Future Focused Safety Assessment SFP Conference, Napier, 2019 Brent Gardiner Massey University, Palmerston North Email: B.D.Gardiner@massey.ac.nz Telephone 06-356-9099

What is “risk” assessment? According to the MoH guidelines: Essentially, the procedure that follows a client presenting with suicidal ideation and/or evidence of self-harm. MoH (2003). Assessment and management of people at risk of suicide.

Why safety assessment? Tapu and Noa – A code for survival. Broad aims: Survival of future generations Adaptation to the environment Developing a guide to social interaction Durie, M. Mauri ora: The metrics of flourishing. (Seminar handout). New Plymouth, N.Z. Compass seminars.

The code Tapu = risk Noa = safety The practical basis for the code has tended to be subsumed into a spiritual code for living. The two perspectives are not necessarily incompatible. Durie, M. Mauri ora: The metrics of flourishing. (Seminar handout). New Plymouth, N.Z. Compass seminars

Signs of safety

Signs of safety This book presents a revolutionary approach to child protection work. It focuses on the question, "How can child protection professionals actually build partnerships with parents where there is suspected or substantiated child abuse or neglect?" The authors bring the solution orientation to child protection work, expanding the investigation of risk to encompass signs of safety that can be built upon to stabilize and strengthen the child's and family's situation. Edwards, S., & Turnell, A. (1999). Signs of safety: A solution and safety oriented approach to child protection casework. WW Norton & Company, New York, NY.

Not either/or So we want to figure out how to ask about problems and risk in a conversation that also points to hope, possibilities and capabilities.

So why not just traditional risk assessment? Questions: Mood Ideation Intent Plan Means Some suggestion that these questions may be helping clients rehearse suicidal plans.

What does the research say about risk assessment as a tool for suicide prevention Not much… at least not much that’s good.

Recent reviews Issues Ment Health Nurs. 2012 Jan;33(1):2-7. doi: 10.3109/01612840.2011.616984. Investigating the evidence for the effectiveness of risk assessment in mental health care. Wand T1.

Wand, T. systematic review Abstract This paper aims to establish the research evidence for the effectiveness of a risk assessment approach in mental health. A search was conducted of the professional literature on risk assessment in mental health, specifically seeking any research on the effectiveness of risk assessment in reducing risk of harm to self or others.

Findings The search found limited research on the effectiveness of risk assessment. "Structured professional judgment" possibly reduces aggression risk but there is no evidence that risk assessment is effective in relation to self-harm or suicide reduction.

Another systematic review : https://newsroom.unsw.edu.au/news/health/study-finds-no-method-reliable-assessing-suicide-risk-mental-health-patients Large, M., Kaneson, M., Myles, N., Myles, H., Gunaratne, P., & Ryan, C. (2016). Meta-analysis of longitudinal cohort studies of suicide risk assessment among psychiatric patients: heterogeneity in results and lack of improvement over time. PloS one, 11(6), e0156322. Meta analysis of 37 studies.

Findings Conclusions The strength of suicide risk categorizations based on the presence of multiple risk factors does not greatly exceed the association between individual suicide risk factors and suicide. A statistically strong and reliable method to usefully distinguish patients with a high-risk of suicide remains elusive.

So why do risk assessment? Primarily to meet professional standards.

Establishing a Common Contract Opening question Establishing a Common Contract ‘What are your best hopes from our talking together today?’ ‘What will be different that will let you know that this conversation has been useful to you?’

Four Useful Questions 1. Exceptions, Strengths and Constructive History 2. Coping Questions 3. The Miracle Question -A preferred future and Other Future Focused Questions 4. Scaling questions

Finding instances of success /exceptions to the problem

Finding exceptions Tell me how you ended up coming to counselling? Where do you get the strengths to cope with all this? Who else knows you have this capability? When are the times that you don’t feel stuck? What’s different then? How will you know when you no longer need to do this?

Finding exceptions If you think back over the last few weeks are there any times you can think of that things were even a little bit better? ‘What are you doing differently and what are others doing that is different at those (exception) times?’ Who else might notice this aside from you?

Follow up exceptions Reinforce Show interest. How did you get that to happen? If he were here what would he say helped that to happen? How did you figure out to do that? Start Over Tell me about another time when this was happening.

Coping questions

Coping questions Great when clients are feeling very despairing, hopeless or overwhelmed - “Given all that’s been happening for you, I’m amazed that you’ve managed to keep going. How have you done that?” “ Since you say you’ve been having suicidal thoughts a lot of the time, how have you managed to survive and get here today?” “With all the problems that you’ve been having, how have you managed to get through?”

Discovering the client’s preferred future

The question is…. NOT “What is the matter with this person?” BUT “What matters to this person?” (Durie, M., 2018)

Discovering the client’s preferred future ‘Suppose that you wake up tomorrow and your best hopes are all happening. How will you know? What will be different?’ ‘Imagine that after you have gone to bed tonight, a miracle happens and (your best hopes are all happening). But since you are asleep, you will not know that the miracle has happened. When you wake up tomorrow morning what will be different that will tell you? What’s the first thing you will notice? Who else will notice? What will be the first thing they will notice? FOLLOW UP…Amplify…Elaborate…ask what else?

Scaling questions

Scaling questions “ On a scale of one to ten, where 1 is the worst things were and 10 is things are back on track, where would you say you are today?” “ On a scale of one to ten, where 1 is the sadness/hurt/ fear are there big time and 10 is you are feeling safe and things are better, where would you put yourself today?” “10 means you have every confidence that you’ll solve this and 1 means you have none, where are you right now?” If you were a point, maybe ½ a point higher, what would be happening that’s not happening now? What would tell you?

Case example Gemma Thanks to the therapist who was Berenice Tanner, then psychologist in an adolescent mental health team based in a Sydney hospital. Now school psychologist at Mt. St. Bernedicts College in northern Sydney.