Risk Reduction Whack-a-Mole

Safeguarding is all about risk reduction. But whose risk? And what risks might we be increasing?

Traditional risk reduction goes something like this:

  1. Who is at risk?
  2. What is the risk?
  3. How serious and/or likely is the risk?
  4. How can we reduce that risk?

Sounds pretty sensible. Only it isn’t.

The problem with traditional risk reduction is that it tends to view risks in isolation. Reduce risk of self harm. Reduce risk of placement breakdown. Reduce risk of CSE.

Examining risks in isolation misses any interplay between risks. It also fails to account for how risk-reduction strategies may inadvertently increase other risks.

 

The Risk Reduction Paradox

Take, for example, self harm. Let’s say that a foster child, Jane, is cutting her arm with a razor blade two or three times a week. The wounds aren’t so serious yet that they need medical attention. But the frequency of the self harm is increasing.

A typical, if simplified, risk-reduction approach would be:

Who is at risk? Jane

What is the risk? Injury by self-harm

How serious and/or likely is the risk? Could lead to permanent injury and frequency is increasing.

How can we reduce that risk? Remove Jane’s access to razor blades and refer her to CAMHS.

Jane doesn’t want to go to CAMHS. She refuses to engage. She resents the care team for making her go, harming her trust in them.

Her need to self harm hasn’t been reduced by removing the blades. If anything, her need has increased.

So, she removes the blade from a pencil sharpener and uses that. Only it is not as sharp as a razor blade, so she applies more pressure to get the same result. The wound she makes is worse than previously.

Before long, Jane’s room will be a mattress on the floor, she will be supervised 24/7 and eventually she will end up an inpatient on an adolescent mental health unit.

The care team are now worried. Jane’s self harm is worse. The injuries are more serious and frequent. She is no longer talking to them about her self harm.

So, they remove pencil sharpeners. And make emergency referrals to a specialist. As a result, Jane uses a broken piece of glass she found on the way home from school. The wound she makes scares her, but she keeps it a secret and it gets infected.

You can see where’s is headed. Before long, Jane’s room will be a mattress on the floor, she will be supervised 24/7 and eventually she will end up an inpatient on an adolescent mental health unit.

Reducing the risk of self harm, using a traditional approach, has increased the risks and created new ones.

 

Risk Whack-a-Mole

This kind of risk reduction is like playing Risk Whack-a-Mole. Everything we hit a risk, another one pops up, often unexpectedly. We then hit that risk. And another pops up. It is a never ending, reactive cycle that we create and sustain by insisting on playing.

Why are we so intolerant of risk that we are prepared to increase it in order to reassure ourselves we have reduced it?

And we entrap ourselves in this cycle. Once we put a risk-reduction measure in place, how do we retract it? At what point could Jane’s care team give her back the razor blades?

Doing so would significantly reduce all the risks that were created by removing them in the first place. But it’s an impossible situation, entirely of the care team’s own making.

Why are we so intolerant of risk that we are prepared to increase it in order to reassure ourselves we have reduced it?

 

Whose Risk is it Anyway

I think the answer lies in answering the question, whose risk is it anyway? Risk-reduction strategies often claim to reduce the risk to the child when they are actually reducing the risk to the team.

Take Jane’s case. If we consider risks to the team, then the strategy may look something like:

Who is at risk? The Care Team

What is the risk? Accusations of Negligence

How serious and/or likely is the risk? Likely to lead to disciplinary proceedings.

How can we reduce that risk? Do something. Do anything.

In this context, the care team’s decisions make perfect sense. Even if the risk of self harm escalates, they will have immunised themselves from the risk of negligence, because they have taken action that looks sensible.

It is unethical to subject a young person to unnecessary and unwanted interventions in order to protect the interests of the care givers

Jane didn’t want to see a therapist. But she’ll get the referral anyway, and be expected to engage. It’s not the care team’s fault if Jane refuses to engage. It will be put down to Jane’s denial, or lack of cooperation.

Yet, it is unethical to subject a young person to unnecessary and unwanted interventions in order to protect the interests of the care givers. It harms trust and honesty. Jane feels less safe with the team and in herself. She is not calling the shots on her own recovery and healing. She is taking the shots of other people’s interventions.

Her care has become a battleground in which she gets pushed into the firing line in order to protect her carers.

Risk reduction is the antithesis of trauma-informed care. It is a power-struggle between care givers and care receivers.

When the people making the decision feel personally vulnerable – e.g. unsupported by their organisation – then it is inevitable that this will affect their approach to managing the risk. Will the organisation sacrifice the care team in order to protect itself?

When everyone is playing Whack-A-Mole, risk just gets shunted down the system, where it all ends up on the shoulders of the most vulnerable person.

 

Risk Sensible

Those involved in child protection must be ‘risk sensible’. Professor Eileen Munro called for changes in how we approach risk in her 2011 report “The Munro Review of Child Protection

The report concluded that “There is no option of being risk averse since there is no absolutely safe option. In reality, risk averse practice usually entails displacing the risk onto someone else.”

The report recommended 10 principles for a risk-sensible approach to child protection (my highlights)

Principle 1: The willingness to make decisions in conditions of uncertainty (i.e. risk taking) is a core professional requirement for all those working in child protection.

Principle 2: Maintaining or achieving the safety, security and wellbeing of individuals and communities is a primary consideration in risk decision making.

Principle 3: Risk taking involves judgment and balance, with decision makers required to consider the value and likelihood of the possible benefits of a particular decision against the seriousness and likelihood of the possible harms.

Principle 4: Harm can never be totally prevented. Risk decisions should, therefore, be judged by the quality of the decision making, not by the outcome.

Principle 5: Taking risk decisions, and reviewing others’ risk decision making, is difficult so account should be taken of whether they involved dilemmas, emergencies, were part of a sequence of decisions or might appropriately be taken by other agencies. If the decision is shared, then the risk is shared too and the risk of error reduced.

Principle 6: The standard expected and required of those working in child protection is that their risk decisions should be consistent with those that would have been made in the same circumstances by professionals of similar specialism or experience.

Principle 7: Whether to record a decision is a risk decision in itself which should, to a large extent, be left to professional judgment. The decision whether or not to make a record, however, and the extent of that record, should be made after considering the likelihood of harm occurring and its seriousness.

Principle 8: To reduce risk aversion and improve decision making, child protection needs a culture that learns from successes as well as failures. Good risk taking should be identified, celebrated and shared in a regular review of significant events.

Principle 9: Since good risk taking depends upon quality information, those working in child protection should work with partner agencies and others to share relevant information about people who pose a risk of harm to others or people who are vulnerable to the risk of being harmed.

Principle 10: Those working in child protection who make decisions consistent with these principles should receive the encouragement, approval and support of their organisation.

 

Risk Obeys the 2nd Law of Thermodynamics

In light of this, I’m of a view that risk behaves like energy in Newton’s 2nd Law of Thermodynamics. Newton proposed that energy is neither created nor destroyed. It is converted from one form into another. Electrical energy into light and heat, for example.

Whenever we reduce one kind of risk, we are actually converting it into another kind of risk. So to reduce a risk, we have to take a risk.

In Jane’s case, reducing her risk of self harm may be more successful if the care team took the risk of leaving her with the razor blades. By pulling some of the risk towards themselves, they can reduce the amount that is on Jane. After all, Jane is the vulnerable party here.

But removing risks just pushes them underground. Jane becomes more secretive. Trust and collaboration are destroyed.

To reduce a risk, we have to take a risk.

By keeping the devil we know in plain sight, we show Jane that we trust her and that we want to be guided by her. Involving her in designing a risk-sensible approach empowers her and enables her to trust us. If she knows we aren’t going to cart her off to a therapist every time she gets overwhelmed, she’s more likely to come and talk to us.

We fall into the trap of making risk-based decisions about children without them. When we do this, we are more likely to default to ‘protecting’ them. And in doing so, we inadvertently put them in harms way to protect ourselves. In this sense, Child Protection becomes a device for sacrificing children in order to protect adults.

 

Trauma-Informed Risk Balancing

Core questions for sensible approaches to risk can be based on the principles of trauma-informed care:

  1. Safety: How do we increase physical and emotional safety?
  2. Trust: How do we increase and create trust and transparency?
  3. Peer Support: How could peer support be useful?
  4. Choice: What is the child’s perspective and what do they want?
  5. Partnership: Who can we collaborate with?
  6. Culture: How might identity and cultural factors be influencing the child’s experiences?

The answers to these questions are likely to result in very different strategies to the initial risk assessment approach.