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

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

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

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?

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)

SUICIDE

Suicide Risk Factors StaticDynamic Male Young/very old Hx previous attempts or self-harm Hx mental illness Hx childhood abuse and/or neglect Alcohol dependency Medical illness Family Hx suicide Family Hx mental illness Low SES or long-term unemployed Rural Available means Suicidal thinking Feelings of hopelessness Harmful use of substances Stressful life events Legal problems Financial problems Poor social support Impulsivity Interpersonal problems Perceived ability to cope Active symptoms of mental illness Chronic medical condition (esp. with pain)

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

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

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

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

Myth busting People of ALL ages commit suicide. “Manipulative” people DO commit suicide % 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.

VIOLENCE

Violence Risk Factors StaticDynamic Previous violence Psychopathy Substance abuse history Male gender (in non-mentally ill) Young age (esp at first offence) Childhood abuse/maladjustment Arrest and criminal history Instability (work/relationships) Personality style (e.g. ASPD) Cognitive functioning Family and social Hx Social class Perceived stress Poor family relations Anger Impulsivity Suicidality Substance abuse Intoxication Lack of community/social supports Treatment non-compliance (in mentally ill) Delusions (esp. persecutory and of infidelity) Hallucinations with delusions Violent fantasy Unstable living arrangements

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

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

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

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.

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

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