Risk management

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Chapter 12 Risk management

Psychiatric risks (chiefly violence to self or other) are manifestations of suffering, and addressing the suffering is the primary way psychiatrists and other mental health care workers should address risk.1

Risk management in a mental health setting is the task of minimising the likelihood of an adverse outcome whilst maintaining a focus on good treatment.

The quote below first appears at the beginning of the book, but it is useful to cite it again here as the message is very important.

Much medical effort goes into managing the risks of complications of disease processes rather than managing the symptoms of the disease itself. Hypertension is the classic example, with no symptoms but plenty of treatments, all aiming to reduce the risk of complications such as strokes and myocardial infarctions. Psychiatry’s misfortune has been to choose diseases where the complications … are homicide, suicide or reduced capacity for self-care and vulnerability.2

This problem becomes the nub of risk management within mental health. On the one hand clinicians try to treat the illness whilst at the same time managing the risk which is often a complication of the disease process rather than a symptom of the disease itself.

Given the examples that have been worked through in this book, it will be apparent by now that risk management is a combination of all the processes that have been described so far. The task now is to combine them into a whole and ensure that the effectiveness of the risk management can be evaluated.

Risk management on its own is meaningless. It is only when it is incorporated into the treatment of the patient’s illness with a focus on recovery that it develops meaning. Before considering anything else, consider the illness. Sometimes in mental health there is no choice but to live with high risk whilst instituting appropriate treatment for the illness. This is no different to any branch of medicine. A pitfall in risk management for clinicians is instituting containment to reduce the risk which does not necessarily improve the outcome for the illness and which may also generate other risks.

EXAMPLE

A common example would be the risk-avoidant clinician with a very low threshold for admission to hospital who unwittingly creates dependence in his or her patients. The dependence created may lead to deterioration of the illness, possibly to chronicity and to further risk.

Trying to incorporate clinical management into risk management tends to lead to an approach in which the illness takes secondary importance. It is more effective to incorporate risk management into clinical management.

Risk management starts from the beginning of the first assessment and continues until the patient is discharged. It involves a series of decisions, some small and some large, made with the patient and often their family over the course of their path through mental health services.

The clinician does not need to predict behaviour in the next 5 years or even 6 months, but only until the next outpatient appointment or home visit by the community psychiatric nurse.3

Imminence and level of risk is assessed during each meeting with the patient and is guided by the risk management plan. (For inpatient settings, this may be formally undertaken on a daily basis but in an outpatient setting, this should occur each time the patient is seen.)

As well as routine management of clinical risk, good risk management should also be able to cover the following situations:

• calculated risk-taking when the level of risk will remain high

• situations in which staff anxiety will remain high

• situations in which it may be contraindicated to reduce the level of risk

• situations in which the proposed management is counterintuitive.

EXAMPLE

The classical situation in which these bullet points arise is when a management plan for a patient with chronic suicidality is first implemented. The plan will often encourage a focus of the patient taking more responsibility for themself whilst continuing to get support from the mental health service. If the self-harming behaviour (e.g. cutting) has been reinforced by frequent long admissions to hospital or by extra phone calls, the shift of focus may cause an escalation of self-harming behaviour in the short term. This should be anticipated and discussed with the patient who will be encouraged to utilise distress tolerance techniques that they will have been learning within their individual and/or group therapy. Nonetheless, there is a real risk of cutting becoming deeper, the patient feeling rejected, and the family being more concerned. The intuitive response is to not create more distress for the patient, which in the short term would help but in the long term would be negligent. Clinician anxiety during these times is often high. (See also the example of Sally, page 115.)

Risk management can be separated into two parts: management of the risk in the here and now and planning for the future. In practice, the two parts tend not to be divided as the management of the current situation should also be future oriented. A risk management plan can be used as a ‘decision support tool’4 both in the acute situation to facilitate immediate intervention as well as for implementing interventions over a longer period.

The tasks of risk management (after the assessment is complete)

1. Decide which treatment option to take and which risk(s) should be managed.

2. Managing risk factors in the context of illness.

3. Managing any other contextual matters.

4. Managing the potential consequences (risk mitigation).

5. Communicate the plan to the patient, other clinicians involved and others involved in the patient’s care.

6. Document, document, document.

7. Implementation.

8. Review and evaluation.

1 Treatment options and risk

This will occur after the assessment and may involve the risk/benefit analysis (see Chapter 10).

2 Managing the risk factors (specific strategies)

To recap:

Likelihood = static risk factors + dynamic risk factors

Once the decision has been made to follow a particular course of action, and the risk/benefit analysis has been documented, the management of the risk factors can be considered. This is no different to routine clinical practice.

The management of both the static and the dynamic risk factors is one which is discussed amongst the treatment team, the patient and family. The focus of trying to reduce the likelihood of the event occurring will invariably focus more on the dynamic factors as the static factors will not change. There is no rank order for predictors. The only change which may occur with the static factors is the patient’s adaptation to them. ‘The value for the clinician is in the interaction of the factors.’5

How frequently the risk factors are reviewed will be dependent on the setting. In services in which levels of risk are used, there should be a schedule for formal reviews to be undertaken whilst other services will determine the frequency of reviews dependent on clinical judgment. In either case, the process will be the same: a review of the risk factors. In services in which standardised rating scales are used, there will be specific risk factors which are reviewed on a regular basis. In those services in which structured clinical judgment is used without standardised rating scales, those risk factors specific to the patient will have been identified and can be considered individually. Some clinicians use simple scales — present, partially present or absent — whilst others may wish to review the efficacy of the interventions.

This step is usually indistinguishable from good clinical management of the disease process. As well as treating and managing risk factors, assessment and interventions for the early warning signs (EWS), triggers and relapse indicators should be undertaken. The aim of looking forward is to anticipate repetition of the context.6 This is the stage when the patterns which were identified as making the risk behaviour more likely are managed. This step is the central task of risk management.

EWS and triggers which may make the risk behaviour more likely are not the same as risk factors. EWS are often more subtle signs, such as irritability, loss of self-care, pre-occupation, etc. These will often be noticed by others before the patient notices them. Developing an awareness of precursors of the risk factors makes the likelihood of early intervention more possible. There will often be overlap between the risk factors, EWS and triggers. In practice it does not matter where they are documented as long as interventions are developed.

Identification of early warning signs (EWS)

Example 1

Chris is a patient with bipolar affective disorder. He usually presents with episodes of mania but has had two episodes of major depressive disorder. He enjoys the early stages of his manic episodes as he has more energy, feels invulnerable and has lots of creative ideas which he would like to incorporate into his business. Because these ideas have not been thought through, when he has implemented them, the business has often lost large amounts of money. Most of his admissions for mania have occurred several weeks into a relapse and have necessitated involuntary admission. His wife notices the early warning signs of a relapse long before Chris does. She notices that he does not sleep well, that he becomes sexually demanding and that he takes a greater interest in fitness than is usually the case for him.

Example 2

John is a patient with schizophrenia, paranoid type. During previous episodes of illness he has hit members of the public for no reason that was immediately apparent. His parents, with whom John lives, have noticed early warning signs of John relapsing into illness and also being more likely to become violent. He withdraws into his room, becomes less communicative and tends not to join them at mealtimes. He begins to pick arguments with his father.

Example 3 — clinical example

Sally is a 24-year-old woman with BPD. Over the last 3 years, she has made repeated superficial cuts to both her forearms at times of distress. Her family have been very concerned that these are attempts at suicide, and on 12 occasions she has had admissions to hospital. Sally has become very close with two of the nurses on the ward.

In recent weeks, as a result of a review of her treatment, education for Sally and her family, and the implementation of dialectical behaviour therapy (DBT), Sally has agreed to utilise some different techniques to try and change the pattern of behaviour. Even though Sally and her family realise that this will be difficult, and that she may actually find herself cutting more frequently for a period of time, she says that she won’t. In fact, much to her distress over the next 3 weeks, she does cut herself more frequently and it is only when she is able to identify how much she misses the two nurses on the ward within her individual therapy, and with her family declining to take her to the ED after each episode, that the frequency of her cutting diminishes dramatically.

Summary of specific strategies

Consideration will need to be given to the threshold for and imminence of the risk behaviour occurring. The concepts of signature risk signs (page 20), critical risk factors (page 20) and risk scenarios (page 34) will help in this regard. For example, if an impulsive patient has a history of being violent with little obvious provocation, violence may always be close by. For other patients, it may take immense provocation for them to become violent.

Sometimes it may be necessary to put short-term measures in place to reduce acute risk whilst waiting for the illness to settle.

A risk management plan will always complement and be a component of a fuller clinical treatment/management plan. The risk documentation should be placed in the patient’s file in such a way that it is easily accessible for all clinicians and written in such a way so that the risk factors, early warning signs and relapse indicators can be cross-checked against the patient’s mental state and external circumstances on the day that they are seen. Working with the patient and their family so that they all have copies of the risk and treatment plans makes this easier. This will also go a long way to increasing the likelihood of the management plan being feasible, the patient having better support and being less likely to be exposed to destabilising influences. These latter three factors rate highly in the Historical/Clinical/Risk Management 20-item (HCR 20) scale7 risk management part of its scale as being of importance in preventing future episodes of violence.

Consideration should always be given to strengthening the protective factors. This is now being explored in one standardised rating scale.8

Note: The treatment plan as well as the risk management plan must include interventions for all the identified dynamic risk factors. The risk factors need to be contextualised where possible to the patient’s illness and their own perspective on recovery.

3 Managing contextual factors

The physical context in which treatment is taking place, the time of day, clinician and team factors will all need to be considered. Management of these factors makes the management plan more feasible. It may be necessary to document how certain external contextual factors, such as lack of resources which are precluding optimal treatment, have been managed. (See the example.)

EXAMPLE

The optimal treatment for this patient would be ‘a, b and c’. However, the resources currently available preclude this approach being taken and we have had to take an alternative approach — ‘d’.

If this is documented in the notes, a clear message is being given that consideration of optimal treatment has been undertaken but because of resource implications, sub-optimal choices were necessary. This type of comment should be followed up by a letter to clinical leadership and management to alert them to the problem of insufficient resources.

4 Managing the potential consequences (risk mitigation)

After the treatment direction has been chosen, there will always be some risk left. Management of the potential consequences is primarily systemic and involves discussing the likelihood of the event occurring with the patient and family. It involves discussing the risk within the multidisciplinary team (MDT) and, if necessary, discussion with the wider management team. It will also involve the usual risk mitigation strategies such as limiting access to the means to complete the risk act; for example, limiting access to medication in the risk of suicidality etc.

Are the following questions able to be answered?

• Does the patient/family/company perceive the risk in the same way as the clinicians? Discrepancies in the perception of the risk by different people will cause substantial problems in the implementation of a risk management plan.

• How much responsibility can the patient or their family take at this time?

• Who is taking responsibility for the risk? Is it the clinician, the patient, the family? Is the responsibility shared? Does the family know the likelihood of death, suicide, assault, etc?

• Does the patient/family support the clinical approach? Patients and families are less accepting of risks over which they have little or no control, or where the consequences are dreaded. Patients and families are less likely to accept risks if there are no perceived benefits.

• Do senior clinicians support the approach? They will be the support if there is an adverse outcome. Do they even know what treatment approach is being followed? Do they need to know?

• Is there agreement from all on the level of risk?

• Will the management of the risk distract from, derail or complement the treatment of the illness?

• Has management of other risks been included; for example, media exposure?

• Consider: is a minor risk being managed because the major ones seem too hard to deal with?

5 Communicate to all concerned

This should be routine. For risk management plans, signatures of everybody who is involved in the treatment should be collected where possible. This is likely to include the patient, family, clinicians and possibly management. If this is not feasible, document who has been consulted in the development of the plan. Asking the patient to sign their plan is a therapeutic intervention, will improve rapport, ensure that the plan is feasible and also make it more likely that it has been written in plain English without ‘psychobabble’ (jargon) getting in the way. Signatories may also include chaplains, GP, medical wards, EDs and friends in more complicated plans.

Duty to warn and protect: a dilemma in communication

Occasionally a patient will threaten violence to a third party. The dilemma that a clinician finds themself in is: when can they breach patient–clinician confidentiality by informing the third party or legal authorities in order to protect them?

The duty to warn and protect is a relatively new concept and is a departure from traditional psychiatric practice. This so-called duty is to a large degree defined by legislation and case law.9

The background case which generated the current focus on this issue was the Tarasoff case. In 1969, Prosenjit Poddar told his treating psychologist that he planned to kill his former girlfriend, Ms Tatiana Tarasoff. In response to this, the clinician provided both oral and written warnings to the campus police who interviewed Mr Poddar and subsequently released him. Mr Poddar later insinuated himself with Ms Tarasoff’s family and then killed her. Her parents initiated a lawsuit. In the second court case, Tarasoff II, the court held that:

… when a therapist determines, or pursuant to the standards of his profession should determine, that his patient presents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim against such danger. The discharge of this duty may require the therapist to take one or more various steps depending on the nature of the case. Thus, it may call for him to warn the intended victim or if it is likely, to appraise the victim of a danger, to notify the police, or take whatever steps are reasonably necessary under the circumstances.10

The onus on the mental health worker is to make him or herself aware of the current legal obligations with respect to duty to warn and protect. It is likely that this evolving area of law will continue to have a substantial impact on the care of the mentally ill.

There are some general guidelines that apply to most situations.

• A full risk assessment should be undertaken before any action is taken.

• The phrase ‘if the release of that information is necessary to prevent or lessen a serious or imminent risk to others’ should be considered as the litmus test for consideration of a breach of confidentiality.

• The clinical conundrum of differentiating between fantasy which needs to be discussed within the context of treatment and the reality of a threat of violence is a difficult area. It is likely that there is a continuum between fantasies of violence and direct threats.

• Laws about breaching confidentiality are slightly different in each country and, if uncertain, advice should be taken from a senior colleague or the legal services of the workplace.

• The person or group at risk needs to be identifiable.

• If usual clinical interventions such as admitting the patient to hospital cannot control the risk, it may be necessary to inform the third-party without the patient’s consent in order to manage the risk. Only enough information to protect the third party should be disclosed. It would be rare that disclosure of psychiatric information would be required.

• Information may be passed on to an authority (e.g. the police) to protect the person at risk. If appropriate, the patient should be told that you are going to do this. If the patient’s condition will worsen as a result, the patient should be told at a later time.

• This is a rare situation and the advice of senior colleagues should always be taken whenever possible.

For further reading see Gellerman (2005).11

6 Documentation of risk management

The level of risk is usually closely linked to acuity of illness. It is usually raised when a patient experiences deterioration of mental state or when situational factors re-occur. On the risk plan there should be spaces for documentation of risk factors, early warning signs and triggers along with recommendations for interventions should these occur in the acute situation. Although interventions may have been implemented to reduce the risk in the long term, crises can still occur. The risk management plan should include recommended interventions for these situations. The proposed interventions can only ever be recommendations. The final decision has to be left to the clinician on the spot because of the many variables which will need to be factored into each unique situation.

Many mental illnesses have an enduring nature and the associated risks will often be increased before florid signs and symptoms emerge. Frequently, the risks will be identified by family and friends. Incorporating this into a plan can be invaluable.

An intervention recommending admission to hospital — voluntarily or involuntarily — dependent on level of insight may be built into a risk management plan. Once it has been identified that the risks are more likely to occur with the onset of a relapse of illness, the issue of enforced compliance with medication will be raised. For those countries that have community treatment orders (CTOs) built into their mental health legislation, life has become easier as it is simpler to work with a seamless continuum between the community and hospital. However, there is a huge debate about the legal and ethical principles behind CTOs which may make their introduction in some countries less likely.

The debate about whether there should be a separate risk management plan or whether it should be incorporated into the treatment plan has not been resolved. If there is a separate risk management plan, at the very least interventions for the dynamic factors, early warning signs and triggers for relapse should be included in the patient’s overall treatment plan as well.

Where possible, the patient should have a copy of their risk and treatment plans.

document, document, document

Consider the nearly fundamental truism: ‘If it wasn’t documented, it didn’t happen’.12

Remember — the documentation in the clinical file is the judgment based on the information that was obtained by the clinician at the time. As long as the information available and the decision-making process was documented, the clinician should not be blamed for later events if the clinical decision-making was sound and well considered.

Example

In 1999 in Ballarat, Australia, a young woman committed suicide some months after discharge from hospital. She had a long history of substantial self-harming behaviour and a diagnosis of borderline personality disorder (BPD). The discharge planning from hospital had involved close consultation with the patient, her family and the wider system involved in her care. Everybody involved knew that there were substantial risks but it was also clear that prolonged inpatient hospitalisation was not improving matters. At the inquest, the coroner was able to review the extensive documentation and communication which occurred. His words were:

… I am satisfied that the deceased received clinical, diagnostic, medicative, social and practical care and management at the highest professional level from these agencies.

The coroner went on to say:

I wish to record the community’s appreciations of the sustained support for the deceased offered by these agencies; and I record the following remarks made by the deceased’s mother, in correspondence to the coroner’s office:

‘I do not blame or criticise anyone for what has happened. It has been an extremely difficult situation. Grampians Psychiatric Services, Centacare and Ballarat Psychiatric Fellowship gave her everything and made a commitment to support her in every way possible. I only have praise for them.’13

Even when the outcome is adverse, clinicians do not need to be blamed.

7 Implement the plan in context of the treatment

Before implementing the plan, check that the future has been considered with reference to the past and present. Table 12.1 has a check list to work through.

Table 12.1 Past, present and future checklist

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8 Review and evaluate the effectiveness of the intervention

Set a date for the review. Make sure that this is communicated to everybody concerned. Preferably, review dates should be built into administrative processes.

BOX 12.1 RISK MANAGEMENT

Practice points

• A risk management plan should be placed in the patient’s file in such a way that it is easily accessible for all clinicians.

• Managing the illness usually reduces risk.

• Imminence of risk is assessed at each meeting with the patient.

• Consider any contextual factors which may be of immediate relevance; for example, time of day, geographical situation, whether family are present, etc.

• Treatment of risk factors combined with assessment and intervention for the EWS, triggers and relapse indicators is the usual practice for reducing the likelihood of the risk behaviour occurring.

• A risk management plan will always complement and be a component of a fuller treatment/management plan.

• Consider the truism, ‘If it wasn’t documented, it didn’t happen’.14

• The treatment plan should include interventions for all the identified dynamic risk factors.

The next two exercises in this section focus on the identification of interventions for the risk factors, early warning signs and triggers. The interventions are likely to be utilised in the treatment plan even if they are generated initially through the pathway of risk management. As described previously, the ability to ‘cut and paste’ makes the process of moving interventions from risk management plans to treatment plans easy. In the exercises, the plans have been partially completed. There is new information for both Colin and Monique and all that is required is for the early warning signs, triggers and interventions to be written in. Be creative with your answers and imagine that you are working alongside your patients whilst you are completing the exercises. The final part of the risk management form is a review of the efficacy of the interventions. Make sure you add a review date. This should be planned after determining how frequently the patient needs to be monitored.

Exercise 1 — Colin (continued)

You will remember Colin from Chapter 9 (exercises 3 and 6) and Chapter 10 (exercise 1).

The original example appears below, along with some new information.

Colin is a 37-year-old man who has just moved down from another city. You are asked to see him in the Emergency Department (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.

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.

At the end of the interview, Colin has declined to take any medication and is making it clear to you that he does not need any further treatment and he can sort all his problems out on his own. You feel that you have developed a reasonably good rapport with him and he has said that he will come back to see you in a few weeks to let you know how he is going. On the other hand, you are concerned about the possibility of him acting on his delusional preoccupations and wonder if he needs to be brought into hospital for treatment involuntarily. He says that he can control his anger and will not be violent.

New information

In fact, Colin returned 1 week later and said that he had changed his mind and would like to try the medication. He said that he was tired of hiding from people and questioning the way that people looked at him. Colin also said that he had come really close to hitting his new flatmate and didn’t want to go to prison. He says that he was a bit of a brawler in the past aside from the 3 convictions and tended to use his fists as a way of resolving arguments. Colin was given some Risperidone and after 3 weeks felt much better.

Colin now says that he is back to his normal self and feels well enough to start smoking cannabis again! You express your concerns and start to talk to him about the nature of psychosis, the links with cannabis and begin to explore with him possible early warning signs of relapse and indicators that he may have relapsed. The trigger of cannabis use is one that you and Colin agree to discuss further.

Parts of the risk management plan (Figure 12.1) have been completed for you. Fill out some EWS, triggers and relapse indicators for the risk management plan. Use your clinical judgment to think of some interventions which may help. Add in a date for when you think the plan should be reviewed.

image image

Figure 12.1 Risk management plan for Colin (exercise 1)

The completed plan appears in Appendix 3.

Exercise 2 — Monique (continued)

You will remember Monique from Chapter 9 (exercises 1 and 5). The original example appears below, along with some new information.

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.

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.

New information

Unfortunately, over the next 3 weeks, Monique has a relapse of her schizophrenia with a worsening of her positive symptoms and increasing difficulty not acting on the voices which are now telling her to kill herself. She is increasingly withdrawn, uncommunicative and preoccupied with her psychotic experiences. Her self-care worsens and she is admitted to your inpatient unit for restabilisation and review of treatment. Over the next 3 weeks, Monique slowly settles and feels ready to return to her supportive accommodation. She is now also on an antidepressant as well as her antipsychotic medications.

Parts of the risk management plan (Figure 12.2) have been completed for you. Fill out some EWS, triggers and relapse indicators for the risk management plan. Use your clinical judgment to think of some interventions which may help. Add in a date for when you think the plan should be reviewed.

image image

Figure 12.2 Risk management plan for Monique (exercise 2)

Comment

The immediate precipitants for Monique’s current difficulties were the breakdown of the relationship with her boyfriend. The documentation in the risk management plan has not identified the importance of giving Monique some assistance and support to help her come to terms with the end of this relationship. Without this, it is likely that the risk of suicide will remain for some time. This is perhaps an example of the focus on risk overriding the need to help the patient manage the real problem, which in this case is the distressing end of a relationship.

The completed plan appears in Appendix 3.

Notes

1 Undrill G. The risks of risk assessment. Advances in Psychiatric Treatment. 2007;13:291–297.

2 Maden A. Violence risk assessment: the question is not whether but how. Psychiatric Bulletin. 2005;29:121–122.

3 Maden A. Risk assessment in psychiatry. British Journal of Hospital Medicine. 56, 1996. No2/3.

4 McNeil D., Gregory A.L., Lam J.N., Binder R.L., Sullivan G.R. Utility of decision support tools for assessing acute risk of violence. Journal Consult Clin Psychol. 2003;71:945–953.

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

6 Grounds A. Risk assessment and management in clinical context. In: Crichton J., ed. Psychiatric Patient Violence: Risk and Response. London: Duckworth; 1995:43–59.

7 Webster C.D., Douglas K.F., Eaves D., et al. HCR-20: Assessing risk of violence (version 2). Vancouver: Mental Health Law and Policy Institute, Simon Fraser University; 1997.

8 Webster C.D., Nicholls T.L., Martin M.L., Desmarais S.L., Brink J. Short-Term Assessment of Risk and Treatability (START): The case for a New Structured Professional Judgment Scheme. Behavioural Science and the Law. 2006;24:747–766.

9 Chaimowitz G.A., Glancy G.D., Blackburn J. The duty to warn and protect — impact on practice. Canadian Journal of Psychiatry. 2000;45:899–904.

10 Applebaum P.S., Gutheil T.G. Clinical Handbook of Psychiatry and the Law, 2nd edn, Baltimore: Williams and Wilkins, 1991.

11 Gellerman D.M., Suddath R. Violent fantasy, dangerousness, and the duty to warn and protect. The Journal of the American of Psychiatry and the Law. 2005;33:484–495.

12 Gutheil T.G. Paranoia and progress notes: a guide to forensically informed psychiatric record keeping. Hospital and Community Psychiatry. 1980;31(7):479–482.

13 Case of AB (1999). Ballarat Coroners Court. 129/1999.

14 Gutheil, above, n 12.

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