Evaluating Risk

1. Evaluating Risk

2. 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

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

4. 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

5. 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 Risk assessment psychol

6. 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

7. Divide into groups Task 5 minutes Discuss all the areas of risk in child and adolescent mental health Feedback Risk assessment psychol

8. Types of adverse outcome Harm to self Harm to others Harm from others Harm from healthcare system Harm to staff in the work Risk assessment psychol

9. 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 Risk assessment psychol

10. 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 Risk assessment psychol

11. 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 Risk assessment psychol

12. 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. Risk assessment psychol

13. 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 Risk assessment psychol

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

15. Some young people to be thinking about Risk assessment psychol

16. 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

17. Are you worried Would you let her home What advice would you give her and her mother Risk assessment psychol

18. Write me a much more worrying scenario Look at each of the factors listed and describe a case that would really worry you Risk assessment psychol

19. 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 Risk assessment psychol

20. Will you send her home What might steer you to allow her home Risk assessment psychol

21. 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 ? Risk assessment psychol

22. 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 Risk assessment psychol

23. 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 Risk assessment psychol

24. 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

25. [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)

26. Clinical versus actuarial risk assessment Risk assessment psychol

27. “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 0.6^0.9%),whichwas 66 (95% CI 52^82) 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” Risk assessment psychol

28. 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. Risk assessment psychol

29. Which of these accounts assists you in clinical decision making more. Risk assessment psychol

30. 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 Risk assessment psychol

31. 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

32. 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

33. 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

34. 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 Risk assessment psychol

35. 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 Risk assessment psychol

36. 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 Risk assessment psychol

37. 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 Risk assessment psychol

38. 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 Risk assessment psychol

39. 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

40. Risk assessment psychol SPJ Define factors as Static Stable Dynamic Future

41. 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

42. 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

43. Risk assessment psychol Note Actuarial methods are solely based on static and stable factors

44. 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

45. 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

46. Risk assessment psychol Static and stable factors give an indication of an individual’s 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

47. 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

48. Risk assessment psychol

49. 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.

50. 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 GCSE’s. 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