Assessment and Management

Intro

Whether we like it or not, the community expects mental health clinicians to assess and manage the risks to those in the community posed by patients with a mental illness.

The public is unlikely to accept excuses by the mental health services when failures occur and a person in the community is seriously harmed, no matter how legitimate they may be.

Intro

In modern culture, greater emphasis is put on the concept of risk, especially in fields concerned with the future consequences of current events. As in business, stock market, investment, politics and psychiatry, all are concerned with methods for better prediction of risk

In psychiatry risk is defined as: The likelihood of an event happening with potentially

harmful or beneficial outcomes for self and others. (possible behaviours include suicide ,self-harm ,self-

neglect ,aggression and violence ;with an additional range of other positive or negative service user experience

Types of Risk

Of suicide Of aggression Of neglect

Types of risk (others)

Self injury Other self harm (e.g eating disorders

Abuse by others

Abuse to others Harassment by others

Harassment to others

Types of risk (others)

Risk to children

Non-violent sex offence

Financial exploitation

Arson Accidental fire risk

predictors 1. For Risk of neglect

Neglect

Despite being under estimated ,this category is with the

highest incidence rates in mental health service .

Neglect

Prev His of neglect

Unable to feed himself

Poor physical health

Poor living conditions

Lack of basic amenities

Poor social support

Inability to maintain hygiene

Financial difficulties

Cant communicate needs

Deny his problems

predictors 2. For Risk of violence

Static predictors:

Young Unemployed Early maladjustment

Substance use

Previous violence

Personality disorder

psychopathy Relationship instability Major mental

illness

Dynamic predictors

Current active substance

abuse Threats Irritability

Lack of insight Negative attitudes Active

symptoms of mental illness

Non response to rx impulsivity

External predictors

- Are the easiest to change - influenced by the dynamic

psychosocial environment of the person,

- the occurrence of things that will alter the persons view of the world , the people they relate to and their situation

Protective predictors

Strong social support

Engagement with service

Good social relationships

Stable employment

Prolonged abstinence

from substance Older age

Staff predictors

Research has shown that inexperienced staff and those with little training in psychiatric care and management of aggressive patients are at an increased risk of being the victim of assault . Staff satisfaction with their working conditions, colleagues, and mangers has also been shown to be associated with lower rates of aggression and violence on inpatient units

predictors 3. For risk of Suicide

Demographic predictors

male Increasing age

Low socio-economic Single

Living alone unemployed

Background history

Deliberate self harm

Childhood adversity (eg sexual abuse)

Family history of suicide

Family his of mental illness

Clinical history

Diagnosis of mental illness

Personality disorder

Physical illness (chronic painful

disabling)

Recent contact with psychiatric

service

Recent discharge from

in-patient

Psychological factors

Hopelessness Impulsivity

Low self esteem Life event

Relationship instability

Lack of social support

Current (context )

Suicidal ideation

Suicidal plans

Availability of means

Lethality of means

Risk assessment

Risk Assessment

The purpose of risk assessment in the inpatient setting is not to predict risk per se, but to identify factors that may indicate risk is elevated and enable a clear and valid risk management plan to be developed

Risk Assessment Sources include : Health Record Discharge summaries Admission assessments Reports Mental Health Act documentation Correspondence from other agencies or individuals

Risk Assessment Sources include : Criminal Offence History and Charge Summaries School reports collateral info (often missed ) Relatives, carers,

General Practitioner and other agencies such as the Police or Ambulance

Risk Assessment For each episode consider either :

5W approach

When the episode occurred Where it occurred Who the victim(s) What behaviour they engaged in What are the consequences Why did they engage in that behaviour

ABC analysis

Antecedents

Behaviour

Consequences

Risk Assessment Clinical and actuarial approaches to risk assessment : 1. Unstructured clinical method Most risk assessment currently performed by clinical methods ,its based on clinical experience ,individual knowledge and person specific assessment to reach a conclusion (only 1/3 are right !)

Risk Assessment Clinical and actuarial approaches to risk assessment : 2. structured clinical risk assessment e.g HCR-20 (historical-clinical and Risk) Compromised of 10 historical items ,5 clinical items and 5 risk management items

Risk Assessment Clinical and actuarial approaches to risk assessment : 3.Actuarial instruments These methods utilise statistical techniques to generate risk predictors. Actuarial risk prediction is primarily based on information about group risk of re- offending, analysed in extensive studies of populations, using meta-analytical techniques.

Risk Assessment Clinical and actuarial approaches to risk assessment : 3.Actuarial instruments Actuarial assessment of an individual measures how far the individual shares the key characteristics of the group, such as age, gender, criminal records, etc. which are found to be associated with levels of risk.

Risk Management

Risk Management Collaborative Vs defensive styles in management

Risk Management Collaborative Vs defensive styles in management

Risk Management The whole purpose of a risk assessment is to provide the foundation for and to guide the development of a risk management plan. A risk assessment is never complete without a risk management plan.

Treatment placement Restrictions Implemen

tation Monitorin

g

Risk Management

Treatment

placement

Restrictions

Implementation

Monitoring

risk management plan addresses

certain static but mainly dynamic risk

factors and capitalises and enhances

protective factors

Risk Management

Treatment

placement

Restrictions

Implementation

Monitoring

by implementing biological,

psychological and social interventions,

traditionally related to mental health,

such as type, duration and dose of

medication, cognitive behaviour

therapy, social supports and vocational

pursuits

Risk Management

Treatment

placement

Restrictions

Implementation

Monitoring

Placement is the environment in which the treatment will be carried out or implemented In deciding on placement, the clinician should always consider the least restrictive alternative that enables safe management of the patient. To do this, the clinician must have regard to the identified risk and the treatment required

Risk Management

Treatment

placement

Restrictions

Implementation

Monitoring

are limitations that are placed on the person in order to make the treatment work in the placement. Restrictions refer to the constraints and coercive mechanisms that might be required to keep the person safe and reduce opportunity to harm others

Risk Management

Treatment

placement

Restrictions

Implementation

Monitoring

There are three areas of restriction that the clinician could consider: Environmental restrictions (external to the person manipulated by others) Personal restrictions (internal and relies on persons motivation to adhere) Legal restrictions (legislation)

Risk Management

Treatment

placement

Restrictions

Implementation

Monitoring

Implementation is about identifying and ensuring that someone is responsible for making the risk management plan happen A persons name or title needs to be entered in the file as the identified person responsible for ensuring the recommendations with regard to treatment; placement and restrictions are carried out as well as monitoring

Risk Management

Treatment

placement

Restrictions

Implementation

Monitoring

is the gathering of information to inform the clinician about and ensure the effectiveness of, treatment, placement, restrictions and implementation.

Risk Management

Treatment

placement

Restrictions

Implementation

Monitoring

Monitoring involves three things: 1. Gathering additional information

(for example the need to refer for a specialist opinion, getting old notes, meeting with the family).

2. The determination of the effectiveness of the treatment, restrictions and placement.

3. The frequency of reviews, by whom, when and where.

conclusion We would argue that there are significant reasons for Mental

Health Services to build on their Risk Assessment and Management skills.

For these reasons our assessment processes need to be state of

the art, transparent and evidence based. Risk Assessment and Management should be an integral part of clinical practice

Thank you

Slide Number 1Assessment and ManagementIntroIntroTypes of RiskTypes of risk (others)Types of risk (others)predictorsNeglectNeglectpredictorsStatic predictors:Dynamic predictors External predictorsProtective predictors Staff predictorspredictorsDemographic predictorsBackground historyClinical history Psychological factorsCurrent (context )Risk assessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementRisk ManagementconclusionThank you