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HEALTH RISK ESCALATORS AND THE REHABILITATION OF
OFFENDERS WITH LEARNING DISABILITIES
Bob Heyman Professor of Health Research St
Bartholomew School of Nursing
Midwifery B.Heyman_at_city.ac.uk
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PRINTED VERSIONS
Heyman B., Buswell Griffiths C., Taylor J. and
OBrien G. (2002) Risk management in the
rehabilitation of offenders with learning
disabilities A qualitative approach. Risk
Management An International Journal, 4,
33-46. Heyman B., Buswell-Griffiths C. and
Taylor J. (2002) Risk escalators and the
rehabilitation of offenders with learning
disabilities. Social Science Medicine, 54,
1429-1440
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QUALITATIVE APPROACH FRAMEWORK INHeyman B.
(1998) Risk, Health and Healthcare A Qualitative
Approach. Edward Arnold
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CONTENTS OF PRESENTATION

• The concept of risk escalator
• A typology of risk escalators
• A case study of a low/medium secure NHS facility
  for offenders with learning disabilities
• Moving down the risk escalator
• Blockages
• The up escalator
• Positive and negative feedback

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THE CONCEPT OF RISK ESCALATOR

• The concept of risk escalator contributes to the
  analysis of health and social care risk
  management systems which have the following
  characteristics
• A presumed consensus about the ordering of risk
  severity within a set of risks (e.g. greater
  probabilities of the same event)
• Availability of a range of preventative
  responses of differing intensity and balance
  between autonomy and safety
• A potential for positive and/or negative
  feedback

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A TYPOLOGY OF RISK ESCALATORS
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CASE STUDY RESEARCH SITE

• Some features of the hospital research site
• There were 121 male and 22 female beds in
  sex-segregated units
• Patients moved from medium secure electronic
  panopticon to unstaffed, unlocked houses via
  intermediate stages
• Patient movements on incentive schemes and
  between units were based on weekly assessments,
  biennial internal reviews and external tribunals
• Progress, officially, resulted from a combination
  of psychotherapy and behavioural management
• Comparison study at forensic mental health unit

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CASE STUDY RESEARCH METHODS

• Research methods included
• General staff interviews about risk management
• Interviews with 11 patients about their
  progress
• Re-interviewing these patients after one year
• Staff interviews (with consent) about
  individual patient progress
• Recording and analysis of biennial reviews
• Follow-up of discharged patients
• During the 1 year study period, 4 patients
  progressed to a unit offering greater autonomy, 1
  was discharged, 4 did not move, 1 moved to a more
  secure unit and 1 moved down and back up

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MOVING DOWN THE RISK ESCALATORThe View from the
Top of the Escalator
Nurse (Hugh) I mean the patients in this place
medium secure unit really don't have a lot of
control over any aspect of their life, other than
ordering their meals. Basically, everything is
done to the rules of the unit, and to the staffs
requests So there wasn't a lot of leeway for
grey areas, whereas in a freer place, there may
well be.
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MOVING DOWN THE RISK ESCALATORThe View from the
Bottom of the Escalator
Consultant You know, you have been a patient.
Now is the time were seeing you as a citizen
looking after yourself. (Transcript of review
for patient Ken) Interviewer I mean, its
house not locked, is it? They can go in and
out as they want. Is that right? Nurse (Heidi)
Yes, but I mean, all the men are conscious, you
know, when its dark, and its late at night,
that they do lock the doors. Theyre very
security conscious.

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MOVING DOWN THE RISK ESCALATORIdeal-typical
Progress

• Nurse (Mary) The house is the step before
  discharge from hospital. So, basically, we feel
  Martin has progressed sufficiently, and has
  showed a, you know, a degree of trust and
  improvement.

• Interviewer Good. So what would you base that
  on?

• Nurse His general behaviour and attitude, as
  well as his response to clinical intervention
  such as psychology focus groups, that sort of
  thing.

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MOVING DOWN THE RISK ESCALATORSubversive Views
about Risk Selection

• Rob (patient) He was only here for a month or
  two, and then went on to Villa 7 less
  restrictive unit probably because hes a
  quiet person, and he didnt express his feelings
  Youre not supposed to express your feelings to
  people.

• Ian (patient) What makes me mad about this
  place, right, is the fact that, like I say,
  people running through the system, and all that,
  right And then you've got, like, on a Saturday,
  they go down to local town by themselves. And
  owt could happen. Anything's i.e. children
  around on Saturday.

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RISKY DOWNWARD MOVEMENT?The Ecological Validity
of Compliance
A report of Robs behaviour during a supervised
trip, discussed at his review, noted signs of
inappropriate behaviour towards children, but
concluded that otherwise his table manners and
behaviour were acceptable.
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MOVING DOWN THE RISK ESCALATORThe Tension
between Psychotherapy and Progression

• Joe (patient) I dont like the therapy group,
  but I cant withdraw because, if I pull out, it
  will look bad on my record because its part of
  my treatment. Also, its held in admission unit
  and I dont like that I was on admission unit
  four or five years, thats enough.

Ian (patient) But some of them staff, they've
got to be into me all of the time. Like, I'm
doing a psychology programme with the
psychologist And staff are saying I'm
getting my own way, doing that, doing this.
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BLOCKED DOWNWARD MOVEMENTDisrupted Chains

• Interviewer What else is different compared with
  there less secure unit, and which do you like
  best?

• Joe (patient) Theres more to do here.

• Interviewer In here?

• Joe And theres less freedom, and I am getting
  all that back now. I am going to less secure
  unit in August.

• Interviewer Are you? Have you just heard that?

• Joe No. I heard it months ago.

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BLOCKED DOWNWARD MOVEMENTThe Political Steer
Towards Caution
Nurse (Mary) Its difficult because you have
someone on the ward whos doing really well, and
you know that they are progressing, and theyre
compliant and really want to progress. And you
might say something to the consultant who doesnt
really see them that often. And theyll say, Oh
no, weve got to tread really carefully with this
chap and the Home Office is really reluctant to
- I sometimes think if it was left up to the
nursing staff, wed probably take more of a
risk because you get to know them so well,
working with them.
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BLOCKED DOWNWARD MOVEMENTThe Ecological Validity
of Compliance
Dave (patient) A patient stood up and hit me in
the face, and I got dropped to grade 1 because
I hit him back. What they are trying to say to me
is, If youre in a community, you dont do
that. But if I was in a community, and I was,
like, walking around, or I was coming home from
work, and somebody just turned around and smacked
me in the face, I wouldnt stand there and let
him hit me again. I mean, nobody in their right
mind would.
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UPWARD MOVEMENT
Nurse (Karen) After a short-lived honeymoon
period following her move to the bungalow less
restrictive unit, Marions behaviour
deteriorated She became emotional, wanting to
return to more restrictive unit. Despite many
attempts to encourage her, it would appear, with
her own admission, she contrived to have her
grades dropped.
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NEGATIVE FEEDBACK AND STAFF INTERVENTION
Interviewer Did you ever go backwards?

• Martin (patient) Yes. I was at grade one
  lowest for about six or seven weeks of it and
  that. Then I knew I had to start picking up again
  and -

Interviewer Right. Did you think it was fair,
the way the system worked for you?
Martin Not all the time, I didn't think so,
because of the way that they tret i.e. treated
me, and that. And there was problems I would
have, but they would just talk it out, and talk
it out, and talk it out. And it really got me
annoyed and angry in times of it you would get
the feeling as if you've been kicked.
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POSITIVE FEEDBACK
Nurse (Hugh) Now, another time in the past, Joe
would have argued the toss with me And I mean,
because he was immature, then there would be
perhaps acting out behaviour, or he wouldn't do
something that you asked him to do, to get back
at you, so to speak. So things would spiral, and
he would end up being booked, as they would say.
And he would loose his grade over it, because a
small confrontation would snowball out of
control.
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CONCLUSIONS

• Rehabilitation systems provide an alternative
  to prison, but at the cost of indeterminate
  sentencing
• Risk escalator blueprints must be distinguished
  from organisational realities
• Risk selection interacts with social
  organisation
• Risk decision-making is laddered and
  multiprofessional