Risk Assessment Self-directed Learning

Module

Overview of Module

All services should have clear policies and procedures around assessment of risk, and should provide training for staff in clinical roles. This module is designed to provide a refresher of key points and principles in the assessment of risk and to help integrate it into the comprehensive assessment.

The module is designed to be completed in your own time. Learning will be assessed within the long case exam on the final block course and in the written exam on the Friday of the final block course.

A high level of competence in risk assessment is required. Failure to adequately assess risk in a clinical situation can be considered negligent and students are required to assess aad deal with risk competently to pass PSMX404.

Contents1. Introduction2. Overview of Risk Assessment3. Risk Screening4. Risk of Violence5. Risk of Harm to Self - Suicide6. Other Risk Issues7. Risk and the Comprehensive Assessment8. Summary

Introduction I

This module provides an overview of the structure of risk assessment and how it should occur in PSMX 404. There has been widespread training in risk management within New Zealand mental health and addiction services over the past few years and it is considered the responsibility of services to ensure practitioners are skilled in assessing and managing risk.

All practitioners are expected to assess and manage risk competently. Failure to do so is clinically unsafe, can have serious consequences for tangata whaiora, whanau and clinicians themselves. Failure to do so on PSMX 404 will mean that students are unable to pass the course.

The resources which were produced by Te Pou to support the risk training initiatives are available for download free fromhttp://www.tepou.co.nz/file/PDF/Risk_Violence_Workbook_S.pdf

For further in depth reading, I would recommend the following book:Tom Flewett. Clinical Risk Management. An Introductory Text for Mental Health Clinicians. Elsevier Australia, 2010. About $90, available from fishpond nz.http://www.fishpond.co.nz/advanced_search_result.php?rid=1367657507&keywords=flewett%20tom

Overview of Risk Assessment IApproaches to Assessing Risk

There are three main approaches to assessing risk of harm to self or others.

1. The clinical approachDecisions made on the basis of a clinicians opinion and judgement. Subjective, based on

experience, and highly inaccurate.

2. The actuarial approachFormal assessment tools leading to a probability statement of risk. For example, the use

of rating scales. Tend to be quite accurate in predicting the probability of future negative outcomes but limited with respect to indicating short term risk and informing clinical management,

3. Structure professional judgement approachClinical assessment in a structured way using evidence-based knowledge of risk factors

and clinical judgment to produce a risk formulation.

Bouch and Marshall. Suicide risk: structured professional judgementhttp://apt.rcpsych.org/cgi/reprint/11/2/84ion.

Overview of Risk Assessment II

Traditional approaches to risk assessment involve trying to predict the likelihood of an unwanted event happening based solely on the clinicians judgement and opinion (the clinical approach). For example estimating that a person is a low or medium or high risk of serious self harm and is based

This approach has significant limitations especially:• while thoughts of suicide or violence towards others are relatively common, actual completed suicide or serious violence towards others is uncommon• suicide or serious violence is often by its nature unpredictable• such an approach tells little about how to manage and reduce the risk.

More recently the structure professional approach has become the gold standard. There are a number of tools available to assist the structured approach, such as the HCR-20 (violenece risk in adults) or the SAVRY (closely related to the HCR-20 and a similar structure, designed for adolescents). Training is required to use these. Based on these approaches is structured judgement which involves identifying evidence-based risk factors and applying them in the individual context of the client.

The key is to identify evidence-based risk factors defining them as either:

1. Static

- these are factors, often past factors that do not change

2. Dynamic

- these are factors that may change and are therefore open to intervention to reduce risk

and then to explore the tangata whiaora’s personal pattern of risk.

Risk Factors

Static Dynamic

Internal External

Classification of risk factors

Overview of Risk Assessment IIIProcess of Assessing Risk

Many tangata whaiora have little significant risk and do not need a full risk assessment which can be complex and time consuming. The first step is to screen for indicators that a fuller risk assessment is needed. If indicators are found, then a full risk assessment can be undertaken.

Screen for indicators of risk

Identify risk factors static, dynamic, future

Identify patterns of risk for the individual & formulate risk

Document and manage risk

Present

Not presentNo further risk assessment

needed

Screening for Risk

Suicidal thoughts are very common, especially in depression.

Every tangata whaiora when first seen should be asked directly if any suicidal thoughts, and if response or body language suggests positive this should be followed up on.

When to undertake a full risk assessment•Current or recent thoughts of suicide, significant self-harm or violence to others or related behaviours•Specific risk factors present•Sense of hopelessness or ‘no way out’ of a psychosocial conflict•Past history of violence or significant self-harm•Incongruity between responses to initial direct questions on risk and presentation

Assessing Risk

The Chronological Assessment of Suicide Events (CASE) Approach

Initially designe as a semi-structured strategy to investigate suicidality aimed at improving accurate responses. Also useful for asking about violence risk.

Shea, S.C. The chronological assessment of suicide events

Validity TechniquesQuestioning strategies to ehance the validity of responses.1. Behavioural incidents

- ask for precise facts, details or trains of thought of an event, step by step rather than opinions. For example, how many pills did you take? What happened then?... in detail.

2. Gentle assumptions- when suspect tangata whaiora reluctant to discuss a specific sensitive issue, assume the behaviour is occuring and gently frame questions accordingly

3. Denial of the specific- if tangata whaiora denies an issue e.g. any drug use, will often answer detailed further questions postively e.g. how often have you used cannabis? Therefore, specific questions to explore, despite denial

Interviewing Strategy

Emotional gatesQuestion cascadesDirect questionsAreas of specific concerns

• Chronological structure

CASE – Interviewing Strategy

Last 8 WeeksPast events Presenting Event

Current Mental State

Historical Recent Current

Organize the broad range of questions into four specific time frames and explore in each in depth before moving to the next.

1. Begin with presenting event and understand it in detail.2. Recent risk events prior to presenting event3. Past risk events4. Current risk and mental state

Other Interviewing Strategies

• Emotional Gates– Engaging on topics of emotional significance: fearfulness, hopelessness, anger, entitlement,

revenge, conflict• Question Cascades

– A series of linked or coherent questions the follow from eah other and lead to more in depth exploration

– Thoughts – Intent – Plan– Thoughts and feelings before – during – after the event

• Areas of specific concern– E.g. for risk of vioelnece: Persecutory delusions, delusions of control or passivity, command

hallucinations, violent religious delusions, morbid jealousy, current violent intent, righteous anger or perceived slight

Individual Patterns

Identification of the persons thoughts of harm and risk factors allows an individualised risk statement to be made:

Risk Statement:… This person is at risk of …

… In the following circumstances …

… When they are experiencing …

… Protective factors include…

Managing Risk

The process of managing risk rests on:• Knowledge of ecidence- based risk factors to violence• Interviewing skills to obtain accurate and specific information• Therapeutic relationship • Clear documentation of risk formulation and strategies to reduce risk• Clear commuication with others involved

Specifically:• Maintain safety

– Is the risk imminent such that immediate action is required?• Consider setting – is admission needed• Develop therapeutic relationship/engage• Share information with all concerned including other professionals and whanau• Actively treat mental health symptoms and disorders• Manage all dynamic risk factors• Document risk assessment and management plan• Actively implement management plan• Continue to monitor risk

Risk of Violence

• Male Gender• Age - Males 20-34yrs, Females 15-24yrs• Childhood maladjustment and behavioural problems• Childhood abuse• Lack of educational achievement or truancy• Employment problems• Previous pattern of violence and aggressive behaviour• Young age at first violence• Previous incarceration• Personality disorder

Static Risk Factors for Violence(Do not change over time or relatively stable)

Dynamic Internal Risk Factors

• Current stated intent or threats to commit violence• Thoughts, intent, plans

• Delusions• Perscutoion, control or passivity, jelousy or love, grandiose

• Hallucinations• Command, especially religious

• Final common pathways• Paranoid thinking• Irritability• Impulsivity• Ego threatened or disrespected

• Emotional states• Suicidal thoughts

• General level of arousal, anger/rage/indignation, blunting, fearfulness• Confused states• General attitudes

• Antisocial attitudes – lack of remorse, empathy or guilt• Lack of insight• Lack of empathy for past victims

Dynamic External Risk Factors

• Lack of engagement with services• Substance abuse, intoxication or withdrawal• Non-adherence with medication (where relevant)• Stressful, poor or inadequate social situations e.g.

• Power supply cut off• Loss of accommodation, homelessness• Overcrowding• Relationship difficulties• Financial stress

• Major life events• Exposure to de-stabilisers

• e.g. Violent sub-culture• Systemic problems

• Lack of coordinated care plan• Lack of information sharing

• Access to weapons• Access to potential victims• Poor social supports

Accurate Information1. Current and historical record of violence and threats

2. Time frames• Past, recent, current

3. Chronology of violent or threatening incidents• Detect escalation in frequency or severity• Useful for detection of patterns e.g. victims, specific times, preceding evetts and precipitants

4. Contextual information• Internal and situational factors

5. Sources of Information• Corroboration, thoroughness, information sharing

Date Risk Behaviours

Internal Factors Situational Factors

Outcome

Past Describe, use of weapons, victims, triggers, limits

Mental state, timeline, early warning signs, coping strategies

Stressors/changes, medication, substances, social situation, resilience factors, access to weapons, access to victims

Critical consequences, interventions, legal consequences

Recent Preparations, weapons, near misses

Pre-occupation, planning, targets, coping

Recent change, stress

Current Presenting incident

Current mental state Current situation

Risk of Harm to Self - Suicide

Risk of Self Harm

• Similar structure to violence risk, differing details

• Historical, recent, current risk

• Risk factors, situational context and experiences (internal)

• Assessment into management

Static Risk Factors for Suicide

• Past self-harm• Seriousness of previous suicidality• Previous hospitalisation• History of mental illness• History of substance use problems• Personality disorder or traits• Childhood adversity• Childhood abuse (sexual abuse especially, but also other forms of abuse)• Family history of suicide• Age, gender, marital status

Higher risk in males, early adulthood and less so elderly, unamarried (males) or divorced/widowed (females)

• Impulsivity and aggression• Homosexuality (especially women)• Ethnic minority

Dynamic Risk Factors for Suicide

Current Dynamic Risk Factors• Suicidal ideation, communication and intent• Hopelessness• Active psychological symptoms• Psychiatric disorders

• Almost all psychiatric diagnoses are associated with increased risk of suicide• eating disorders, major depression (esp melancholia), substance abue, bipolar disorder (in descending order of risk)• More than one axis 1 disorder (comorbidity) significantly increases the risk.

• Active psychological symptoms• panic attacks, anxiety, loss of pleasure and interest, poor concentraion, rucurring insomnia, depressive turmoil and agitation

• Substance use• Physical illness (especially in the elderly)• Treatment compliance• Substance use• Psychiatric admission and discharge• Psychosocial stress• Problem-solving deficits

Future Risk Factors•Access to preferred method of sucide•Future service contact•Future response to drug treatment•Future response to paychosocial intervention•Future stress

Protective Factors for Suicide

• Family connection• Better coping skills• Fear of social disaproval• Moral reasons against suicide• Fear of suicide• Strong religious affiliation

• A contract not to commit suicide is NOT protective

Other Risks

Other Risks

Do not forget other risks, including:• Ability to care safely for self ande dependents (e.g. memory impairment leaving stove on,

intoxication impairing ability to care for children)• Sexual predation• Driving under the influence

These should be assessed and managed following the principles mentioned above.

Risk and the Comprehensive Assessment

• There are a number of areas within the comprehensive assessment that contribute to a risk assessment and management plan.

– Wellbeing and reasons for living in the introduction– Presenting problems– Specific suicidal, violence or other risk behaviours in the mental health history where related

to mental health problems, or possibly in the Personal Developmental history when related to personality disorder especially ASPD

– Aggression and impulsivity in Mental Health or Personal History– Psychiatric diagnoses– Physical problems– Psychosocial stressors in the history of presenting problem or the personal history– Support networks, social and coping skills– History of past self-harm in the Mental Health history and violence in the mental health,

forensic or personal history.

• Risk should be identified in the problem list and included in the aetiological formulation

• The management plan needs to include comments regarding management of risk where it is though to be significant.

• Risk is also relevant to the prognosis

The End