Evaluating Risk. Risk assessment psychol Remember We cannot read the future Human nature is...
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Transcript of Evaluating Risk. Risk assessment psychol Remember We cannot read the future Human nature is...
Evaluating RiskEvaluating Risk
Risk assessment psycholRisk assessment psychol
RememberRemember
We cannot read the futureWe cannot read the future
Human nature is impossibly complexHuman nature is impossibly complex
Risk assessment is highly inexactRisk assessment is highly inexact
Risk management does not equal risk eliminationRisk management does not equal risk elimination
Responsibility is not a binary issueResponsibility is not a binary issue
RiskRisk
Originally a sailing term from Portuguese 'sailing into Originally a sailing term from Portuguese 'sailing into uncharted waters'.uncharted waters'.
Risk is often assessed in binary termsRisk is often assessed in binary terms
Risk assessment psycholRisk assessment psychol
Risk assessment psycholRisk assessment psychol
RiskRisk
‘‘the possibility of beneficial and harmful outcomes and the the possibility of beneficial and harmful outcomes and the likelihood of their outcome in a stated timescalelikelihood of their outcome in a stated timescale
Separate danger from riskSeparate danger from risk
Danger is the damage or harm that may occur from an Danger is the damage or harm that may occur from an eventevent
Risk is the likelihood of the eventRisk is the likelihood of the event
Risk is not static, it is dynamic.Risk is not static, it is dynamic.
Risk assessment is a cross-sectional view but Risk assessment is a cross-sectional view but may take changing factors into considerationmay take changing factors into consideration
We are not proficient at quantifying risk( one We are not proficient at quantifying risk( one study suggests we're wrong 95% of the time‘study suggests we're wrong 95% of the time‘
Thankfully wrong by overstimation in the mainThankfully wrong by overstimation in the main
Risk assessment psycholRisk assessment psychol
Risk assessment psycholRisk assessment psychol
Dangerousness and risk are different. Dangerousness and risk are different.
Dangerousness can be seen as a property of the Dangerousness can be seen as a property of the individual. It is a composite of risk and subjective individual. It is a composite of risk and subjective
perception of the riskperception of the risk
Risk involves consideration of the context and leads to a Risk involves consideration of the context and leads to a set of further questionsset of further questions
Divide into groupsDivide into groups
Task 5 minutesTask 5 minutes
Discuss all the areas of risk in child and Discuss all the areas of risk in child and adolescent mental healthadolescent mental health
FeedbackFeedback
Risk assessment psycholRisk assessment psychol
Types of adverse outcomeTypes of adverse outcome
Harm to selfHarm to selfHarm to othersHarm to others
Harm from othersHarm from othersHarm from healthcare system Harm from healthcare system
Harm to staff in the workHarm to staff in the work
Risk assessment psycholRisk assessment psychol
Types of adverse outcomeTypes of adverse outcome
•Harm to selfHarm to self Self-mutilationSelf-mutilationSuicidal actsSuicidal actsSelf neglect and starvationSelf neglect and starvation
•Harm to othersHarm to others Emotional abuse and violenceEmotional abuse and violencePhysical abuse and violencePhysical abuse and violence
•Harm from othersHarm from others Emotional abuse and exploitationEmotional abuse and exploitationPhysicalPhysicalSexualSexual
•Harm from healthcare system Harm from healthcare system
•Harm to staff in the workHarm to staff in the work
Risk assessment psycholRisk assessment psychol
Harm from othersHarm from others
Usually well covered in Child Protection Usually well covered in Child Protection proceduresprocedures
CAMHS: special role in raising awareness of CAMHS: special role in raising awareness of parental mental illness and substance misuseparental mental illness and substance misuse
High proportion of 'grey' cases and need to High proportion of 'grey' cases and need to balance need to report against potential balance need to report against potential
disruption of therapeutic interventiondisruption of therapeutic intervention
Risk assessment psycholRisk assessment psychol
Harm from healthcare system/staffHarm from healthcare system/staff
It should be consideredIt should be consideredDamaging effects of treatmentDamaging effects of treatment
Adverse effects of inpatient treatment Adverse effects of inpatient treatment Lack of resources/ training limiting effective Lack of resources/ training limiting effective
interventionsinterventionsAbuse by staffAbuse by staff
Risk assessment psycholRisk assessment psychol
Harm to staffHarm to staff
Physical assault and threatening behaviourPhysical assault and threatening behaviourTraining in de-escalation/ proper supervisionTraining in de-escalation/ proper supervision
Lone working after hoursLone working after hoursHome and community visitsHome and community visits
Psychological damage and stress caused by Psychological damage and stress caused by the work.the work.
Risk assessment psycholRisk assessment psychol
Adult MH services main focus on violence Adult MH services main focus on violence and self harmand self harm
CAMHS different issues CAMHS different issues
Of particular interest are situations of Of particular interest are situations of conflicting obligation. Tension between the conflicting obligation. Tension between the
rights of different individuals/ groups of rights of different individuals/ groups of individualsindividuals
Autonomy versus justiceAutonomy versus justiceAutonomy versus respect for parental rights/ Autonomy versus respect for parental rights/
respect for family liferespect for family life
Risk assessment psycholRisk assessment psychol
Overdose AssessmentOverdose Assessment
Separate up into groups and take 10 minutesSeparate up into groups and take 10 minutes
Tell me how you make an overdose Tell me how you make an overdose assessment of a young personassessment of a young person
Risk assessment psycholRisk assessment psychol
Some young people to be thinking aboutSome young people to be thinking about
Risk assessment psycholRisk assessment psychol
Risk assessment psycholRisk assessment psychol
16 year old girl
Overdose of 10 paracetamol
Did not know about potential lethality
Taken when angry
Immediately told mother
Came to hospital without resistance
Regrets action
No major history of emotional disturbance
Parental support
Are you worriedAre you worried
Would you let her homeWould you let her home
What advice would you give her and her What advice would you give her and her mothermother
Risk assessment psycholRisk assessment psychol
Write me a much more worrying scenarioWrite me a much more worrying scenario
Look at each of the factors listed and Look at each of the factors listed and describe a case that would really worry youdescribe a case that would really worry you
Risk assessment psycholRisk assessment psychol
16 year old girl16 year old girl
Overdose 90 paracetamolOverdose 90 paracetamolTaken with the intention of dying. Planned for 2 weeksTaken with the intention of dying. Planned for 2 weeks
Church in the evening, quietly made her peace with Church in the evening, quietly made her peace with friendsfriends
Went homeWent homeMother drunkMother drunk
Went upstairs, took the tablets alone and soberWent upstairs, took the tablets alone and soberNo direct triggerNo direct trigger
Knew mother would not disturb her until the Tuesday Knew mother would not disturb her until the Tuesday (college day)(college day)
Mother found her unconscious on TuesdayMother found her unconscious on TuesdayPhoned ambulance, only got into it for her motherPhoned ambulance, only got into it for her mother
Risk assessment psycholRisk assessment psychol
Will you send her homeWill you send her home
What might steer you to allow her homeWhat might steer you to allow her home
Risk assessment psycholRisk assessment psychol
Coldly tells you of her intent in front of parentsColdly tells you of her intent in front of parentsParents not angry, but incredulous initiallyParents not angry, but incredulous initially
Then profoundly anxious mother and Then profoundly anxious mother and dismissive fatherdismissive father
States that she has thrown her life to god and States that she has thrown her life to god and he has replied that she should livehe has replied that she should live
Agrees to engage in outpatient therapyAgrees to engage in outpatient therapyDifficult to read as to whether she has a Difficult to read as to whether she has a
depressiondepression
What would you do ?What would you do ?
Risk assessment psycholRisk assessment psychol
Attends outpatient therapy twiceAttends outpatient therapy twiceThen 2 weeks later further massive overdoseThen 2 weeks later further massive overdose
Took herself away after churchTook herself away after churchTook public transport to secluded spot after Took public transport to secluded spot after
darkdarkTook off outer clothesTook off outer clothes
Drank alcoholDrank alcoholTook over 100 paracetamolTook over 100 paracetamol
Woke 2 hours later, had vomited, and was Woke 2 hours later, had vomited, and was cold and alive so phoned her father who cold and alive so phoned her father who
called the ambulance to pick her upcalled the ambulance to pick her up
Risk assessment psycholRisk assessment psychol
ExampleExample
15 year old girl. From intact family. No known history of intra-familial 15 year old girl. From intact family. No known history of intra-familial violence or abuse. Presents after a significant overdose. She has a 4 violence or abuse. Presents after a significant overdose. She has a 4
month history of low mood, with the core, accessory and somatic month history of low mood, with the core, accessory and somatic symptoms of depression. She tells you that she does not wish to have symptoms of depression. She tells you that she does not wish to have any psychotherapeutic treatments despite your advice to her that this any psychotherapeutic treatments despite your advice to her that this
is the best first line treatment. She demands to be treated with is the best first line treatment. She demands to be treated with antidepressants. She absolutely forbids you to allow her parents to be antidepressants. She absolutely forbids you to allow her parents to be
part of the consultation, and threatens to leave if you do. part of the consultation, and threatens to leave if you do.
What are the clinical, legal and ethical issuesWhat are the clinical, legal and ethical issues
Divide into groups and discuss for 5 minutesDivide into groups and discuss for 5 minutes
Risk assessment psycholRisk assessment psychol
Risk assessment psycholRisk assessment psychol
Public EnquiriesPublic Enquiries Frequent findingsFrequent findings
Confusion over diagnosisConfusion over diagnosisEpisodes viewed in isolationEpisodes viewed in isolation
Delays Delays Poor record keepingPoor record keeping
Poor interagency communication and coordinationPoor interagency communication and coordination
Training in risk assessment is lackingTraining in risk assessment is lacking
[Evaluating Risk ( Kapur 2000)][Evaluating Risk ( Kapur 2000)]
““We are not proficient at quantifying risk.”We are not proficient at quantifying risk.”
Mental Health Professionals are wrong 95% of the timeMental Health Professionals are wrong 95% of the time
Fortunately wrong the right way ( falsely identifying those at risk, not Fortunately wrong the right way ( falsely identifying those at risk, not falsely identifying those not at risk)falsely identifying those not at risk)
Clinical versus actuarial risk Clinical versus actuarial risk assessmentassessment
Risk assessment psycholRisk assessment psychol
““This 15 year old girl took an overdose of paracetamol. She has no past This 15 year old girl took an overdose of paracetamol. She has no past history of overdose. She has a family history of depression and suicide history of overdose. She has a family history of depression and suicide
attempts but is not clinically depressed herself. attempts but is not clinically depressed herself.
In 2007 in the female 15-44 year old population the suicide rate was 4.2 per In 2007 in the female 15-44 year old population the suicide rate was 4.2 per 100,000. Family history of depression suicide attempts may increase this risk 100,000. Family history of depression suicide attempts may increase this risk
furtherfurther
In a 16 year follow up of mixed age and gender 1000 patients following self In a 16 year follow up of mixed age and gender 1000 patients following self harm by overdose the suicide rate was 3.5 % Owens 2005harm by overdose the suicide rate was 3.5 % Owens 2005
In a 20 year follow up study of 12000 patients mixed age and gender, three hundred patients had died by suicide or probable suicide. The risk in the first
year of follow-up was 0.7% (95% CI 0.6^0.9%),whichwas 66 (95% CI 52^82) times the annual risk of suicide in the general population. The risk after 5
years was 1.7%, at10 years 2.4% and at 15 years 3.0% Hawton 2003””
Risk assessment psycholRisk assessment psychol
This 15 year old girl took an overdose of 9 paracetamol. She expected This 15 year old girl took an overdose of 9 paracetamol. She expected them to kill her. She took them whilst alone at home after an argument with them to kill her. She took them whilst alone at home after an argument with
her mother. She was noticeably upset and told her mother what she had her mother. She was noticeably upset and told her mother what she had done. Her mother called an ambulance and she came into hospital. She done. Her mother called an ambulance and she came into hospital. She
was not drunk and did not need hepatic support. was not drunk and did not need hepatic support.
She gave a history of intermittent low mood, but was not clinically She gave a history of intermittent low mood, but was not clinically depressed. Her low moods seemed to occur at times when her mother was depressed. Her low moods seemed to occur at times when her mother was
low in mood, and she was expected to remain in the house and help out. low in mood, and she was expected to remain in the house and help out. Her schoolwork has recently been building up and her boyfriend has been Her schoolwork has recently been building up and her boyfriend has been
pressurising her to come out instead of staying at home to help. pressurising her to come out instead of staying at home to help.
She regrets her overdose, and commits to working with the counsellor at She regrets her overdose, and commits to working with the counsellor at school and coming to an appointment next week. Her mother is horrified school and coming to an appointment next week. Her mother is horrified that her daughter acted in such a way, and at present her own mental that her daughter acted in such a way, and at present her own mental
health is solid. She will support her daughter in accessing support. health is solid. She will support her daughter in accessing support.
Risk assessment psycholRisk assessment psychol
Which of these accounts assists you in Which of these accounts assists you in clinical decision making more. clinical decision making more.
Risk assessment psycholRisk assessment psychol
Actuarial risk assessmentActuarial risk assessment
• EpidemiologicalEpidemiological• MathematicalMathematical• Sensitivity not good, specificity good.Sensitivity not good, specificity good.• Inflexible and not easy to generaliseInflexible and not easy to generalise• Clinicians usually have only part of the informationClinicians usually have only part of the information• May be the best way of assessing e.g risk of violence or sexual May be the best way of assessing e.g risk of violence or sexual
offendingoffending
Risk assessment psycholRisk assessment psychol
Risk assessment psycholRisk assessment psychol
Actuarial risk assessmentActuarial risk assessment
• May give a 40 % chance of committing a violent act in the next 3 May give a 40 % chance of committing a violent act in the next 3 yearsyears
• But no information about the imminence, circumstances and But no information about the imminence, circumstances and severity of the actseverity of the act
• May be mathematically correct but of little use in informing May be mathematically correct but of little use in informing managementmanagement
Clinical risk assessmentClinical risk assessment
Some say unsystematic version of actuarialSome say unsystematic version of actuarial
‘‘prestigious synonym for anecdotal evidence’prestigious synonym for anecdotal evidence’
But more than this reallyBut more than this reallyIt is person specific, takes into account past behaviour and contextIt is person specific, takes into account past behaviour and context
‘‘balanced summary of prediction derived from knowledge of the individual, balanced summary of prediction derived from knowledge of the individual, present circumstances and the disorder from which he is suffering’present circumstances and the disorder from which he is suffering’
Should be multidisciplinaryShould be multidisciplinary
Can lead to better clinical understandingCan lead to better clinical understanding
Risk assessment psycholRisk assessment psychol
Clinical risk assessmentClinical risk assessment
• It is not about absolute prediction but about balanced, informed, It is not about absolute prediction but about balanced, informed, defensible decision makingdefensible decision making
• Define the concerning behaviourDefine the concerning behaviour• Distinguish probability from severity of consequencesDistinguish probability from severity of consequences• Be aware of sources of errorBe aware of sources of error• Interaction of internal and external circumstancesInteraction of internal and external circumstances• Think about missing informationThink about missing information• Modify the factors that you canModify the factors that you can
Clinical risk management Clinical risk management
Development of strategies to reduce the severity and frequency of Development of strategies to reduce the severity and frequency of identified risksidentified risks
‘‘the process of creating and maitaining safe systems of care while the process of creating and maitaining safe systems of care while taking considered therapeutic risks which serve the best interests of taking considered therapeutic risks which serve the best interests of
service users’service users’
Key components Key components Good quality recordsGood quality records
Thorough notekeepingThorough notekeepingOpen communication Open communication
Guidelines, checklists, protocols and access to advice all assist the Guidelines, checklists, protocols and access to advice all assist the process organisationallyprocess organisationally
Risk assessment psycholRisk assessment psychol
Most sensible to synthesise actuarial and clinicalMost sensible to synthesise actuarial and clinical
Bind together best research knowledge about risk Bind together best research knowledge about risk variables and use clinical skills to balance the evidencevariables and use clinical skills to balance the evidence
Perhaps less about accuracy than informed, defensible Perhaps less about accuracy than informed, defensible decisionsdecisions
Risk assessment psycholRisk assessment psychol
What are the factors that would particularly worry you What are the factors that would particularly worry you about thoughts or acts of suicideabout thoughts or acts of suicide
THINK ABOUTTHINK ABOUT
The actual thoughts or actsThe actual thoughts or actsThe trigger and contextThe trigger and contextThe mental state factorsThe mental state factors
The clinical and developmental historyThe clinical and developmental historyThe systemic responseThe systemic response
Write me a list of factorsWrite me a list of factors
Risk assessment psycholRisk assessment psychol
What are the resilience factors that you would focus on What are the resilience factors that you would focus on in young peoplein young people
Write me a list of balancing factors that might mitigate Write me a list of balancing factors that might mitigate against adverse riskagainst adverse risk
Risk assessment psycholRisk assessment psychol
Design a tool for assessing risk of self harm and Design a tool for assessing risk of self harm and suicidesuicide
Separate into groups Separate into groups
Spend 15 minutesSpend 15 minutes
Ideas for a template that could be used for both Ideas for a template that could be used for both screening and more detailed assessmentscreening and more detailed assessment
Risk assessment psycholRisk assessment psychol
Structured professional judgement (SPJ)Structured professional judgement (SPJ)
Particular form of clinical risk assessment and managementParticular form of clinical risk assessment and management
Aim is to combine the evidence base for risk factors with individual Aim is to combine the evidence base for risk factors with individual patient assessmentpatient assessment
Clinicians make a structured assessment which is used in a form a risk Clinicians make a structured assessment which is used in a form a risk management planmanagement plan
Risk assessment psycholRisk assessment psychol
SPJ Define factors asSPJ Define factors as
StaticStatic
StableStable
DynamicDynamic
FutureFuture
Risk assessment psycholRisk assessment psychol
StaticStatic
Fixed and historicalFixed and historicalE.g. family history of suicideE.g. family history of suicide
StableStable
Long term and enduring for many yearsLong term and enduring for many yearsE.g. Personality DisorderE.g. Personality Disorder
Risk assessment psycholRisk assessment psychol
Static and stable risk factors for suicideStatic and stable risk factors for suicide
History of self harmHistory of self harmSeriousness of past suicidalitySeriousness of past suicidality
Past hospitalisationPast hospitalisationHistory of mental disorderHistory of mental disorder
History of substance misuseHistory of substance misusePersonality DisorderPersonality DisorderChildhood adversityChildhood adversity
Family history of suicideFamily history of suicideAge, gender and marital statusAge, gender and marital status
Risk assessment psycholRisk assessment psychol
Note Note
Actuarial methods are solely based on static and stable factorsActuarial methods are solely based on static and stable factors
Risk assessment psycholRisk assessment psychol
DynamicDynamic
Fluctuate markedly in intensity and duration, unstable over timeFluctuate markedly in intensity and duration, unstable over time
Suicidal ideasSuicidal ideasHopelessnessHopelessness
Active psychological symptomsActive psychological symptomsTreatment adherenceTreatment adherence
Substance misuseSubstance misusePsychiatric admission and dischargePsychiatric admission and discharge
Psychosocial stressPsychosocial stressProblem-solving deficitsProblem-solving deficits
Risk assessment psycholRisk assessment psychol
FutureFuture
Result from changing circumstancesResult from changing circumstances
Access to preferred methodAccess to preferred methodFuture service contactFuture service contact
Future response to drug treatmentFuture response to drug treatmentFuture response to psychosocial interventionFuture response to psychosocial intervention
Future stressFuture stress
Risk assessment psycholRisk assessment psychol
Static and stable factors give an indication of an individual’s propensityStatic and stable factors give an indication of an individual’s propensity
They do not capture the fluctuating riskThey do not capture the fluctuating risk
Dynamic and future factors are essential for considering the particular Dynamic and future factors are essential for considering the particular conditions and circumstances associated with riskconditions and circumstances associated with risk
Comprehensive consideration of all factors will inform risk management Comprehensive consideration of all factors will inform risk management strategiesstrategies
Risk assessment psycholRisk assessment psychol
Chronic high risk due to static and stable risk factorsChronic high risk due to static and stable risk factors
Male. 17 years. Schizophrenia. Cannabis use from 14. Alcohol Male. 17 years. Schizophrenia. Cannabis use from 14. Alcohol
dependent from 15. Progressive deficit state in schizophrenia. dependent from 15. Progressive deficit state in schizophrenia.
Reasonable insight. Multiple past admissions to adolescent units. Early Reasonable insight. Multiple past admissions to adolescent units. Early
parental neglect and physical abuse. Two attempts at suicide before. parental neglect and physical abuse. Two attempts at suicide before.
One particularly worrying with trip to railway sidings to jump in front of One particularly worrying with trip to railway sidings to jump in front of
train, and only disturbed by chance encounter with railway worker. train, and only disturbed by chance encounter with railway worker.
Limited social network. Voices telling him to kill himself. His resolve to Limited social network. Voices telling him to kill himself. His resolve to
ignore their instructions varies but is reasonable at present and he ignore their instructions varies but is reasonable at present and he
feels less hopeless and pessimistic. He is not using cannabis heavilyfeels less hopeless and pessimistic. He is not using cannabis heavily
Risk assessment psycholRisk assessment psychol
1 2 3 4 5 6 7 8
Months
Lev
el o
f ri
sk Dynamic
Static andstable
Risk assessment psycholRisk assessment psychol
Background risk factors present. Risk lower at present but Background risk factors present. Risk lower at present but could escalate, particularly associated with impulse could escalate, particularly associated with impulse control problems associated with drugs and alcohol. control problems associated with drugs and alcohol. Changes tend to be slow and to emerge within the Changes tend to be slow and to emerge within the
context of the work. context of the work.
Risk assessment psycholRisk assessment psychol
Rapid onset of dynamic risk factorsRapid onset of dynamic risk factors
• 16 year old female. No past history of self harm or 16 year old female. No past history of self harm or psychiatric contact. High achiever. Close relationship psychiatric contact. High achiever. Close relationship with parents who are active in Christian church. She with parents who are active in Christian church. She does not share parents beliefs which causes does not share parents beliefs which causes embarrassment to parents. As a result cannot confide in embarrassment to parents. As a result cannot confide in parents. Falls away from studies without parents parents. Falls away from studies without parents knowledge. New relationship. Fails GCSE’s. Goes to knowledge. New relationship. Fails GCSE’s. Goes to party. Places herself in vulnerable position and is raped. party. Places herself in vulnerable position and is raped. Ashamed. Does not disclose. Discloses rape to friends Ashamed. Does not disclose. Discloses rape to friends who call her names and alienate her. Deliberate attempt who call her names and alienate her. Deliberate attempt to hang herself in garage. Only discovered by chance to hang herself in garage. Only discovered by chance because of early return of parentsbecause of early return of parents
Risk assessment psycholRisk assessment psychol
1 2 3 4 5 6
Weeks
Lev
el o
f ri
sk Dynamic
Static andstable
Risk assessment psycholRisk assessment psychol
Worrying escalation in dynamic stresses, in a girl with Worrying escalation in dynamic stresses, in a girl with coping strategies which are overwhelmed by their coping strategies which are overwhelmed by their
apparent intensity. Not mentally ill but at high risk of apparent intensity. Not mentally ill but at high risk of killing self. killing self.
Risk assessment psycholRisk assessment psychol
DSHDSH
This is an event with meaningThis is an event with meaning
Particularly social or relational meaningParticularly social or relational meaning
Usually people who use DSH remain in contact with Usually people who use DSH remain in contact with others, and there is an element of warning, or appeal others, and there is an element of warning, or appeal
for help from anotherfor help from another
Whether taken in context around others or not, there Whether taken in context around others or not, there is always symbolic meaning to be made: ‘cutting the is always symbolic meaning to be made: ‘cutting the
bad out of me’bad out of me’
The attempt : ActionsThe attempt : Actions
What was takenWhat was takenWhere was it takenWhere was it takenWas there alcohol and drugs Was there alcohol and drugs
involvedinvolvedWere there attempts at Were there attempts at
concealmentconcealmentHow did it come to attentionHow did it come to attentionAny resistance to medical Any resistance to medical
interventionintervention
The attempt : ThinkingThe attempt : Thinking
IntentIntentPlanningPlanningFinal acts, suicide noteFinal acts, suicide noteExpectation of lethalityExpectation of lethalityHow quickly changed mindHow quickly changed mindTrigger factorTrigger factorPredisposing stressesPredisposing stresses
Risk assessment psycholRisk assessment psychol
Assessment, underlying problems and screening for Assessment, underlying problems and screening for relevant mental disordersrelevant mental disorders
Mood disordersMood disorders
PsychosisPsychosis
Personality DisorderPersonality Disorder
Drug and alcohol misuseDrug and alcohol misuse
Risk assessment psycholRisk assessment psychol
IntentIntent
In the context of the assessment you have just made, what In the context of the assessment you have just made, what is the ongoing intentionis the ongoing intention
‘‘What a thing to do, I’ve found out she loves me after all, I’ll What a thing to do, I’ve found out she loves me after all, I’ll never do this again’ Impulsive regretted actnever do this again’ Impulsive regretted act
‘‘I’m going to do it again and there’s nothing you can do I’m going to do it again and there’s nothing you can do about it’ Threat of further actabout it’ Threat of further act
Nothing offeredNothing offered
Quietly and logically, someone describes to you why Quietly and logically, someone describes to you why suicide is the sensible thing for them suicide is the sensible thing for them
Risk assessment psycholRisk assessment psychol
Things that ring bells of alarmThings that ring bells of alarm
• DepressionDepression• Intent and planning now and at the timeIntent and planning now and at the time• Logical conclusion of series of dreadful eventsLogical conclusion of series of dreadful events• HopelessnessHopelessness• No moderating factors ( protective relationship, religious No moderating factors ( protective relationship, religious
belief)belief)• Past suicide attemptPast suicide attempt• Impulsive personality and substance misuseImpulsive personality and substance misuse• Psychosis particularly if under instruction or controlPsychosis particularly if under instruction or control
Risk assessment psycholRisk assessment psychol
Risk assessment psycholRisk assessment psychol
RememberRemember
We cannot read the futureWe cannot read the future
Human nature is impossibly complexHuman nature is impossibly complex
Risk assessment is highly inexactRisk assessment is highly inexact
Risk management does not equal risk eliminationRisk management does not equal risk elimination
Responsibility is not a binary issueResponsibility is not a binary issue