As many of you may already know, Bill Thomas and I came up with the notion of “surplus safety” in 2009 during a class in the Erickson School Master’s degree program to characterize the result of a culture of safety that does harm by preventing people from achieving future development that comes from taking risks and learning from the resultant success/mistakes. Since then, we and others have been working on the concept to refine the concept, catalogue its many manifestations, the roles of various stakeholders, and how current regulations and practices frame the issue and potential solutions. We learned in our Surplus Safety Symposium last September, sponsored by the Hulda B. and Maurice L. Rothschild Foundation, that was attended by over 50 stakeholder representatives that safety and risk have numerous definitions and a complex relationship with issues like choice, legal liability and OBRA 87. Carmen Bowman, culture change advocate and Symposium planner and leader, blogged about, there are a slew of reasons why this culture prevails. Let’s be clear about something: safety is good; danger can be bad, even very bad. Risk, or the probability that the outcome will be different than expected, is what lies between danger and safety. Risk has two variants: downside risk- the probability that the outcome will be worse than expected, and upside risk, the probability that the outcome will be better than expected.
We know that human development and growth doesn’t take place without taking risks. If the person is to survive, he/she must get good at knowing the difference between upside and downside risk, and how likely each may occur as a result of any action. The human brain seeks novelty – that is what is behind learning and increased competency. In environments with little or no novelty, the brain will motivate the person to search for it mentally by using their imagination, or physically, by scanning the environment for new information and moving toward it. Human development is predicated upon the dynamic of person-environment interaction where the person tends to engage with stimuli that are just different enough from what it knows to be interesting and therefor inspire exploration resulting in a modification of its store of knowledge. The child’s developing motor maturity and brain work in tandem and rely on this to happen so that the person becomes able to live safely on his/her own. This dynamic relies on engaging with the environment so as to learn about what is out there, what is safe, what is dangerous, i.e. how to improve upside risk and reduce downside risk, and what must be done to safely expand and differentiate knowledge and autonomy.
Three concepts are important here:
1. Safety and danger are distributed along a continuum of risk that in large part varies according to an individual’s abilities and judgment and environmental conditions at any given time. Risk happens, then, in the context of person-environment interaction. What constitutes safe and risky behavior changes as we grow from infancy and develop more competencies and better judgment of our risk tolerance and probability of success in doing anything. Risk is a factor that goes into each person’s motivational calculus before an action and is the result of a subjective appraisal made by a person and/or persons in their environments (or memories of what they said) based on a sense of the specific skills needed for success and if the person has them. Sometimes the risk assessments are congruent, sometimes widely incongruent – and arguments ensue. For example, a person may decide that it’s safe to walk around their neighborhood. The relative safety or danger depends on any given day on factors such as the time of day, weather, kind of neighborhood, orientation ability, gait and balance, vision, etc. of the person. This is true for a person at any age.
2. Risk, a broad territory that lies between safety and danger, is relative to each person’s competencies, and is an appraisal in the person’s mind that is the product of an assessment of his/her ability to produce an outcome that is at least equal to or better than expected when they contemplate the action and its results. If the probability of success is less than expected, depending on one’s risk tolerance, the behavior may not be initiated. A person may take a chance, or decide it’s not worth the risk. But it is important to remember that what I decide is relatively dangerous for me because I lack the requisite skills for success may be for pretty safe for you. So except for extreme conditions, like jumping out of an airplane without a parachute where the danger is so high that it is universally considered to be a sure recipe for danger and therefore a bad idea, risky behavior exists along a continuum for and among people. That is, the probability of a better or worse outcome than expected (our definition of risk) is not fixed. It is a variable depending on how well the risk taker appraises his/her ability be safe and avoid danger that would cause grave harm. When the appraisal is not made and the person takes a risk that has not been appraised, we call it impulse.
3. Development is a big factor in diversifying the range of actions that each person comes to see as acceptable risks. In fact, we can think of development in one sense as a process of taking risks and learning how appropriate the risk assessment was and what we can and can’t do. In that process, the most important result is learning what we are capable of and where we need to improve our abilities and knowledge to reduce danger in pursuit of a goal and thereby lower risk. The older people become, the more individualized and diverse become the range of skills, risk tolerance, risk aversion and what is considered a good risk worth taking. Physical limitations, wisdom and interests, as well as the proximity of needed resources are some of the factors that determine which risks people will take as they age. In extreme situations, elders may take greater risks when a particular goal is perceived by them to be important that appraisals of potential danger are minimized. That is, they are worth the risk. This happens, for example, when people feel desperate, are bored, feel that they are in danger, or have lost contact with their actual skill levels such that they remember themselves as they once were but not as they are now.
Changing the culture in environments where elders’ development is not blocked as they age through surplus safety practices means that at a minimum, we have to come up with accurate, reliable ways to assess each elder’s risk tolerance, accuracy of their future planning strategy for appraising the expected outcome of an action, and their readiness to act safely in light of the attendant dangers. Bill [Thomas] and I have taken great care to specify that this does not mean that all downside risk is bad and all upside risk is good. Our intention is that places where elders live develop ways to promote opportunities for continued development by optimizing conditions where upside risk can be found, downside risk reduced, and danger and safety go from being seen as binary and age specific (something is safe or dangerous for everyone who is old) to a portfolio of individualized opportunities for growth that meet the needs of all who live there depending on each one’s risk tolerance. Our task is to go beyond anecdotes and develop research programs that test these concepts to that we can affect policy and society at large.
Dr. Ronch is a nationally renowned expert on improving the treatment and mental well-being of elders. Prior to coming to the Erickson School, Dr. Ronch was Vice President of Resident Life, Mental Health and Wellness for Erickson Retirement Communities, where he was responsible for developing person-centered, strengths-based approaches to best serve the mental wellness needs of Erickson’s over 20,000 residents on 18 campuses. He has been on the faculties of Vassar College, the University of Miami and Dutchess Community College. His numerous publications include the critically acclaimed Alzheimer’s Disease: A Practical Guide for Families and Other Helpers and The Counseling Sourcebook: A Practical Reference on Contemporary Issues (winner of the 1995 Catholic Press Association of the United States Book Award). He is co-editor of Mental Wellness in Aging: Strength Based Approaches (winner of the 2004 Mature Media Award), and Culture Change in Long-Term Care – the first text published about culture change in aging services.
He is currently working on co-editing a new two-volume set called Making the Case for Culture Change in Elder Care, due out in 2012. His numerous journal articles and professional presentations include contributions in psychotherapy and counseling with the aged, care of persons with Alzheimer’s Disease and related disorders, caregiver issues, staff training and service delivery issues in geriatric care. He has also been named a Fellow of the New York Academy of Medicine.