As more people with learning disabilities are supported to live in the community, issues of safety have increased in salience. This, coupled with the increasing focus on the rights of people with learning disabilities, has meant that services and support staff in particular must focus on balancing risks with empowering people to live the life they choose. The types of risk situations people with learning disabilities will face can be many and varied. Where previously people have been denied their rights and choices through a model of support that is over protective or risk averse, this is no longer considered in keeping with espoused values, nor acceptable within law.
As a retired Clinical and Forensic Psychologist, Sellars has over 30 years of experience of working in the NHS with a range of client groups. This is her second edition of Risk Assessment in People with Learning Disabilities, the first being published some ten years ago. In this edition of the book Sellars attempts to provide staff who are responsible for assessing risk with “an awareness of the requirements of the Mental Capacity Act, supporting the human rights of those in their care [along with a] systematic approach to risk assessment”. The intention is that the reader would be enabled to enhance not restrict the life of the person they support through making decisions based on a valid risk assessment of likely costs and benefits to the person and others.
For the purposes of the book, Sellars has used the term “intellectual impairment” or “intellectually impaired” to refer to people with learning disabilities, making its content of interest to a wider readership, some of whom may be staff supporting people who have an intellectual impairment of a different nature. This is an accessible book at only 165 pages, so will also appeal to those who want to dip in and out of specific chapters of interest.
The first three chapters outline the risk assessment process including the problems of predicting and assessing risk, and establishing care plans. In Chapter One Sellars discusses the fact that some people with intellectual impairment will have been denied the opportunity to make decisions for many years, thus have not developed the ability to learn from experiences of when things go well and when they go less well. In this chapter the key principles that underpin the Mental Capacity Act are outlined and the implications they have for community care introduced. These include the importance of not seeking to avoid risky situations by assuming (without assessment) the person does not have capacity to make their own decisions just because the decision they make is considered to be unwise.
An understanding of risk and specifically the problems of predicting risk is covered in Chapter Two. The nature of risk assessment means that all staff have to be skilled in supporting individuals to make decisions. Given that decision-making capacity is not stable, but fluctuates due to health, the decision at hand, the information available and an understanding of this information, staff also have to be skilled at judging an individual's capacity. If capacity is not stable then risk situations are even less stable, making risk assessment an on-going task. Given this picture it is clear why Sellars promotes an approach to risk assessment that does not champion the paper-based proformas of old, seeing the attribution of numbers to the assessment of risk as giving a “false air of scientific validity”. Instead, Sellars introduces the reader to an approach that considers the impact of risk decisions for the person and all around them, and in the context of the legal responsibilities that must be met. At the end of Chapter Two the reader is provided with a list of questions to help guide discussions and decision making about risk and capacity, emphasising that it is these discussions that are the most important part of the process.
The challenges Sellars set out here are twofold: for staff to support people to learn how to make choices with an appreciation of the risk involved, thus considering both short-term gains vs long-term costs; and for service managers “to develop a climate where constructive risk taking is acceptable”. This final point is emphasised as being even more important given the increasing austerity under which services are now required to support people.
A framework for addressing the problems of assessing and managing risk is provided in Chapter Three and covers the importance of considering the person's history, such as previous risk taking behaviour, as well as other factors affecting risk such as functional assessments for behaviours that may challenge. In assessing risk one must first classify it, and to do so Sellars suggests we consider risks to the person themselves and to others, the frequency of the risk activity/behaviour, likelihood of an undesirable outcome occurring, all of the outcomes (short and long term, positive and negative) and who is affected by them. In considering the management of risks the laying out of a number of options with a consideration of the advantages and disadvantages of each (including consideration of the individual's choice) is recommended as the basis for a team or interdisciplinary discussion.
The remaining chapters cover a plethora of specific risk problems from everyday risks, to risks associated with being a parent with an intellectual impairment, self-harm and mental illness, violence and offending behaviours, as well as sexual offending. Each of the chapters provides a number of case examples analysed using the structure and approach provided in Chapter Three. These case examples bring the topic of risk assessment to life and will give the reader both a tangible approach to apply and an opportunity to compare and contrast them with situations similar to those they are faced with in their own roles.
The final chapter concludes by suggesting the way forward in assessing risk. It brings together the content covered in the preceding chapters and discusses ways to record and communicate decisions, as well as monitoring and re-assessing risk. The author also provides the reader with references and suggested further reading.
Like the game of Jenga (originally derived from a Swahili word meaning “to build” and depicted on the cover of the book), risk assessment is a constant balancing act. Risk is a part of life and an inevitable accompaniment to real choice. Combining Sellars’ person-centred approach to balancing risks with other enabling approaches (like Active Support, to name but one) will make it possible to support people with an intellectual impairment to build a life like that of any other person.
