Risk Assessment & Treating Clients in Crisis
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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.

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 Risk Assessment & Treating Clients in Crisis Presentation Transcript

  • David D Nowell PhD www.DrNowell.com
  • A challenge….
  • Risk Assessment & Clients in Crisis An overview of the day: • Assessment of risk • Mental status examination • Intervention planning • Documentation
  • Patient at risk? male personality divorce pain guns alcohol
  • David D Nowell PhD DavidNowell DavidNowellSeminars www.DrNowell.com
  • Psychodynamic Issues Anxiety mastery Depression mastery Capacity to feel real and continuous across time
  • Edwin Schneidman • Psychache • Press • Perturbation
  • Edwin Schneidman • Psychache (pain) • Press • Perturbation
  • And so I leave this world, where the heart must either break or turn to lead. Nicolas-Sebastien Chamfort, French writer, d. 1794
  • 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
  • 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
  • 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
  • Edwin Schneidman • Psychache (pain) • Press (stress) • Perturbation (agitation)
  • Edwin Schneidman • Psychache (pain) • Press (stress) • Perturbation (agitation)
  • When to assess risk?
  • When to assess risk?
  • When to assess risk?
  • 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
  • SUICIDE PREDICTION vs. SUICIDE RISK ASSESSMENT
  • 300.4, rule out 296.25
  • 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
  • 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
  • Risk Assessment & Management Predisposing factors • Older • White • Male • Personality disorder • Substance abuse • Access to guns • Recent stress or public humiliation
  • 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
  • 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
  • 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
  • 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
  • DSM-IV 5-Axis System • Axis I • Axis II • Axis III • Axis IV • Axis V
  • DSM-IV 5-Axis System • Axis I • Axis II • Axis III • Axis IV • Axis V
  • • Axis I • Axis II • Axis III • Axis IV • Axis V
  • Predisposing Clinical Risk Factors • Mood disorders –15% lifetime risk –50 – 70% of all suicides
  • Predisposing Clinical Risk Factors • Depression
  • Predisposing Clinical Risk Factors • Bipolar Disorder
  • Predisposing Clinical Risk Factors • Substance Abuse / Dependence
  • Predisposing Clinical Risk Factors • Substance Abuse / Dependence –Lifestyle Issues
  • Predisposing Clinical Risk Factors • Anxiety Disorders
  • Predisposing Clinical Risk Factors • Schizophrenia
  • Predisposing Clinical Risk Factors • Personality disorders –5 – 10% lifetime risk –15 – 25% of all suicides
  • Borderline Personality and Risk  Lifetime rate of suicide - 8.5%  With alcohol problems -19%  With alcohol problems and major affective disorder -38%
  • Borderline features which increase risk • Impulsivity • Hopelessness-despair • Antisocial features • Aloofness • Self-mutilating tendencies • Psychosis
  • Borderline features which ameliorate risk • Clinging • Dependency • Use of suicidal behavior to maintain connections
  • Antisocial Personality Disorder • Concurrent Axis I disorder • Over age 40 • Recent narcissistic injury / impulsivity
  • Narcissistic Personality Disorder • Failure • Humiliation • Criticism
  • 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
  • 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
  • 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
  • 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
  • COMORBIDITY In general, the more diagnoses present, the higher the risk of suicide.
  • 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
  • Predisposing Medical Risk Factors • Chronic Pain • Chronic illness
  • 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.
  • Predisposing Demographic Risk Factors • Male • Older • Lives alone • Widowed / separated • White, or Native American • Access to weapons • Sexual minority (GLBT)
  • • Mexico 4.0 • Dominican 2.3 • Puerto Rico 7.4 • Colombia 4.9
  • • S. Korea 31.7 • China 22.3 • India 10.5
  • 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
  • Potentiating Risk Factors • Recent stressor • Contagion • Recent diagnosis of major illness • Recent relapse of major illness • Hepatitis C treatment
  • Potentiating Risk Factors • Recent stressor –Legal Problems –Loss of Job –Relationship issues –Homeless –Finances
  • Potentiating Risk Factors • Recent stressor • Contagion • Recent diagnosis of major illness • Recent relapse of major illness • Hepatitis C treatment
  • Admiral Jeremy Boorda
  • Choi Jin-sil
  • Patient at risk? male personality divorce pain guns alcohol
  • 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
  • 1 – Item Suicidality Assessment
  • Specific Suicide Inquiry • (Current) Ideation • (History of ) Threats • (History of) Attempts
  • Ideation • Passive thoughts • Active thoughts Duration: Frequency: Persistent? Obsessive?
  • Suicidal ideation • Able to control suicidal thoughts? • Has made preparations for death? • Has rehearsed? • Command hallucinations?
  • Suicidal plan: • No concrete plan but has intent • Plan without means • Plan with means: • Lethality
  • 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
  • History of threats • Seek collateral information • Determine context of threats
  • History of attempts • Actions imply gestures vs. intent? • Dangerous/not believed to be lethal? • Dangerous/potentially lethal? • History of self-injurious behavior?
  • Competency / Capacity • Psychosis • Impaired judgment • Decompensated • Overwhelmed
  • Impulsivity • History of money management? • Impulsive relapses? • Domestic violence? • Abrupt firings from jobs? • How have relationships ended? • History of impulsive suicidality?
  • Deterrents to suicide • Religious faith • Hopefulness re: resolution • Ambivalence • Reasons for living • Loved ones • Relationship with therapist
  • “signs” and “symptoms”
  • Current risk factors, reported (symptoms) • Self-report • Collateral data –Records –Significant others, family, friends
  • Current risk factors, observed (signs) • mental status examination
  • Current risk factors, observed • mental status examination –Behavior –Emotional –Cognitive
  • 90791
  • ABC STAMPLICKER
  • ABC STAMPLICKER • appearance
  • “client appears his stated age…”
  • ABC STAMPLICKER • behavior
  • ABC STAMPLICKER • cooperation
  • ABC STAMPLICKER • speech
  • ABC STAMPLICKER • thought
  • ABC STAMPLICKER • Thought –form –content
  • Common abnormalities of thought form • Loose associations • Clang • Overinclusiveness • Pressure • Tangentiality
  • Common abnormalities of thought content • Delusions • Obsessions • Phobias • Violent ideation. • Hallucinations (abnormal perception)
  • ABC STAMPLICKER • affect
  • Euthymic: • Calm • Comfortable • Euthymic • Friendly • Normal • Pleasant • Unremarkable
  • Angry: • Angry • Bellicose • Belligerent • Confrontational • Frustrated • Hostile • Sullen • Impatient • Irascible • Irate • Irritable • Oppositional • Outrage
  • Dysphoric: • Despondent • Distraught • Dysphoric • Grieving • Hopeless • Overwhelmed • Remorseful • Sad
  • Terms to describe parameters of affect: • Appropriateness • Intensity • Range
  • ABC STAMPLICKER • mood
  • ABC STAMPLICKER • perception
  • “sensorium intact…”
  • Person Place Time Situation “Oriented X 3” “O X3”
  • Person Place Time Situation “Oriented X 3” “O X3” “Oriented X 4” “OX4”
  • ABC STAMPLICKER • Level of arousal
  • “Patient is an 89 year old male, A+O x 3, no AH/VH, denies SI/HI.”
  • ABC STAMPLICKER • insight
  • Disorders that contribute to impaired insight • Drug and alcohol dependence • Depression • Mania • Psychosis • Personality disorders • Delirium • Dementia • ADHD • Conversion disorder • Factitious disorder
  • Judgment • The ability to weigh and compare the relative values of different aspects of an issue.
  • ABC STAMPLICKER • cognition
  • ABC STAMPLICKER • Cognition –Attention –Memory
  • 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
  • ABC STAMPLICKER • Knowledge
  • ABC STAMPLICKER • Endings
  • ABC STAMPLICKER • reliability
  • Patient at risk? male personality divorce pain guns alcohol
  • Validity techniques in risk assessment • Behavioral incident • Shame attenuation • Gentle assumption • Symptom amplification • Denial of the specific • Normalization
  • 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
  • Suicide Risk Classification High risk Moderate Risk Low risk
  • Suicide Risk Classification High risk Moderate Risk Low risk
  • Suicide Risk Classification High risk Moderate Risk Low risk
  • 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
  • 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
  • Determine level of intervention 1. Acute versus chronic 2. Evaluate competence and impulsivity 3. Assess therapeutic alliance 4. Plan reassessments
  • Determine level of intervention 1.Acute versus chronic 2. Evaluate competence and impulsivity 3. Assess therapeutic alliance 4. Plan reassessments
  • Disorder-based (acute) Personality- based (chronic)
  • Disorder- based (acute) Personality-based (chronic)
  • Determine level of intervention 1. Acute versus chronic 2.Evaluate competence and impulsivity 3. Assess therapeutic alliance 4. Plan reassessments
  • 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?
  • Determine level of intervention 1. Acute versus chronic 2. Evaluate competence and impulsivity 3.Assess therapeutic alliance 4. Plan reassessments
  • Determine level of intervention 1. Acute versus chronic 2. Evaluate competence and impulsivity 3. Assess therapeutic alliance 4.Plan reassessments
  • Consultation with others • When appropriate involve family members in decision making. • Other professionals • Collaboration with the patient
  • Consultation with others • When appropriate involve family members in decision making. • Other professionals • Collaboration with the patient
  • No Harm Contracts
  • An Alternative Approach: Collaborative approach
  • 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.
  • • 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.
  • 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?
  • 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?
  • Providing Feedback
  • Feedback approach –Collaborative –Mutuality –Curiosity
  • Feedback approach –Review chief complaints –Add pertinent info re: signs
  • Feedback approach –Offer diagnosis • Share attitude of round pegs/square holes • Emphasize hope –Request feedback –Offer accurate empathy
  • Feedback approach • Feedback provides three types of information for patient –Confirms the obvious –Gently challenges –Doesn’t fit
  • Feedback approach • Feedback regarding personality disorder
  • Oldham & Morris. Personality Self- Portrait
  • Personality Styles • Narcissistic • Dependent • Paranoid • Anti-social • Borderline • Self-confident • Devoted • Vigilant • Adventurous/challenger • Mercurial
  • Adventurous/Challenger • Nonconforming • Daring • Mutual independence • Persuasive • Charming • Free lance • No regrets
  • Mercurial • Romantic attachment • Intensity • Heart • Unconstraint • Activity • Open mind • Alternate states
  • Self-Confident • Self-regard • Red carpet • Ambition • Competition • Stature • Dreams • Poise
  • 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
  • Documentation
  • Documentation
  • 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
  • 300.4, rule out 296.25
  • The Written Report • Identifying data • HPI / background info • Med hx • Social hx
  • The Written Report • MSE • Review of systems –Somatic –Cognitive –Affective
  • The Written Report • Impression • Summary –Differential –Contributing factors –Further information needed –Prognosis –Response to referral questions
  • The Written Report • Risk Potential – Low/moderate/high – Safety plan (if appropriate to level of risk) • Treatment Plan • Cost / Benefit Comments re: alternate treatments
  • How to Use the Form Provided Today
  • CSSRS.COLUMBIA.EDU Columbia Suicide Severity Rating Scale (CSSRS)
  • Clinical examples
  • 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
  • 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
  • Disposition Determine level of intervention 1. Acute versus chronic 2. Evaluate competence and impulsivity 3. Assess therapeutic alliance 4. Plan reassessments
  • 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
  • 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
  • Disposition Determine level of intervention 1. Acute versus chronic 2. Evaluate competence and impulsivity 3. Assess therapeutic alliance 4. Plan reassessments
  • 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
  • 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
  • Risk Management Guidelines
  • Documentation • Evidence of an “assessment of risk”
  • Information on Previous Treatment • The past is the best predictor of the future. • All available sources of information should be pursued.
  • Involvement of the Family & Significant Others • Good sources of collateral data and integral components of the patient’s support system.
  • Consultation on Present Circumstances • Two perspectives are always better than one when assessing risk.
  • “Good care” • Intervention appropriate to the level of risk • Intervention in timely manner
  • Knowledge of Community Resources • Crisis numbers, in-patient options, substance abuse resources. • Documentation that these sources have been discussed.
  • 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.
  • Malpractice • Failure to take adequate protective measures • Early patient release • Abandonment
  • 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
  • Assessment of Risk for Violence
  • 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
  • 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
  • Legal history associated with risk for violence • Reckless use of a weapon • Destruction of property • Has been stalking or harassing others
  • Risk Potential • Low –Denies current violent or homicidal ideation, no indicators evident. • Moderate –Violent/homicidal ideation without intent. • High –Strong ideation with intent.
  • Risk Potential • Low (Potential) • Moderate (Urgent) • High (Emergent)
  • Risk Potential • Potential – Rules – Physical indicators – Boundaries
  • Risk Potential • Urgent – Curious compassionate nonjudgmental – Behind all anger is hurt – One: one – Win-win – Offer incompatible behavior
  • Risk Potential • Emergent – Escape – Five: one – Debrief
  • Risk Assessment in Schools • Targeted violence versus general aggression
  • Risk Assessment in Schools • Profiling • Structured clinical assessment • Automated decision making / actuarial formulas
  • Risk Assessment in Schools • Profiling • Structured clinical assessment • Automated decision making / actuarial formulas
  • Risk Assessment in Schools • Profiling • Structured clinical assessment • Automated decision making / actuarial formulas
  • Risk Assessment in Schools • Threat assessment approach
  • Risk Assessment in Schools • Threat assessment approach –“making a threat” –“posing a threat”
  • Risk Assessment in Schools • Threat assessment approach –Perpetrator –Situation –Target –Setting
  • 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;
  • 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;
  • 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.
  • A challenge….
  • 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