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Tizard Learning Disability Review Volume 14 Issue 4 October 2009 © Pier Professional Ltd 17
A positive approach to
risk requires personcentred thinking
Feature
Introduction
The problems of traditional risk assessment are
becoming increasingly recognised by people who
use human services, their families and carers, and
now by many service providers, who are looking
for alternative approaches to risk:
thorough, professional, personalised risk
management (Bates & Silberman, 2007 p6)
that recognises that life and risk are inseparable,
and that look at risk from the point of view of
the person, their family and friends and the wider
community, rather than solely from the point of
view of the service provider.
Bates and Silberman argue that any such
positive approach to risk would need to meet a
number of requirements, and see it as the ‘holy
grail’ of mental health and other services.
We have been working on applying personcentred thinking tools to the issue of risk, building
them into a person-centred approach to risk. The
full exposition of this process is described in the
Person Centred Risk Course Book (Allen et al,
Abstract
This article discusses the question of risk in the lives of people who are supported by human services. It
responds to the way in which risk, as it has traditionally been approached by these services, imposes a
barrier to social inclusion and to an interesting and productive life. The article proposes an alternative
person-centred risk process. We argue that, by beginning with a focus on who the person is, their gifts
and skills, and offering a positive vision of success, it could be possible to avoid the implied aversion to
any form of risk embedded in the traditional approaches and attitudes.
Key words
risk management; risk assessment; person-centred
Max Neill
PCP Co-ordinator, NHS Central Lancashire,
UK
Julie Allen
Family Group Conference Co-ordinator,
South Eastern Trust, UK
Neil Woodhead
PCP Co-ordinator, Derbyshire Mental
Health Services NHS Trust, UK
Helen Sanderson
Director, Helen Sanderson Associates, UK
Stephen Reid
Assessment Treatment & Support Service,
Derbyshire Mental Health Services Trust, UK
Lori Erwin
Mentor Trainer for Person Centred
Approaches and Lead on Children & Young
People, Helen Sanderson Associates, UK
18 Tizard Learning Disability Review Volume 14 Issue 4 October 2009 © Pier Professional Ltd
2008). We believe that this alternative approach
does not lose the person in a sea of tick-boxes
and charts, and that it has a more balanced
approach to risk, having an inbuilt assumption
that the purpose of any risk assessment is as
much about the happiness of the person,
their family and the community as it is about
their safety.
We also believe that the person-centred
approach to risk can be shown to meet all the
requirements set by Bates and Silberman (which
are discussed in more depth later in this article),
and that it provides a productive way forward for
many people who wish to take meaningful steps
forward in their lives, but find themselves trapped
in boring, unproductive and segregated lifestyles
by traditional service-centred approaches to risk.
Finally we argue that any positive approach to
risk must include the basic tenets of all personcentred approaches: keeping the person at the
centre, treating family and friends as partners,
focusing on what is important to the person, an
intent to build connections with the community,
being prepared to go beyond conventional service
options, and continuing to listen and learn with
the person.
What is ‘risk’?
The experience of many people who have to rely
on human services for their support is that ‘risk’
is the reason given to them by services why they
cannot do the things that other people are doing
every day.
When we delve into the word ‘risk’, we find
that it has a multitude of meanings, and that
it is nowhere near as clear and precise as the
advocates of traditional risk assessment assert.
For example, Hansson (2002) identifies five
different common uses for the word risk, and
Ekberg points to a ‘proliferation of risk definitions’
and a whole range of different understandings of
risk (2007 p345).
Risk literature often separates ‘risk’ from
‘uncertainty’, defining the risk as a measurable
probability that something will happen. However,
even where experts claim that they can give an
exact probability value to a risk, there is always
a possibility that the experts might be wrong
(Hansson, 2002 p4). In common usage the words
‘risk’ and ‘uncertainty’ are often synonymous
(Lupton, 1999 p9). Risk is sometimes used as
a verb – a person ‘risks’ doing something, and
sometimes a noun – a person is labelled as a ‘risk
to society’.
The drive for a single definition of ‘risk’ has
been described as ‘a futile form of linguistic
imperialism’ (Hansson, 2000 p3). He argues that
risk in its popular usage is just as valid as the
narrow technical values attached to the term, as
it allows inclusion of the philosophical and ethical
values, the bargaining and the compromises that
are excluded from ‘the expert-driven risk analysis
process’ but are essential for social and political
decision-making processes (Hansson, pp5–8).
Risk decision making is often complicated
by the fact that the person or group taking
the decision is not always the person or group
affected by the risk. Hansson argues that:
risks are inextricably connected with
interpersonal relationships. They do not
just ‘exist’; they are taken, run or imposed
(2000 p4).
Differences in power and status affect the extent
to which people influence risk decision making;
the views of developers wishing to build a dam
across a river may well be given more weight
than those of people living near that river. Where
a person with less power and status might wish
to take a risk and the consequences of that risk
would affect more powerful people, it is more
likely that they will be prevented from taking it.
This is the problem faced by people supported
by services and professionals, where the services
and professionals fear various real and imagined
consequences to them of the risk-taking of the
people they support.
A positive approach to risk requires person-centred thinking
Tizard Learning Disability Review Volume 14 Issue 4 October 2009 © Pier Professional Ltd 19
A positive approach to risk requires person-centred thinking
This problem is deepened in modern society as
the power of the news media, and the pervasive
fear of legal action, mean that the unpredictable
actions of an individual can now have an
amplified impact on the reputation of services,
and on political and corporate institutions.
Services that are now becoming increasingly
concerned with ‘reputational risk management’
find that this demands ‘the risk management of
everything’ (Power, 2004 p36). In the case of
human services, this means an ever more intrusive
and obsessive focus on every aspect of the lives,
behaviours and potential behaviours of the
people they support. It can also mean increasing
‘proceduralisation’ of work, as defensive practice
and blame avoidance (Power, 2004 p46) become
more important than the particular lives of
individual people.
Risk can become a highly charged and politically
loaded issue. The parties involved can have very
different interests at stake in debates about
particular risks, and they often become full-on
conflicts, with the result that the parties take
entrenched positions that prevent co-operation,
agreement and action, and further trap the person.
Person-centred approaches, with their focus on
the person and a strategy of building an alliance
of supporters around the person, often cut across
this entrenchment and generate new and creative
ways forward, providing that services are prepared
to face this challenge. This is now being recognised
by government departments; the Department of
Health publication Independence, Choice and
Risk wholeheartedly commends person-centred
approaches for everyone because they:
identify what is important to a person from his
or her own perspective and find appropriate
solutions (DH 2007 p4).
Regulators too want to see the balance of risk
decision making shifting towards:
supporting individuals who choose to take
informed risks in order to improve the quality of
their lives (CSCI, 2006 pvii).
In this case CSCI is talking about older people,
but this shift in attitude to risk is being advocated
for all services that offer health or social care to
human beings.
For the purposes of this article, we consider
‘risk’ as it presents to people who use services:
any issue, real or imagined, which is being used
as an objection to their moving towards increased
inclusion in community life.
What is wrong with traditional
risk assessment?
A focus on risk:
encourages practitioners to look for what is
going wrong rather than what is going right
(Booth & Booth, 1998 p205).
Traditional technocratic and spuriously
‘objective’ approaches to risk ‘lose the person’;
philosophically they treat the person as an object
to be assessed by the ‘experts’ rather than as
an agent in their own lives, part of a family,
community and society, with legal rights and
choices. They focus on what is wrong with the
person, often treating the person as a problem to
be managed rather than a person to be enabled
to fulfil their ambitions and offer a contribution to
society.
The implicit purpose of traditional risk
assessment is often to protect professionals and
services from their fears of litigation or bad media
coverage – ‘covering our backs’.
Alaszewski and Alaszewski (2002) argue that
taking ‘a narrow hazard approach to risk’ will
contribute to people’s disempowerment. Power
(2004) calls for ‘intelligent’ risk management that
does not:
20 Tizard Learning Disability Review Volume 14 Issue 4 October 2009 © Pier Professional Ltd
swamp managerial attention and independent
critical imagination [and is characterised by]
learning and experiment rather than rule-based
processes,
and can be sustained subject to challenge,
questioning and criticism (p61), while the Better
Regulation Commission has called for an emphasis
in risk management on:
resilience, self-reliance, freedom, innovation and a
spirit of adventure (BRC, 2006 p3).
The Government too is calling for:
a culture of choice that entails responsible,
supported decision making (Lewis, 2007 p1),
and for everyone involved in the lives of people
who use services to:
work together to help people achieve their
potential without compromising their safety
(Lewis, 2007 p2).
To give proper, balanced consideration to questions
of risk and achievement in the diverse and complex
lives of human beings, we need an entirely different
approach from the methods that services use to
‘risk assess’ their hoists, fridges and kettles.
Bates and Silberman’s ‘holy grail’
criteria
Bates and Silberman have described effective risk
management as the ‘holy grail’ of mental health
and other care services (2007 p6). They see it as
finding an integrated balance between ‘positive
risk-taking’ around the values of autonomy and
independence and a policy of protection for the
person and the community based on minimising
harm. While they do not give an exact description
of what such an approach would look like, they
give a list of seven criteria that any such approach
would have to fulfil:
s involvement of service users and relatives
in risk assessment
s positive and informed risk-taking
s proportionality
s contextualising behaviour
s defensible decision making
s a learning culture
s tolerable risks.
A person-centred approach
to risk
There are many tools and approaches available
to support person-centred thinking, many of
which have come from ‘deconstructing’ the
processes of Smull and Sanderson’s (2005)
Essential Lifestyle Planning approach, while
some have come from other strands in the
growing family of person-centred approaches
and early work applying person-centred
approaches to risk by Duffy and Kinsella
(Kinsella, 2000).
Practitioners of person-centred approaches
who were dissatisfied with the traditional
repertoire of risk management tools have
begun to recombine these person-centred tools
in innovative and creative ways, and to apply
them to thinking, acting and learning in real
risk situations.
The learning from this experience, reflection
and discussion has been refined and crystallised
into a process that can be shared and applied
constructively to a variety of risk situations,
bringing together people who use services and
the people who know and care about them most
to think about how they wish to move forward,
the risks involved, making decisions, taking
actions and learning together. We have called
this process a ‘person-centred approach to risk’
(Allen et al, 2008).
In this section we will look at the ‘holy grail’
criteria put forward by Bates and Silberman
and show how we believe the person-centred
approach to risk meets these criteria.
A positive approach to risk requires person-centred thinking
Tizard Learning Disability Review Volume 14 Issue 4 October 2009 © Pier Professional Ltd 21
Involvement of service users and
relatives in risk assessment
Involving the person concerned and the people
who care about them most is one of the most
fundamental tenets of any person-centred
approach. The process we have put together
considers carefully the people who need to be
involved, using the ‘relationship circle’ to help the
person and their allies identify key people who
could form the person’s ‘circle of support’. This
group of people is involved from the outset, in the
initial gathering of information, in framing what
the risk under discussion actually is, in thinking
that generates ideas and solutions, in evaluating
these solutions, in decision making about the risk,
in implementing the actions and in the learning
that takes place during these actions. Bates and
Silberman suggest that:
staff must understand what service users and
others want, how they view their own risks
and what responsibilities each person has in
managing risks effectively (2007 p7).
The person-centred approach meets this criterion
by asking for a clear picture of what the person
wishes to achieve, why it is important to the
person, what success would look like and a
history of the risk, and uses the ‘doughnut’
tool (distinguishing core responsibilities from
areas where staff can use judgement and
creativity, and from the areas that are definitely
not the responsibility of staff) and decisionmaking agreement tools to look at who will be
responsible for important decisions in relation to
the risk.
Positive and informed risk-taking
The process is built on a positive view of the
person; it seeks to learn what the person’s gifts
and skills are, what people like and admire about
them, as well as investigating what would be
necessary to keep them and others safe while
taking the risk. The process is based on finding
creative solutions rather than simply ruling things
out. Bates and Silberman argue here that quality
of life should be:
maximised while people and communities are
kept as safe as can be reasonably expected
within a free society (2007 p7).
Thinking about what it would take to keep the
person and others safe while taking the risk is a
key part of the positive and productive process,
as is the use of a ‘happy/safe’ grid which looks
at how much solutions would make the person
happy, by meeting what is important to them,
and how much they would keep them and others
safe, by meeting what is important for them. One
section of the process includes the question ‘What
does the law say?’ (Allen, 2008 p20), enabling
the process to be informed by the current law,
including legislation such as the Human Rights Act.
Proportionality
The management of the risk must match the
gravity of potential harm. (Allen et al, 2008 p8)
Using the person-centred thinking tools enables
flexibility in the risk process. The more serious the
issue, the more people and the more time can
be spent considering it in greater detail. Unlike
conventional risk assessment, the approach also
explores the consequences of not taking the risk,
to the person, to their family, to the community
and to services, balancing these against the
potential consequences of taking the risk.
Contextualising behaviour
Why did the person behave in this way? At this
time? In this situation? (Allen et al, 2008 p8)
The process includes gathering together previous
information about the person, including a history
of the person’s experience of the risk issue from
A positive approach to risk requires person-centred thinking
22 Tizard Learning Disability Review Volume 14 Issue 4 October 2009 © Pier Professional Ltd
their own perspective, as well as other historical
data gleaned from a variety of sources including
learning logs which look at what has worked and
what has not worked in particular situations, and
communication charts which explore a person’s
words and behaviours, seeking their meanings
and considering what the best response to these
messages should be. The ‘4+1 questions’ (What
have we tried? What have we learned? What
are we pleased about? What are we concerned
about?) help not only to gain a co-produced
understanding of a person’s behaviour in a variety
of contexts, but also to build a picture of what
has been learnt about what is the best support for
that person.
Defensible decision making
There is an explicit and justifiable rationale for
the risk management decisions. (Allen et al,
2008 p8)
Following the person-centred approach generates
a clear trail of written records of what has been
discussed, the different perspectives, issues and
solutions that have been considered, along with
any legal issues, such as the Human Rights Act or
the Mental Health Act, that might affect the risk
decision. The paperwork generated during the
process provides a clear rationale for the decisions
that emerge during the process, and why other
options have been rejected. The rationale for
decision making is also expounded and recorded
more clearly than in traditional risk assessment
forms in common usage.
A learning culture
The positive and productive approach to risk has a
deep emphasis within it on ongoing learning using
learning and reflective tools like the learning log,
the 4+1 questions and what’s working/what’s not
working, and by clearly defining for staff their core
duties and their zone of judgement and creativity
in relation to the risk. If it is part of a serious
and concerted attempt by services to change
their philosophy and practice in a person-centred
direction, it can contribute significantly to building
a learning culture within organisations.
Tolerable risks
A key aspect of the person-centred approach
is that it uses creative thinking techniques in
methods to mitigate the risk and improve quality
of life, moving from situations which make the
person happy but unsafe, to those where they
and the community are safer, and from strategies
where the person is ‘safe but unhappy’, to those
where they can be happier. Experience of using
the process is that it enables participants to take
a more balanced and rational approach to risk,
finding ways to enable the person to achieve what
is important to them while considering what keeps
that person and the community safe in a way that
makes sense for that individual.
The process summarised
A person-centred approach to risk uses questions
in a framework of purpose, people, process
and progress; it is important that right at the
beginning of the process we think seriously about
what it is we are trying to achieve. Our thinking
about how the process can be used to enable the
person to have choice and control in their life, and
to be a citizen in the community, will influence
which people are called to participate in the
process.
Who is the person?
Once the purpose is understood and people are
gathered, the first and biggest priority of the
process is to gain an understanding of who the
person is. The ultimate success of any strategies
or solutions will depend on how well we listen
for the person’s capacities, gifts and skills, and to
what is important to the person, as well as our
understanding of what makes the best support for
the person. The best support is what keeps the
person healthy and safe in a way that is congruent
A positive approach to risk requires person-centred thinking
Tizard Learning Disability Review Volume 14 Issue 4 October 2009 © Pier Professional Ltd 23
with how they wish to live now, and what they
wish to achieve in the future.
Tools to explore this include a full personcentred plan; if the person does not have such a
plan, then a ‘one page profile’ is used.
Where are we now?
A picture of what is working and not working
now, from the perspective of the person and from
the perspectives of others, is built up, and the risk
issue is clearly defined. It’s important to know
what is working now, so that when strategies
are developed they do not conflict with what we
know already works well.
Where do we want to be?
Traditional risk assessments lack any sense of
vision about how things could be different or
better for the person. In the person-centred
approach it is central that a vision of what success
could look like is put together, beginning with the
person’s perspective, then adding in others. This
vision, coupled with a picture of who the person
is, can generate the energy and commitment in the
group to work towards real and lasting changes.
What have we tried and learned
already?
A huge amount of people’s learning and
knowledge about risk issues is wasted when new
strategies are tried without reference to what has
gone before. Here person-centred thinking tools
are used to gather the knowledge of the person
and their allies around the history of the issue,
and to bring all the information together using
four questions: What have you tried?, What have
you learned?, What are you pleased about? and
What are you concerned about?
The consequences of doing nothing are
considered, including the opportunities that will
be lost to the person, their family, the community
and the service if we don’t support the person to
take the risk. What the law says on the issue is
also thought about.
What shall we do next?
Obvious solutions are considered first, then more
creative ‘blue sky’ thinking techniques are used to
generate a wider range of solutions – good, bad
and indifferent. All the various solutions are mapped
on to the ‘happy/safe’ grid, according to how happy
they make the person and how safe they keep the
person and the community. This clear mapping
enables action planning that gives a clear rationale
for adopting some strategies and rejecting others.
Strategies for ensuring that the person has as
much choice and control as possible are developed
using the ‘decision making agreement’, and people’s
responsibilities are made clearer using the ‘doughnut’
tool. Contingency plans are developed in case the
agreed strategies don’t go to plan.
Finally, methods of reviewing progress are agreed,
including a clear picture of how we will know things
are not working.
Conclusion
Services are good at highlighting the downside
of risk, but poor at thinking about the great
opportunities that facing up to risk and finding
positive solutions in a creative and mindful way
could mean for people, their families and their
communities. Traditional methods of risk assessment
are full of charts and scoring systems, but the person,
their objectives, dreams and life seem to get lost
somewhere in the pages of tick-boxes and statistics.
We feel it is important to remember people’s
rights, including the right to make ‘bad’ decisions,
and to gather the fullest information and evidence
to demonstrate that we have thought deeply about
all the issues involved and made decisions together
based on what is important to the person, what is
needed to help them stay healthy and safe and on
what the law tells us.
The Government say:
It should be possible for a person to have a
support plan which enables them to manage
identified risks and to live their lives in ways
which best suit them (DH, 2007 p4).
A positive approach to risk requires person-centred thinking
24 Tizard Learning Disability Review Volume 14 Issue 4 October 2009 © Pier Professional Ltd
In order to achieve this, a person-centred
approach is required, based on use of personcentred thinking tools, to help people and those
who care about them most to think in a positive
and productive way about how to ensure that
they can achieve the changes they want while
keeping risk in its place.
Address for corespondence
Max Neill
Person Centred Planning Coordinator
NHS Central Lancashire
UK
Email: max.neill@centrallancashire.nhs.uk
References
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Booth T & Booth W (1998) Growing up With Parents who
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CSCI (2006) Making Choices: Taking Risks. London:
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DH (2007) Independence, Choice and Risk: A Guide to Best
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A positive approach to risk requires person-centred thinking
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