Risk Management

Week 4

Context

"Safety is at the centre of all good healthcare. This is particularly important in mental health but it is also more sensitive and challenging. Patient autonomy has to be considered alongside public safety. A good therapeutic relationship must include both sympathetic support and objective assessment of risk" (National Mental Health Risk Management Programme, 2007).

Keeping someone safe means identifying and managing risk. The main risk is of harm to themselves or others, and in this section we will explore the assessment of suicide risk.

Content

Risk Management Triage

"An act of self-harm is a not necessarily an attempt or even indicator of suicide, indeed it can sometimes be a bizarre form of self-preservation. Nevertheless it covers a wide spectrum of behaviour, with harmful physical effects, and a person who repeatedly self-harms is at a higher risk of suicide" (Royal College of Psychiatrists, 2010)

As soon as there is a question over the safety of any person with a mental illness, it is important to establish the best place for them to be observed and kept safe, depending on the circumstances. Can they to wait to be seen or is this an emergency situation that requires immediate intervention?

Risk assessment is based on identifying any: potential to harm themselves or others; the intensity of their thoughts and their behaviour; and and history of harm to themselves or others.

If a carer is present can they wait with the person, and for how long? What is the relationship with the carer - are they part of the problem or solution?

Suicide Risk

If you suspect that a person is at risk of suicide, then you must do something. This might be seeking help and support from a professional colleague or a more senior and experienced colleague. Ask the person at risk if they have thoughts or any plans around their death or suicide. Questions to ask:

1. Do you feel life is worth living?
2. Have you felt like acting on any of your thoughts?
3. Have you made any plans?
4. Have you made attempts before?

If yes to feelings (1), then monitor and encourage them to seek treatment for depression. 
If yes to (1) and (2), Intentions but no plans or prior history - monitor closely over the coming days and consider a referral to a health care worker who is a specialist in this area.
If yes to (3) and / or (4) - plans/ past attempts then urgently refer to emergency/ specialist services and closely monitor, making sure they are not left alone to act on any plans.

If you were in a discussion over the telephone with a friend who says they are wanting to harm themselves, what are some of the steps that you recommend to help keep safe?

Distinguish between just thoughts and actual intentions, actual plans and previous attempts. If the person has any ideas and vaguely phrased intentions but no definite plans or history, then seek help for their depression and put in a system that will enable them to be monitored closely. Involve family or carers in monitoring where possible. Consider what additional support the family / carers might also require to help them during this difficult time.If there is clear intent, planning, or past history then urgent referral is required. 

Other Suicide Risk Factors

Factors that might predispose someone to suicide include a family history of suicide, mental illness, self harm, depression or misuse of alcohol or other substances. Someone who is living alone' unemployed, or socially isolated is also at greater risk. Anyone with a diagnosis of depression, substance misuse (including alcohol), or schizophrenia, is also at greater risk.

When dealing with someone else in a period of distress, it often has an impact and effect on you. Consider what and how you are feeling now, having read and watched Carol's situation What helps you when you are scared, tired, anxious or stressed? How might some of these techniques be used to help others?

 

 References and Further Reading

 National Mental Health Risk Management Programme (2007) Best Practice in Managing Risk: Principles and evidence for best practice in the assessment and management of risk to self and others in mental health services Download Best Practice in Managing Risk: Principles and evidence for best practice in the assessment and management of risk to self and others in mental health services

. London: Department of Health

Royal College of Psychiatrists (2010) Self-harm, suicide and risk: helping people who self-harm Download Self-harm, suicide and risk: helping people who self-harm

. London: Royal College of Psychiatrists

Scottish Government Social Research (2008) Risk and Protective Factors for Suicide and Suicidal Behaviour: A Literature Review Download Risk and Protective Factors for Suicide and Suicidal Behaviour: A Literature Review

.Edinburgh: Scottish Government