Risk assessment in mental health: So much more than you might think

If you work in mental health, what’s the first thing you think about when the word ‘risk’ is stated? For many of us, the first thing that springs to mind is risk of harm to self. I know that when I have interviewed new graduates for mental health positions, a common area they struggle in seems to be considering risk holistically. We are all trained in suicide risk assessment and management, but not always so much the many other types of risk that we may encounter.

The things that cause people living with mental illness to often have shorter lives than others include so much more than suicide.

For much of my career, I have worked with complexity and risk. I’ve worked with the consequences of when workplace safety systems and risk management fails as a Rehabilitation Counselor, and in my work in mental health programs, I’ve had to consider a whole range of risks in outreach-based sub-acute mental health care, not only to service users, but risks that may be presented to staff.

I take risk management very seriously. I make a habit of reading Coroner’s findings in mental health and any health legal reports I can. When I read Coroner’s findings, I learn about the worst case scenarios that I need to be prepared for in my work. I am a fan of the concept of root cause analysis as a means of better understanding risk.

So, when I think of risks related to clients, I don’t just think about suicide. And whilst I place client need first and foremost, I also consider risks to myself as a practitioner. I currently work entirely with clients with complex and substantial needs, and so risk assessment and management planning in my work role is accordingly quite robust with information from multiple sources and detailed and individualised plans.

These are just some of the things I routinely consider about risk:

  • Suicide risk assessment and management. There are many guidelines that I draw on in my work, bearing in mind that risk assessment is not easy and that suicide risk assessment and management of people from different age groups can have specific challenges. 
  • Risk of non-suicidal self injury. I’m careful to distinguish this from suicide risk and consider appropriate strategies. 
  • Risk of violence / harm to others. We may from time to time work with clients who may become violent. Violence is not limited to forensic work. If you don’t assess this, you won’t know if you need to consider potentially issuing a Tarasoff Warning, consistent with the APS Code of Ethics A.5.2.
  • Risk of harm to self or others because of psychosis. Some symptoms can lead to behaviours with tragic consequences.
  • Risk of harm caused by others. People living with severe mental illness are at much, much higher risk of being victims of violent crime than other members of the population. Anyone can be impacted by domestic violence. What vulnerabilities may the person be living with?
  • Risks related to medical conditions. The gap in life expectancy of people living with severe mental illness is something I find appalling, particularly because at least some of it is attributed to members of the medical profession assuming that the medical concerns of their patients who also happen to have mental illness are all in their heads.

A basic risk management plan for one of my clients will be a great deal longer than this blog entry, and will consider more factors as well. But I hope this summary provides a starting point of things to think about other than suicide risk!

If you ever get the chance, it’s well worth doing training or seeking supervision. In psychology, forensic psychologists frequently have extensive training and expertise in risk assessment and management given the unique nature of their work, but there are professionals with extensive skill and experience in risk assessment and management in a broad range of settings. Some of the most risk-aware professionals I’ve worked in have spent extensive time in public mental health and outreach settings, particularly when they must take ‘all comers’ to their services.

If you find yourself now feeling an immediate desire to learn more about risk and safety, Vicserv are providing outreach safety training for support staff facilitated by Holland Thomas & Associates in February in Melbourne. The training provides information about personal safety in outreach settings and is particularly useful if you are a sole worker. There are often other options that come up from time to time across Australia and many employers will also provide some training – I’ve completed training delivered by Holland Thomas and enjoyed it.

When you have any niggling concerns about risk, always remember there are supports available, such as community mental health teams and crisis lines that work with risk on a daily basis. If you realize there might be some risks in your work that you are unsure how to address, please seek supervision. You could also discuss the ethics of the situation with organizations such as The Ethics Centre. In the event of a crisis (or if in doubt), each state and territory provides crisis services.

The Mental Health Commission lists the following state mental health crisis numbers:

NSW – 1800 011 511- Mental Health Line

VIC – 1300 651 251 – Suicide Help Line

QLD – 13 43 25 84 – 13 HEALTH

TAS – 1800 332 388 – Mental Health Services Helpline

SA – 13 14 65 – Mental Health Assessment and Crisis Intervention Service

WA – 1800 676 822 – Mental Health Emergency Response Line

NT – 08 8999 4988 – Top End Mental Health Service

ACT – 1800 629 354 – Mental Health Triage Service

And in an emergency, dial 000 for police and/or ambulance.

 

By Ceara Rickard 

Ceara Rickard is a mental health professional with diverse professional interests, including adult and youth mental health, the consumer movement, career development and professional ethics. She has extensive experience in program development and management, mental health, and working with mandated clients. Ceara holds membership of the Australian Society of Rehabilitation Counsellors, Professional Membership of the Career Industry Council of Australia, Associate Membership of the Australian Psychological Society, and registration with the Australian Health Practitioner Regulation Agency as a Psychologist with Provisional Registration.