This slideshow considers the constructs of Risk and Recovery and the apparent tension between ‘Recovery’ approaches in forensic mental health care and effective management of risk. This dichotomy is a reflection of broad social trends that influence the delivery of all contemporary human services. Services and workers faced with this tension can feel crushed between ‘a rock and a hard place’ – forced to meet evidently conflicting demands. This presentation considers the values involved in this challenge with special reference to forensic mental health. I firmly conclude that Recovery approaches and effective management of risk can in fact work in synergy rather than in opposition. It was my privilege to present this at Forensicare in Victoria this month as a staff broadcast.

1. RISK & RECOVERY
Andrew Carroll
Forensic Psychiatrist
• Forensicare
• Centre for Forensic Behavioural Science
• ‘Our Curious Minds’ (training company)
• Private Medicolegal Practice
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2. “FORENSIS”: OF THE ‘FORUM’
•Latin adjective
•Forensis
•“of or pertaining to the
market or forum”
•“public”
2

3. • Imposed duties on services
and professionals
• Assessment tools
• Policies and procedures
Risk management
• Autonomy
• Rights
• RECOVERY
Consumer empowerment
Trends in public life from the 1990s onwards…
3

4. The contemporary
mental health service
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5. How might we manage this predicament ???
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6. .
6
Recovery
Connectedness
Hope
Identity
Meaning
Empowerment

7. A SHIFT FROM: “the paternalistic approach of trying to get the
person to understand what the professionals can see they need…”
Perkins, R. and J. Repper (2016)
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CLINICIAN
PATIENT

8. BUT NOT : “crudely asking people what they want and
blindly doing it…” Perkins, R. and J. Repper (2016)
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CLINICIAN
PATIENT

9. IS about “…a relationship that
enables people to discover their
possibilities and make the
most of things”
Perkins, R. and J. Repper (2016)
9
PATIENT
FAMILY & CARERS
SIGNIFICANT
OTHERS

10. Relationships are central to safety
“Danger can only be reduced within a trusting relationship within
which each understands where the other is coming from, feels
able to express their fears and concerns, and can share
responsibility for safety”
Perkins, R. and J. Repper (2016)
10

11. 11
VALUES-based
relationships

12. VALUES associated
with Recovery
approach are
‘promotional’ in
tone
12
‘Promotional’:
seeking to
gain a POSITIVE

13. AUTONOMY
DIGNITY
POWER
social
inclusion
QUALITY
OF LIFE
13
‘Promotional’:
seeking to
gain a POSITIVE

14. The Values of Recovery…
Emphasise PROMOTION of
‘positives’
Rather than PREVENTION of
‘negatives’
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15. 15
PROMOTIONAL
VALUES
RECOVERY-ORIENTED
ACTIONS

16. Encouraging autonomous
coping strategies at times
of suicidal ideation rather
than rapid resort to
externally imposed
control
Community leave
programs from long-
term secure hospital
care
Facilitating social
connections including
work and intimate
relationships, despite
risk of “stress” involved
Examples of ‘promotional’
values in action
16

17. Encouraging autonomous
coping strategies at times
of suicidal ideation rather
than rapid resort to
externally imposed
control
Community leave
programs from long-
term secure hospital
care
Facilitating social
connections including
work and intimate
relationships, despite
risk of “stress” involved
Examples of ‘promotional’
values in action
17

18. Encouraging autonomous
coping strategies at times
of suicidal ideation rather
than rapid resort to
externally imposed
control
Community leave
programs from long-
term secure hospital
care
Facilitating social
connections including
work and intimate
relationships, despite
risk of “stress” involved
In short-term, therapeutic risk-taking involves
some risk of harm…BAD STUFF does happen…
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19. And so,
conversely,
many
legitimate
values are
‘preventive’ in
tone
Preventive:
seeking
to avoid a
NEGATIVE

20. Client harm
Public harm
Client
exploitation
or abuse
Damage to
service
reputation
'Relapse’ of
illness or
addiction Preventive:
seeking
to avoid a
NEGATIVE

21. The Values of ‘Risk Management’
Rather than PROMOTION of
‘positives’
Emphasise PREVENTION of
‘negatives’ by way of
‘precautions’
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22. 22
PREVENTIVE
VALUES
‘RISK MANAGEMENT’
ACTIONS

23. Involuntary
hospitalisation to
manage suicide risk
Prolonged detention in
hospital or other secure
setting to prevent re-
offending
Minimising psychosocial
stimulation to reduce
risk of ‘relapse’
Examples of ‘preventive’
values in action
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24. Involuntary
hospitalization to
manage suicide risk
Prolonged detention in
hospital or other secure
setting purely to
incapacitate and
prevent re-offending
Minimising psychosocial
stimulation to reduce
risk of ‘relapse’
Examples of ‘preventive’
values in action
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25. Involuntary
hospitalisation to
manage suicide risk
Prolonged detention in
hospital or other secure
setting to prevent re-
offending
Minimising psychosocial
stimulation to reduce
risk of ‘relapse’
BUT: this may increase risk of other harms…
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26. Such risks usually
become more evident in
the longer term…
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27. The paradox…
“…in our attempts to minimise risk we may
inadvertently increase risk in a vicious cycle of
compulsion and enforced treatment that destroys trust
or a cycle of compliance that destroys hope and
ambition.”
Perkins, R. and J. Repper (2016).
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28. These two sets of values align with
distinct GOALS
• Long-term recovery
• Autonomy and dignity
• Promoting health
PROMOTIONAL
• Safety in the
immediate future
• Protection
• Avoiding illness
PREVENTIVE
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29. And different clinical interventions
prioritise different values…
• Usually address long-term ‘care
needs’ that change slowly e.g.
self-control skills, coping,
resilience
• Usually involve enabling and
supporting client’s own choices
PROMOTIONAL
• Usually involve ‘taking precautions’
e.g. short-term containment when
emotionally dysregulated
• Sometimes coercive - overriding
autonomy and preferences of client
PREVENTIVE
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30. There are associated risks whatever we do…
• Serious adverse outcomes:
suicide, violence
• Absconding from secure hospital
• Relapse into severe illness
• Others…
PROMOTIONAL
• Diminished trust
• Reduced self-efficacy
• Lowered resilience
• Poorer quality of life
• Wasted resources
• Others…
PREVENTIVE
30

31. But these risks have a different ‘feel’…
• Serious adverse outcomes
• Absconding
• Relapse
• Usually:
• concrete
• highly visible
• immediate
• readily appear ‘obvious’ in
hindsight
PROMOTIONAL
• Diminished trust
• Reduced self-efficacy
• Lowered resilience
• Poorer quality of life
• Wasted resources
• Usually:
• abstract
• silent
• delayed
• difficult to ‘prove’ in
individual case
PREVENTIVE
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32. So, when might each approach be indicated ?
• Patient has capacity to take the
relevant decision, take
ownership and responsibility for
risk and prefers promotional
option : “therapeutic
risk-taking”
PROMOTIONAL
• High likelihood of serious harm
in short-term
• Patient’s ‘mental capacity’
impaired
• In forensic work, does a severe
‘index offence’ inevitably tip
balance towards ‘preventive’ ??
PREVENTIVE
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33. RISKS BENEFITS
SUPPORTING THE
PLAN---
PROMOTIONAL
• Deterioration outside
structure of ward
• Access to means of
harm to self /others
• Might decide to not
return
• Testing of how robust
recovery is
• Support patient choice
• Build longer term trust,
engagement,
resilience, coping…
OPPOSING THE
PLAN---
PREVENTIVE
• Disengagement
• Loss of hope and
worsened mental state
• Higher level of
supervision
• ‘Compliance’ ensured
HOW VALUES MIGHT PLAY OUT IN A CLINICAL DILEMMA : FIRST OVERNIGHT LEAVE FROM TEH…
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34. Promotional values of the
Recovery approach
Preventive values of
‘Risk Ax and Mx’
34

35. Promotional values of the
Recovery approach
Preventive values of
‘Risk Ax and Mx’
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36. Mutually interdependent and
complementary---they NEED each other!
Recovery
Risk
Management
“From managing risk to
co-production of safety
and opportunity”
Safety Opportunities…
36

37. Promotional values of the
Recovery approach
Preventive values of
‘Risk Ax and Mx’
• Allow system to support
defensible, judicious exposure to
risk  personal growth, resilience,
learnings even when
failures or harms do occur  SAFETY
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38. Promotional values of the
Recovery approach
Preventive values of
‘Risk Ax and Mx’
• OPPORTUNITIES  draw on lived experience
 individualised understanding of risks
• EmPOWERment  Self-RESPONSIBILITY for
managing own risks
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39. Preventive values of
‘Risk Ax and Mx’
HELPS
HELPS
• OPPORTUNITIES  draw on lived experience
 individualised understanding of risks
• EmPOWERment  Self-RESPONSIBILITY for
managing own risks
• Allow system to support
defensible, judicious exposure to
risk  personal growth, resilience,
learnings even when
failures or harms do occur  SAFETY
Promotional values of the
Recovery approach
39

40. Take home messages
We must respect BOTH
‘preventive’ and ‘promotional’ values
Recovery is about
empowerment
Empowerment involves the
assumption of responsibility
Forensic rehabilitation : a graduated
(re)assumption of self-responsibility
Recovery approaches can
support risk management
Effective risk management
supports Recovery approaches

41. Resources
• https://bit.ly/tickboxcourse : Risk Management course for
Psychiatrists
• www.ourcuriousminds.com
• Perkins, R. and J. Repper (2016). "Recovery versus risk ? From
managing risk to co-production of safety and opportunity."
Mental Health and Social Inclusion 20(2): 101-109.
• https://bit.ly/RiskRecovery : ‘Risk management in the era of
recovery and rights’ Carroll & McSherry (2021)
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