APIR

Assessing Risk

When assessing risk a five step approach is often followed. This process with Jenifer appears like this:

Key Principles

3. How likely are these outcomes?

• Jenifer’s increased use of alcohol poses a significant higher risk of an accident occurring. However, as the alcohol consumption has started only a year ago, and she has previously been able to cope, finding new coping strategies could be an effective preventative method

• Without intervention, there is an extremely high risk of detrimental effects on Chloe’s development. History shows however, that Chloe has had the ability to do well both in terms of education and health, suggesting intervention can combat this risk.

• A family breakdown is an increasingly high risk, and they are at risk of reaching a crisis situation.

4. How Undesirable are they?

• An accident around the home could lead to a child protection enquiry under s47 of the Children Act 1983. This would put increased strain on the family, and risks further increasing Jenifer’s behaviours.

• A family breakdown would compound Jenifer’s anxieties and inability to cope with daily life situations.

• Chloe’s development is paramount, as recognized in the Children Act 1983. If there was not recognized improvement

2. What might happen?

• Jenifer’s alcohol consumption could result in an accident around the home.

• There will be a long term effect on Chloes health and development needs

• It could lead to a family breakdown, which could compound the problem.

1. What has been happening?

• Jenifer shows a history of anxiety and self-harm, and has been diagnosed with an anxious avoidant personality disorder (static risk). However, history shows that for a period she was able to manage the characteristics of this.

• She is currently alcohol dependant and is using this as a crux to cope with her anxieties. There is no mention of this happening in the past. (Acute Dynamic risk)

• She is unable to manage the day to day running of the house, and looking after her children, resulting in a severe physical and emotional burden on daughter Chloe. (Acute Dynamic risk)

5. Overall judgement of risk

The risks identified have to be balanced against protective factors, and underpinned by the law and policies. A clinical judgement of risk taking into account all these factors will follow.

Gather Information

Hypothesis

Actuarial Judgement

Having more than one initial hypothesis will prevent premature framing of the situation that could influence the progress and outcome of the case (Sheldon, 1996, cited in Milner and O’Bryne, 2009)

Actuarial judgements are often used when looking at static risk factors.

Initial Hypothesis:

Jenifer’s behaviour is stemming from her personality disorder and a feeling of disempowerment.

Jenifer’s behaviour is stemming from a maladaptive attachment with her mother.

Jenifer’s behaviour is stemming from unresolved issues from her rape.

Jenifer’s behaviour is stemming from her (possibly untreated) postnatal depression

Testing the hypothesis

Using research and theory’s to test hypothesis reduces the impact of bias (Mantell, 2013)

There are two broad types of personality disorder:

1. One that developed in childhood (that is often episodic)

2. One that develops in adolescence (that develops in response to psychosocial adversities in the environment)

(Siever et al, 2002, cited in Prichard, 2006).

Beck’s Cognitive theory (cited in Payne, 2005) cognitive theory argues that behaviour is affected by an individual’s interpretation or perception of their environment during learning.

Assessment

Legal Framework

Risk Assessment

Chloe

• Under s17 of the Children Act Chloe is defined as a child in need.
• She would be entitled to an assessment and intervention under Under the Framework for assessment of Children in Need

As the paramouncy principle of the Children Act states that Chloe’s welfare is paramount, any intervention with Jenifer must have a positive impact upon Chloe (Braye and Carr, 2012).

Jenifer

• Jenifer would be entitled to support under the Care Programme Approach
• This would entitle Jenifer to a ‘care co-ordinator’ who would assess needs, work in partnership to develop a care plan and regularly review progress
• She would be entitled to self-directed support under the Personalisation agenda that would help pay for her social care needs

Assessment Models and Tools

Building Relationships (Person Centred Practice)

Establishing a relationship is crucial for engaging with service users and aids understanding of the outcomes that are important to them (Cook and Miller, 2012, cited in Mantell, 2013).

Transference of feelings, from Jenifer’s previous professional involvement whether positive or negative, may have an effect on our relationship (Mantell, 2013).

Partnership in working relationships can help to tackle resistance, and build trust (Milne, and O’Bryne, 2009).

By focusing solely on risks there is scope for resources to be inappropriately targeted and risks further disempowering Jenifer, leaving her unmotivated to change (Watson and West, 2006).

Assessment Baseline and Tools

The assessment must start with understanding the baseline for the situation at present, as without this, there can be no measure of improvement (Watson and West, 2006).

An eco-map can help identify support networks, and identify under-utilised resources to help achieve goals (Egan, 2014).

Working with Jenifer to complete a social functioning scale (Withnell and Murphey, 2012) could provide a baseline for future reviews, and understand areas that can be developed.

Completing a Manchester Short Assessment of Quality of Life (MANSA) will aid understanding of 16 areas of Jenifers life.

Any intervention with Jenifer must have a positive impact upon Chloe. Here, understanding her baseline will prove as an indicator of progress. I would suggest Chloe currently rates in category C on the Continuum of Need (2007), and will need intergrated support from child services.

Assessment Models

Egans Skilled Helper Model

Three models of assessment from Smale and Tuson (1991, cite in Egan, 2014):

Procedural Model; Questioning Model; Exchange Model

Clinical Judgement

Assessment

Risk Assessment

Let's talk about it

Collaborative Working and Partnership Values

With scope for so many professionals involved in an individual’s care, an effective, integrated response, with the service user at the centre is crucial (Carpenter and Dickinson, 2008).

Collaboration between adults and children’s services is recognized in policies such as Working Together to Safeguard Children’.

A holistic plan will ensure a multi-agency response, that is needed to meet the needs of an individual like Jenifer, with complex need, where no single agency will be able to meet her needs ( Davison, 2002).

To ensure a bio-psychosocial approach, effective collaboration with her GP and Community Psychiatric Nurse is essential. Whilst medication cannot treat personality disorders, it can aid the depressive overlay (Pritchard, 2006).

To ensure Chloe's needs can be met, a holistic plan must be created with collaboration from childrens services, family support and her School. Plans should follow SMART techniques and be reviewed regularly.

APIR

Planning

Review

Planning

Planning to meet needs

Egans (2014) Model suggests that all service users will have blind spots, which prevent them from seeing both problems and opportunities in full.

When working with an individual with a personality disorder, realistic and moderate goals are essential (Davison, 2002)

Planning should incoperate regular reviews to meet changing needs and risks

Family Group Conferencing (FGC) : Based on values such as partnership, empowerment and trust, a referral to FGC could create an opportunity for discussion conflict resolution between the familyand in a safe environment (Milner and O’Bryne, 2009).

As identified before, an assessment is a dynamic and continuous process. Regular reviewing, and identifying this, services can be adapted accordingly (Parker and Bradley, 2011).

By understanding the purpose of reviewing, Jenifer is empowered to take more control (Parker and Bradley, 2011)

The assessment tools used, provide an effective method for reviewing the effectiveness of the interventions and provides and opportunity to empower Jenifer as she sees the achievements made in her life (Parker and Bradley, 2011).

Review

Planned reviews will ensure Chloe is meeting her SMART goals.

This will also add to her feelings of support and control over the situation.

Intervention

Cognitive Behavioural Inerventions for Jenifer

Following Berks (Cited in Payne, 2005) cognitive theory of distorted perception, and Jenifer’s diagnosis of Category C Personality disorder, evidence suggests a bio-psychosocial intervention of anti-depressant medication and Dialectical Behavioural therapy (DBT) would be the most effective with Jenifer (Linehan et al, 2002, cited in Pritchard, 2006).

Dialectical Behavioural therapy is a form of Cognitive behavioural therapy designed to break the cycle of upsetting emptions, and a feeling of guilt and worthlessness for having these emotions that many people with this disorder have (NHS, 2014).

DBT has been proved extremely effective in women with personality disorder who have a history of self-harm and is recommended by NICE as the first treatment to try (NHS, 2014).

DBT should increase Jenifer’s capacity to manage daily tasks such as household duties, and caring for her children.

Intervention

Ecological Interventions for Jenifer

Through his networking intervention, Trevillion (1999, cited in Payne, 2009) identifies five interventions. From these, I believe that building Jenifer’s Community networks, alongside the DBT will have the most positive effect.

Social skills exposure is shown to be effecive alonside DBT (Davison, 2002)

Commissioning a support worker under the Self Directed Support provision of the Personalisation agenda should help to rebuild social connections (Davison, 2002).

The group therapy aspect of DBT will also help to build up social situations in a safe environment.