Assessment > Risk Assessment

Risk Assessment

TYPES: What are the main types of risk? 

 

  • To self

  • To others

  • From others

 

These are the basic ones. But in practice there are so many more and it can become quite complex.

 

You could consider this as a template for a more detailed approx. 

  • To Self: deliberate self-harm, suicide, self-neglect, accidents

  • To others: intentional (usually involving violence), accidental (including by driving), via neglect (e.g. unable to look after dependents)

  • From others: vulnerable to deliberate harm from others, vulnerable and susceptible to exploitation

  • To mental health: poor engagement with services, non-compliance of medication leading to a possible deterioration in mental health, absconding from support, etc

  • To physical health: poor engagement and compliance leading to a possible deterioration in physical health. Self-neglect could also contribute

ASSESSMENT: How to ask:

**There is no evidence that asking about suicide increases risk**. However, if not asked in appropriate detail, an important aspect could be missed that may lead to an inappropriate action being taken and no safe plan being made. 

 

Suggestions of how to ask about suicidal thoughts:

  • ‘Sometimes when people are feeling stressed/low, they may experience thoughts of harming themselves- have you ever felt this way?

  • ‘What you are saying does really difficult for you. Have you ever felt that life is not worth living?’ 

  • ‘How do you see the future?’

  • ‘This is a question I ask everyone- do you have moments when you feel life is not work living?’

 

When assessing risk, you must consider the following:

  • Risk factors that the patient has- stable and dynamic (see below). And absence of protective factors

  • Current mental state (e.g. currently psychotic, severely depressed and hopelessness)

  • Historical risk (have they don’t it before)

  • Current situation/ triggers, anything else you would consider?

 

When considering all types of risk, never ignore an instinct you have. This also applies to if you are considering risk to yourself as a professional. If you ever feel unsafe when taking to someone- always try and find a way to leave or get help

 

Risk Factors

Static vs dynamic

(dynamic are potentially changeable, states are not)

STATIC

  • Age

  • Sex

  • Family history- ? genetic link but also may have emotional, psychological and developmental links

  • Past Psychiatric history

  • Previous attempts

  • Personality traits

  • History of trauma

  • Marital status

DYNAMIC

  • Current thoughts- e.g. suicidal ideation, intent, plans

  • Current mental state: depressive or psychotic symptoms

  • Hopelessness

  • Guilt

  • Poor physical health (e.g. cancer, HIV)

  • Psychiatric admission

  • Triggers: eg loss of job, loss of partner, finances etc

Risk factors and protective factors for suicide

Risk factors for suicide​

Could include: 

  • Male gender

  • Age (typically over 45 years but also under 19)

  • Previous history

  • Alcohol and drug use

  • Separated/divorced/ lack of social supports

  • Mental state changes (e.g. depressive or psychotic symptoms) with current suicidal ideas, intent and a plan

​Protective factors for suicide​

  • For men: being married

  • Active religious beliefs

  • Meaningful employment

  • Social supports

  • Another factor with particular significant to individual

Risk of harm to others: See the HCR risk model:

Clinical

  • Lack of insight

  • Negative attitudes

  • Active symptoms of major mental illness

  • Impulsivity

  • Unresponsive to treatment

Historical

  • Previous violence

  • Young age at first onset

  • Relationship instability

  • Employment problems

  • Substance misuse

  • Major mental illness

  • Psychopathy

  • Early maladjustment

  • Personality disorder

  • Prior supervision failure

Risk Management

  • Plans lack feasibility

  • Exposure to destabilizers

  • Lack of personal support

  • Non compliance with remedition attempts

  • Stress

How to structure your risk assessment:

If you are asking about IDEAS (e.g. suicidal thoughts): Thoughts -> Intent -> Consideration of methods -> Plan -> Attempts

Example of history format for suicidal ideas:

  • Thoughts: what thoughts are they having? For how long? Nature of thoughts? What triggers these thoughts? What led to these thoughts?

  • Intent:do they want to act on these thoughts? Do they ever want to act on these thoughts?

  • Consideration of methods:Have they thought how they would try to end their life? Have they done research? Do they have any particular previous knowledge or experience? 

  • Plan: do they plan to act on these thoughts? Have they got a particular time and date in mind? Have they made preparations (e.g. Obtained the right equipment/tablets, made a will, written a note, made allowances so they will not be found during the act)

  • Attempts: Have they recently acted on these thoughts? Is the presentation to mental health services following an attempt? Have they attempted suicide in the past?

  • Protective factors: if they have not yet acted, what is stopping them? Is it some hope for the future, a particular date, friends or family etc?

 

If you are asking about an EVENT (e.g. suicidal attempt or an act of violence): Before, during, after

Example of history format for a suicidal event (e.g. attempt or severe thoughts with plan):

Before

  • Triggers?

  • Impulsive or planned?

  • Amount of planning/research-

  • Final acts: Wills or notes, Organisation of affairs 

During

  • Method used 

  • Intent during the act

  • Perception of lethality

  • Attempts to avoid discovery

  • Perception of likelihood of being interrupted

  • Any attempts to obtain help

  • Were they intoxicated with drugs or alcohol

After

  • How they came to medical attention

  • Views on self-harm episode

  • Any regret?

  • Continuing ideation or plans

  • Evidence of hopelessness and views of future

 

 

EXERCISE:

 

https://www.youtube.com/watch?v=0XEKrRJeB5I

 

Watch this consultation. Imagine you need to document the discuss and the risk assessment that the professional made. Use the above template to consider your ideas: WRITE NOTES and try not to look at answers until after the exercise

 

See Quiz 5 for a suggested answer.