Module 11

11.1 Risk and Violence

Risk and risk assessment on clinical settings refers to:

· The risk a person might self harm or suicide

· The risk a person may be harmed, including harm caused to a child

· The risk the client may harm someone else

Harm can be physical, sexual, and emotional, and includes neglect.

Violence in Australia

2 in 5 Australians have experienced some form of violence since the age of 15. Men and women experience violence, though women are more often victimised by people they know, while men are more often victimised by strangers. Common types of violence that a counsellor or therapists might deal with in their work include:

· Family violence: violence between family members and intimate partners. The most common form of violence among Indigenous Australians as it covers extended family and kinships.

· Domestic violence: a subset of family violence occurring between current or former intimate partners, typically by means of control or fear. Can include physical, sexual, emotion, and psychological abuse.

· Sexual violence: broader range of violence that includes behaviours of a sexual nature carried out against a person using physical force or coercion. Sexual violence can be perpetuated by current for former intimate partners, people known to the victim, or strangers. Sexual violence includes child sexual abuse which can be perpetuated by adults, adolescence, or other children.

Note that family violence includes coercion and control; and child abuse includes exposing a child to psychological harm via family violence.

Domestic Violence

Intimate partner violence is one of the most common forms of domestic violence. In Australia:

· 1 in 6 women report having experienced intimate partner violence since the age of 15.

· 1 in 5 women have experienced sexual violence since the age of 15

· 1 in 6 women have experienced physical or sexual abuse since the age of 15.

The most common perpetuators of violence against women are male intimate partners. Women are less likely to leave an abusive relationship and report higher levels of fear after being victimised.

Domestic violence also occurs against men and tends to go unrecognised. Men are less likely to report domestic violence when it occurs, and male victims are more likely to be ignored by police. Few female perpetrators are arrested and fewer are convicted.

· 1 in 3 Australian family violence cases report violence against men

· 1 in 4 young people are aware of their maternal figure hitting their paternal figure.

· Male and female victims receive similar numbers and types of injuries.

· Male victims are 2-3x more likely to not tell anyone about their abuse.

· Male victims may face less support, more social prejudice, more victim blaming, and more threats with legal action within the family.

11.2 Family Violence

Family violence can include:

· Physical abuse

· Sexual abuse

· Verbal abuse

· Emotional abuse

· Financial abuse

· Coercion and control

· Technology-facilitated abuse

· Social abuse

· Spiritual abuse: restriction of how someone engages in spiritual and religious practices.

Family violence is more common in Indigenous families

· Includes extended family and kinship relationships

· Can occur within families, intimate violence

· Extended families, kinship networks and communities

· Violence in indigenous populations is a cause and effect of social disadvantage and intergenerational trauma.

Assessment of the presence and risk of family violence. Assessment needs to be:

· Collaborative with the victim or perpetrator

· Respectful

· Inclusive of diversity

· Strengths-focussed

· Evidence-based

Assessment also needs to consider:

· The victims view of their risk level: listen to what they have to say.

· The presence of evidence-based risk indicators: can use a checklist or formal screening tools

· Required professional judgement based on a comprehensive appraisal of all relevant circumstances.

o Based in your own competency; know your limits and level of training

· Assessment is continuous and risk management is an ongoing task.

· Level of risk may need to be communicated to other services and referrals made to appropriate support services.

Family Violence among Adults and Older Adults

· How would you describe your relationship?

· Have there been times where you have felt unsafe?

· How have you managed conflict as a couple or family?

· Has there been any form of violence?

· Is this currently happening?

· Do you feel safe going home today?

Know factors associated with higher risk for the victim:

· Victims own assessment of risk

· Pregnancy

· Isolation

· Depression and other mental health issues

· Suicidal ideation or attempt

· Drug and alcohol misuse (including prescribed medication)

Known risk factors for perpetrators (* = higher risk of lethality):

· Use of weapons in most recent event*

· Access to weapons*

· Previously threatened to harm the victim

· Previous choking of the victim*

· Previous threat to kill the victim*

· Stalking*

· Sexual assault*

· Previous or current breach of an intervention order

· Drug or alcohol misuse*

· Obsession or jealous behaviour*

· Controlling behaviours*

· Unemployment*

· Depression and mental illness

· History of violent behaviour

Relationship factors associated with higher risk of DV

· Separation*

o Especially just prior to leaving or in the first 2 months after

o Women are at the highest risk of violence at this time

o Victims appraisal of risk are usually very accurate

· Escalation*: increased frequency or intensity

· Financial pressures

Children and DV

Are they affected and are they safe?

· Are there children involved?

· How are they coping?

· Where are they when violence occurs?

· Is there any form of violence against them?

Common forms of child abuse (substantiated; many forms are not easily proven):

· Emotional abuse: includes witnessing violence in the family

· Neglect

· Physical abuse

· Sexual abuse

· Non-descript abuse

Indicators of abuse in children

· Physical injuries (often hidden): bruises, burns, sprains, dislocations, bites, cuts, fractures, etc

· Fear behaviours when in contact with parents or other adults

· Over-compliance or passive behaviour

· Age-inappropriate sexual behaviours

· Developmental issues such as speech impairments

· Academic impairment due to problems with concentration, memorisation, and completing school work.

Trauma in Young People (Lewis et al (2019)

· 2232 children born in England and Wales in 1994-95

· 31.1% exposed to trauma in childhood

· Reported higher pathology (e.g., depression, conduct disorder, alcohol dependence, self-harm, suicidality, violence)

· Also reported sig functional impairment

· 7.8% experienced PTSD by age 18

· Only 20.6% of these received help from a mental health professional

Asking Children about Family Violence

· Tell me about the good things at home

· Are there things you wish you could change?

· What don’t you like about home?

· Do you worry about going home?

· Tell me about the ways mum and dad look after you?

· What happens in your house when people have arguments?

· Do you worry about mum/ brothers/ sisters for any reasons?

11.3 Family Violence in Broader Context

Family violence is often thought at occurring in the nuclear family unit. However, it can occur at a much broader level (e.g., kinship or caring relationships). Elder abuse is a commonly neglected area of FV.

Elder Abuse: a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person.

· Most commonly perpetuated by a spouse/ partner, or adult children/ other relatives.

1 in 6 older adults experience elder abuse, with those with complex dependency needs at a higher risk. Elder abuse can be:

· Physical

· Verbal

· Psychological

· Financial

· Sexual

· Abandonment

· Neglect

· Serious loss of dignity and respect

Elder abuse is similar to intimate partner violence but often involves greater financial exploitation and loss of dignity.

11.4 Understanding Suicide

Anyone can play an important role in suicide prevention.

Most people who consider suicide do not actually want to die.

Suicide: death with evidence that it was self-inflicted.

Suicide attempt: non-fatal self-inflicted action or behaviour with evidence of intention to die.

Suicide-related behaviour (parasuicide): potentially self-injurious behaviour, where there is evidence that death was not intended but wished to give the appearance or intent

Suicide threat: any interpersonal verbal or non-verbal behaviour stopping short of a self-harm act that a reasonable person would interpret that a suicidal act might occur in the near future.

Suicidal ideation: thoughts of engaging in suicide-related behaviour.

Suicidal Ideation

· 30-50% of the total population acknowledges suicidal ideation at some point in their lives

· Focus is on assessing the risk of suicide and on hearing the person’s psychological ache.

· There are factors that increase the likelihood of suicide.

· Risk assessment is a dynamic and ongoing process.

· From ideation to attempt – more women than men attempt suicide with less lethal means.

o Men have higher suicide rate but women have higher attempt.

2020 National Suicide Data

· 3139 suicide deaths total

o 2384 men

o 755 women

Psychosocial Risk Factors:

· Personal history of self-harm

· Disruption of family by separation and divorce

· Problems in relationships with spouse or partner

Associated Risk factors:

· Mood disorders including depression

· Acute use and intoxication of psychoactive substances

· Suicidal ideation

· Problem in spousal relationship

· Chronic psychoactive substance use disorders

· Personal history of self-harm

· Anxiety and stress-related disorders

· Problems related to legal circumstances

· Problems related to employment and unemployment

· Family issues

Background

Prevalence of suicidality in Australian clients:

· Trimble et al (2000):

o 39% of therapists have had a client die by suicide

§ 10.8% has more than 4 clients

o 76% had a client attempt suicide

o 86% has a client threaten or gesture suicide

o 90% had a client report suicide ideation

§ 99% of clinical psychologists and 88% of counselling psychologists

Myths about Suicide

· Asking someone if they are suicidal puts the idea in their head and encourages them

· Everyone who engages in suicidal behaviour had a mental illness

· People who talk about suicide are attention seeking or manipulative

· People that talk about suicide don’t do it

· Someone who has attempted suicide will not attempt again

· People who think about suicide are weak or selfish; suicide is cowardly

· Suicidal thoughts mean a person really wants to die

· It is impossible to stop suicide

· Every suicide can be prevented by a therapist

· Only experts should ask about suicide.

Understanding a Suicidal Person

· Often has tunnel vision

· Desperate to end their pain and escape a situation

· Perceive themselves to be a failure, or burden

· Are reluctant to ask for help

· Feel their situation is totally hopeless

· Feels isolated and alone: has a thwarted sense of belonging

· Likely to be ambivalent about dying

· Most (~75%) visit a doctor within 3 months prior to an attempt

· May not necessarily be mentally ill

Risk Factors for Successful Suicide

· Mental disorders

· Male

· Previous attempt

· Recent suicide of a known person

· Family history of suicide

· Social isolation

· Divorce or relationship breakdown

· Unemployment

· Incarceration

· Rural employment

· Gambling

· Media publicity

· Access to means

· Physical illness

11.5 Suicide Risk Assessment

Risk Assessment Process

· Formal assessment tools: formal tools that the client fills out that the counsellor then scores.

o Beck Scale for Suicide Ideation

o Beck Depression Inventory

o Reasons for Living Inventory

o Helps balance clinician judgement

We cannot solely rely on assessment tools – they can never replace the clinical interview and professional judgement

· Most important: open conversation with the client

o Client self-report has better predictive validity than therapist perceptions.

Comprehensive risk assessment covers the following 10 factors:

· Distress and suffering

· Meaning and motivation

· At-risk mental states

· History of suicide behaviour

· Current suicidal thoughts

· Lethality and intent

· Presence of suicide plan

· Access to means and knowledge

· Coping potential and reasons to live

· Safety of others

The safety of others assessment may include:

· Have the persons thoughts ever included harming others?

· Has the person every harmed anyone?

· What is the rationale for harming others?

· Is the person psychotic or having delusions?

· Is there a possibility of murder-suicide?

· Are there indicators of post-natal depression?

What do you say?

· De direct but non-judgemental.

· You have to ask the question.

The Risk Assessment Process

Open exploration of suicidal thoughts:

· Discussion can alleviate stress and provide relief

· Discussion can provide deeper understanding of the clients psychological pain as well as further information

· Sign to the person that what is happening is important and needs addressing

· Ongoing risk assessment – continue to monitor the frequency and intensity of thoughts.

Important Points:

· Remain calm

· Have risk assessment procedures and phone numbers easily accessible at all times

· Do not put yourself in physical danger at any time – your safety takes priority

· You don’t have to determine risk on your own – if in doubt ring 000 or other contacts

· Ask questions irrespective of the role:

o About family violence

o Abut suicidal thinking

· Always debrief after these conversations

· Risk assessment requires professional judgement