LMSW: Danger to self and others

Low Risk

Risk factors

• Limited thoughts of harm to self/others

• No plan or intent

• Few risk factors

Intervention

• Identify social supports

• identify coping mechanisms

• provide referrals for clinical contacts

• reassess frequently

Moderate Risk

Risk Factors

• Ideation with limited plans and no intent( or vice versa)

• some risk factors present

Intervention

low risk intervention plus

• Explore alternatives to violence

• remove lethal means to harm self/other

• decrease isolation

• explore the option of medication

High Risk

Risk factors

• Specific plan with intent

• access to lethal means

• many risk factors present

• limited social support

• impaired self control

Intervention

• Client should not be left alone

• if client cannot engage in safety planning, hospitalization should occur

• involuntary hospitalization for potential violence can occur is client is mentally ill

• duty to warm

Danger to self risk factors

Males are more likely to complete suicide than females

● White people, American Indians, and Alaska Natives have the highest suicide rates (Hispanics, African Americans, Asians, and Pacific Islanders have the lowest rates)

● Older adults have a higher risk (white men over the age of 85 have the highest risk factor)

● History of mental illness

● Substance abuse

● Prior suicide attempt(s)

● Family history of mental illness or substance abuse

● Family history of suicide

● Family violence including physical or sexual abuse

● Firearms/lethal means available and easy to access

● Hopelessness

Danger to others risk factors

Prior history of violence

● An identified victim/plan

● History of mental illness

● Substance abuse

● Psychotic symptoms (command hallucinations, paranoid delusions)

● History of previous involuntary hospitalization

● Social isolation or limited support system

● Firearms/lethal means available and easy to access

Intervention and risk assessment steps

1. Assess lethality and imminence of danger to self or others and conduct a biopsychosocial assessment

2. Establish rapport with the individual.

3. Identify the major problems and what preceded the crisis.

4. Encourage exploration of feelings and emotions

5. Explore possible alternatives and positive coping skills

6. Formulate an action plan

7. Follow up with client regarding the resolution of the crisis and to assess

1. Assess lethality and imminence of danger to self or others and conduct a biopsychosocial assessment:

Ask about suicidal or homicidal thoughts and feelings

● Estimate the strength of the individual’s psychological intent to inflict harm

● Level of emotional distress (hopelessness, rage)

● Recent behaviors (current substance use or intoxication)

● Nature of the situation described

● Gauge if a plan is made (e.g. does this person have access to firearms?)

● Assess history of suicide or violence

● Take into consideration risk factors and presence of recent external sources of stress (e.g., job, school, relationship loss/changes/trauma, victimization history).

● Environmental supports and stressors

● Medical needs and medications

● Current use of drugs and alcohol

● Coping methods and resources

2. Establish rapport with the individual.

Facilitated through a nonjudgmental attitude, respect, reinforcing small gains and resiliency

3. Identify the major problems and what preceded the crisis

● Inquire about the precipitating event and how that turned into a crisis

● Assess client’s current coping skills—adaptive vs. maladaptive

● Assess the extent of the support system and willingness to use it

● Assess the meaning of the event and what it is symbolic of in this person’s life

4. Encourage exploration of feelings and emotions through the use of:

● Active listening

● Paraphrasing

● Reflecting

5. Explore possible alternatives and positive coping skills

● What has been helpful in responding to previous crises?

6. Formulate an action plan:

If client is low to moderate risk for harm to self or others (no plan and/or no intent, limited risk factors present, limited intensity and duration of suicidal thoughts, mild dysphoria, positive support system):

● Explore alternatives to violence

● Identify and engage supports and/or significant others to decrease isolation, provide support, and remove lethal means to harm self/others

● Implement coping mechanisms

● Establish future linkage (events to look forward to)

● Provide clinical referrals for outpatient services and medication if appropriate and a 24-hour crisis number

If client is at high risk for harm to self (specific plans and/or intent, impaired self-control, multiple risk factors present, limited social supports, hopelessness regarding future, severe mental illness/psychosis, access to means, prior attempts):

● Hospitalization should occur if a specific suicidal plan and intention is in place and the client is unable to effectively engage in safety planning for his/her own safety

● The client should not be left alone and an ambulance should be called

If client is at high risk for violence towards others (specific plans and/or intent toward identified victim, current substance use, rage, hostility, limited social supports, severe mental illness/psychosis, access to means, prior violence):

● An ambulance or police can be called for involuntary hospitalization for potential violence only if a person has a DSM-5 diagnosis (psychosis, depression, mania, dementia)

● In a case of potential violence, the clinician has a duty to warn the intended victim and police.

7. Follow up with client regarding the resolution of the crisis and to assess:

● Physical condition of the client (sleeping, hygiene, eating)

● Cognitive understanding of the precipitating event and why the crisis occurred

● Overall functioning including employment, social, spiritual, and academic (if relevant)

● How current stressors are being handled