Risk Assessment & Treating Clients in Crisis

David D Nowell PhDwww.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?




• 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 protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment




Predisposing factors

• Older• White• Male• Personality disorder• Substance abuse• Access to guns• Recent stress or public humiliation









DSM-IV 5-Axis System

• Axis I• Axis II• Axis III• Axis IV• Axis V

DSM-IV 5-Axis System



Predisposing Clinical Risk Factors

• Mood disorders–15% lifetime risk–50 – 70% of all suicides


• Depression


• Bipolar Disorder


• Substance Abuse / Dependence


• Substance Abuse / Dependence–Lifestyle Issues


• Anxiety Disorders


• Schizophrenia


• 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 27.5Bipolar disorder 21.7 0.310 15.5Major depression 20.4 0.292 14.6Mixed drug abuse 19.2 0.275 14.7Dysthymia 12.1 0.173 8.6Obsessive-compulsive 11.5 0.143 8.2Panic disorder 10.0 0.160 7.2Schizophrenia 8.45 0.121 6.0Personality disorders 7.08 0.101 5.1Alcohol abuse 5.86 0.084 4.2Cancer 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


General population 1.0 0.014 0.72




Prior suicide attempt 38.4 0.549 27.5Bipolar disorder 21.7 0.310 15.5Major depression 20.4 0.292 14.6




Dysthymia 12.1 0.17 8.6Panic disorder 10.0 0.16 7.2



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



Potentiating Risk Factors

• Recent stressor• Contagion• Recent diagnosis of major illness • Recent relapse of major illness• Hepatitis C treatment


• Recent stressor–Legal Problems–Loss of Job–Relationship issues–Homeless–Finances


• 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



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…”

PersonPlaceTime

Situation

“Oriented X 3”“O X3”

PersonPlaceTime

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 normsEighth 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



Suicide Risk Classification

High risk

Moderate Risk

Low risk


High risk

Moderate Risk

Low risk


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



Determine level of intervention1. Acute versus chronic2. Evaluate competence and impulsivity3. Assess therapeutic alliance4. Plan reassessments


Disorder-based (acute)

Personality-based (chronic)

Disorder-based (acute)

Personality-based (chronic)

Determine level of intervention1. Acute versus chronic

2. Evaluate competence and impulsivity

3. Assess therapeutic alliance4. 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 intervention1. Acute versus chronic2. Evaluate competence and impulsivity

3. Assess therapeutic alliance4. Plan reassessments

Determine level of intervention1. Acute versus chronic2. Evaluate competence and impulsivity3. 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 protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. 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





Disposition






Disposition





Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention

1. Acute versus chronic2. Evaluate competence and impulsivity3. Assess therapeutic alliance4. 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


• 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


• Threat assessment approach


• Threat assessment approach–“making a threat”–“posing a threat”


• Threat assessment approach–Perpetrator–Situation–Target–Setting

10 Elements of Threat Assessment

1. motivation for the behavior at hand2. communication about ideas and

intentions;3. unusual interest in targeted violence; 4. evidence of attack-related behaviors

and planning;


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;


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

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Risk Assessment & Treating Clients in Crisis

Health & Medicine

suicide risk assessment

lifetime risk

risk assessment clients

potentiating factors

risk lifetime rate of

axis system axis

high risk client

specific suicide inquiry