Assessing and Managing Risk of Suicide and Violence

1. Assessing and Managing Risk of Suicide and Violence Brief presentation by Mr Geoff Argus (MAPS) & Dr Rachel Inglis (MAPS) APS Toowoomba Branch Meeting 14 June 2011

2. Caveat Due to presentation time constraints, this is only a VERY brief introduction to concepts of risk assessment and management.

3. Risk Framework Consider: • Components of risk • Domains of risk • Static and Dynamic Factors • Risk increasing/reducing factors

4. Components of Risk • Likelihood - How likely is it that the event will occur? • Immediacy/imminence - When and under what conditions is the event likely to occur? • Severity of outcome - If the event did occur, how serious would it be?

5. Risk Domains • Dispositional factors • Individual background, personality traits, cognitive functioning, etc • Historical factors • Past events that predisposes the person to harm self or others • Clinical factors • Diagnoses and symptoms of mental illness or disorder • Contextual factors • Current environmental factors (e.g., relationships, finance, etc)

6. SUICIDE

7. Suicide Risk Factors

8. Special groups • Indigenous Australians • Higher rates than general population • Higher risk under 29 years of age • High rates of incarceration • People from non-English speaking backgrounds • Rates vary among immigrant groups • High rates among elderly immigrants • Females at greater risk • Trauma or torture considerations • Cultural isolation

9. Risk INCREASING Dynamic processes Hopelessness Distress Suicidal ideation Suicidal plans Anger/impulsivity Intoxication Previous attempts Recent losses Poor coping skills Fear or shame Mental disturbance (e.g., depression, psychosis) Single/divorced/widow(er) Chronic pain

10. Risk REDUCING Dynamic Processes Positive about the future Feels supported Feels able to cope Seeks help when needed Insight/coping strategies Good problem solving Stable mental state Stable relationships No major stressors Sobriety

11. Suicide Risk Management • Address immediate concerns for safety • TALK WITH THE PERSON • Discuss options, alternatives and strategies • Increase social support network • Remove access to weapons • Assist with coping and problem-solving skills • Consider after hours options • Hospitalisation (EEO, JEO, local Mental Health Service) • Speak with key people (e.g., family, other service providers). Consider confidentiality and consent issues. • Plans for further appts and follow-up

12. Myth busting • People of ALL ages commit suicide. • “Manipulative” people DO commit suicide. • 60-70% of people who suicide HAVE NO KNOWN history of prior attempts. • Asking someone about suicide WON’T give a person ideas to commit suicide. There may actually be some relief. • People who say they want to kill themselves while intoxicated DO commit suicide. • A non threatening life attempt DOES NOT mean that the person is not a high risk.

13. VIOLENCE

14. Violence Risk Factors

15. Risk INCREASING Dynamic Processes Substance use Active symptoms Multiple psych. diganoses Treatment non-compliance/engagement Violent ideation Opportunity/access Impulsivity Anger Recent relationship breakdown Younger adult Lower SE group Unstable living situation

16. Risk DECREASING Dynamic Processes Minimal substance use No active symptoms Engaged in treatment Insight/coping strategies Social supports Stable living situation Few stressors No opportunity/access Conflict resolution skills Good problem solving

17. Violence Risk Management • Compliance with/engagement in treatment • Removing access to weapons • Increase support network • Stable accommodation • Assistance with problem-solving and coping skills • Strong follow-up support • Duties to third parties (e.g., intended victim, police, other agencies • Hospitalisation (EEO, JEO, local mental health service) • Attention to the environment • TALK TO THE PERSON

18. Justices Examination Order (JEO) • Applied for by any community member • At the court house or with a JP • Used for non-urgent mental health assessment If a JEO is then issued- • JEO is faxed by Justice to nearest mental health service. • Valid for up to seven days • Authorises a doctor or authorised mental health practitioner to assess the person • Police assistance may be sought • Person can only be taken to an mental health service if the assessment documents are made.

19. Emergency Examination Order (EEO) • Can be made by a police officer, ambulance officer or a psychiatrist. • Strict criteria apply • Used in urgent or emergency circumstances • Authorises a person to be taken to mental health service and detained for up to six hours • The person must be examined by a doctor or authorised mental health practitioner • If a recommendation for assessment is not made, the person must be returned to home

20. Acknowledgements Information gathered from the following sources • Community Forensic Outreach Service (2003) Clinical Risk Assessment and Management Training Project • Commonwealth Government Department of Health and Ageing and Government of South Australia. (2007). SQuARe – Suicide, QUestions, Answers and Resources: An education resource for primary health care, specialist and community settings. • Commonwealth Government Department of Health and Ageing. (2007). Living is for everyone (LIFE): A framework for the prevention of suicide in Australia