Understanding the risk

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Chapter 4 Understanding the risk

It is not sufficient to simply identify the risk and risk factors associated in order to manage the risk. It is also necessary to identify patterns which make the risk behaviour more likely and, to do this, the previous episodes of risk behaviour will need to be explored in as much detail as possible. It is from the analysis of previous episodes of risk behaviour that the patterns will begin to emerge. Further information which will yield more information about the patterns of risk are the elements of personal meaning which a patient will attach to the risk.

From the identification of patterns and understanding of the meaning attached to the risk, critical risk factors may be identified.

The process for exploring this information is termed the ‘anamnestic analysis’ (anamnesis — the recalling of things past). The term anamnesis has a long history in mental health work and refers more specifically to a reconstruction of the historical development of the behaviour.1 A structure for this aspect of the risk assessment, such as a chain analysis2 or functional analysis,3 may be used. The behaviour is examined step-by-step as closely as possible to try and pick up the antecedents as well as the behavioural and emotional consequences to the behaviour.

There are three main ways in which this information can be found:

1. taking the history from the patient

2. discussion with relatives and friends, other health care providers and so forth

3. examination of previous case files, criminal records and so forth.

It is very common for some of this information to be gleaned from previous case files. Taking the collateral history is a routine part of history taking within mental health practice and this is no different when undertaking a risk assessment.

Exploring past episodes of risk behaviour and identifying patterns

If the risk behaviour has occurred before, it is extremely likely that there is a pattern to the behaviour. Either the external events are being repeated (e.g. loss of job, loss of relationship) or the patient’s mental state is the same (e.g. relapse of psychosis with command hallucinations). Sometimes the external events will cause a relapse of the patient’s illness or a relapse will create a change in the external environment making the risk behaviour more likely to occur.

Within the risk assessment, looking for patterns to the risk behaviour is a very important guide for future risk management.

The patterns usually relate to the dynamic factors. The discovery of these patterns is important for two reasons:

1. if the external environment and/or mental state match previous patterns, the level of risk is likely to be high

2. the patterns identified will lay the foundation for future interventions. From here, triggers and early warning signs can be identified, which can ultimately lead to relapse prevention work.

The importance of exploring previous risk episodes in detail cannot be emphasised enough.

The history of past episodes of risk behaviours needs to include:

• the mental state at the time — whether it occurred in the context of illness

• treatment at the time — whether medication was being taken

• the social circumstances at the time — when, where and to whom it happened

• whether substance use was involved.

Example 1

If Bobby discontinues his medication, stops washing himself and becomes pre-occupied with the Old Testament in the Bible, it is likely that his delusional pre-occupation with Satan has returned. This has been linked to his violent outbursts in the past.

Comment: although the major risk factor leading to violence is a delusional pre-occupation with Satan, this may not be evident to his clinicians as Bobby may not speak about it. The risk factors of stopping medication, not washing and reading the Old Testament together is the pattern which is of more use.

Example 2 Suicidal intent in the context of intoxication

It is not unusual to come across patients who only express suicidal intent in the context of intoxication.

Emma is a 28-year-old woman who has a binge pattern of alcohol abuse. She has co-morbid problems of dysthymia and she also has post-traumatic stress disorder (PTSD). From time to time, her intrusive memories of her trauma (a rape at the age of 18) become more pervasive and to manage these memories, she often turns to alcohol. She describes her depression as getting the better of her at these times and she is clear that she is only ever actively suicidal when drunk. She has now made three substantive efforts to kill herself when intoxicated. When each suicide attempt was explored in detail with Emma, several recurring themes/patterns emerged: intoxication, intrusive memories and difficulties within her relationship with her boyfriend. These were explored further when her boyfriend’s perspective was heard (with Emma present) and when her previous notes were reviewed.

Emma was able to identify these patterns at an earlier stage as time went by and was able to request support before she slipped into an alcohol binge.

This exploration will yield the most important patterns of risk factors particular to that patient — the signature risk signs and/or the critical risk factors and may highlight the pathway that leads to the risk behaviour. ‘Risk scenarios’ — situations or states of mind when the risk is more likely to occur — are another way in which the patterns leading to the risk behaviour are sometimes described.

BOX 4.1 ANAMNESTIC ANALYSIS OF RISK

Practice points

• A detailed analysis of past episodes of the risk behaviour should always be undertaken.

• Patterns of risk behaviours should be identified; critical risk factors and/or signature risk signs for individual patients can be identified from the patterns.

• A chain or functional analysis of events, thoughts and emotions leading up to the risk behaviour and following on from it can help in understanding the function of the behaviour.

• The exploration of the function can assist in elucidating pathways and patterns for the risk behaviour.

Not infrequently, there will be substantial resistance to an exploration of the history of the risk behaviour. A good example would be the patient who has committed sexual crimes. For a patient to discuss this with a clinician is extremely difficult and the process may take not just weeks but often months. Nonetheless, the same process should occur and as more meaning is obtained by both the patient and the clinician, a better understanding can be had of the drivers of the risk behaviour.

The function of risk behaviours — more detailed analysis

A further component of the assessment of risk is the exploration of the function of the risk. This can also be considered as an exploration of the meaning of, motivation behind, or purpose of the risk behaviour.

An example is of a patient who has a delusional belief that if he doesn’t kill his mother, the world will end. For this poor man, the function of acting on the delusional belief would be to save the world even if it means sacrificing his mother, and for him, the risk behaviour has substantial meaning.

The risk behaviour now becomes understandable. It puts the behaviour firmly back into the context of the patient’s illness and allows for an exploration of treatment modalities as well as ways of limiting the opportunities for the patient to act on the impulse. Making sense of the risk behaviour with the patient is a good way of improving rapport.

Another example is the patient with borderline personality disorder (BPD) who cuts herself in order to be able to feel emotion. Knowing that she does not have any other skills for the expression of emotion makes the behaviour understandable even if there is a risk of exsanguination from deep cuts. (This example becomes complicated as there is often an associated desire for death or peace at the time of the cutting which adds further meaning to the risk behaviour.)

A further example would be a patient who is violent but only in certain circumscribed situations. Exploring this and discovering that his father had sadistic tendencies, which the patient is repeating, provides a meaning and understanding to the violent behaviour which can be utilised in treatment.

Exploring the function of the risk behaviour can be broken down into two parts. The first part is looking into the patient’s thoughts and feelings before the risk behaviour occurs. In the first example, the risk factor of the delusional belief is already present but for the patient to act on the delusional belief, he will need to go through the anguish of trying to work out whether he should kill his mother or not. In the example of the patient who is only violent in certain situations, a similar exercise would be undertaken of exploring the thoughts and feelings which are occurring for the patient prior to the risk behaviour occurring.

The second part is looking at the patient’s thoughts and feelings after the risk behaviour has happened. This is more relevant for those risks where the behaviour is reinforcing in some way for the patient. For those patients where the risk behaviour is reinforcing, there may be immense difficulty in attempting to reduce the risk as there will be barriers erected to prevent this from happening. As well as documenting the meaning or purpose of the risk behaviour, it is important to explore whether there are any reinforcers of it.

For example, a patient says that he is more likely to assault his girlfriend if he is not given benzodiazepines. The threats of assault are regarded as the risk but there will be resistance to the management of them by the patient because this would cause his supply of benzodiazepines to dry up. The real problem is the patient’s dependence on benzodiazepines. As treatment proceeds, there is a possibility that the threats will increase before they are extinguished.

Another common example is when a patient with BPD finds their self-harming behaviour reinforcing as it reduces their distress, causes their family to be worried about them and for mental health professionals to display rescuing behaviour by admitting them to hospital.

In both of these examples, there will be substantial conscious and unconscious resistance to having the risk behaviour reduced. This resistance can also be seen in clinicians who will need to sit with higher levels of risk and anxiety in the short term in order for the problem behaviours to be successfully managed.

To further complicate matters, sometimes there is substantial ambivalence. In the latter example, a part of the patient may want to ‘die’ (often there is a desire for death, peace and a break from the torment) whilst another part will want the rescuing behaviour of family and mental health staff.

Patients with an alcohol or drug disorder or with a coexisting mental illness and substance abuse create further complications. Sometimes distress will be alleviated by using substances which then become reinforcing. The difficulty is that substance use can become risky behaviour in its own right.

This is explored further in Chapter 16, Psychodynamic principles and boundary issues.

BOX 4.2 CLINICAL TIP

Risk behaviours in mental health settings are invariably associated with fear. It is unusual for patients not to experience fear as a result of their altered mental state. This is certainly the case for patients who are suicidal or who are preoccupied with self-harm thoughts but it is also very common in patients who demonstrate violence. It would not be unusual for a patient to display violence as the only way that they feel they can protect themselves from a perceived threat. Exploring a patient’s fear will help in understanding the function of the risk behaviour.

For the patient to be able to understand the function of the risk is often the beginning of a therapeutic shift for the patient and their family. As a component of risk assessment and management, this cannot be undertaken without the patient (and their family when appropriate) being an active participant. This discussion during the assessment often becomes the starting point for the development of interventions and a shared perspective of the risk. In conjunction with the management of the risk factors, clinicians can then plan interventions with the patient based on the knowledge gained and the risk is reduced.

BOX 4.3 PATTERNS OF RISK BEHAVIOUR

Practice points

The following four points need to be covered when looking for the patterns of risk:

1. the mental state at the time — whether it occurred in the context of illness

2. treatment at the time — whether medication was being taken

3. the social circumstances at the time — what was happening, and when, where and to whom it happened

4. whether substance use was involved.

Notes

1 Jung C.G. Collected Works. The Development of Personality. 1934;vol 17:177–180.

2 Linehan M.M. Cognitive Behavioural Treatment of Borderline Personality Disorder. New York: The Guilford Press; 1993.

3 Sturmey P. Functional Analysis in Clinical Psychology. New York: Wiley; 1996.

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