Risk Assessment

If there is one thing we need to be unfailingly conscientious about as therapists, it is risk assessment. While it is of course not possible to prevent all harm to or by our clients, nobody wants to be second-guessing themselves (or have others second-guessing) about whether we did everything we could to ensure our clients' safety. Therefore, it's good to have a system in place for assessing risk. At the minimum, risk should be assessed at the beginning and end of treatment, periodically throughout (e.g., when doing treatment plan updates), and whenever there is a change in a client's mental status.

It takes some practice to get comfortable asking about and talking about risk issues. I made the following "cheat sheet" for my students, and decided to share it here as well. It includes questions to ask to assess five categories of risk: suicidality, non-suicidal self-injury, homicidality, hallucinations, and substance abuse.

Of course, these are just my ways of approaching assessment. Different clinicians may have different styles, and therefore use different wording. If there are things that you've found particularly effective, or if there are other mnemonics you use to remember what to ask, please share a comment below!

Suicidality

• Assess past suicidality
• “Have you ever thought about suicide?”
• “When was that?”
• “What was going on in your life that led you to consider suicide?”
• “Did you ever act on those thoughts?”
• When
• What method
• Did it lead to medical or psychiatric hospitalization?
• “Has anyone in your family ever attempted suicide?”
• Assess current suicidality?
• “Are you having any thoughts of suicide now?”
• “When did you have those thoughts most recently?”
• “When did the thoughts start?”
• “How frequent are they?”
• “Do they feel intrusive or obsessive? Can you stop them or control them?"
• Passive SI = Wanting to die without planning to take action
• Active SI = Plan or intent to end one’s own life
• Assess for a Plan: “Do you have a plan for what you would do?” (acronym: SLAP; P=plan)
• Specificity
• Lethality
• Violent/irreversible methods are most lethal
• Likelihood of rescue
• Accessibility
• Assess Intent
• “Do you think you would act on it?”
• “What will you do if the thoughts become more intense, and you’re feeling more likely to act on them?” (is the patient able to convincingly contract for safety)
• Assess Meaning/Motivation: “What seems appealing about dying?”
• Relief (from distress, psychological or physical pain, unbearable circumstances)
• Revenge (to hurt/punish someone else, or punish oneself)
• Rebirth or Reunion (to escape the current unsatisfactory life through rebirth into a better life; reunion with others who have died)
• High Risk BehaviorPreparation – obtaining supplies to implement plan, writing a suicide note, arranging finances/giving away belongings
• Rehearsal – going through the motions, starting the plan but stopping before the lethal gestureLosses or anticipated losses of relationships or reason for living
• Mood change, including marked brightening of mood

Non-Suicidal Self-Injury

• “Have you ever thought about other ways of hurting yourself or causing yourself pain, like cutting or burning yourself?”
• “Have you ever acted on those thoughts?”
• When, and when most recently
• What did you do
• How often
• Assess potential lethality
• “Did you ever hurt yourself badly enough to need medical attention?”
• Location on body
• Severity (e.g., depth of cut, proximity to blood vessels)
• Assess whether self-injury is:
• Compulsive
• Habitual and repetitive
• Ego-dystonic
• E.g., hair pulling, skin picking, severe nail biting, purging
• Impulsive
• Episodic
• Gratifying
• A reaction to events
• Ego-syntonic
• E.g., cutting, burning, suicide attempts, substance abuse, including laxative/diuretic

Homicidality

• “Have you ever thought about harming someone else?”
• “Have you ever gotten into a physical fight or attacked someone?”
• When, and when most recently
• Frequency
• How
• “Did the other person require medical attention?”
• “Have you ever been arrested?”
• “Have you ever thought about killing someone?”
• Past homicidal ideation:
• When, and when most recently
• “Have you ever acted on those thoughts?”
• How
• “Did the other person require medical attention?”
• Outcome (legal, social, psychological)
• Current homicidal ideation: “Are you having thoughts like that now?”
• Toward whom
• Assess plan (SLAP), intent and ability to contract for safety
• Duty to Warn (Tarasoff): providers must notify the intended victim if s/he is in imminent danger

Hallucinations

• “Have you ever seen or heard something other people couldn’t see or hear?”
• What
• When
• How often
• Is it persistent, intrusive, obsessional
• Assess whether it is a thought or a perceptual disturbance
• “Does the voice seem like it’s inside or outside of your head?”
• “Is it more like picturing something, or seeing a picture?”
• Content
• “Is it one voice, or multiple voices? What does it say?”
• Are there Command Auditory Hallucinations (CAH)?
• Do the voices tell the patient to do something?
• Do the voices command the person to harm self or others?
• Are the visual hallucinations of a violent or scary nature?
• Is the content mood congruent or incongruent?

Substance Use/Abuse

• “Do you currently use any kind of drugs or alcohol?”
• What, how often, how much
• How (method, e.g. smoking, snorting, IV)
• Any negative consequences
• “Have you used any (or any additional) substances in the past?”
• What, how, how often, how much
• Any negative consequences
• “What made you decide to stop using this/these substance(s)?”
• Assess for substance abuse/dependence
• Purpose: “What does (the substance) do for you?” (e.g., social use; lower inhibitions; numbness; euphoria )
• CAGE:
• “Have you ever felt you should CUT DOWN on your use?”
• “Have you ever felt ANNOYED by other people criticizing your use?”
• “Have you ever felt GUILTY about your use?”
• “Have you ever used first thing in the morning (to get over a hangover)?” (EYEOPENER)
• Tolerance: “Have you had to use progressively more of the substance to get the same result?
• Withdrawal: “Have you experienced any kind of side effects when you stopped or cut back on your use?”
• “Have you ever needed detox or other treatment for substance abuse?”