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.
Contents
1. Introduction
2. Overview of Risk Assessment
3. Risk Screening
4. Risk of Violence
5. Risk of Harm to Self - Suicide
6. Other Risk Issues
7. Risk and the Comprehensive Assessment
8. 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 from
http://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%20to
m
Overview of Risk Assessment I
Approaches to Assessing Risk
There are three main approaches to assessing risk of harm to self or others.
1. The clinical approach
Decisions made on the basis of a clinicians opinion and judgement. Subjective, based on
experience, and highly inaccurate.
2. The actuarial approach
Formal 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 approach
Clinical 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 judgement
http://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.
Classification of risk factors
Risk Factors
Static
Dynamic
Internal
External
Overview of Risk Assessment III
Process 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
Not present
No further risk
assessment
needed
Present
Identify risk factors static, dynamic, future
Identify patterns of risk for the individual & formulate risk
Document and manage risk
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 Techniques
Questioning 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 gates
Question cascades
Direct questions
CASE – Interviewing Strategy
Chronological structure
•
Past events
Last 8 Weeks
Historical
Recent
Presenting
Event
Current
Mental State
Current
Organize the broad range of questions into four specific time frames and explore in each
in depth before moving to the next.
1.
2.
3.
4.
Begin with presenting event and understand it in detail.
Recent risk events prior to presenting event
Past risk events
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
Static Risk Factors for Violence
(Do not change over time or relatively stable)
•
•
•
•
•
•
•
•
•
•
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
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 Information
1.
Current and historical record of violence and threats
Date
Past
2.
Risk
Behaviours
Describe, use of
weapons, victims,
triggers, limits
Internal Factors
Mental state, timeline,
early warning signs,
coping strategies
Situational
Factors
Stressors/changes,
medication,
substances, social
situation, resilience
factors, access to
weapons, access to
victims
Outcome
Critical
consequences
,
interventions,
legal
consequences
Time frames
•
Past, recent, current
3. Chronology
of violent or threatening
incidents
Recent
Preparations,
Pre-occupation,
Recent change,
• weapons,
Detect escalation
in
frequency
or
severity
near
planning, targets,
stress
• misses
Useful for detection of patterns
e.g.
victims,
specific
times,
preceding evetts and precipitants
coping
4. Contextual information
Current• Presenting
Current mental state
Current situation
Internal and situational factors
incident
5. Sources of Information
•
Corroboration, thoroughness, information sharing
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