Approaches to risk assessment 2

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Chapter 9 Approaches to risk assessment 2

Risk assessment is best described in terms of human endeavour, not in the language of scientific measurement.¹

Screening for risk

Screening for risk is a routine part of all assessments. Screening for suicide risk will be used as the example to describe the process. The assessment of suicidal risk is one of the most common and basic procedures in psychiatry.² It is probably the purest example of a risk assessment as the process requires close interaction with the patient, is incremental in that the next question is based on the response to the previous question, and interventions will be based on both treating the underlying illness and preventing the risk behaviour from occurring.

Unless the patient spontaneously comments that they are considering suicide, the clinician will need to prompt for it. An index of suspicion should be present for any patient with mood symptoms. If the primary problem is another problem such as psychosis, the mood symptoms may be hidden but the screening questions should still be asked. The first screening question may lead on to an in-depth assessment of the risk or may be sufficient to allow the clinician to determine that the current risk is negligible or absent.

After working towards the questions about suicidality with a question such as, ‘How bad have things been?’, it will be possible to move on to an initial screening question such as, ‘Have you ever felt that life is no longer worth it?’ or ‘Have you ever felt that you can’t carry on?’

If the verbal and/or non-verbal response to these opening questions is positive, the clinician will then continue to ask more probing questions until the extent of the preoccupation with suicide is apparent. From there, in conjunction with the rest of the assessment, management decisions will be made. For suicide,

BOX 9.1 CLINICAL TIP

When asking the initial screening questions for risk to self or others, the good clinician will be looking for incongruity between the verbal and non-verbal responses. For example, the non-verbal response of averted eyes, or shifting in the chair should be a prompt for further exploration either later on in the interview or in the near future, depending on the situation.

because of the acuity which may be present, it is not uncommon for a full assessment to be conducted during the first meeting to determine the level of risk. This is less likely to be the case for violence where the focus is more often on preventing future episodes.

Suicide assessment is incorporated into the body of the clinical assessment. For other risks such as violence and self-harm the process is the same but the index of suspicion may not be as high on the part of the clinician. Suicide is an easily recognised complication of mood disorders whilst other risks such as violence and sexual predation are more likely to be hidden; there may be more shame or a fear that disclosure will be punished in some way, such as incarceration. Violence may be a complication of several different disease processes and may occur even when there is no disease process. A clinician should, however, always include a basic screening for violence. Sexual predation is unlikely to be part of routine general mental health screening unless an index of suspicion is raised in the assessment.

Static factors in the history which make the propensity for violence greater should be considered. These should emerge during the routine questioning of the childhood and personality development. The patient’s response to dynamic factors should be explored. A classical example would be an exploration of the patient’s likelihood of acting on command hallucinations.

When there is uncertainty about how detailed the risk assessment should be, the rule of thumb should be — do a complete assessment.

The negatives if the risk is minimal will make the process quick, the discovery of positives and consideration of interventions makes it worthwhile.³

There are screening tools available (one is included in Chapter 15, risk of violence) but a useful rule of thumb is to consider a more detailed assessment if:

• there are substantive risk issues

• the patient is likely to require treatment after hours

• the patient is likely to make contact with the service in between appointments

• the patient is admitted for treatment to either a respite facility or hospital

• there is a past history of violence, self-harm or suicide attempts.

The decision about the level of detail required within the assessment will also be based on the following question; ‘What is the likelihood and imminence of the risk behaviour occurring and what will the consequences be if it occurs?’

As the patient becomes better known and treatment continues, the assessment of the risk will continue alongside the continuing assessment of the patient’s clinical condition.

BOX 9.2 CLINICAL TIP

OBSESSIVE-COMPULSIVE DISORDER (OCD)⁴

Learning points:

• Obsessional ruminations are often misinterpreted as indicating risk. There are no recorded cases of a person with OCD carrying out their obsession. By definition, such intrusions are unacceptable and ego-dystonic.

• Risk in OCD is usually related to the consequences of acting on compulsions and urges in order to avoid the anxiety-provoking situations; for example, harm from washing hands too frequently, harm from compulsive hoarding.

• Risk to others may occur when well-meaning attempts are made to prevent compulsive behaviours being carried out.

• Secondary co-morbid illnesses such as depression, which is driven by the distress of the OCD, may create risk of suicide and should be assessed.

Assessment and documentation exercise

The first exercise in this section starts the process of assessing and documenting risk. Often, the first presentation is a phone call or an assessment in the Emergency Department (ED). Information may be limited but a start needs to be made. The initial identification of the risk may also create anxiety on the part of the clinician. The process of simply documenting what is known creates a degree of objectivity which will immediately reduce anxiety. The purpose of the following exercise is to simply practise documenting identified risk and consider to whom, when, where and what means might be used. Practising the exercises will give you an opportunity to get used to the routine questions which are central to any risk assessment. With practice, there will be increasing familiarity which is a risk management skill in its own right. Familiarity with the process can reduce risk by a factor of 17.⁵

For each of the examples below answer the following questions.

1. What are the risks?

2. Whom is the risk to?

3. When may it happen?

4. Where may it happen?

5. What means might be used?

Try and write your answers in narrative form. Imagine that this information is being communicated to a colleague who will be seeing the patient after hours.

Exercise 1 — Monique

Monique is a 28-year-old woman with schizophrenia. Her boyfriend has recently left her and staff in the supported accommodation home in which she lives report that she is tearful, distraught and withdrawn. They wonder if she is going to kill herself. The staff phone you and your task is to complete the risk documentation on the triage form. Refer to the template in Figure 9.1. The completed form appears in Appendix 3.

Figure 9.1 Risk assessment and management template

Comment on the completed form

For Monique, she will need to be seen relatively urgently for a more complete assessment. The staff in the supported accommodation are anxious and part of the task of the assessment will be to manage this anxiety. Hopefully, she will already have a risk management plan which will make the process easier. This is how the risk may be documented in a triage form written by a duty worker receiving the call from the supported accommodation home. See Appendix 1 for an example of a triage form, including a place for documenting risk.

Exercise 2 — Phoebe

Phoebe is an 83-year-old woman with a major depressive illness characterised by delusions that her body is rotting, suicidal intent and psychomotor retardation. She has not eaten for 3 days. You see her in the ED.

Use the risk assessment template in Figure 9.1. The completed form appears in Appendix 3.

Comment on the completed form

Phoebe is at high risk. Documenting the risk in this way will facilitate admission to a hospital bed if there are resource limitations. Documenting the level of risk creates a requirement for monitoring to be set up at defined intervals of time. See page 26.

Exercise 3 — Colin

Colin is a 37-year-old man who has just moved from another city. You are asked to see him in the ED. He was brought in by the police after a report of a disturbance in the main shopping street where he was shaking his fist angrily at all and sundry and chanting. He is staring at you intently and says to you: ‘There’s nothing wrong with me’. There is a smell of cannabis in the room.

Use the risk assessment template in Figure 9.1. The completed form appears in Appendix 3.

Comment on the completed form

For Colin, the risk assessment starts immediately with your interpretation of his intent stare. His opening statement, ‘There’s nothing wrong with me’, is likely to be made aggressively. Is this statement made because he is frightened or angry or both? His stare and the tone of his voice are important factors which will help in the identification of the potential risk and in the determination of its severity. Commenting on the lack of knowledge of whether a weapon exists or not is important for the continuing assessment. The answer has not commented on the smell of cannabis. Is he currently intoxicated? Is cannabis use a risk factor for violence — possibly not unless accompanied by psychosis. Does he have a psychotic illness related to substance abuse or is his psychosis possibly schizophrenia? There are a lot of unknowns in this example which will be common in an acute presentation.

Exercise 4 — Rebecca

Rebecca is a 26-year-old woman with borderline personality disorder (BPD). She phones you at 4.30 p.m. on a Friday saying that she has had an argument with her boyfriend and is going to self-harm. You know that she has razor blades in her bag. She asks you what you are going to do about it.

Use the risk assessment template in Figure 9.1. The completed form appears in Appendix 3.

Comment on the completed form

In this example, it is likely that, because Rebecca is already known to staff, she will have a risk management plan and possibly a crisis plan in place. This should give guidance about how to respond in this type of situation, which will be a recurring pattern of behaviour for Rebecca. Her somewhat aggressive approach may cause staff to become defensive or aggressive in turn, which may increase the risk. The other problem is that many patients who self-harm do not see the behaviour as risky. In fact self-harming may be seen as an effective solution to control overwhelming emotions. In these situations, there is often a large discrepancy between the assessment of level of risk as seen by the patient, their family and clinicians.

Discussion of exercises 1–4

You have been given limited information in the examples in these exercises. Nonetheless, being able to document the risk will assist in developing an immediate plan to deal with the crisis and, once the patient has stabilised somewhat, consideration can be given as to whether a more complete assessment needs to be undertaken. This is developed further in Chapter 11.

The following exercises extend the risk assessment and include the assessment of the static and dynamic risk factors. You are now being given more information and will need to practise documenting the risk factors. To help you, a list of risk factors for suicide accompanies the example of Monique and factors for violence accompany the example of Colin. The development of the risk factors is described in Part 3.

Exercise 5 — Monique (continued)

Refer to exercise 1 (page 76) for Monique’s story.

BOX 9.3 RISK SCREENING

Practice points

• Documenting the risk allows for a degree of objectivity which reduces anxiety.

• Predicting when it may happen is difficult.

• If uncertain about whether to complete a full risk assessment, do it. If the risk is minor, the time spent will be small.

• An index of suspicion should be taken into all interviews to prompt for risk as patients will often not disclose risk issues spontaneously.

Monique’s illness is characterised by both positive and negative symptoms. She continues to have auditory hallucinations which comment on her actions and occasionally put her down. Sometimes her voices tell her to hurt herself. Her self-care has deteriorated over the last few years, she has lost some of her outgoing vivaciousness and she has fewer friends. She continues to smoke cannabis from time to time. Six years ago, she became pregnant and had a termination. One year later, she became pregnant again and the baby was adopted out. She now uses a depot injection for contraception.

In her childhood, she says that she was happy and describes no major problems. She cannot remember too much about her childhood. She did not do well at school and left at the age of 16 with no qualifications. Monique’s father has a diagnosis of schizophrenia. Her mother is well and she visits Monique about once a fortnight.

In her history, Monique has made three serious suicide attempts. The first attempt was 5 years ago and the last one 18 months ago. On each occasion, she was suffering a relapse of her schizophrenia and took overdoses of her medication.

Monique was in a relationship with another resident at the hostel.

Two weeks ago that relationship broke down after the boyfriend had a relapse and became violent. Since then, Monique has been frequently tearful and has withdrawn. Staff at the hostel have always felt that Monique is vulnerable to abuse by others but now say that they have a gut feeling that she is suicidal.

From the information given, document the current risk. Identify static and dynamic risk factors which will help you in your assessment of the risk of suicide. Include the protective factors. Use the risk factors for suicide in Table 9.1 to help you. Are there any patterns?As you do this exercise, imagine you are discussing your thinking with Monique.

Table 9.1 Suicide risk factors

Risk factors for suicide
Static factors • Male gender. Ratio approx 4:1. Age groups 15–24 and over 60. • Previous attempt. If previously attempted, 10–20% will succeed. • A history of neglect or sexual abuse. • Substance use disorder. • Family history of suicide. • A history of self-harm. • History of mental disorder.

Nature of the risk

• Well formulated or poorly developed plan?

• What means have been considered?

Illness (dynamic) factors

• Current suicidal ideation, communication and intent. Feelings of desperation, abandonment, hopelessness, rage, self-hatred or anxiety.

• Co-morbid depression. The more severe the illness, the greater the risk.

• Current alcohol use.

• Other psychiatric illness with affective component.

• Physical illness.

• Current diagnosis of personality disorder, especially borderline and antisocial personality disorders.

• Impaired rational thinking: especially schizophrenia and psychosis.

Situational factors

• Isolation, loneliness.

• Recent suicide of friend, family member or public figure.

• Recent loss — bereavement, divorce or job.

• Recent experience of adversity or stressful event.

• In youth, an identifiable stressful event precedes 70% of suicides.

Protective factors

• Has the patient previously sought help?

• Therapeutic alliance? Family support?

• Concerns about the effect of a suicide on others.

• Awareness of early warning signs.

Systemic factors

• Do others think there is a problem?

Early warning signs and triggers

• What has indicated or triggered events in the past? Can the patient recognise their triggers?

• Does the patient have good or poor insight into his/her illness?

Relapse indicators

• Does the patient or his/her carers recognise indicators of relapse?

• Will the patient accept treatment voluntarily?

Use the template in Figure 9.2, over the page. The completed risk assessment and management form appears in Appendix 3.

Comment on the completed form

The box focussing on past episodes of risk yields very important information which would be a major focus for any clinician seeing Monique out of hours. A clinician seeing Monique for the first time would use this information carefully in their assessment of the level of risk.

The answers given for the static risk factors above (‘What in this person’s history …’) have been documented in the form of a running list. Although they may be correct, they are difficult to read and if you are the clinician on call at night being asked to see Monique, it would be easy to skip over the static risk factors and focus more on the current mental state, situational and protective factors which have been documented in a narrative form.

BOX 9.4 CLINICAL TIP

When documenting risk, think about your colleague who will be seeing your patient after hours. Whilst trying to be succinct, it is sometimes easier to read when put in a narrative form rather than a running list, or list of dot points, or a series of tick boxes.

Exercise 6 — Colin (continued)

Refer to exercise 3 (page 77) for Colin’s story.

In ED, Colin allows you to take a history. There is a significant family history of abuse, mental health issues and substance misuse. For the last 10 years Colin has been smoking five joints of cannabis per day and tends to drink between 10 and 20 cans of beer per week. He says that approximately 6 months ago, he felt that his flatmate became more interested in his girlfriend and wondered if the flatmate was putting cameras in the ceiling to watch him making love to her. Initially he thought that this was a ridiculous idea but he became sufficiently concerned over a period of time to start checking around his room for hidden cameras and tape recorders. Shortly after this, Colin developed an unshakable idea — the newsreader on the television was giving him special messages.

These thoughts went on for some time and became more problematical for him. His girlfriend thought he was going crazy and left. In the end, Colin decided to leave his flat and moved to your town to start afresh. He has no family support in your town and finds himself wandering the streets where he recites prayers to try and distract himself from thinking that people are talking about him. Approximately 1 month ago, Colin noticed that when he smoked more cannabis, the ‘paranoid’ ideas became stronger and he wondered if the cannabis was the problem. He has used speed (methamphetamine) occasionally. He decided to stop the cannabis and, over the last few weeks, the paranoia has settled slightly, but it has certainly not gone away. Colin has found himself wondering if people on the streets are talking about him and has also wondered if his new flat mate is watching him. Colin has past convictions for assault; when he was 19 years old and again at 21 and 24. He tells you that he has learned to control himself since that time and wouldn’t hurt anybody now. These assaults occurred in the context of brawls, which he got into when he was drunk. He says he normally wouldn’t hurt a fly.

Colin says that he is getting increasingly angry about what is going on. Despite your best efforts to persuade him to take medication, Colin feels that he can manage this on his own using willpower and prayer. He thanks you for your help and says that he will be all right.

From the information given, document the current risk, identify static and dynamic risk factors which will help you in your assessment of the risk of violence. Include the protective factors. Use the risk factors for violence in Table 9.2 to help you. Are there any patterns? As you do this exercise, imagine you are discussing your thinking with Colin.

Table 9.2 Violence risk factors

Risk factors for violence
Static factors • Male gender and younger age of first violent incident. • Past history of violence. Consider the degree of violence and the frequency. • Substance use. Is this historical and/or is it continuing today? • Childhood maladjustments and behavioural problems and childhood abuse.

Nature of the risk

• Risk to whom, type of weapon? Well formulated or poorly developed plans?

• Predatory or affective type of violence?

Illness (dynamic) factors

• Psychosis — is the patient threatened, frightened and are normal controls overridden?

• Does the patient feel persecuted?

• Is the patient having command hallucinations?

• Changing symptoms. A tendency to act on symptoms.

• Impulsivity. Lack of Insight.

• Violent thoughts being expressed? Morbid jealousy?

• Threatening or fearful behaviour.

• Current diagnosis of personality disorder — especially psychopathy but include antisocial personality disorder.

• Self-report of thoughts of violence.

Situational factors

• Current substance use.

• Unstable accommodation. Unemployed. Current stressors.

• Poor compliance with medication. Poor therapeutic alliance.

• Access to weapons.

Protective factors

• What has worked previously to prevent violence?

• Good therapeutic alliance.

• Family support?

• Concern about harming others. Awareness of triggers.

Systemic factors

• Do carers think there is a problem?

• Is the situation at home deteriorating?

• Is the treatment plan feasible?

Early warning signs and triggers

• What has helped in the past?

• Does the patient have good or poor insight into his/her illness?

• Can the patient recognise their triggers?

Relapse indicators

• Does the patient or their carers recognise indicators of relapse?

• Will the patient accept treatment voluntarily?

Use the template in Figure 9.2. The completed risk assessment and management form appears in Appendix 3.

Figure 9.2 Risk assessment and management template

identified with no particular critical factors noted. In neither example was the management of the risk documented. It is hoped that this was included in the management section of these patients’ documentation!

The problem with documenting risk in this way is that it may be difficult to find it in the body of the notes later.

If need be, both of these examples could be adapted and put into the risk tool quite easily if it was thought the patient may present after-hours or in a crisis. Some clinicians might say that risk should always be documented separately and placed in the file in a place which is easily seen. This is discussed further in Chapter 11.

Notes

1 Murphy D. Risk assessment as collective clinical judgment. Criminal Behaviour and Mental Health. 2002;12:169–178.

2 Gutheil T.G., Schetky D. A date with death: management of time-based and contingent suicidal intent. American Journal of Psychiatry. 1998;155:1502–1557. November.

3 Maden A. Treating Violence: a Guide to Risk Management in Mental Health. Oxford.: Oxford University Press; 2007.

4 Veale D., Freeston M., Krebs G., Heyman I., Salkovskis P. Risk assessment and management in obsessive-compulsive disorder. Advances in Psychiatric Treatment. 2009;15:332–343.

5 Williams J. A database method for assessing and reducing human error to improve operational performance. In: Hagen W., ed. ILEEE Fourth Conference on Human Factors and Power Plants. New York: Institute for Electrical and Electronic Engineers; 1988:200–231.

6 Winestock M. Risk assessment. ‘A word to the wise’? Advances in Psychiatric Treatment. 1996;2:3–9.

7 Higgins N., Watts D., Bindman J., Slade M., Thornicroft G. Assessing violence risk in general adult psychiatry. Psychiatric Bulletin. 2005;29:131–133. 3–9.