Managing Risk, Self- Harm and Suicidal Behaviour Shaunie Hill and - PowerPoint PPT Presentation

Managing Risk, Self- Harm and Suicidal Behaviour Shaunie Hill and Lauren Dowson

Risk management Risk management is the identification, assessment, and management of potential and actual adverse events (Sperry, 2015) Clinical risk management is concerned with the development of strategies that prevent such an action or event occurring, or if prevention is not possible the focus would be on minimising harm (Smith, 2014)

Positive Risk The idea that measuring risk involves balancing the positive benefits gained from taking short term risks against the negative effects, possibly causing harm of attempting to avoid risk altogether (Rahman, S. 2015) Weighing up potential risk with positive benefits and deciding what is an acceptable risk, is as important as minimising harmful consequences of risk (Bryant, 2014).

Harm minimisation seeks to answer five basic questions in support of a person’s recovery: What can go wrong? Risk Assessment How bad would it be? How likely is it to happen? Do we need to do something about it? Risk Management & Safety Planning Who needs to do what?

An important principle is that service users have the right to make individual decisions or choices in their own recovery and how to minimise harm. This includes the right to fail or get it wrong. This principle is enshrined in the Human Rights Act 1998. The Trust supports reaching a shared understanding with service users when judging potential risks and how these should be managed. This involves shared decision making and supporting service users in taking positive risks when it is safe and appropriate for them to do so. By fully involving service users in risk assessment and management, you minimise the risk of unintended harms being caused.

Seven principles for managing safety  Assess risk - escalating risk and risk to others require immediate attention  When someone has self-harmed, attending to any immediate dangers from injury or self- poisoning should be a first step.  Validate distress and express concern, evidence suggests that the attitudes and behaviour of staff towards people who self-harm is the most significant factor affecting their experience of care.  Clarify precipitants – chain analysis and seek interpersonal events  Ask what the service user thinks will help – foster sense of self agency  Be clear about your limits  Discuss with colleagues

Crisis management • To create a hierarchy of responses, considering least restrictive options first, to reduce potential for long term harm from short term risk reduction, such as admission. • Deskill, disempower patient • Breakdown of therapeutic relationship • Precipitates poor engagement • Reinforces care seeking behaviours • Evidence suggests people recover quicker within home environment • Takes away responsibility and ownership

Formulating Risk • TYPE: historical, current, imminent • PATTERN: Recognisable decompensation over time, or sudden, apparently random acts • EXTENT OF HARM: historically and whether this was intent or not – has bearing on intent of harm in future • However – potential of harm or death by misadventure should always be noted. • RISK MODFIED BY: protective factors, active coping strategies, engagement • However – potential for services to intervene to modify risks can be limited by factors such as: pattern of the act, patients poor engagement with service and available interventions, or patients exposure to triggers outside scope of service to influence at this time. Look for pattern or gradient!

Emergency Urgent Routine Risk: Risk: Risk: Deterioration in mental state and Deterioration in mental state and associated risks. Deteriorating mental state, however, associated risks associated risks. Presenting with a high/moderate risk of harm to self or others. are low . Presenting with immediate risks of harm Gatekeeping assessment. Presentation: to self or others. Requires specialist mental health assessment but is Overdose/suicide attempt/violent or stable and at low risk of harm during waiting period. aggressive Possession of a weapon Other services able to support or provide care for the person until mental health service assessment (+/- Presentation: Presentation: Suicidal ideation with plan or ongoing history of suicidal ideas with possible telephone advice). intent. Known service user requiring non urgent review, adjustment of treatment or follow up. (CPA) Rapidly increasing symptoms of psychosis and/or severe mood disorder. Referral for diagnosis. High risk behaviour associated with perceptual or thought disturbance, delirium, dementia or impaired impulse control. Requests for capacity (if required to inform immediate treatment and care) assessment, service access for dementia or service review/carer support. Risk due to significant cognitive impairment. Vulnerable; isolation or abuse in association with mental health presentation. Deteriorating mental health state in perinatal presentation, lower threshold in regards to crisis response. All of the above is inclusive of those people with Learning Disability. Not known to service Known to service Liaise with associated practitioner/duty responder during where available to offer response

Crisis Plans • What can the patient do and not do? • What can other people do and not do? • What can Services do and not do? Note: an effective crisis plan is one of the most important interventions we can do

Crisis Recovery Plan How I and Others Might Notice When I Am Unwell or Need Extra Help Triggers Early Signs Crisis Signs

Things that are helpful Things that are helpful What Helps? Who helps? How? What's Unhelpful?

Crisis Plan identified by me and others Crisis Plan Goals To be reviewed and updated 6 monthly or sooner, upon any additional information or significant changes, copy to GP.

Individualised crisis strategies  Problem solving underpins all strategies  What has and has not worked in the past  Safe people to contact, safe places to go  Activities that make the person feel safe  Self-soothing, emotional regulation skills  Alternatives to self-harm  Developed collaboratively  Understanding and recognising early warning signs

As risk fluctuates it needs to be considered within the context of the person’s current situation, being mindful of historical harm and the circumstances that could lead to a repetition of that harm. Therefore risk assessment and harm minimisation is a continuous proactive process . Understanding the person’s circumstances as well as the evidence base for any risk (such as risk factors) creates a balanced approach to minimise the risk of harm. Also understanding what the person is trying to communicate, such as not being able to articulate their emotions (alexithymia).

Lauren Dowson & Shaunie Hill Scarborough, Whitby & Ryedale Crisis Resolution & Home Treatment Team. Tel: 01723 384645 • Thank you for Listening.