3. Risk Assessment & Clients in Crisis
An overview of the day:
• Assessment of risk
• Mental status examination
• Intervention planning
• Documentation
9. And so I leave this world, where the
heart must either break or turn to
lead.
Nicolas-Sebastien Chamfort, French
writer, d. 1794
10. I haven’t felt the excitement of listening to as
well as creating music…for too many years
now. I feel guilty beyond words about these
things.
Kurt Cobain, musician,
d. 1994
11. I must end it. There's no hope left. I'll be at
peace. No one had anything to do with this.
My decision totally.
Freddie Prinze, comedian,
d. 1977
12. I feel certain that I'm going mad again. I feel
we can't go thru another of those terrible
times. And I shan't recover this time. I begin to
hear voices.
Virginia Woolf, author,
d. 1941
41. Predisposing Clinical Risk Factors
• Personality disorders
–5 – 10% lifetime risk
–15 – 25% of all suicides
42. Borderline Personality and Risk
Lifetime rate of suicide - 8.5%
With alcohol problems -19%
With alcohol problems and major affective disorder -38%
43. Borderline features which increase risk
• Impulsivity
• Hopelessness-despair
• Antisocial features
• Aloofness
• Self-mutilating tendencies
• Psychosis
44. Borderline features which ameliorate risk
• Clinging
• Dependency
• Use of suicidal behavior to maintain
connections
47. SUICIDE RISKS IN SPECIFIC DISORDERS
Prior suicide attempt 38.4 0.549 27.5
Bipolar disorder 21.7 0.310 15.5
Major depression 20.4 0.292 14.6
Mixed drug abuse 19.2 0.275 14.7
Dysthymia 12.1 0.173 8.6
Obsessive-compulsive 11.5 0.143 8.2
Panic disorder 10.0 0.160 7.2
Schizophrenia 8.45 0.121 6.0
Personality disorders 7.08 0.101 5.1
Alcohol abuse 5.86 0.084 4.2
Cancer 1.80 0.026 1.3
General population 1.0 0.014 0.72
Condition RR %-yr %-Lifetime
Adapted from A.P.A. Guidelines, part A, p. 16
48. SUICIDE RISKS IN SPECIFIC DISORDERS
General population 1.0 0.014 0.72
Adapted from A.P.A. Guidelines, part A, p. 16
Condition RR %-yr %-Lifetime
49. SUICIDE RISKS IN SPECIFIC DISORDERS
Prior suicide attempt 38.4 0.549 27.5
Bipolar disorder 21.7 0.310 15.5
Major depression 20.4 0.292 14.6
Adapted from A.P.A. Guidelines, part A, p. 16
Condition RR %-yr %-Lifetime
50. SUICIDE RISKS IN SPECIFIC DISORDERS
Dysthymia 12.1 0.17 8.6
Panic disorder 10.0 0.16 7.2
Adapted from A.P.A. Guidelines, part A, p. 16
Condition RR %-yr %-Lifetime
52. COMORBIDITY
In general, the more diagnoses present, the
higher the risk of suicide.
Psychological Autopsy of 229 Suicides
• 44% had 2 or more Axis I diagnoses
• 31% had Axis I and Axis II diagnoses
• 50% had Axis I and at least one Axis III
diagnosis
• Only 12 % had an Axis I diagnosis with no
comorbidity Henriksson et al, 1993
54. Predisposing Family History Risk Factors
Relatives of suicidal subjects have a two-fold increased risk
compared to relatives of non-suicidal subjects.
Twin studies indicate a higher concordance of suicidal
behavior between identical rather than fraternal twins.
Adoption studies: a greater risk of suicide among biologic
rather than adoptive relatives.
55. Predisposing Demographic Risk Factors
• Male
• Older
• Lives alone
• Widowed / separated
• White, or Native American
• Access to weapons
• Sexual minority (GLBT)
68. Risk Assessment &
Management
Overview of risk assessment protocol
1. Identify predisposing factors
2. Examine potentiating factors
3. Conduct a specific suicide inquiry
4. Determine level of intervention
5. Document the assessment
69. Potentiating Risk Factors
• Recent stressor
• Contagion
• Recent diagnosis of major illness
• Recent relapse of major illness
• Hepatitis C treatment
71. Potentiating Risk Factors
• Recent stressor
• Contagion
• Recent diagnosis of major illness
• Recent relapse of major illness
• Hepatitis C treatment
80. Suicidal ideation
• Able to control suicidal thoughts?
• Has made preparations for death?
• Has rehearsed?
• Command hallucinations?
81. Suicidal plan:
• No concrete plan but has intent
• Plan without means
• Plan with means:
• Lethality
82. Suicidal intent:
• No intent but does not feel capable of
maintaining safety plan
• Intent related to:
–Wish to die
–Desire to hurt someone else
–Need to escape
–Need to punish self
84. History of attempts
• Actions imply gestures vs. intent?
• Dangerous/not believed to be lethal?
• Dangerous/potentially lethal?
• History of self-injurious behavior?
86. Impulsivity
• History of money management?
• Impulsive relapses?
• Domestic violence?
• Abrupt firings from jobs?
• How have relationships ended?
• History of impulsive suicidality?
87. Deterrents to suicide
• Religious faith
• Hopefulness re: resolution
• Ambivalence
• Reasons for living
• Loved ones
• Relationship with therapist
124. MMSE norms
Eighth Grade Education
Ages 18 to 69: Median MMSE Score 26-27
Ages 70 to 79: Median MMSE Score 25
Age over 79: Median MMSE Score 23-25
High School Education
Ages 18 to 69: Median MMSE Score 28-29
Ages 70 to 79: Median MMSE Score 27
Age over 79: Median MMSE Score 25-26
College Education
Ages 18 to 69: Median MMSE Score 29
Ages 70 to 79: Median MMSE Score 28
Age over 79: Median MMSE Score 27
Crum (1993) Journal of the American Medical Association
135. Moderate
Risk
• Follow-up evaluation of risk
• Increased frequency of outpatient
contact.
• Involvement of family members, if
possible.
• 24 hour availability of crisis centers
• Referral for consideration of
pharmacological tx
• Use of telephone contacts to
monitor progress
• Safety plan
136. Risk Assessment &
Management
Overview of risk assessment protocol
1. Identify predisposing factors
2. Examine potentiating factors
3. Conduct a specific suicide inquiry
4. Determine level of intervention
5. Document the assessment
137. Determine level of intervention
1. Acute versus chronic
2. Evaluate competence and impulsivity
3. Assess therapeutic alliance
4. Plan reassessments
138. Determine level of intervention
1.Acute versus chronic
2. Evaluate competence and impulsivity
3. Assess therapeutic alliance
4. Plan reassessments
141. Determine level of intervention
1. Acute versus chronic
2.Evaluate competence and
impulsivity
3. Assess therapeutic alliance
4. Plan reassessments
142. Competency / Capacity
• Client able to indicate a preference?
• Able to weigh the pros/cons of
various options?
• Able to apply pros/cons to her own
specific situation?
143.
144.
145.
146. Determine level of intervention
1. Acute versus chronic
2. Evaluate competence and impulsivity
3.Assess therapeutic alliance
4. Plan reassessments
147. Determine level of intervention
1. Acute versus chronic
2. Evaluate competence and impulsivity
3. Assess therapeutic alliance
4.Plan reassessments
148.
149. Consultation with others
• When appropriate involve family
members in decision making.
• Other professionals
• Collaboration with the patient
150. Consultation with others
• When appropriate involve family
members in decision making.
• Other professionals
• Collaboration with the patient
153. Elements of the collaborative
approach
• Educate the patient about the
uncertainty inherent in treatment.
• Underscore the mutual responsibility of
sharing the burden of managing suicidal
thoughts.
• Directly discuss the risk of death from
suicide.
• Discuss risks other than suicide such as
dependence and regression.
154. • Discuss the patient’s competence or capacity
to give informed consent.
• Warn the patient about the serious
consequence of not following treatment
recommendations.
• Consult with a peer when possible.
• Prepare concise documentation of assessment
and treatment planning emphasizing
collaboration.
155. Elements of a safety plan
• How will I know that my risk for self-
harm has become more serious?
• What are the coping strategies which I
will use if I feel more distressed or sad?
• Who can I contact if I need someone to
spent time with and distract me from
my distress?
156. Elements of a safety plan
• Who can I contact if I need to seek support
or talk me through difficult feelings?
• Who are the helping professionals to
whom I will reach out if I need support?
(include contact information; include
contacts available on 24 hour basis such as
EMH)
• What specific steps will I take to make my
home environment safer for me?
171. 4 Reasons to Document Carefully
• Good documentation keeps us out of
court
• If we must defend our decision-making,
good documentation helps our legal
counsel
• Good documentation drives good care
• Good documentation helps treaters
communicate among ourselves
175. The Written Report
• Impression
• Summary
–Differential
–Contributing factors
–Further information needed
–Prognosis
–Response to referral questions
176. The Written Report
• Risk Potential
– Low/moderate/high
– Safety plan (if appropriate to level of risk)
• Treatment Plan
• Cost / Benefit Comments re: alternate
treatments
201. Knowledge of Community Resources
• Crisis numbers, in-patient options,
substance abuse resources.
• Documentation that these sources
have been discussed.
202. The 4Ds of Malpractice
• A doctor-patient relationship creating a DUTY
of care must be present.
• DEVIATION from the standard of care must
have occurred
• DAMAGE to the patient must have occurred.
• The damage must have occurred DIRECTLY as
result of deviation from the standard of care.
203. Malpractice
• Failure to take adequate protective
measures
• Early patient release
• Abandonment
204. When a Suicide Occurs
Ensure that the patient’s records are complete
Be available to assist grieving family members
Remember the medical record is still official
and confidentiality still exists
Seek support from colleagues / supervisors
Consult risk managers
206. Clinical features associated with risk
for violence
• Has threatened harm
• Entertains thoughts of violence
• Has access to means/weapons
• Has taken steps to secure means
• Reports command hallucinations
207. Clinical features associated with risk
for violence
• History of Paranoid Schizophrenia
• Recent ETOH/drug abuse
• Quarreling
• Intense jealousy
• Habitual rage response
• Childhood fire setting/cruelty to animals
• Violence in family of origin
208. Legal history associated with risk for
violence
• Reckless use of a weapon
• Destruction of property
• Has been stalking or harassing others
209. Risk Potential
• Low
–Denies current violent or homicidal
ideation, no indicators evident.
• Moderate
–Violent/homicidal ideation without
intent.
• High
–Strong ideation with intent.
221. 10 Elements of Threat Assessment
1. motivation for the behavior at hand
2. communication about ideas and
intentions;
3. unusual interest in targeted violence;
4. evidence of attack-related behaviors
and planning;
222. 10 Elements of Threat Assessment
5. mental condition;
6. level of cognitive sophistication or
organization to execute an attack
plan;
7. recent losses (including losses of
status);
8. consistency between communications
and behaviors;
223. 10 Elements of Threat Assessment
9. concern by others about the
individual’s potential for harm;
and
10. factors in the individual’s life
and/or environment that might
increase or decrease the likelihood
of attack.
225. David D Nowell PhD
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