Understanding the risk

Published on 24/05/2015 by admin

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Last modified 24/05/2015

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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.

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