While I was in hospital ‘managing risk’ was mentioned a lot. Usually in conversations about why something was impossible. During my last admission I more than half a year on a PICU because when the inpatient team first said I was ready to step down the community team said that they couldn’t come up with a ‘package to manage the risks’ without going through a long funding process first and the acute ward said they would only take me as a step down when a discharge had been agreed.

During those months while the funding process didn’t get started I had a lot of conversations about what could be funded that would ‘manage the risks.’ None of us could think of anything.

My care coordinator said that because they couldn’t think of a way to ‘manage the risks’ he didn’t think that I could ever live in the community again. I asked for a new care coordinator.

No one had thought of anything when the mental health review tribunal discharged me. However one of my new workers was clear that being in hospital was not managing my risks or helping me get better. Together we took things one step at a time.

Another five months later when the funding assessment happened I was coping. I was told that based in the assessment any package to manage my risks could have been funded but that something had to be suggested.

Risks are scary and it’s easy to get paralysed with fear like this. It’s even easier if it seems like you have a safe option even though it has lots of downsides. Luckily for me the nursing team on the mental health ward constantly struggled with basics like needing to take my insulin with food (not and hour later or ‘when we aren’t busy’ or ‘when the nurse is back from lunch to stay’) This protected me from believing hospital was safe even if my care coordinator had fallen into that trap.

My life still involves lots of big risks so how do I manage them now?

1. Be specific

If you are talking about ‘risks’ in the plural then it’s going to get overwhelming. For one conversation you need to define a particular risk really tightly, make a plan about how to manage it and then repeat as often as necessary.

For example following my experiences in hospitals I find it very difficult to be in any kind of medical environment or deal with any doctor or nurse. Some of the risks I’ve looked at around this have been:

That my distress at being in a hospital setting could trigger a mental health assessment when I attended for physical a physical problem.

That doctors might interpret my physical problems as being caused by a mental illness or self harm as has happened in the past.

That I might be too afraid to take my son for medical care when he needs it.

I’ve found it helpful to define these risks as I see them. My care coordinator would have expressed them differently but when I wrote it it felt like we were addressing the things that I found a problem that sometimes escalated into the things she would have listed. For me at least managing the situations I was worried about well has stopped me escalating into the responses that so concerned my old care coordinator.

2. Plan to succeed.
To do this I find it helpful to imagine scenarios in which this risk could occur and work out what healthy responses could be.

I’ve worked through a lot of risk assessments that focussed on how I handled such situations badly in the past. They seemed to be about helping other professionals take things seriously and not ‘underestimate the risks’. It does seem an important process but leaves me focused on those things that haven’t worked.

For instance in terms of seeking help for my son I imagined I might be responding to an accident or serious illness where I needed to call an ambulance or take him to A&E. I might also be making a call about whether a minor illness was improving on its own or if he needed to see a GP. I want to make a choice that is based on his needs not my fears.

If you struggled with this before it will still be hard so what can you do to make it easier to follow your plan. What can you prepare in advance and who could help you when the time comes?

We took an infant first aid course and I regularly run over the times when I’d need to call an ambulance in my head.

I identified professionals that I did feel confident I could access (our health visitor, our local pharmacists and the 111 operators.) When in doubt about whether I need to take him to A&E or a doctor I planned to ask their advice and follow it. We also let my health visitor know about this plan so she could encourage me.

I identified people who could come with us to an appointment starting with my husband but including a list of friends as back up options. I also worked out several ways to get us to both A&E and the GP at different times so that I wouldn’t have to work it out on the day. Like many of my risk management plans this is stuff any person might do.

3. Did it work?
So far I have been able to overcome my fears and take my sin for meducal help each time. On different occasions I have now used all three sources of advice and with my husband taken my son to the out of hours GP and to A&E based on that advice.

Other risk plans have helped me avoid overdosing while my blood sugar was low or I was exhausted as I had in the past for over 3 years.

Each time I encounter these risky situations ask myself afterwards what went well and what didn’t. I try and imagine myself coping better with the parts I’d like to manage better. I do this with all the plans I have for managing risks.

If I change something I also think about whether other plans would benefit from the same change. For instance when I wrote a one page bullet point summary of my mental health issues as they show in medical settings after finding I couldn’t explain when I was struggling we also made a summary of how high and low blood glucose levels could impact my mental health to put in my psychiatric notes.

Also if someone you hoped would help couldn’t consider if they need something to help them do so (my care coordinator and I wrote a detailed emergency contact plan for duty staff because if this) or if they are the wrong person or organisation for this particular risk management scenario (which doesn’t necessarily mean they are wrong for all your others though it’s worth checking which.)

Although professionals I work with have to write stuff because they are dealing with so many people I find that being able to remember what my plan is to manage these risks is important to help me follow them. When I make or change a plan I need to run over and over it in my head so it will feel automatic when I need it. Other people like my husband, close friends, care coordinator, diabetes specialist nurse, midwife and health visitor have also helped at different times by reminding me what we’ve planned.

So my advise on risk management is to:

‘Be specific’ and plan to manage each situation where things start going wrong differently.

‘Plan to succeed‘ focus on how you want to manage those situations and be detailed about how you will do it who can help you and do anything you can to prepare ahead of time.

Ask ‘Did it work‘ keep refining your plans so they stay up to date and in your head when you need them.

BPD, hmm that’s familiar!