Evaluating Risk

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Evaluating Risk
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Risk assessment psychol

• Remember
• We cannot read the future
• Human nature is impossibly complex
• Risk assessment is highly inexact
• Risk management does not equal risk elimination
• Responsibility is not a binary issue

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Risk assessment psychol

• Risk
• Originally a sailing term from Portuguese
  'sailing into uncharted waters'.
• Risk is often assessed in binary terms

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Risk assessment psychol

• Risk
• the possibility of beneficial and harmful
  outcomes and the likelihood of their outcome in a
  stated timescale
• Separate danger from risk
• Danger is the damage or harm that may occur from
  an event
• Risk is the likelihood of the event

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Risk assessment psychol

• Risk is not static, it is dynamic.
• Risk assessment is a cross-sectional view but may
  take changing factors into consideration
• We are not proficient at quantifying risk( one
  study suggests we're wrong 95 of the time
• Thankfully wrong by overstimation in the main

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Risk assessment psychol

• Dangerousness and risk are different.
• Dangerousness can be seen as a property of the
  individual. It is a composite of risk and
  subjective perception of the risk
• Risk involves consideration of the context and
  leads to a set of further questions

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Risk assessment psychol

• Divide into groups
• Task 5 minutes
• Discuss all the areas of risk in child and
  adolescent mental health
• Feedback

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Risk assessment psychol

• Types of adverse outcome
• Harm to self
• Harm to others
• Harm from others
• Harm from healthcare system
• Harm to staff in the work

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Risk assessment psychol

• Types of adverse outcome
• Harm to self Self-mutilation
• Suicidal acts
• Self neglect and starvation
• Harm to others Emotional abuse and violence
• Physical abuse and violence
• Harm from others Emotional abuse and exploitation
• Physical
• Sexual
• Harm from healthcare system
• Harm to staff in the work

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Risk assessment psychol

• Harm from others
• Usually well covered in Child Protection
  procedures
• CAMHS special role in raising awareness of
  parental mental illness and substance misuse
• High proportion of 'grey' cases and need to
  balance need to report against potential
  disruption of therapeutic intervention

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Risk assessment psychol

• Harm from healthcare system/staff
• It should be considered
• Damaging effects of treatment
• Adverse effects of inpatient treatment
• Lack of resources/ training limiting effective
  interventions
• Abuse by staff

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Risk assessment psychol

• Harm to staff
• Physical assault and threatening behaviour
• Training in de-escalation/ proper supervision
• Lone working after hours
• Home and community visits
• Psychological damage and stress caused by the
  work.

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Risk assessment psychol

• Adult MH services main focus on violence and self
  harm
• CAMHS different issues
• Of particular interest are situations of
  conflicting obligation. Tension between the
  rights of different individuals/ groups of
  individuals
• Autonomy versus justice
• Autonomy versus respect for parental rights/
  respect for family life

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Risk assessment psychol

• Overdose Assessment
• Separate up into groups and take 10 minutes
• Tell me how you make an overdose assessment of a
  young person

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Risk assessment psychol

• Some young people to be thinking about

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Risk 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
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Risk assessment psychol

• Are you worried
• Would you let her home
• What advice would you give her and her mother

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Risk assessment psychol

• Write me a much more worrying scenario
• Look at each of the factors listed and describe a
  case that would really worry you

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Risk assessment psychol

• 16 year old girl
• Overdose 90 paracetamol
• Taken with the intention of dying. Planned for 2
  weeks
• Church in the evening, quietly made her peace
  with friends
• Went home
• Mother drunk
• Went upstairs, took the tablets alone and sober
• No direct trigger
• Knew mother would not disturb her until the
  Tuesday (college day)
• Mother found her unconscious on Tuesday
• Phoned ambulance, only got into it for her mother

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Risk assessment psychol

• Will you send her home
• What might steer you to allow her home

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Risk assessment psychol

• Coldly tells you of her intent in front of
  parents
• Parents not angry, but incredulous initially
• Then profoundly anxious mother and dismissive
  father
• States that she has thrown her life to god and he
  has replied that she should live
• Agrees to engage in outpatient therapy
• Difficult to read as to whether she has a
  depression
• What would you do ?

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Risk assessment psychol

• Attends outpatient therapy twice
• Then 2 weeks later further massive overdose
• Took herself away after church
• Took public transport to secluded spot after dark
• Took off outer clothes
• Drank alcohol
• Took over 100 paracetamol
• Woke 2 hours later, had vomited, and was cold and
  alive so phoned her father who called the
  ambulance to pick her up

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Risk assessment psychol

• Example
• 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 month history of low mood, with the core,
  accessory and somatic symptoms of depression. She
  tells you that she does not wish to have any
  psychotherapeutic treatments despite your advice
  to her that this is the best first line
  treatment. She demands to be treated with
  antidepressants. She absolutely forbids you to
  allow her parents to be part of the consultation,
  and threatens to leave if you do.
• What are the clinical, legal and ethical issues
• Divide into groups and discuss for 5 minutes

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Risk assessment psychol

• Public Enquiries Frequent findings
• Confusion over diagnosis
• Episodes viewed in isolation
• Delays
• Poor record keeping
• Poor interagency communication and coordination
• Training in risk assessment is lacking

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Evaluating Risk ( Kapur 2000)

• We are not proficient at quantifying risk.
• Mental Health Professionals are wrong 95 of the
  time
• Fortunately wrong the right way ( falsely
  identifying those at risk, not falsely
  identifying those not at risk)

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Risk assessment psychol

• Clinical versus actuarial risk assessment

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Risk assessment psychol

• 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 attempts but is not clinically depressed
  herself.
• 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 further
• 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 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
  0.60.9),whichwas 66 (95 CI 5282) 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

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Risk assessment psychol

• 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 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 was not drunk and did not need hepatic
  support.
• 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 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
  pressurising her to come out instead of staying
  at home to help.
• She regrets her overdose, and commits to working
  with the counsellor at 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 health is solid. She will
  support her daughter in accessing support.

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Risk assessment psychol

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

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Risk assessment psychol

• Actuarial risk assessment
• Epidemiological
• Mathematical
• Sensitivity not good, specificity good.
• Inflexible and not easy to generalise
• Clinicians usually have only part of the
  information
• May be the best way of assessing e.g risk of
  violence or sexual offending

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Risk assessment psychol

• Actuarial risk assessment
• May give a 40 chance of committing a violent
  act in the next 3 years
• But no information about the imminence,
  circumstances and severity of the act
• May be mathematically correct but of little use
  in informing management

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• Clinical risk assessment
• Some say unsystematic version of actuarial
• prestigious synonym for anecdotal evidence
• But more than this really
• It is person specific, takes into account past
  behaviour and context
• balanced summary of prediction derived from
  knowledge of the individual, present
  circumstances and the disorder from which he is
  suffering
• Should be multidisciplinary
• Can lead to better clinical understanding

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Risk assessment psychol

• Clinical risk assessment
• It is not about absolute prediction but about
  balanced, informed, defensible decision making
• Define the concerning behaviour
• Distinguish probability from severity of
  consequences
• Be aware of sources of error
• Interaction of internal and external
  circumstances
• Think about missing information
• Modify the factors that you can

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Risk assessment psychol

• Clinical risk management
• Development of strategies to reduce the severity
  and frequency of identified risks
• the process of creating and maitaining safe
  systems of care while taking considered
  therapeutic risks which serve the best interests
  of service users
• Key components
• Good quality records
• Thorough notekeeping
• Open communication
• Guidelines, checklists, protocols and access to
  advice all assist the process organisationally

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Risk assessment psychol

• Most sensible to synthesise actuarial and
  clinical
• Bind together best research knowledge about risk
  variables and use clinical skills to balance the
  evidence
• Perhaps less about accuracy than informed,
  defensible decisions

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Risk assessment psychol

• What are the factors that would particularly
  worry you about thoughts or acts of suicide
• THINK ABOUT
• The actual thoughts or acts
• The trigger and context
• The mental state factors
• The clinical and developmental history
• The systemic response
• Write me a list of factors

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Risk assessment psychol

• What are the resilience factors that you would
  focus on in young people
• Write me a list of balancing factors that might
  mitigate against adverse risk

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Risk assessment psychol

• Design a tool for assessing risk of self harm and
  suicide
• Separate into groups
• Spend 15 minutes
• Ideas for a template that could be used for both
  screening and more detailed assessment

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• Structured professional judgement (SPJ)
• Particular form of clinical risk assessment and
  management
• Aim is to combine the evidence base for risk
  factors with individual patient assessment
• Clinicians make a structured assessment which is
  used in a form a risk management plan

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Risk assessment psychol

• SPJ Define factors as
• Static
• Stable
• Dynamic
• Future

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Risk assessment psychol

• Static
• Fixed and historical
• E.g. family history of suicide
• Stable
• Long term and enduring for many years
• E.g. Personality Disorder

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Risk assessment psychol

• Static and stable risk factors for suicide
• History of self harm
• Seriousness of past suicidality
• Past hospitalisation
• History of mental disorder
• History of substance misuse
• Personality Disorder
• Childhood adversity
• Family history of suicide
• Age, gender and marital status

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Risk assessment psychol

• Note
• Actuarial methods are solely based on static and
  stable factors

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Risk assessment psychol

• Dynamic
• Fluctuate markedly in intensity and duration,
  unstable over time
• Suicidal ideas
• Hopelessness
• Active psychological symptoms
• Treatment adherence
• Substance misuse
• Psychiatric admission and discharge
• Psychosocial stress
• Problem-solving deficits

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Risk assessment psychol

• Future
• Result from changing circumstances
• Access to preferred method
• Future service contact
• Future response to drug treatment
• Future response to psychosocial intervention
• Future stress

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Risk assessment psychol

• Static and stable factors give an indication of
  an individuals propensity
• They do not capture the fluctuating risk
• Dynamic and future factors are essential for
  considering the particular conditions and
  circumstances associated with risk
• Comprehensive consideration of all factors will
  inform risk management strategies

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Risk assessment psychol

• Chronic high risk due to static and stable risk
  factors
• Male. 17 years. Schizophrenia. Cannabis use from
  14. Alcohol
• dependent from 15. Progressive deficit state in
  schizophrenia.
• Reasonable insight. Multiple past admissions to
  adolescent units. Early
• parental neglect and physical abuse. Two attempts
  at suicide before.
• One particularly worrying with trip to railway
  sidings to jump in front of
• train, and only disturbed by chance encounter
  with railway worker.
• Limited social network. Voices telling him to
  kill himself. His resolve to
• ignore their instructions varies but is
  reasonable at present and he
• feels less hopeless and pessimistic. He is not
  using cannabis heavily

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Risk assessment psychol
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Risk assessment psychol

• Background risk factors present. Risk lower at
  present but could escalate, particularly
  associated with impulse control problems
  associated with drugs and alcohol. Changes tend
  to be slow and to emerge within the context of
  the work.

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Risk assessment psychol

• Rapid onset of dynamic risk factors
• 16 year old female. No past history of self harm
  or psychiatric contact. High achiever. Close
  relationship with parents who are active in
  Christian church. She does not share parents
  beliefs which causes embarrassment to parents. As
  a result cannot confide in parents. Falls away
  from studies without parents knowledge. New
  relationship. Fails GCSEs. Goes to party. Places
  herself in vulnerable position and is raped.
  Ashamed. Does not disclose. Discloses rape to
  friends who call her names and alienate her.
  Deliberate attempt to hang herself in garage.
  Only discovered by chance because of early return
  of parents

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Risk assessment psychol
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Risk assessment psychol

• Worrying escalation in dynamic stresses, in a
  girl with coping strategies which are overwhelmed
  by their apparent intensity. Not mentally ill but
  at high risk of killing self.

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Risk assessment psychol

• DSH

This is an event with meaning Particularly
social or relational meaning Usually people who
use DSH remain in contact with others, and there
is an element of warning, or appeal for help from
another Whether taken in context around others
or not, there is always symbolic meaning to be
made cutting the bad out of me
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Risk assessment psychol

• The attempt Actions
• What was taken
• Where was it taken
• Was there alcohol and drugs involved
• Were there attempts at concealment
• How did it come to attention
• Any resistance to medical intervention

• The attempt Thinking
• Intent
• Planning
• Final acts, suicide note
• Expectation of lethality
• How quickly changed mind
• Trigger factor
• Predisposing stresses

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Risk assessment psychol

• Assessment, underlying problems and screening for
  relevant mental disorders
• Mood disorders
• Psychosis
• Personality Disorder
• Drug and alcohol misuse

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Risk assessment psychol

• Intent
• In the context of the assessment you have just
  made, what is the ongoing intention
• What a thing to do, Ive found out she loves me
  after all, Ill never do this again Impulsive
  regretted act
• Im going to do it again and theres nothing you
  can do about it Threat of further act
• Nothing offered
• Quietly and logically, someone describes to you
  why suicide is the sensible thing for them

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Risk assessment psychol

• Things that ring bells of alarm
• Depression
• Intent and planning now and at the time
• Logical conclusion of series of dreadful events
• Hopelessness
• No moderating factors ( protective relationship,
  religious belief)
• Past suicide attempt
• Impulsive personality and substance misuse
• Psychosis particularly if under instruction or
  control

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Risk assessment psychol

• Remember
• We cannot read the future
• Human nature is impossibly complex
• Risk assessment is highly inexact
• Risk management does not equal risk elimination
• Responsibility is not a binary issue