Evaluating Risk. Risk assessment psychol Remember We cannot read the future Human nature is impossibly complex Risk assessment is highly inexact Risk

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



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



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


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


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


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


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


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.


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


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


Some young people to be thinking aboutSome young people to be thinking about



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


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


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


Will you send her homeWill you send her home

What might steer you to allow her homeWhat might steer you to allow her home


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 ?


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


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



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


““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””


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.


Which of these accounts assists you in Which of these accounts assists you in clinical decision making more. clinical decision making more.


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



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


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


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


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


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


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


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


SPJ Define factors asSPJ Define factors as

StaticStatic

StableStable

DynamicDynamic

FutureFuture


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


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


Note Note

Actuarial methods are solely based on static and stable factorsActuarial methods are solely based on static and stable factors


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


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


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


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


1 2 3 4 5 6 7 8

Months

Lev

el o

f ri

sk Dynamic

Static andstable


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.


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


1 2 3 4 5 6

Weeks

Lev

el o

f ri

sk Dynamic

Static andstable


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.


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


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


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


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



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

Documents

Evaluating Risk. Risk assessment psychol Remember We cannot read the future Human nature is impossibly complex Risk assessment is highly inexact Risk