Risk Assessment & Treating Clients in Crisis

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Here are the complete slides for attendees at my PESI/CMI workshops on the topic of suicide risk assessment.

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Risk Assessment & Treating Clients in Crisis

  1. 1. David D Nowell PhD www.DrNowell.com
  2. 2. A challenge….
  3. 3. Risk Assessment & Clients in Crisis An overview of the day: • Assessment of risk • Mental status examination • Intervention planning • Documentation
  4. 4. Patient at risk? male personality divorce pain guns alcohol
  5. 5. David D Nowell PhD DavidNowell DavidNowellSeminars www.DrNowell.com
  6. 6. Psychodynamic Issues Anxiety mastery Depression mastery Capacity to feel real and continuous across time
  7. 7. Edwin Schneidman • Psychache • Press • Perturbation
  8. 8. Edwin Schneidman • Psychache (pain) • Press • Perturbation
  9. 9. And so I leave this world, where the heart must either break or turn to lead. Nicolas-Sebastien Chamfort, French writer, d. 1794
  10. 10. I haven’t felt the excitement of listening to as well as creating music…for too many years now. I feel guilty beyond words about these things. Kurt Cobain, musician, d. 1994
  11. 11. I must end it. There's no hope left. I'll be at peace. No one had anything to do with this. My decision totally. Freddie Prinze, comedian, d. 1977
  12. 12. I feel certain that I'm going mad again. I feel we can't go thru another of those terrible times. And I shan't recover this time. I begin to hear voices. Virginia Woolf, author, d. 1941
  13. 13. Edwin Schneidman • Psychache (pain) • Press (stress) • Perturbation (agitation)
  14. 14. Edwin Schneidman • Psychache (pain) • Press (stress) • Perturbation (agitation)
  15. 15. When to assess risk?
  16. 16. When to assess risk?
  17. 17. When to assess risk?
  18. 18. When to assess risk? • At first contact • At any time of loss or uptick in stress • At any follow-up contact with “high risk” client
  19. 19. SUICIDE PREDICTION vs. SUICIDE RISK ASSESSMENT
  20. 20. 300.4, rule out 296.25
  21. 21. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  22. 22. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  23. 23. Risk Assessment & Management Predisposing factors • Older • White • Male • Personality disorder • Substance abuse • Access to guns • Recent stress or public humiliation
  24. 24. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  25. 25. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  26. 26. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  27. 27. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  28. 28. DSM-IV 5-Axis System • Axis I • Axis II • Axis III • Axis IV • Axis V
  29. 29. DSM-IV 5-Axis System • Axis I • Axis II • Axis III • Axis IV • Axis V
  30. 30. • Axis I • Axis II • Axis III • Axis IV • Axis V
  31. 31. Predisposing Clinical Risk Factors • Mood disorders –15% lifetime risk –50 – 70% of all suicides
  32. 32. Predisposing Clinical Risk Factors • Depression
  33. 33. Predisposing Clinical Risk Factors • Bipolar Disorder
  34. 34. Predisposing Clinical Risk Factors • Substance Abuse / Dependence
  35. 35. Predisposing Clinical Risk Factors • Substance Abuse / Dependence –Lifestyle Issues
  36. 36. Predisposing Clinical Risk Factors • Anxiety Disorders
  37. 37. Predisposing Clinical Risk Factors • Schizophrenia
  38. 38. Predisposing Clinical Risk Factors • Personality disorders –5 – 10% lifetime risk –15 – 25% of all suicides
  39. 39. Borderline Personality and Risk  Lifetime rate of suicide - 8.5%  With alcohol problems -19%  With alcohol problems and major affective disorder -38%
  40. 40. Borderline features which increase risk • Impulsivity • Hopelessness-despair • Antisocial features • Aloofness • Self-mutilating tendencies • Psychosis
  41. 41. Borderline features which ameliorate risk • Clinging • Dependency • Use of suicidal behavior to maintain connections
  42. 42. Antisocial Personality Disorder • Concurrent Axis I disorder • Over age 40 • Recent narcissistic injury / impulsivity
  43. 43. Narcissistic Personality Disorder • Failure • Humiliation • Criticism
  44. 44. SUICIDE RISKS IN SPECIFIC DISORDERS Prior suicide attempt 38.4 0.549 27.5 Bipolar disorder 21.7 0.310 15.5 Major depression 20.4 0.292 14.6 Mixed drug abuse 19.2 0.275 14.7 Dysthymia 12.1 0.173 8.6 Obsessive-compulsive 11.5 0.143 8.2 Panic disorder 10.0 0.160 7.2 Schizophrenia 8.45 0.121 6.0 Personality disorders 7.08 0.101 5.1 Alcohol abuse 5.86 0.084 4.2 Cancer 1.80 0.026 1.3 General population 1.0 0.014 0.72 Condition RR %-yr %-Lifetime Adapted from A.P.A. Guidelines, part A, p. 16
  45. 45. SUICIDE RISKS IN SPECIFIC DISORDERS General population 1.0 0.014 0.72 Adapted from A.P.A. Guidelines, part A, p. 16 Condition RR %-yr %-Lifetime
  46. 46. SUICIDE RISKS IN SPECIFIC DISORDERS Prior suicide attempt 38.4 0.549 27.5 Bipolar disorder 21.7 0.310 15.5 Major depression 20.4 0.292 14.6 Adapted from A.P.A. Guidelines, part A, p. 16 Condition RR %-yr %-Lifetime
  47. 47. SUICIDE RISKS IN SPECIFIC DISORDERS Dysthymia 12.1 0.17 8.6 Panic disorder 10.0 0.16 7.2 Adapted from A.P.A. Guidelines, part A, p. 16 Condition RR %-yr %-Lifetime
  48. 48. COMORBIDITY In general, the more diagnoses present, the higher the risk of suicide.
  49. 49. COMORBIDITY In general, the more diagnoses present, the higher the risk of suicide. Psychological Autopsy of 229 Suicides • 44% had 2 or more Axis I diagnoses • 31% had Axis I and Axis II diagnoses • 50% had Axis I and at least one Axis III diagnosis • Only 12 % had an Axis I diagnosis with no comorbidity Henriksson et al, 1993
  50. 50. Predisposing Medical Risk Factors • Chronic Pain • Chronic illness
  51. 51. Predisposing Family History Risk Factors  Relatives of suicidal subjects have a two-fold increased risk compared to relatives of non-suicidal subjects.  Twin studies indicate a higher concordance of suicidal behavior between identical rather than fraternal twins.  Adoption studies: a greater risk of suicide among biologic rather than adoptive relatives.
  52. 52. Predisposing Demographic Risk Factors • Male • Older • Lives alone • Widowed / separated • White, or Native American • Access to weapons • Sexual minority (GLBT)
  53. 53. • Mexico 4.0 • Dominican 2.3 • Puerto Rico 7.4 • Colombia 4.9
  54. 54. • S. Korea 31.7 • China 22.3 • India 10.5
  55. 55. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  56. 56. Potentiating Risk Factors • Recent stressor • Contagion • Recent diagnosis of major illness • Recent relapse of major illness • Hepatitis C treatment
  57. 57. Potentiating Risk Factors • Recent stressor –Legal Problems –Loss of Job –Relationship issues –Homeless –Finances
  58. 58. Potentiating Risk Factors • Recent stressor • Contagion • Recent diagnosis of major illness • Recent relapse of major illness • Hepatitis C treatment
  59. 59. Admiral Jeremy Boorda
  60. 60. Choi Jin-sil
  61. 61. Patient at risk? male personality divorce pain guns alcohol
  62. 62. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  63. 63. 1 – Item Suicidality Assessment
  64. 64. Specific Suicide Inquiry • (Current) Ideation • (History of ) Threats • (History of) Attempts
  65. 65. Ideation • Passive thoughts • Active thoughts Duration: Frequency: Persistent? Obsessive?
  66. 66. Suicidal ideation • Able to control suicidal thoughts? • Has made preparations for death? • Has rehearsed? • Command hallucinations?
  67. 67. Suicidal plan: • No concrete plan but has intent • Plan without means • Plan with means: • Lethality
  68. 68. Suicidal intent: • No intent but does not feel capable of maintaining safety plan • Intent related to: –Wish to die –Desire to hurt someone else –Need to escape –Need to punish self
  69. 69. History of threats • Seek collateral information • Determine context of threats
  70. 70. History of attempts • Actions imply gestures vs. intent? • Dangerous/not believed to be lethal? • Dangerous/potentially lethal? • History of self-injurious behavior?
  71. 71. Competency / Capacity • Psychosis • Impaired judgment • Decompensated • Overwhelmed
  72. 72. Impulsivity • History of money management? • Impulsive relapses? • Domestic violence? • Abrupt firings from jobs? • How have relationships ended? • History of impulsive suicidality?
  73. 73. Deterrents to suicide • Religious faith • Hopefulness re: resolution • Ambivalence • Reasons for living • Loved ones • Relationship with therapist
  74. 74. “signs” and “symptoms”
  75. 75. Current risk factors, reported (symptoms) • Self-report • Collateral data –Records –Significant others, family, friends
  76. 76. Current risk factors, observed (signs) • mental status examination
  77. 77. Current risk factors, observed • mental status examination –Behavior –Emotional –Cognitive
  78. 78. 90791
  79. 79. ABC STAMPLICKER
  80. 80. ABC STAMPLICKER • appearance
  81. 81. “client appears his stated age…”
  82. 82. ABC STAMPLICKER • behavior
  83. 83. ABC STAMPLICKER • cooperation
  84. 84. ABC STAMPLICKER • speech
  85. 85. ABC STAMPLICKER • thought
  86. 86. ABC STAMPLICKER • Thought –form –content
  87. 87. Common abnormalities of thought form • Loose associations • Clang • Overinclusiveness • Pressure • Tangentiality
  88. 88. Common abnormalities of thought content • Delusions • Obsessions • Phobias • Violent ideation. • Hallucinations (abnormal perception)
  89. 89. ABC STAMPLICKER • affect
  90. 90. Euthymic: • Calm • Comfortable • Euthymic • Friendly • Normal • Pleasant • Unremarkable
  91. 91. Angry: • Angry • Bellicose • Belligerent • Confrontational • Frustrated • Hostile • Sullen • Impatient • Irascible • Irate • Irritable • Oppositional • Outrage
  92. 92. Dysphoric: • Despondent • Distraught • Dysphoric • Grieving • Hopeless • Overwhelmed • Remorseful • Sad
  93. 93. Terms to describe parameters of affect: • Appropriateness • Intensity • Range
  94. 94. ABC STAMPLICKER • mood
  95. 95. ABC STAMPLICKER • perception
  96. 96. “sensorium intact…”
  97. 97. Person Place Time Situation “Oriented X 3” “O X3”
  98. 98. Person Place Time Situation “Oriented X 3” “O X3” “Oriented X 4” “OX4”
  99. 99. ABC STAMPLICKER • Level of arousal
  100. 100. “Patient is an 89 year old male, A+O x 3, no AH/VH, denies SI/HI.”
  101. 101. ABC STAMPLICKER • insight
  102. 102. Disorders that contribute to impaired insight • Drug and alcohol dependence • Depression • Mania • Psychosis • Personality disorders • Delirium • Dementia • ADHD • Conversion disorder • Factitious disorder
  103. 103. Judgment • The ability to weigh and compare the relative values of different aspects of an issue.
  104. 104. ABC STAMPLICKER • cognition
  105. 105. ABC STAMPLICKER • Cognition –Attention –Memory
  106. 106. MMSE norms Eighth Grade Education Ages 18 to 69: Median MMSE Score 26-27 Ages 70 to 79: Median MMSE Score 25 Age over 79: Median MMSE Score 23-25 High School Education Ages 18 to 69: Median MMSE Score 28-29 Ages 70 to 79: Median MMSE Score 27 Age over 79: Median MMSE Score 25-26 College Education Ages 18 to 69: Median MMSE Score 29 Ages 70 to 79: Median MMSE Score 28 Age over 79: Median MMSE Score 27 Crum (1993) Journal of the American Medical Association
  107. 107. ABC STAMPLICKER • Knowledge
  108. 108. ABC STAMPLICKER • Endings
  109. 109. ABC STAMPLICKER • reliability
  110. 110. Patient at risk? male personality divorce pain guns alcohol
  111. 111. Validity techniques in risk assessment • Behavioral incident • Shame attenuation • Gentle assumption • Symptom amplification • Denial of the specific • Normalization
  112. 112. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  113. 113. Suicide Risk Classification High risk Moderate Risk Low risk
  114. 114. Suicide Risk Classification High risk Moderate Risk Low risk
  115. 115. Suicide Risk Classification High risk Moderate Risk Low risk
  116. 116. Moderate Risk • Follow-up evaluation of risk • Increased frequency of outpatient contact. • Involvement of family members, if possible. • 24 hour availability of crisis centers • Referral for consideration of pharmacological tx • Use of telephone contacts to monitor progress • Safety plan
  117. 117. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  118. 118. Determine level of intervention 1. Acute versus chronic 2. Evaluate competence and impulsivity 3. Assess therapeutic alliance 4. Plan reassessments
  119. 119. Determine level of intervention 1.Acute versus chronic 2. Evaluate competence and impulsivity 3. Assess therapeutic alliance 4. Plan reassessments
  120. 120. Disorder-based (acute) Personality- based (chronic)
  121. 121. Disorder- based (acute) Personality-based (chronic)
  122. 122. Determine level of intervention 1. Acute versus chronic 2.Evaluate competence and impulsivity 3. Assess therapeutic alliance 4. Plan reassessments
  123. 123. Competency / Capacity • Client able to indicate a preference? • Able to weigh the pros/cons of various options? • Able to apply pros/cons to her own specific situation?
  124. 124. Determine level of intervention 1. Acute versus chronic 2. Evaluate competence and impulsivity 3.Assess therapeutic alliance 4. Plan reassessments
  125. 125. Determine level of intervention 1. Acute versus chronic 2. Evaluate competence and impulsivity 3. Assess therapeutic alliance 4.Plan reassessments
  126. 126. Consultation with others • When appropriate involve family members in decision making. • Other professionals • Collaboration with the patient
  127. 127. Consultation with others • When appropriate involve family members in decision making. • Other professionals • Collaboration with the patient
  128. 128. No Harm Contracts
  129. 129. An Alternative Approach: Collaborative approach
  130. 130. Elements of the collaborative approach • Educate the patient about the uncertainty inherent in treatment. • Underscore the mutual responsibility of sharing the burden of managing suicidal thoughts. • Directly discuss the risk of death from suicide. • Discuss risks other than suicide such as dependence and regression.
  131. 131. • Discuss the patient’s competence or capacity to give informed consent. • Warn the patient about the serious consequence of not following treatment recommendations. • Consult with a peer when possible. • Prepare concise documentation of assessment and treatment planning emphasizing collaboration.
  132. 132. Elements of a safety plan • How will I know that my risk for self- harm has become more serious? • What are the coping strategies which I will use if I feel more distressed or sad? • Who can I contact if I need someone to spent time with and distract me from my distress?
  133. 133. Elements of a safety plan • Who can I contact if I need to seek support or talk me through difficult feelings? • Who are the helping professionals to whom I will reach out if I need support? (include contact information; include contacts available on 24 hour basis such as EMH) • What specific steps will I take to make my home environment safer for me?
  134. 134. Providing Feedback
  135. 135. Feedback approach –Collaborative –Mutuality –Curiosity
  136. 136. Feedback approach –Review chief complaints –Add pertinent info re: signs
  137. 137. Feedback approach –Offer diagnosis • Share attitude of round pegs/square holes • Emphasize hope –Request feedback –Offer accurate empathy
  138. 138. Feedback approach • Feedback provides three types of information for patient –Confirms the obvious –Gently challenges –Doesn’t fit
  139. 139. Feedback approach • Feedback regarding personality disorder
  140. 140. Oldham & Morris. Personality Self- Portrait
  141. 141. Personality Styles • Narcissistic • Dependent • Paranoid • Anti-social • Borderline • Self-confident • Devoted • Vigilant • Adventurous/challenger • Mercurial
  142. 142. Adventurous/Challenger • Nonconforming • Daring • Mutual independence • Persuasive • Charming • Free lance • No regrets
  143. 143. Mercurial • Romantic attachment • Intensity • Heart • Unconstraint • Activity • Open mind • Alternate states
  144. 144. Self-Confident • Self-regard • Red carpet • Ambition • Competition • Stature • Dreams • Poise
  145. 145. Disposition Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  146. 146. Documentation
  147. 147. Documentation
  148. 148. 4 Reasons to Document Carefully • Good documentation keeps us out of court • If we must defend our decision-making, good documentation helps our legal counsel • Good documentation drives good care • Good documentation helps treaters communicate among ourselves
  149. 149. 300.4, rule out 296.25
  150. 150. The Written Report • Identifying data • HPI / background info • Med hx • Social hx
  151. 151. The Written Report • MSE • Review of systems –Somatic –Cognitive –Affective
  152. 152. The Written Report • Impression • Summary –Differential –Contributing factors –Further information needed –Prognosis –Response to referral questions
  153. 153. The Written Report • Risk Potential – Low/moderate/high – Safety plan (if appropriate to level of risk) • Treatment Plan • Cost / Benefit Comments re: alternate treatments
  154. 154. How to Use the Form Provided Today
  155. 155. CSSRS.COLUMBIA.EDU Columbia Suicide Severity Rating Scale (CSSRS)
  156. 156. Clinical examples
  157. 157. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  158. 158. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  159. 159. Disposition Determine level of intervention 1. Acute versus chronic 2. Evaluate competence and impulsivity 3. Assess therapeutic alliance 4. Plan reassessments
  160. 160. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  161. 161. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  162. 162. Disposition Determine level of intervention 1. Acute versus chronic 2. Evaluate competence and impulsivity 3. Assess therapeutic alliance 4. Plan reassessments
  163. 163. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 5. Document the assessment
  164. 164. Risk Assessment & Management Overview of risk assessment protocol 1. Identify predisposing factors 2. Examine potentiating factors 3. Conduct a specific suicide inquiry 4. Determine level of intervention 1. Acute versus chronic 2. Evaluate competence and impulsivity 3. Assess therapeutic alliance 4. Plan reassessments 5. Document the assessment
  165. 165. Risk Management Guidelines
  166. 166. Documentation • Evidence of an “assessment of risk”
  167. 167. Information on Previous Treatment • The past is the best predictor of the future. • All available sources of information should be pursued.
  168. 168. Involvement of the Family & Significant Others • Good sources of collateral data and integral components of the patient’s support system.
  169. 169. Consultation on Present Circumstances • Two perspectives are always better than one when assessing risk.
  170. 170. “Good care” • Intervention appropriate to the level of risk • Intervention in timely manner
  171. 171. Knowledge of Community Resources • Crisis numbers, in-patient options, substance abuse resources. • Documentation that these sources have been discussed.
  172. 172. The 4Ds of Malpractice • A doctor-patient relationship creating a DUTY of care must be present. • DEVIATION from the standard of care must have occurred • DAMAGE to the patient must have occurred. • The damage must have occurred DIRECTLY as result of deviation from the standard of care.
  173. 173. Malpractice • Failure to take adequate protective measures • Early patient release • Abandonment
  174. 174. When a Suicide Occurs  Ensure that the patient’s records are complete  Be available to assist grieving family members  Remember the medical record is still official and confidentiality still exists  Seek support from colleagues / supervisors  Consult risk managers
  175. 175. Assessment of Risk for Violence
  176. 176. Clinical features associated with risk for violence • Has threatened harm • Entertains thoughts of violence • Has access to means/weapons • Has taken steps to secure means • Reports command hallucinations
  177. 177. Clinical features associated with risk for violence • History of Paranoid Schizophrenia • Recent ETOH/drug abuse • Quarreling • Intense jealousy • Habitual rage response • Childhood fire setting/cruelty to animals • Violence in family of origin
  178. 178. Legal history associated with risk for violence • Reckless use of a weapon • Destruction of property • Has been stalking or harassing others
  179. 179. Risk Potential • Low –Denies current violent or homicidal ideation, no indicators evident. • Moderate –Violent/homicidal ideation without intent. • High –Strong ideation with intent.
  180. 180. Risk Potential • Low (Potential) • Moderate (Urgent) • High (Emergent)
  181. 181. Risk Potential • Potential – Rules – Physical indicators – Boundaries
  182. 182. Risk Potential • Urgent – Curious compassionate nonjudgmental – Behind all anger is hurt – One: one – Win-win – Offer incompatible behavior
  183. 183. Risk Potential • Emergent – Escape – Five: one – Debrief
  184. 184. Risk Assessment in Schools • Targeted violence versus general aggression
  185. 185. Risk Assessment in Schools • Profiling • Structured clinical assessment • Automated decision making / actuarial formulas
  186. 186. Risk Assessment in Schools • Profiling • Structured clinical assessment • Automated decision making / actuarial formulas
  187. 187. Risk Assessment in Schools • Profiling • Structured clinical assessment • Automated decision making / actuarial formulas
  188. 188. Risk Assessment in Schools • Threat assessment approach
  189. 189. Risk Assessment in Schools • Threat assessment approach –“making a threat” –“posing a threat”
  190. 190. Risk Assessment in Schools • Threat assessment approach –Perpetrator –Situation –Target –Setting
  191. 191. 10 Elements of Threat Assessment 1. motivation for the behavior at hand 2. communication about ideas and intentions; 3. unusual interest in targeted violence; 4. evidence of attack-related behaviors and planning;
  192. 192. 10 Elements of Threat Assessment 5. mental condition; 6. level of cognitive sophistication or organization to execute an attack plan; 7. recent losses (including losses of status); 8. consistency between communications and behaviors;
  193. 193. 10 Elements of Threat Assessment 9. concern by others about the individual’s potential for harm; and 10. factors in the individual’s life and/or environment that might increase or decrease the likelihood of attack.
  194. 194. A challenge….
  195. 195. David D Nowell PhD Let’s stay in touch! Join my e-newsletter list: • Fill out a card today and drop it in the box. • Text to join: text DNSEMINARS to 22828 • Sign up at www.DrNowell.com

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