Module 8: Risk

1. Module 8: Risk

2. Objectives • To be aware of the kinds of risks associated with dual diagnosis • To be aware of how substance use and mental health increase risks of violence and self-harm • To be able to identify risks and develop a risk management plan

3. Dual Diagnosis Capabilities • Assess risks and devise a management plan in conjunction with service user and other relevant personnel, ensure that all parties are aware of their own role in risk management. Dual Diagnosis Capability 10 level 2 • Multi-agency/professional working: To understand the roles and responsibilities of the range of professionals and service providers, and to share care, and work in partnership with them. Dual Diagnosis Capability 15 level 2.

4. Exercise 1: Risks associated with dual diagnosis • Thinking about your work experience, what are the risks associated with people with co-morbid mental health and substance use problems? • Discuss in pairs, and make a list. (10 minutes)

5. Risks • People with dual diagnosis are far more likely than people with single diagnoses to be at risk of harm either to themselves or others. • Risks include: • violence • suicide • self-harm • accidental overdose from alcohol and/or illicit drugs, • self-neglect and malnutrition. • physical health problems (such as blood borne viruses and injecting related problems) • victimisation (bullying).

6. Risk Management • Requires effective interpersonal and engagement skills, good communication between service user and all the services involved in their care, good support, and monitoring. • It is almost impossible to prevent every untoward incident from occurring, but a lot can be done to minimize the risk and reduce the likelihood of it occurring. • The service user should be placed at the centre of any risk management plan, and their needs should be addressed as far as possible. • However there will be times in which the needs of the individual cannot be met as this poses a threat to others. • This dilemma needs to be managed with as little confrontation as possible and with as much dignity as possible for the service user. • For example, if you are aware that the person is likely to harm a relative then immediate action should be taken in order to prevent this. This may involve informing the relative of the threat posed, or preventing the service user from access to that person until the threat has subsided or if the safety of that person can be protected (supervised contact for example).

7. Recommendations From “Avoidable Deaths”(National Confidential Enquiry into Homicides and Suicides by those with Mental Illness 2006) • Reduce levels of absconding as deaths occurred after absconding from inpatient wards • Transition from ward to community- ensure a safe transition from ward to home. • Use of CPA and management of risk- comprehensive risk assessment and high risk service users subject to enhanced CPA (including substance users). • Responding quickly when a care plan breaks down • Improve observation on inpatient wards. • Change attitude of “inevitability” towards suicides by people with mental illness • Improve services for dual diagnosis

8. Exercise 2 : Risk identification and Management • In small groups, read scenario then consider: • What are the main concerns you would have about this man? • From the case history, make a list of the risk factors and explain why they are significant • What kind of risk management plan would you want to implement? • Who would be involved in this plan?