University of Southern California Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy
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Every time we make a decision, we are taking a risk, whether it's a small and realistic one (like, choosing something to eat that we may decide later wasn't that tasty), or a big and dangerous one (like, racing to cross a railroad track before the safety barrier comes down, like our study participant Billy did). It might be hard to know for sure whether a decision is the right one until after the choice has been made and we see what the result is. However, it is usually quite clear to us whether the risk involved is the "normal" type we face every day (like about what to have for dinner, or whether to drive on a busy highway or a less busy side street) or a potentially dangerous one (like whether to leave the hospital against doctors' advice, like our study participant Alley did). So when someone takes a real risk, it becomes very, very necessary to stop a minute and look at what could happen, so that if they still decide to take that risk, at least they know what's at stake. Thinking about consequences, that is, the possible results of an action, might help people to decide whether it's worth it to take a risk or not.

It might help to start talking about this subject by being very clear what is the difference between making a decision and taking a risk. "Making a decision" is just picking what you want, whether there are only two possible choices (like "yes" or "no"), or whether there are many possible choices, like deciding what to wear, what movie to watch, or what to eat. Typically, when a person makes a decision, although they might be disappointed with their choice later, they probably won't "lose" anything by the choice. For example, if someone decides to wear a sports jersey and later it starts raining, they might be get wet, get cold or get their jersey dirty, but the consequences were not really too bad. (If you would like to see some helpful tips about how to make the best possible decisions, we have a section called "Decision-making" in this publication. Check it out!)

"Taking a risk" means making a decision where you know that one or more of the possible choices has a strong chance of hurting you, or turning out in a way that will be really unpleasant. For example, if someone decides to wear a Denver Broncos or Philadelphia Eagles sports jersey to a sports bar popular with Oakland Raiders or New York Giants fans, that might be taking a risk. It can be a risk to wear the wrong colors in the wrong neighborhood. Or it can be a risk to smoke cigarettes when you know that lots of people don't like the smell of smoke, that smoking is prohibited in many public places, and that smoking can cause cancer. It's definitely a risk to drink alcohol and then drive; not only is there a possibility of having a car accident that could injure or kill the driver and other people, there is also a risk of being arrested for driving under the influence (DUI).

When it comes to health, there is also a difference between making a decision and taking a risk, and here's an example: for most people, eating a piece of cake just means deciding if they like that kind of cake, if they are already too full, or if they are worried about gaining weight, but eating a piece of cake means taking a big health risk if the person has diabetes. It can also be taking a risk to spend hours up in a wheelchair when a person already has redness or a small pressure ulcer (which means the same thing as "pressure sore" or "bedsore") on their bottom; they might be lucky and be able heal it while it is still a small pressure ulcer, but it might also blow up into an infection that will lead to hospitalization, surgery, and weeks of recovery.

Taking a risk can be dangerous, but it can also be exciting for anyone, no matter what their health is like; think of all the people who skateboard, race cars, windsurf, bungee jump, skydive, BMX bike, off-road race, and so on. Some people seek risks for fun, like those who enjoy extreme sports. Other people seem to enjoy "proving" they can beat the odds and stay safe when doing something dangerous, like people who feel a thrill when engaged in criminal activity. It can make someone feel very powerful to "get away with it," and that's a possible reason why people take certain risks. But the problem is not "getting away with it;" the problem is the times that you don't. Sometimes getting caught means being arrested and facing the legal system; sometimes, it means getting injured, whether it is a small injury or a serious one, or, in the absolute worst case, getting killed.

Some people take a risk with their lives by getting involved with a gang. Six participants in our study, or 30% of the total number who took part, were involved with gangs, and five of them received their spinal cord injuries in shootings that were gang-related. (The sixth gang member was injured in a high-speed car chase, trying to escape the police after he got drunk and stole a car.) And one of them was later killed in street violence related to drug-dealing. Obviously, gangbanging is risk in life that can be a very dangerous choice.

While there are many activities that people with a spinal cord injury can take part in and do very well, the truth is that, no matter where they live or what their income, a person with spinal cord injury has more risks to their health than a person without a disability, including being more likely to develop some kind of illness or medical complication, requiring more specialized or complicated health care, and often needing extra health supports such as medications, care attendants, and medical equipment (such as a wheelchair or air mattress) 1. Because people with spinal cord injury have more health risks, it becomes more important to be aware of what the risks might be, and to use that knowledge when deciding if the possible rewards of taking a risk are worth more than those possible risks.

Sometimes people take risks or make bad decisions about their health as a form of denial (that is, acting like nothing is wrong when it would be upsetting to admit there's a problem) about their spinal cord injury 2 3, like our study participant Rachel, who refused to learn how to feed herself or have her truck adapted so she could drive it herself because, as she put it, "I don't have transverse myelitis [the illness that paralyzed her]. I don't claim it. just do not. I don't claim it. I feel in my heart that I am going to get up, so I don't claim it." They might even take risks because they feel "there's nothing left to lose," 3 like Steve, a study participant who returned to dealing drugs and challenged rivals to kill him after he broke up with his wife.

It is also important to see if there are ways of doing an activity that would make it less risky; this is sometimes called "harm reduction," and research shows that it can help keep people from getting hurt, or even improve their health 4. For example, when a driver uses a seat belt, there's less risk that the driver would be injured in an accident because they have thought about harm reduction. In the same way, when a person with a spinal cord injury spends hours up in their wheelchair, there will be less risk of getting a pressure ulcer if the person remembers to do pressure reliefs and makes an extra careful skin check before going to bed that night. The advantage of harm reduction is that you can still do the activity that you were interested in, but with a much better chance of staying healthy.

One way to do harm reduction, and to make something less risky, is to prepare yourself very completely. Find out everything you can about the activity you want to do, or the situation you are interested in. Talk to an expert on the subject, if one is available. Once you have educated yourself, make sure that anyone else who will be joining you, such as a care attendant, partner, friend or family member, also knows about the activity or situation. Have the materials you need to do things right, whether it's special equipment, a permit, license or reservation, or anything else. And make some preparations so that you will be ready incase there is a problem, such as having a cell phone, extra cash, or first aid supplies, to name just a few examples.

Despite all the possibility of injury when someone takes a risk, it really doesn't mean that you have to live your life quietly shut away in your room, never taking a chance on anything. There are people who look at the possible good results of an action or decision (the pros) and the possible bad results (the cons), compare them, and then choose to take that risk because the pros are more important to them than the cons. A good example was when one of our study participants, Alma, has expressed her adventurous spirit and proved herself by going parasailing, hang-gliding and skydiving. But she practiced harm reduction in these activities by taking precautions including going in tandem, that is, harnessed as a team, with a skydiving instructor who operated the parachute and helped her to land safely. (To celebrate his 80th birthday, former President George H. W. Bush also went skydiving safely in tandem with an expert.) For Alma, the excitement and satisfaction of participating in thrill-seeking activities, but doing them in an adapted or safer way, were the pros that were more important than the cons of possibly getting injured. You might not make the same decision as Alma, but there might be another activity that would be important, meaningful or satisfying to you that you would decide to do; what really counts is that you take the time to think twice about your choice, and use the best decision-making skills possible.

Life would be boring if there were no risks at all, but risks can also lead to a bad result, ranging from feeling disappointed to getting a serious injury. Using decision making skills to think carefully about whether or not to take a risk can help you to avoid unnecessary risks. Looking for ways to do things more safely - harm reduction - can help make things a little less risky. Preparing yourself by learning everything you can about the risk you plan to take, and by having supplies on hand in case there is a problem, can also help to keep you healthy. Always take the time to make a risk, less risky!

If you use the Internet to learn more about risk-taking and how it relates to spinal cord injury, you might find that many websites focus on how risky behavior can lead to getting a spinal cord injury. The Last Shot, on the website of the Boston Globe daily newspaper, interviews former gang members and others who have gotten spinal cord injuries because of gunshot wounds. (Some of the people in the article were not doing anything risky when they were hurt; they were just bystanders wounded in drive-by shootings.)

The Ottawa Personal Decision Guide, on the website of the Ottawa Health Research Institute in Canada, is designed to help people assess their decision making needs, plan the next steps, and track their progress in decision making, and can be used for any health-related and/or social decision. (Note: the OHRI website gives you an option of registering or not; if you do choose to register on this website, it is free, and they don't request any personal information.) There is also a very interesting article called You Are How You Feel on the website of Craig Hospital in Denver, Colorado, which starts off by talking about how much your attitude about your health can influence how you feel, but then takes it one step further by giving suggestions about how a good attitude can help you make good choices. And good choices are what it takes to make risks less risky!

1 DeJong, G., Palsbo, S. E., Beatty, P. W., Jones, G. C., Kroll, T. & Neri, M. T. (2002). The organization and financing of health services for persons with disabilities. The Milbank Quarterly, 80, 2, 261-301.

2 Wichowski, H. C., & Kubsch, S. M. (1997). The relationship of self-perception of illness and compliance with health care regimens. Journal of Advanced Nursing, 25, 548-553.

3 Witkowski, J. A., & Parish, L. C. (2000). The decubitus ulcer: Skin failure and destructive behavior. International Journal of Dermatology, 39, (12), 894-896.

4 Schmidt, J., & Williams, E. (1999). When all else fails, try Harm Reduction. American Journal of Nursing, 99, (10), 67-70.