Risk Management

1
Risk Management

• Theodore M. Godlaski
• University of Kentucky
• College of Social Work

2
Legal Concerns

• The law in Kentucky requires reporting of
  knowledge or reasonable suspicion of child or
  adult abuse, neglect, or exploitation.
• Child and adult protective services are obliged
  to investigate all reports.
• Courts and social service agencies have a variety
  of methods to assist in the resolution of
  situations of domestic violence.

3
Ethical Considerations

• Under Fidelity, the therapist owes the client
  confidentiality.
• This is a consensual not a natural right.
• When the natural right to live free from the fear
  of harm is at risk, it overrides confidentiality.

4
Ethical Considerations

• Under Beneficence/Nonmaleficence the therapist
  must act in the best interest of the client and
  do nothing to bring the client to harm.
• Doing nothing to limit risk is never considered
  preferable to doing something.
• The therapist is obliged to do what is possible
  to insure the clients safety and that of others.

5
Risk Assessment

• Theodore M. Godlaski
• Robert Walker

6
Risk Management as a Duty of Care

• Clinicians have an obligation to see to the
  safety of clients.
• Clients may be at risk of self harm
• Harm to others
• Harm from others.
• Thus, this duty extends to all those who might be
  at risk from their clients as well.

7
Risk Management as a Duty of Care

• This duty of care falls under the rubric of due
  diligence.
• This duty of care cannot be met by a single risk
  assessment.
• It extends, over time, throughout the clinical
  relationship.
• Consequently, the need to be alert to indications
  that risk is present is always part of the
  therapeutic relationship.
• A risk assessment is not the work of the first
  session only.

8
Risk Management as a Duty of Care

• Risk management is not a matter of diagnosis but
  of behavioral and descriptive assessment.
• Because the circumstances of the client are
  dynamic and ever changing, so too the clinician
  must be aware of the effect of these changing
  circumstances on the risks of victimization and
  perpetration.

9
Risk Management as a Duty of Care

• Once it is determined that significant risk is
  present the clinician is obliged to take all
  reasonable measures to protect the client and
  others.
• These measures may include clear and sustained
  focus on lethal circumstances, increased
  intensity of treatment (including involuntary
  treatment), involvement of external agencies.
• Determining such measures should 1) respect the
  clients interest in preserving freedom, 2) favor
  the least restrictive effective care, 3)
  recognize the resources available.

10
Risk Management as a Duty of Care

• It is important to remember that one kind of risk
  does not eliminate the possibility of other kinds
  of risk
• Individuals who are perpetrators may also be at
  risk of harm to self
• Individuals who are victims may also be at risk
  of harm to self
• Victims can also be at risk of harming others.

11
Techniques of Risk Assessment

• Global-Clinical
• Construct-Based
• Actuarial
• Actuarially Anchored
• Structured Clinical Judgement

12
Global-Clinical Risk Prediction

• Only method until 1980s, leading method until
  1990s
• Methodology Interview, personality testing,
  skill and experience of assessor, global
  judgement of dangerousness
• Assessors tend to focus on a few key factors
  and make judgements simply, despite subjective
  feeling of complex consideration of many factors
• Approach found to be of little value in
  predicting violence

13
Construct-Based Risk Prediction

• Identification of personality characteristics
  associated with violence
• Only one such method shown to work -- the
  Psychopathy Checklist - Revised (Hare, 1991)
• Combination of behavioural, historical, and
  clinical items related to two factors an
  antisocial, criminal lifestyle, and a callous,
  remorseless use of other people
• Individuals identified as psychopaths on the
  PCL-R far more likely than non-psychopathic
  individuals to commit further violent offences,
  and at a much faster rate
• PCL-R revitalized the science of risk assessment,
  but only applies to a small number of those being
  assessed

14
Actuarial Risk Prediction

• Historical information about the person is placed
  into an actuarial formula related to risk for
  violence
• Several methods available -- the Violence Risk
  Assessment Guide, the Sex Offender Risk
  Assessment Guide, the Static-99
• Methods allow for placement of individuals into
  risk groups compared to a large normative
  sample
• Methods show good predictive validity, allow for
  prediction of specific types of violence over a
  defined time frame
• Criticized for focussing on historical elements
  that cannot change, may miss dynamic and crucial
  risk elements

15
Actuarial-Anchored Risk Prediction

• Attempt to address some criticisms of strict
  actuarial approach by allowing for clinical
  information to influence risk judgement
• Actuarial risk is adjusted up or down from an
  anchor based on the presence or absence of
  clinical elements that seem to increase or
  decrease risk
• Some initial proponents of this approach have
  abandoned it, stating that actuarial predictions
  are too good, and clinical predictions too poor,
  to risk contaminating the former with the latter

16
Structured Clinical Judgment

• Most recent development in risk prediction
• Attempt to synthesize individual factors known to
  be empirically related to risk into an evaluation
  system
• Not an actuarial formula, no comparisons to
  normative samples or placement in risk groups
• Clinician considers and rates all of the known
  factors and makes a judgement of risk
• Approach useful for assessing risk for particular
  types of violence for which not enough normative
  data is available, but in most cases validity not
  established

17
THE FOUR DOMAINS OF RISKMonahan, J. Steadman,
H.J. (2001). Violence risk assessment A quarter
century of research. In Frost, L. E. , Bonnie,
R J. (Eds.) The evolution of mental health law.
(pp. 195-211). Washington, DC, US American
Psychological Association.

• DISPOSITIONAL RISK FACTORS
• CLINICAL RISK FACTORS
• HISTORICAL RISK FACTORS
• CONTEXTUAL RISK FACTORS

18
DISPOSITIONAL FACTORS

• These are life-long, enduring traits (with
  probable genetic contributions) that are
  associated with increased risk of harm including
• SUSTAINED ANGRY DISPOSITION
• PERSISTENT NEGATIVE, HOSTILE, INFERENCES
• SUSTAINED HOSTILE ATTITUDE
• PERSISTENT INFERENCE OF BEING INJURED, HARMED BY
  OTHERS

19
DISPOSITIONAL FACTORS

• HYPOAROUSABILITY - The under inhibited
  temperamental type
• HYPERAROUSABILITY - The overly inhibited
  temperamental type
• LIMITED INTELLECTUAL OR COGNITIVE ABILITY

20
DISPOSITIONAL FACTORS

• IMPULSIVITY
• - Cognitive impulsivity i.e., jumping to
  conclusions, hasty inferences
• Behavioral impulsivity
• THRILL SEEKING 
• ATTENTIONAL DEFICITS

21
CLINICAL FACTORS

• CONDITIONS THAT CONTRIBUTE TO HEIGHTENED RISK
• Command hallucinations - particularly when
  content is threatening harm
• Severely compromised sensorium
• Hallucinations secondary to withdrawal or
  intoxication
• Highly suspicious attitude or thinking
• Poor adherence to prescribed medications

22
CLINICAL FACTORS

• Acquired brain injury
• Delusions
• Alcohol, cocaine, amphetamine, hallucinogen,
  inhalant use (marijuana - only as it impedes
  psychotropic medications and contributes to
  social skill deterioration)

23
CLINICAL FACTORS

• Severely depressed mood - particularly agitated
  depression
• PTSD
• Panic
• Antisocial personality traits - the greater the
  number of these, the higher the risk profile
• Borderline traits

24
HISTORICAL FACTORS

• Events in the persons history that are
  associated with heightened risk of harm
  including
• Childhood victim experiences of sexual abuse -
  particularly when accompanied by threats
• Childhood victim experiences of physical abuse or
  witnessing violence toward other family members
  or parents

25
HISTORICAL FACTORS

• Severe and persistent neglect in childhood
• Attachment disorders
• Early onset of aggression (pre-adolescent)
• This does not necessarily include all conduct
  disorder traits - but refers to higher levels of
  aggressive behavior that causes injury and is
  persistent, not reactive to abuse incidents

26
HISTORICAL FACTORS

• Suicide attempts and family history of suicide
  completion
• Adult victim experiences of physical and/or
  sexual violence
• Childhood placements in foster care or
  institutions - the greater the number, the higher
  the risk profile

27
CONTEXTUAL FACTORS

• Circumstances and situations that aggravate risk
  and that can potentiate dispositional, clinical,
  and historical factors including
• Loss or threatened loss of residential setting
• Loss of loved one, caregiver, or significant
  relationship
• Loss of income, job or financial benefits

28
CONTEXTUAL FACTORS

• Living in unmarried relationship
• Presence and availability of handguns
• Availability of lethal amounts of medication
• Serious legal problems
• Living with or in relationship with violent
  partner
• Adult males living with non-biologically related
  children
• Environmental exposure to heavy substance use

29
RISK LEVELS

• LOW RISK
• MODERATE RISK
• HIGH RISK
• CRITICAL RISK
• There are no no risk individuals

30
LOW AND MODERATE RISK STATUS

• LOW RISK status may be assigned to those who show
  few if any identifiable risk factors or
  predisposing factors for harm and no expressed
  intent to harm self or others
• Low risk cases call for occasional risk scanning
  to determine changes in situation or status, but
  NO definitive or targeted risk management
  actions.
• MODERATE RISK status is assigned to those who do
  not have significant risk factors but who have
  expressed threats to harm self or others.
  Situational (contextual) factors are very
  important in these cases. Clinical responses
  should be shaped by the nature of the expressed
  risk and risk should be monitored nearly every
  session.

31
HIGH AND CRITICAL RISK STATUS

• HIGH RISK status should be assigned to those who,
  independent of immediate threats to harm self or
  others, have significant risk factors that
  predispose toward danger. These individuals
  should be monitored closely every session and
  treatment should be aimed at harm
  reduction/prevention.

32
HIGH AND CRITICAL RISK STATUS

• CRITICAL RISK status should be assigned to those
  who have significant risk factors AND are
  expressing (verbally or behaviorally) intent to
  harm self or others. They combine high levels of
  predisposing factors plus situations and intent
  to harm. The clinical response must be aimed at
  harm reduction and vigilant care to protect self
  and/or others.

33
RISK SCANNING

• RE Self harm -
• Have you thought of harming yourself?
• How would you do this?
• Have you given thought to suicide in the past?
  Are you thinking of it now?

34
RISK SCANNING

• Harm to others -
• Have there been times in the past when you have
  injured others?
• How so?
• Have you found yourself thinking about harming
  others?
• In what ways?
• Do you find yourself losing your temper easily?
• What happens when you do this?

35
RISK SCANNING

• Harm to self from others -
• Do you ever find yourself fearing injury or harm
  from someone?
• How so? What do you think would explain this?
• Is anyone threatening to harm you?
• Have you been seriously injured by anyone before?
  
• How so?
• Do you feel unsafe in your home?
• In what way?

36
RISK SCANNING

• If the individual answers in the affirmative to
  any of these items and the immediate follow-up
  questions elicit positive answers, then the
  clinician should go ahead and conduct a full risk
  assessment.

37
RISK SCANNING

• If the individual answers these items negatively
  and does not fall into any of the high risk
  groups then the scan should suffice. This
  individual would fit into the low risk category
  described above. The clinician should remain
  vigilant for the appearance of risk factors at
  any time in therapy and should re-visit this scan
  from time to time in treatment.

38
Risk Assessment Perpetrators DISPOSITIONAL
CHARACTERISTICS

• Look For
•   BASIC DISPOSITIONAL CHARACTERISTICS
• males are far more likely to batter, threaten or
  coerce spousal partners.
• males with early age onset of alcohol use and
  whose fathers were alcoholic have higher risk of
  aggression than others
• an angry, hostile disposition is a significant
  marker for harm to others and to self -- there
  are three variations (there are at least three
  types of batterers in the literature)

39
Risk Assessment Perpetrators DISPOSITIONAL
CHARACTERISTICS

• emotionally reactive type (hostile/depressive)
• poor inhibition of impulses
• poor social skills
• has an explosive, volatile quality
• experiences a feeling of loss of control when
  angry - is highly aroused by angry states
• impresses others as being immature and often
  ineffectual

40
Risk Assessment Perpetrators DISPOSITIONAL
CHARACTERISTICS

• instrumental type (perfectionistic/over
  controlling)
• is very controlling
• experiences calming effects from violence and
  anger episodes - opposite to the reactive type
• is extremely suspicious and jealous
• is emotionally constricted
• has rigid, controlling, personality style

41
Risk Assessment Perpetrators DISPOSITIONAL
CHARACTERISTICS

• antisocial type (antisocial)
• is not attached to others
• very likely to abuse drugs or alcohol
• has poor impulse control
• blames others for negative outcomes
• little or no remorse
• uses violence to get his way rather than to
  control others

42
Risk Assessment Perpetrators DISPOSITIONAL
CHARACTERISTICS

• risk taking temperamental traits - particularly
  when associated with temperament of
  hypoarousability - the trait of needing high
  thresholds of excitement in order to achieve
  desired mental state
• poorly regulated emotions
• poor ability to inhibit impulses
• attentional deficits
• poor ability to put ideas and feelings into
  words
• hyperactivity

43
Risk Assessment Perpetrators Clinical Features

• Clinical Features
• use of substances (use, not necessarily abuse or
  dependence, is a factor)
• cocaine, amphetamine (including MDMA, post
  intoxication), and alcohol are most often
  associated with violence and harm to others.
• alcohol use may be associated with the degree of
  injury or harm caused by the aggressive act. It
  is a potentiator, but not a cause of violence.

44
Risk Assessment Perpetrators Clinical Features

• acquired brain injury
• affective instability and extreme mood variations
• in batterers, extreme controlling behaviors
• jealousy and suspicious attitudes toward partners
• beliefs about the legitimacy of male dominance
  and rigid stereotypes about male roles
• fatalistic beliefs

45
Risk Assessment Perpetrators Clinical Features

• poor self esteem and, most importantly, low self
  efficacy ( the belief that one is actually able
  to affect change in his or her life)
• personality disorder - particularly the B
  Cluster disorders
• Primarily Antisocial and Borderline, secondarily
  Narcissistic
• bipolar disorder
• presence of suicidal thinking

46
Risk Assessment Perpetrators Clinical Features,
B Cluster

• Antisocial
• Conformity to law lacking
• Obligations ignored
• Reckless disregard for safety
• Remorse lacking
• Underhanded (lies and cons)
• Planning insufficient (impulsive)
• Temper (irritable aggressive)

47
Risk Assessment Perpetrators Clinical Features,
B Cluster

• Borderline
• Abandonment fear of
• Mood instability
• Suicidal (self-mutilating) behavior
• Unstable, intense relationships
• Impulsive (2 potentially damaging areas)
• Control of anger lacking
• Identity disturbance
• Dissociative symptoms (transient and
  stress-related)
• Emptiness, chronic feelings of

48
Risk Assessment Perpetrators Clinical Features,
B Cluster

• Narcissistic Personality Disorder
• Special (believes he/she is)
• Preoccupied with fantasies
• Entitlement
• Conceited (grandiose and self-important)
• Interpersonal exploitation
• Arrogant (haughty)
• Lacks empathy

49
Risk Assessment Perpetrators Life History

• Life History
• childhood experience of physical, sexual, and
  emotional abuse
• childhood witness to domestic violence
• early history of aggression and bullying
• early history of sexual aggression or adult-like
  sexual pursuits
• poor adaptations to social norms in school and in
  personal relationships

50
Risk Assessment Perpetrators Life History

• early experience with alcohol, inhalants,
  tobacco, and other drugs
• history of conflicts and instability in personal
  relationships that lead to physical harm to self
  or others (adolescent experiences with date
  violence)
• history of sexual promiscuity and HIV high risk
  sexual activity

51
Risk Assessment Perpetrators Life History

• history of suicidal attempts or gestures (the
  greater the number of attempts, the greater the
  risk both for suicide and uxoricide)
• adult experiences of violent crime, rape, or
  brutality (can include witnessing AND being a
  victim)

52
Risk Assessment Perpetrators Context and
Environment

• Context and Environment
• partners decision or action to separate or
  divorce
• belief that spouse or partner is involved with
  another person
• ready availability of guns - particularly
  handguns
• loss of employment and/or significant economic
  hardship

53
Risk Assessment Perpetrators Context and
Environment

• incidents of perceived injury to self esteem
• partner has children from an earlier
  relationship living in the family
• partner is enjoying greater success in work or
  other social settings
• individuals socialization is predominantly in
  male-only settings OR the individual is socially
  isolated

54
Risk Assessment Perpetrators Mitigating Factors

• Mitigating Factors
• desire to avoid negative consequences such as
  arrest, protective order, or incarceration
• belief that there will be legal or other serious
  consequences for violence toward partner or
  children
• willingness to participate in batterers treatment
  programs AND any other treatment that might be
  indicated (medication or other therapy - e.g.,
  substance abuse treatment)

55
Risk Assessment Perpetrators Mitigating Factors

• empathy for others, realistic guilt for harmful
  actions - including harm to the children in the
  family who witness the violence
• history of periods of alcohol and drug abstinence
  
• belief that violence to self or others is wrong
• childhood or other experiences that instill a
  conviction against violence to self or others

56
What to Ask

• When you become angry, do you ever have thoughts
  of hurting yourself?
• What kind of event is MOST likely to make you
  feel suicidal?
• When you feel suicidal, what are you thinking
  about your partner?
• Do you ever find yourself wanting to die?
• How would you harm yourself?
• How would you put the plan in place - step by
  step?
• What weapons do you have access to? What about
  drugs or other means of self harm?

57
What to Ask

• Where would your family or partner be at the time
  of your harming yourself?
• When you have attempted suicide in the past, how
  have you done it?
• What has happened in the past to keep you from
  killing yourself?
• What has made the hopelessness go away?
• How much more likely is that you will try to hurt
  yourself when you are high or drunk?
• When you want to harm yourself are you more
  likely to want to harm others as well?

58
What to Ask

• In what way do you take control when angry at
  your partner?
• What are the steps by which you insure that you
  are not going to be put down?
• When you think about getting back at your
  partner, how do you do it?
• When you have been angry, how have you dealt with
  it in the past?
• Have you gotten back at your partner in the past?
• How do you follow through on threats?

59
What to Ask

• What was the earliest time in your life that you
  were involved in a fight? Threatened others with
  a weapon?
• What injuries resulted?
• What happened to you after this - any
  consequences?
• What was the first time you used force with a
  girl friend or date when she was not acting the
  way you thought she should?
• What has helped to prevent you from following
  through on threats in the past?
• Do you plan these things out in your mind or do
  they just happen out of the blue?
• If they just happen, what has helped you to
  contain them in the past?

60
What to Do

• Explore the victims experience of the offender
  and her assessment of intent, degree of harm,
  history of events and sequences.
• Explore the victims plans for her own safety and
  take steps to link her with services that can
  assist this including
• make a report to DSS pursuant to applicable law
• execute any duties to warn if actual specific
  threats are present
• make a referral to law enforcement where the
  victim can achieve legal remedies and protection
  (EPOs, DVOs)
• maintain open line of communication between
  victim and clinician
• advise offender of necessity for making reports
  and for keeping open communications between
  public agencies, collateral parties and others
  when domestic violence is present

61
What to Do

• If the individual is making threats of actual
  specific harm, execute duties to warn and to
  protect by contacting the victim and law
  enforcement agency nearest the victim.
• Do not rely on any form of treatment as the sole
  means of reducing risk of harm or protection for
  the victim - treatment settings may be considered
  IN ADDITION to law enforcement or other safety
  referrals for the victim.
• When the individual discloses acts of domestic
  violence, set aside traditional mental health or
  substance abuse counseling and shift focus to
  risk reduction.

62
What to Do

• Where there is high or critical risk, AND
  evidence of serious mental disorder (bipolar
  disorder, delusional disorder, schizophrenia)
  consider hospitalization and execute duties to
  warn/protect.
• If the high risk is associated with alcohol
  intoxication, refer for detoxification AND
  execute duties to warn/protect.

63
What to Do

• With evidence of domestic violence risk,
  discontinue any marital or family counseling
  until the violence is sufficiently dormant for
  safety to be reasonably predictable for the
  victim and other family members.
• Be exceedingly cautious about the use of
  individual therapy with individuals who present
  with domestic violence but no other severe mental
  disorder.

64
Risk Assessment Victims Dispositional
Characteristics

• Dispositional Characteristics
• a shy personal style or a temperament that is
  characterized by hyperarousability may be
  associated with increased risk of harm from
  others
• alternatively, risk taking temperamental traits
  and a combative reaction to assault can be
  associated with increased risk of harm

65
Risk Assessment Victims Clinical Features

• Clinical Features
• use of substances (use, not necessarily abuse or
  dependence, is a factor)
• cocaine, amphetamine (including MDMA), and
  alcohol are most associated with increased risk
  of harm
• alcohol and Benzodiazepine use associated with
  impaired ability to make sound judgments about
  safety and to take steps to avoid harm
• alcohol and other CNS depressants are associated
  with suicide and self-mutilation in those with
  severe sexual and/or physical abuse in childhood
  - watch for chemical dissociation
• narcotic analgesic use can result in danger due
  to its illegality and exposure to antisocial
  lifestyle more than pharmacological factors

66
Risk Assessment Victims Clinical Features

• Clinical Features
• acquired brain injury can greatly impair the
  victims ability to make sound decisions
  regarding safety for herself and children and it
  is associated with diminished ability to be a
  reliable witness with law enforcement and in
  court
• depression
• beliefs about the legitimacy of male dominance
  and rigid stereotypes about male roles - rigid
  religious beliefs about marital obligations and
  the roles of women

67
Risk Assessment Victims Clinical Features

• Clinical Features
• poor self esteem and, most importantly, low self
  efficacy (the belief that one is actually able to
  affect change in his or her life)
•  lack of belief in a better future
• personality disorder - particularly the B
  Cluster disorders
• bipolar disorder
• presence of suicidal thinking

68
Risk Assessment Victims Life History

• Life History
• childhood experience of being a victim of
  physical, sexual, and emotional abuse -
  particularly sexual abuse
• childhood witness to domestic violence
• poor adaptations to social norms in school and in
  personal relationships
• early experience with alcohol, inhalants,
  tobacco, and other drugs

69
Risk Assessment Victims Life History

• Life History
• history of conflicts and instability in personal
  relationships that lead to physical harm to self
  or others (adolescent experiences with date
  violence)
• history of suicidal attempts or gestures (the
  greater the number of attempts, the greater the
  risk)
• adult victim experiences of violent crime, rape,
  or brutality (can include witnessing AND being a
  victim)

70
Risk Assessment Victims Context and Environment

• Context and Environment
• a decision or action to separate or seek a
  divorce from a battering partner
• Pregnancy
• having young dependent children
• ready availability of guns in the home -
  particularly handguns
• partners loss of employment and/or significant
  economic hardship in the family

71
Risk Assessment Victims Context and Environment

• Context and Environment
• victim has children from her earlier relationship
  living in the family
• victims partner perceives her family of origin
  as adversarial
• social isolation - including geographical
  isolation
• victim is enjoying greater success than partner
  in work or other social settings
• victim is isolated by partner and has limited
  freedom of access to goods and services

72
Risk Assessment Victims Mitigating Factors

• Mitigating Factors
• desire to seek safety and work toward a safety
  plan
• belief that there will be legal or other serious
  consequences for violence toward self or children
• willingness to use treatment and social services
• availability of shelter services

73
Risk Assessment Victims Mitigating Factors

• Mitigating Factors
• availability of advocacy services
• ability to reduce drug or alcohol use
• availability of effective law enforcement
  personnel and policies
• availability of supportive family and friends

74
What to Ask

• Do you have thoughts of hurting yourself?
• What situation is MOST likely to make you feel
  suicidal?
• Do you ever find yourself wanting to die?
• How would you harm yourself?
• How would you put the plan in place - step by
  step?

75
What to Ask

• Where would your family be at the time of your
  harming yourself how would you protect your
  children?
• When you have attempted suicide in the past, how
  have you done it?
• What has happened in the past to keep you from
  killing yourself?
• What has made the hopelessness go away?
• How much more likely is that you will try to hurt
  yourself when you are high or drunk?

76
What to Ask

• How have you been injured by others, including
  your partner, in the past?
• Are you in danger now? How so?
• What is the history of events and how violence
  erupts?
• Have threats been made against you, your children
  or other family members recently?

77
What to Ask

• Are you in danger of being harmed physically?
  Sexually? Emotionally?
• Has anyone been a witness to the threats or the
  assault?
• Where are you most threatened? At home? At
  work?
• Have you been more likely to be harmed when on
  drugs or alcohol? How so?

78
What to Ask

• What plan do you have for your safety?
• What has protected you in the past?
• Is there anything about the present situation
  that makes it different from the past?

79
What to Do

• Begin safety planning with the victim and
  children
• Make referrals to shelters, victim advocates and
  to law enforcement where indicated
• Rehearse safety plans with victim
• Address treatment needs along with safety
  planning, but do not use treatment as an
  alternative to safety planning
• If the individual is intoxicated and in need of
  shelter, consider detoxification program (crisis
  stabilization unit)
• Link the individual with a victims advocate in
  the local area.

80
What to Do

• Look closely at the individuals level of
  impulsivity and her history of acting on impulses
  during crises or intoxicated states.
• Pay special attention to the availability of the
  means for suicide.
• When suicidality has been identified, the
  clinician should
• 1) explore enhanced safety arrangements for the
  individual
• 2) engage the individual in a no-harm agreement
  until treatment can move beyond crisis
  management and
• 3) be available to the individual for continuing
  crisis management.

81
What to Do

• Do active telephone follow-up on missed
  appointments if the individual has told the
  clinician that this is safe and will not provoke
  harm from the offender
• Continue to monitor suicidal thoughts from
  session to session
• At any point in the interview, seek consultation
  when in doubt about the degree of lethality of
  the individuals responses and the appropriate
  risk management actions.