Professional Risk Assessment: Suicide and Self Harm Risk

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Presentation delivered to Lifeworks Australia as part of their professional development in 2013. …

Presentation delivered to Lifeworks Australia as part of their professional development in 2013.

Specifically discusses how to conduct a comprehensive risk assessment and the implications for different levels of risk. Also highlights, ethical and legal responsibilities of the practitioner.

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  • Philosophical orientations – “suicide is a viable life choice” – with suicide prevention efforts as potentially interferring with patients rights

    “the desirability of according suicide the status of a basic human right… I do not mean that killing oneself is always good or praiseworthy: I mean only that the power of the state should not be legitimately invoked or deployed to prohibit or prevent persons from killing themselves: (Szasz, 1986)

    Whereas others argue strongly against the “right” to suicide

    “suicide is not a “right” anymore than is the “right to belch” if the individual feels forced to do it he will do it” (Shneidman, 1984)

    What is important here is is having strong feelings and beliefs about suicide is not necessarily a problem, but rather that psychologists and counsellors examine their own feelings and attitudes about suicidal patients before beginning clinical work. Clinical objectivity and effectiveness is enhanced when practitioners have a high level of self-awareness about their underlying personal biases and vulnerabilities.
  • Depression – present in as many as 70% completed suicides; this risk is greater with symptoms of anhedonia and more severe depression
    Anxiety – People with anxiety disorders co-occuring with depression have an increased risk of suicide.

    Substance use and intoxication are strong risk factors for suicidal behaviour. Of people who die by suicide, 25-50% consume alcohol before taking their lives, and suicide risk is substantially enhanced among people with co-morbid substance abuse, depression and hopelessness

    Personality disorders – diagnoses of anti-social and borderline personality disorders with and without co-occuring Axis I disorders are associated with a increased risk of suicide. Diagnosis of Conduct disorder and Oppositional Defiant Disorder among youth are also risk actors

    When rational thinking is impaired in disorders like schizophrenia, 10-15% die by suicide. The risk of dying by suicide is especially elevated in people with persecutory delusions, command hallucinations or psychotic depression.

  • Previous suicide attempts – recency, motivation, lethality

    Loss of parent in early life

    Previous psychiatric treatment , suggestive of possible cognitive/motivational risk factors

    Involvement in the justice system

    Experiences of adversity , particularly experiences of humilation, social and educational disadvantage, a family history of psychiatric illness, poor relationships with parents, being in trouble with the law

    ++ People who have experienced all forms of abuse and neglect are at a greater risk of attempting suicide
  • Reasons for living
    Survival and coping beliefs
    I still have many things left to do
    I believe killing myself would not really accomplish anything
    I believe I can find other solutions to my problems
    Responsibility to family
    I would hurt my family too much
    My family depends on me, they need me
    Child related concerns
    The effect on my children would be harmful
    I want to watch my children grow
    It would not be fair to leave my children
    Fear of suicide
    I am afraid of dying
    I am afraid I would fail and be injured
    I don’t have the guts to do it
    Fear of social disapproval
    Other people would think I was weak or selfish
    Moral objections
    My religious beliefs forbid it
    I believe only god has the right to end life
    I consider it morally wrong

Transcript

  • 1. Suicide Risk Assessment Dr Gemma Russell Clinical Psychologist Lifeworks August 2013
  • 2. Objectives • Recognising clinical indicators of suicide/self harm • Assessing level of risk of harm • Understanding LifeWorks’ relevant policies • Knowing what our duty of care is • Appropriate documentation in session notes • Interventions/referral when mod- hi SASH risk is identified.
  • 3. Life Threatening Behaviours Risk to self: • Suicide – The action of killing oneself intentionally • Para-suicide attempt - Non-fatal act in which a person deliberately causes injury to him or herself or ingests any prescribed or generally recognised therapeutic dose in excess • Self-harm - The deliberate attempt to harm or destroy the body with no intent of killing oneself
  • 4. Death By Suicide Suicide is the leading cause of death in Australia for men under 44 and women under 34 The most recent Australian data (ABS, Causes of Death, 2009) reports deaths due to suicide at 2,132. That equates to 6 deaths by suicide a day, or one every four hours
  • 5. Suicide Attempts For every completed suicide it is estimated that as many as 30 people attempt That’s 180 attempts per day, with at least one new suicide attempt in Australia, every 10 minutes
  • 6. Thoughts of Suicide (Suicidal Ideation) It is estimated that 249 people make a suicide plan everyday It is estimated that as many as 1014 people think about suicide every day
  • 7. WE HAVE A CRITICAL ROLE TO PLAY IN SUICIDE PREVENTION
  • 8. Duty of Care The clinician’s general obligation or duty of care refers to the ethical and legal duty to provide ordinary and reasonable care. This means: • To use available and reasonable means to ensure the safety of the clients and those who may also be affected A working therapeutic alliance is aided by prior informed consent around the parameters of confidentiality and intervention required to ensure safety.
  • 9. Factors that Inhibit Suicide Prevention • Lack of awareness of suicide being a major cause of death • Taboo in society to openly discuss suicide or self harming behaviours • Stigma around the experience of suicidality creates barriers to discussion/disclosure of suicide prevention efforts with a professional or confidant and therefore inhibiting help seeking avenues • Philosophical orientations toward suicide • Fear, anxiety or lack of knowledge about how to help
  • 10. General Risk Factors for Suicide • Precipitating Factors • Motivation/Cognitive Factors • Personality-based Factors • Disorder-related Factors • Historical Factors • Family Factors • Demographic Factors
  • 11. Precipitating Risk Factors • Majority of suicides are precipitated by an identifiable stressful event (70-97%) • Loss of parents or partner by death, separation or illness • Conflict with parents or partner • Involvement in judicial system • Severe personal illness/sickness • Major exam failure • Unwanted pregnancy • Imitation of other suicides
  • 12. Cognitive/Motivational Risk Factors Suicidal thoughts or attempts that serve the function of: • Escaping an unbearable psychological state or situation • Gaining revenge by inducing guilt • Inflicting self-punishment • Gaining care and attention • Sacrificing the self for a greater good
  • 13. Personality-based Risk Factors • High level of hopelessness • High level of perfectionism • High level of impulsivity • High levels of hostility and aggression • Inflexible coping style • Emotional dysregulation • Low distress tolerance • Limited pro-social problem solving skills
  • 14. Disorder-related Risk Factors • Depression symptomology • Anxiety disorders (particularly panic disorder) • Substance use or dependence • Conduct disorder (adolescents) • Personality disorders (adults) • Psychotic symptomology (particularly persecutory delusions or command hallucinations)
  • 15. Historical Risk Factors • Previous suicide attempts • Loss of parent in early life • Previous psychiatric treatment • Involvement in the justice system • Experiences of adversity
  • 16. Family Risk Factors • Family history of suicide attempts • Family history of depression • Family history of substance abuse • Family history history of assaultive behaviour • Disorganized, unsupportive family • Family denies seriousness of suicide attempts • Family has high stress and crowding • Family has low social support and is socially isolated
  • 17. Demographic Risk Factors • Sex More males die by suicide, many more females attempt suicide • Age Highest risk groups are those aged 15-24 years and those over age 60
  • 18. KEY CLINICAL RISK FACTORS • Sex • Age • Depression • Previous suicide attempts • Ethanol and drug abuse • Rational thinking is impaired • Social support lacking • No spouse/partner • Adversity or abuse • Loss • Sickness
  • 19. Assessment of Suicide Risk • Clear limits of confidentiality and informed consent explained • Detailed psychosocial history if possible to identify risk factors • Always assess risk to self, risk to others and risk from others • Decision about risk level • Identify intervention level and action plan
  • 20. Assessing Severity of Risk • Depressive symptomology • Suicidal Ideation (thoughts of ending of life) • Advanced Planning • Previous suicide attempt/s • Level of Self-control • Degree of Intent of acting on plan • Absence of help seeking • A final act • Specificity • Lethality • Availability • Proximity of support
  • 21. Scenario 1 John and Sarah have recently separated. You have been advised that Sarah has an intervention order against John, due to previous intimate partner violence. John is experiencing a range of difficulties including the breakdown of this relationship, loss of control, as well as strong feelings of anger and rejection. He has attended an initial session at Lifeworks and voiced to you thoughts about harming himself. 1. Identify John’s (general) risk factors 2. What information would you need to know to identify John’s risk of suicide or self/harm?
  • 22. Assessing Risk Level Level of Risk Acute Risk Factors Action Plan Minimal Risk Minimal risk factors Monitor as required Low Risk - Occasional suicidal thoughts - Minimal risk factors - No previous suicide attempts - No specific plan, intent or means - Self harm is superficial or minor - Protective factors available 1. Follow-up appointment 2. Monitor mood, mental state 3. Assess changes, noting deterioration or worsening of mental state 4. Agree on verbal crisis plan, provide support numbers 5. Follow-up support and develop treatment plan
  • 23. Assessing Risk Level Level of Risk Acute Risk Factors Action Plan Moderate Risk - Suicidal thoughts - Some risk factors - Suicide plan with some detail - Means are available - Vague intention to act (no timeframe) - Some protective factors 1. Consult with peers and team leader 2. Refer to GP for mediation and/or further assessment 3. Follow-up appointment within one week, consider phone support 4. Monitor mood and risk until no further suicidal ideation 5. Agree on written Safety Management Plan with client 6. Request permission to inform emergency monitoring team (e.g. CATT) and/or family
  • 24. Assessing Risk Level Level of Risk Acute Risk Factors Action Plan High Risk - Suicidal thoughts - Previous suicide attempts - Numerous risk factors - Clear and detailed suicide plan - Immediate intent to act - Means are available (and lethal) - Social isolation - Limited engagement with formal support services 1. Urgent consult with team leader/manager 2. Immediately contact CATT for psychiatric assessment and treatment 3. Attempt to engage client in developing safety plan 4. Ask the patient/client to stay until emergency help is obtained, if they refuse, call 000 5. Contact support person/family
  • 25. Developing a Safety Management Plan
  • 26. After the Safety Plan is Developed • ASSESS the likelihood that the overall safety plan will be used and problem solve with the patient to identify barriers or obstacles to using the plan. • DISCUSS where the patient will keep the safety plan and how it will be located during a crisis. • EVALUATE if the format is appropriate for patient’s capacity and circumstances. • REVIEW the plan periodically when patient’s circumstances or needs change. • Remember: the safety plan is a tool to engage the patient and is only one part of a comprehensive suicide care plan
  • 27. Management of Suicide Risk - In Session • Aim to modify dynamic risk factors that were present during previous/current risk state (i.e., social isolation) • Containment of emotional turmoil • What are the patient/client’s reasons for living? - Survival and coping beliefs - Responsibility to family - Child related concerns - Fear of suicide - Fear of social disapproval - Moral objections • You are the reason, if there is no other reason for living (Carl Rogers – Unconditional Positive regard)
  • 28. Scenario 2 Ingrid is a woman in her mid 20s that lives alone. She has an extended trauma history and ongoing comorbid depression and anxiety. When she feels hopeless and overwhelmed she has tried on two occasions to kill herself by taking a large number of benzodiazepine pills and drinking alcohol. Ingrid has a 2 year old daughter who currently lives with Ingrid’s mother. Ingrid currently reports that she does not want to die as she wants to see her daughter grow up. 1. Identify Ingrid’s level of risk of suicide/self harm 2. Develop a safety plan to manage her current risk
  • 29. Scenario 3 Barwon is a 17 year old man from rural Victoria who has recently been moved to live with family in Melbourne after multiple family difficulties. He presents with symptoms of depression and anxiety, and is a daily user of cannabis and occasionally uses methamphetamine on the weekends with peers Barwon has never lived in an urban environment and is struggling to fit in with his peers at his new school. . Last weekend Barwon attempted to ‘train surf’ as a dare and fell onto the train tracks. 1. Identify Barwon’s level of risk of suicide or self-harming behaviours 2. Identify appropriate interventions (in session) and referral pathways
  • 30. Documentation Health Records Act 2001 • Legal obligation to document thoroughly all information recorded during or following an interaction with a patient/client. • All notes pertaining to the client and recorded by a psychologist (psychologist's records) are to be maintained as confidential information as required by both relevant national and state legislation and the Australian Psychological Society Code of Ethics.
  • 31. Documentation Privacy Act 1988 and amendments - Access to records Confidentiality of patient records and protocols to protect anonymity are observed, unless: • The health, wellbeing, or safety of the patient/client is threatened by the behaviour of the patient/client (suicide/self-harm) • There is a direct and imminent threat to the health, wellbeing, or safety of another person who identity is known caused by the behavior of the patient/client (harm towards others) • The health, wellbeing, or safety of the patient/client is directly threatened by another person (harm from others) Legislation permits the right to provide access to the information to those who must be involved to protect the patient/client or the threatened person.
  • 32. Documentation Coroners Act 2008 • The usual obligation to maintain confidentiality regarding patient information under the Health Records Act 2001 (Vic) and the Privacy Act 1988 (Cth) does not apply to requests for information by someone acting on behalf of the coroner. • Hence, if health care providers are requested by the coroner (or a police member acting on their behalf) to give any information or assistance for the purposes of a coronial investigation they must provide it.
  • 33. Documentation Guidelines • Document all steps used (clinical interview, consult with peers, supervisor etc.) to establish risk • Document all pre-disposing risk factors • Document all population-based risk factors • Detailed assessment of the precipitants of the person’s suicidal crisis • Exploration of factors maintaining distress • Mental state examination • Current risk assessment (severity and reasons why) • Short-term safety management plan • Medium-Long term treatment plan/referral avenues
  • 34. Question Time? Contact details: Dr Gemma Russell Clinical Psychologist Director of Clever Minds Psychology director@clevermindspsychology.com.au Telephone: 0435854205 Fax: 03 86922708