as equals

The clinicians all reported that they believed the CD-RAP positively impacted the care of

service users. The over-arching theme that emerged from this was that it was seen to be

an empowering process for the service user by sharing knowledge and understanding,

giving back control and responsibility and valuing and acknowledging the service user’s

perspective.

Sub-theme: Therapeutic Intervention

It was suggested that the CD-RAP was a therapeutic intervention in itself. By doing the

assessment, clinician’s reported that it increased both the professional’s and the service

user’s understanding of the difficulties and that this then positively impacted and

informed their care. It was considered to help improve communication between the

service user and the MDT and thus improves the care by providing a shared language.

Sub-theme: Feeling understood and a fair representation of themselves

From the clinicians’ perspectives, the most significant benefit of the CD-RAP for the

service users was that they would feel heard, valued and listened to. It was suggested that

the service user would gain insight and awareness and that this would then move away

from blame and they would feel that there was shared meaning and understandings. It

could also be seen as a way to illustrate what is going well or what strengths the service

user has, so that the service user feels that it is more representative of them and their life.



3.9 Challenges for service users

Theme: Difficult emotions

It was suggested that what may be most difficult about the CD-RAP for the service users

was the difficult emotions that it may bring up. It was reported that it can be an exposing

and difficult conversation to have which may bring up feelings of shame, anger and

sadness for the service user. There was a worry that it may cause an emotional fallout

after the assessment and that this might have repercussions on the ward. However,

although this was a worry this was not reinforced by actuarial experiences of this

happening.

4. Discussion

The results will now be discussed in terms of the aims of the project.

4.1 Previous experience of risk assessment vs. the dynamiccollaborative process and the circles tool

Clinicians’ previous experience of risk assessment was in keeping with the phase of

actuarial measurement and structured clinical judgement. All of the participants reported

using structured tools such as the HCR-20 or the FACE risk assessment, however this

was seen as led by service needs rather than the needs of the service users. Several of

them expressed their dissatisfaction at this way or working, describing it as a ‘paper

exercise’ and ‘just ticking boxes’. This seemed to go against their values of working with

someone, being transparent and taking the service user’s view into account, yet they felt

restricted by the requirements of the service. They described that this kept a power

differential between the professional and the service user, with the person not being

present during the assessment and just being told what their risk and what this meant for

them. Again this went against the clinicians’ values of reducing power imbalances and

valuing the service user’s perspective Therefore, when the CD-RAP was introduced,



clinicians were enthusiastic about a way of working that was in keeping with their values.

Participants reported that the theoretical understanding of risk being an interaction of

dynamic factors rather than one static rating made sense to them and was in line with

their knowledge of formulation. However, several individuals expressed their hesitancy

when they were first introduced to the collaborative process and circles tool. Although it

matched their values and made theoretical sense to them, there were concerns about how

it would actually look and work in reality and there was also a general fear of the

unknown and doing something different. Nonetheless, these worries and concerns were

overshadowed by the positivity towards introducing a way of working that was

collaborative, innovative and was led by the needs of the service user.

4.2 Ward staff’s perceptions of the collaborative dynamic riskassessment process and the circles tool

When looking at then perceived strengths and limitations of the CD-RAP and the circles

tool, it was evident that there was a wealth of strengths compared to a smaller number of

challenges raised by the ward staff. Clinicians commented on strengths regarding the

content, process and structure of the assessment and this all positively reflected their

professional values. For the clinicians, ‘being on the same page’ as the service user was

the over-arching strength. This was being enacted through the physical structure of the

assessment (the circles sheet), the collaborative process and the shared knowledge and

psychological theory. Strengths across all of these areas, were described by clinicians and

were embedded within the clinicians’ value system of working collaboratively. There was

a significant strength discussed regarding the structure of the assessment and the resource

sheet (circles tool). Clinicians described how having the circles sheet out on the table

rather than being held by the professional, created a shared task and focus for the

assessment. Not only did this help to alleviate the pressure from the service user but it

also re-configured the power balance in the room by being transparent about what was on

the sheet as well as giving control to the service user, where they could direct the

conversation and choose which circle to discuss first. Further to this, was the theme of

knowledge sharing. Clinicians expressed their belief that using the CD-RAP and the



circles tool helped to develop a service user’s insight and awareness of their difficulties.

This was achieved by explaining the psychological theory of how these factors may

interact and moderate risk, providing the service user with the same knowledge as the

professional. So instead of professionals holding all of the knowledge and keeping the

individual in the dark, this sharing of knowledge through the assessment was perceived to

again keep both parties on the same page, addressing the inherent power imbalance.

Clinicians also reported that the theory underpinning the assessment process and tool,

helped to normalise the concept of risk, by illustrating how it is an interaction of factors

that we can all be susceptible to. This normalisation helps to move away from blaming

the individual and was believed to facilitate engagement in the assessment.

The limitations of the CD-RAP and the circles tool were more focused than the strengths.

Nearly all of the participants spoke about service user suitability for engaging in the

assessment as being a potential barrier. Clinicians described that timing may be important

as some service users may not be in the right place or able to engage in the process.

Individuals may not be emotionally prepared to engage in the assessment e.g. being

actively paranoid or not willing to accept responsibility for risk. It was also suggested that

some people may not be cognitively able to engage in the process e.g. individuals with a

learning disability. However, this was also seen to be a generic difficulty with all

psychological interventions. Clinicians suggested that instead of this being a barrier to the

assessment being possible, it just means that the timing of the assessment may need to be

thought about or the structure adapted for different abilities. Another limitation that was

raised by the clinicians was regarding the language used on the circles sheet. Some of the

terminology was reported as offensive or did not convey a shared meaning. Clinicians

described that when the language did not reflect the service users’ experiences or beliefs,

it created a rupture or barrier in the assessment process and needed to be adapted. It was

suggested that terms such as ‘psychotic thinking’ or specific labels such as ‘anxiety’ had

caused difficulty and clinicians described that if these terms did not match the service

user’s experience then this would be a barrier to them engaging fully in the process as

they could not relate to the ideas.



4.3 Recommendations for improvements

The recommendations for improving the CD-RAP and the circles tool were based on the

idea of ‘expanding its reach’. Clinicians described different ways of adapting the circles

tool so to fit different experiences and to be suitable for different needs. In addition, there

were suggestions of being able to adapt the language which again was proposed as a way

to broaden it out to more people, who may hold different meanings or experiences which

can then be reflected in the adaptations of the language used. This idea of expanding the

reach of both the process and the tool was similarly reflected in the theme of embedding

it in the culture. Again clinicians wanted the collaborative dynamic process to be

supported more broadly by the service and for the intervention itself to be taken on board

by other parts of the service so that it has more recognition and strength as a useful and

beneficial resource. It was proposed that if it was embedded in the culture of the service,

the information and process would not be lost in translation and the rich understanding

that was formulated from it would be able to follow the service user through different

parts of the service to increase continuity and improve care.

Improvements to both confidence and competence, came from learning and knowledge.

Clinicians believed that having a thorough understanding of the theoretical and empirical

background of the process and the dynamic risk factors would improve both confidence

and competence at facilitating the risk assessment. For some clinicians, they reported that

disciplines outside of psychology are not trained in formulation or the rationale behind

working collaboratively. They suggested that this may be a reason for other disciplines

not having confidence in facilitating the assessment and therefore not doing it. It was

proposed that increased training in collaborative formulation would be beneficial, so that

the process can hopefully be taken on by other professions to widen its reach and embed

it more within different parts of the service. One suggestion was to have a peer

supervision space where clinicians could discuss their experience and learn from each

other. Several of the clinicians made reference to learning from others (role-play,

watching those more experienced) and this seemed pivotal in helping to improve their

confidence and competence in conducting the risk assessments.



4.4 Perceived Impact

Overall, the clinicians proposed that the collaborative dynamic process and tool helped to

increase their understanding and confidence in talking about risk. They found that it

broadened their thinking to see risk as a set of changeable factors, rather than a fixed

negative category. This then also impacted their confidence as it broke it down to

something more manageable to discuss and also gave control and responsibility back to

the service user, allowing it to be a more positive conversation.

From the clinicians’ perspectives, there was a strong sense of a positive impact on the

service users, from being part of the process. There was a belief that the process

empowered the individual and this was done through being treated as an equal, feeling

understood and it being of benefit to the service user as an intervention itself. It was put

forward that the collaborative process allowed the power differential to be reduced and

for the service user to be an active participant in the process, contributing and shaping the

assessment and formulation. The staff perceived the challenges to be the difficult

emotions that the assessment may raise such as shame or anger. However, this was

generally seen to be part and parcel of all therapeutic work in this field.

4.5 Limitations

It is important to acknowledge the limitations of this project. Firstly, six out of the eight

participants were from the psychology discipline. Although there are other disciplines

that facilitate the risk assessments, it was predominantly psychology who were keen to

engage in the evaluation. 15 clinicians had done the collaborative risk assessment across

the 3 wards but only 2 people who agreed to take part were not from the psychology

department. This may have been because psychologists are trained to think about

formulation and therefore may be more positive to this way of working. Also,

psychologists usually only see service users for sessions and therefore unlike other

professions may not have to deal with any emotional fallout on the ward that may occur

after the assessment. Secondly, this evaluation was limited to one service. There may be



differences with the way other services are set up and run which may encounter different

experiences and opinions. Finally, this research project only looks at one half of the

participants in the risk assessment; the staff. There is another evaluation project which is

separately looking at the experiences and opinions of the service users. Therefore, it

would be most beneficial to look at these two sets of data together to get a more

representative picture of the overall impact of the process and tool.

5. Conclusion5.1 Summary

Overall, clinicians recounted positive experiences and opinions of the CD-RAP and

circles tool. Their experiences reflected those in the current literature, where there is a

draw to move towards risk formulation. The use of structured professional judgement

tools such as HCR-20, creates a focus on the risk status and doesn’t inform intervention

(Douglas & Skeem, 2010). Risk of violence is not certain or fixed, which ultimately

means that managing risk is about managing uncertainty (Cooke & Mitchie, 2013). We

need to understand the impact of risk factors, moving from a static risk status to looking

at why certain factors increase violence for that individual; we need to move to process

rather than structure. The CD-RAP provides a space and intervention to do this, so to

understand the changeability of risk and to work with the uncertainty rather than against

it.

5.2 Recommendations

From the analysis, the following recommendations can be put forward:

Making the circles tool applicable to different presentations (i.e. LD, female).

Reviewing the language and potentially making it flexible to the needs of the

individual.

Increased training for staff, including increased opportunities to observe more

experienced clinicians and opportunities for role-play.



Implementation of a peer supervision space, to learn from each other’s

experiences.

Training to include the theoretical underpinnings, particularly for those not trained

in formulation.

Working with other parts of the service to embed it more into the culture and to

increase transferability of the assessment.

5.3 Dissemination

Results have been reported in a poster presentation to staff and students from the

D.Clin.Psychology programme. A copy of this report will be provided to the

commissioners.



References

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative

research in psychology, 3(2), 77-101.

Cooke, D. J. & Michie, C. (2013). Violence risk assessment: From prediction to

understanding - or from what? To why? In Logan, C. & Johnstone, L. Managing Clinical

Risk: A guide for effective practice. Routledge; Oxford, UK

Douglas, K. S. (2013). Version 3 of the Historical-Clinical-Risk Management-20 (HCR-

20 V3): Relevance to violence risk assessment and management in forensic conditional

release contexts. Behavioural Sciences and the Law. 32(5); 557-576.

Douglas, K. S., Blanchard, A. J. E. & Hendry, M. C. (2013). Violence risk assessment

and management. In Logan, C. & Johnstone, L. Managing Clinical Risk: A guide for

effective practice. Oxford, UK: Routledge.

Douglas, K. S. & Skeem, J. L. (2005). Violence Risk Assessment: Getting specific about

being dynamic. Psychology, Public Policy and Law, 11(3); 347-383.

Quinsey, V. L., Harris, G. T., Rice, M. E. & Cormier, C. A. (1998). Violent Offenders:

Appraising and managing risk. American Psychological Association; Washington DC.

Skeem, J. & Mulvey, E. (2002). Monitoring the violence potential of mentally disordered

offenders being treated in the community. In Buchanan, A. (Ed.). Care of the mentally

disordered offender in the community. New York; Oxford Press.



Skeem, J., Mulvey, E. & Lidz, C. (2000). Building clinicians’ decisional models into tests

of predictive validity: The accuracy of contextualised predictions of violence. Law and

Human Behaviour; 24(6); 607628.

Singh, J. P. & Fazel, S. (2010). Forensic Risk Assessment: A Metareview. Criminal

Justice and Behaviour. 37(9); 965-988.

Willing, C. (2008). Introducing Qualitative Research in Psychology, Second Edition.

McGraw Hill, Open University Press; New York.



Appendices

1. Circles Tool

2. Interview Schedule

3. Information sheet and consent form

4. University Ethics approval letter

5. LYPFT Ethics confirmation

6. Stages of Thematic Analysis

7. Detailed thematic map

8. Commissioner’s appraisal form

9. Self-appraisal form



Appendix 1: Circles Tool



Appendix 2: Interview Schedule

Service Evaluation Project: Inpatient staff experiences of a collaborative dynamic risk assessment

process

Interview Questions for Inpatient Staff Team

1. Can you tell me about your previous experiences of risk assessment and

conversations with service users about risk?

2. What were your initial thoughts on the collaborative dynamic risk assessment

process and the ‘circles’ tool?

3. What do you think are the strengths or benefits of the collaborative dynamic risk

assessment process and the ‘circles’ tool?

4. What do you think are the difficulties or limits of the collaborative dynamic risk

assessment process and the ‘circles’ tool?

5. Is there anything that you can think of that would improve the collaborative

dynamic risk assessment process and the ‘circles’ tool?

6. What would help to improve either your confidence or competence in conducting

a collaborative dynamic risk assessment independently?

7. Has being part of the collaborative dynamic risk assessment process affected

how you think about risk? If yes, in what way?

8. From your point of view, how do you think it has affected the care given to

service users?

9. From your point of view, what do you think are the benefits and challenges of this

type of conversation for service users?



Appendix 3: Information Sheet and Consent Form



Appendix 4: Ethics Approval



Appendix 5: LYPFT Ethics Confirmation



Appendix 6: Stages of analysis (Braun & Clarke, 2006, p.87)

Stage Process

1 Responses collected and transcribed. Read and re-read and initial

thoughts noted.

2 Codes are generated through initial reading of the data, collating data

relevant to each code.

3 Codes are organised into potential themes and relevant coded data

extracts gathered within themes and subthemes.

4 Coded extracts for each theme are reviewed and an initial thematic map is

generated. Themes are reviewed ensuring internal homogeneity and

external heterogeneity.

5 Ongoing analysis to refine themes. Themes defined and named.

Validation of themes and subthemes by independent verifier.

6 Themes refined and thematic map created. Themes supported with a

selection of supporting data extracts.



Appendix 7: Detailed Thematic Map

Evaluating the use of the collaborative dynamic risk ... · assessment process and circles tool...

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