Presentation delivered to Lifeworks Australia as part of their professional development in 2013. Specifically discusses how to conduct a comprehensive risk assessment and the implications for different levels of risk. Also highlights, ethical and legal responsibilities of the practitioner.

1. Suicide Risk
Assessment
Dr Gemma Russell
Clinical Psychologist
Lifeworks August 2013

2. Objectives
• Recognising clinical indicators of
suicide/self harm
• Assessing level of risk of harm
• Understanding LifeWorks’
relevant policies
• Knowing what our duty of care is
• Appropriate documentation in
session notes
• Interventions/referral when mod-
hi SASH risk is identified.

3. Life Threatening
Behaviours
Risk to self:
• Suicide – The action of killing oneself intentionally
• Para-suicide attempt - Non-fatal act in which a person
deliberately causes injury to him or herself or ingests any
prescribed or generally recognised therapeutic dose in
excess
• Self-harm - The deliberate attempt to harm or destroy
the body with no intent of killing oneself

4. Death By Suicide
Suicide is the leading cause of death in Australia for men
under 44 and women under 34
The most recent Australian data (ABS, Causes of Death,
2009) reports deaths due to suicide at 2,132. That equates
to 6 deaths by suicide a day, or one every four hours

5. Suicide Attempts
For every completed suicide it is estimated that as many as
30 people attempt
That’s 180 attempts per day, with at least one new suicide
attempt in Australia, every 10 minutes

6. Thoughts of Suicide
(Suicidal Ideation)
It is estimated that 249 people make a suicide plan
everyday
It is estimated that as many as 1014 people think about
suicide every day

8. WE HAVE A CRITICAL
ROLE TO PLAY IN
SUICIDE PREVENTION

9. Duty of Care
The clinician’s general obligation or duty of care refers to
the ethical and legal duty to provide ordinary and
reasonable care.
This means:
• To use available and reasonable means to ensure the
safety of the clients and those who may also be affected
A working therapeutic alliance is aided by prior informed
consent around the parameters of confidentiality and
intervention required to ensure safety.

10. Factors that Inhibit
Suicide Prevention
• Lack of awareness of suicide being a major cause of
death
• Taboo in society to openly discuss suicide or self
harming behaviours
• Stigma around the experience of suicidality creates
barriers to discussion/disclosure of suicide prevention
efforts with a professional or confidant and therefore
inhibiting help seeking avenues
• Philosophical orientations toward suicide
• Fear, anxiety or lack of knowledge about how to help

11. General Risk Factors for
Suicide
• Precipitating Factors
• Motivation/Cognitive Factors
• Personality-based Factors
• Disorder-related Factors
• Historical Factors
• Family Factors
• Demographic Factors

12. Precipitating Risk Factors
• Majority of suicides are precipitated by an identifiable stressful
event (70-97%)
• Loss of parents or partner by death, separation or illness
• Conflict with parents or partner
• Involvement in judicial system
• Severe personal illness/sickness
• Major exam failure
• Unwanted pregnancy
• Imitation of other suicides

13. Cognitive/Motivational
Risk Factors
Suicidal thoughts or attempts that serve the function of:
• Escaping an unbearable psychological state or situation
• Gaining revenge by inducing guilt
• Inflicting self-punishment
• Gaining care and attention
• Sacrificing the self for a greater good

14. Personality-based Risk
Factors
• High level of hopelessness
• High level of perfectionism
• High level of impulsivity
• High levels of hostility and aggression
• Inflexible coping style
• Emotional dysregulation
• Low distress tolerance
• Limited pro-social problem solving skills

15. Disorder-related Risk
Factors
• Depression symptomology
• Anxiety disorders (particularly panic disorder)
• Substance use or dependence
• Conduct disorder (adolescents)
• Personality disorders (adults)
• Psychotic symptomology (particularly persecutory
delusions or command hallucinations)

16. Historical Risk Factors
• Previous suicide attempts
• Loss of parent in early life
• Previous psychiatric treatment
• Involvement in the justice system
• Experiences of adversity

17. Family Risk Factors
• Family history of suicide attempts
• Family history of depression
• Family history of substance abuse
• Family history history of assaultive behaviour
• Disorganized, unsupportive family
• Family denies seriousness of suicide attempts
• Family has high stress and crowding
• Family has low social support and is socially isolated

18. Demographic Risk Factors
• Sex
More males die by suicide, many more females attempt
suicide
• Age
Highest risk groups are those aged 15-24 years and
those over age 60

19. KEY CLINICAL
RISK FACTORS
• Sex
• Age
• Depression
• Previous suicide attempts
• Ethanol and drug abuse
• Rational thinking is impaired
• Social support lacking
• No spouse/partner
• Adversity or abuse
• Loss
• Sickness

20. Assessment of Suicide
Risk
• Clear limits of confidentiality and informed consent
explained
• Detailed psychosocial history if possible to identify risk
factors
• Always assess risk to self, risk to others and risk from
others
• Decision about risk level
• Identify intervention level and action plan

21. Assessing Severity of Risk
• Depressive symptomology
• Suicidal Ideation (thoughts of
ending of life)
• Advanced Planning
• Previous suicide attempt/s
• Level of Self-control
• Degree of Intent of acting on
plan
• Absence of help seeking
• A final act
• Specificity
• Lethality
• Availability
• Proximity of
support

22. Scenario 1
John and Sarah have recently separated. You have been
advised that Sarah has an intervention order against John, due
to previous intimate partner violence. John is experiencing a
range of difficulties including the breakdown of this relationship,
loss of control, as well as strong feelings of anger and rejection.
He has attended an initial session at Lifeworks and voiced to you
thoughts about harming himself.
1. Identify John’s (general) risk factors
2. What information would you need to know to identify John’s
risk of suicide or self/harm?

23. Assessing Risk Level
Level of Risk Acute Risk Factors Action Plan
Minimal Risk Minimal risk factors Monitor as required
Low Risk - Occasional suicidal
thoughts
- Minimal risk factors
- No previous suicide
attempts
- No specific plan, intent
or means
- Self harm is superficial
or minor
- Protective factors
available
1. Follow-up
appointment
2. Monitor mood,
mental state
3. Assess changes,
noting deterioration
or worsening of
mental state
4. Agree on verbal crisis
plan, provide
support numbers
5. Follow-up support
and develop
treatment plan

24. Assessing Risk Level
Level of Risk Acute Risk Factors Action Plan
Moderate Risk - Suicidal thoughts
- Some risk factors
- Suicide plan with some
detail
- Means are available
- Vague intention to act
(no timeframe)
- Some protective factors
1. Consult with peers and
team leader
2. Refer to GP for mediation
and/or further assessment
3. Follow-up appointment
within one week,
consider phone support
4. Monitor mood and risk
until no further suicidal
ideation
5. Agree on written
Safety Management Plan
with client
6. Request permission to
inform emergency
monitoring team (e.g.
CATT) and/or family

25. Assessing Risk Level
Level of Risk Acute Risk Factors Action Plan
High Risk - Suicidal thoughts
- Previous suicide
attempts
- Numerous risk factors
- Clear and detailed
suicide plan
- Immediate intent to
act
- Means are available
(and lethal)
- Social isolation
- Limited engagement
with formal support
services
1. Urgent consult with
team leader/manager
2. Immediately contact
CATT for psychiatric
assessment and
treatment
3. Attempt to engage
client in developing
safety plan
4. Ask the patient/client
to stay until
emergency help is
obtained, if they
refuse, call 000
5. Contact support
person/family

26. Developing a Safety
Management Plan

27. After the Safety Plan is
Developed
• ASSESS the likelihood that the overall safety plan will be
used and problem solve with the patient to identify
barriers or obstacles to using the plan.
• DISCUSS where the patient will keep the safety plan and
how it will be located during a crisis.
• EVALUATE if the format is appropriate for patient’s
capacity and circumstances.
• REVIEW the plan periodically when patient’s
circumstances or needs change.
• Remember: the safety plan is a tool to engage the
patient and is only one part of a comprehensive suicide
care plan

28. Management of Suicide
Risk - In Session
• Aim to modify dynamic risk factors that were present during
previous/current risk state (i.e., social isolation)
• Containment of emotional turmoil
• What are the patient/client’s reasons for living?
- Survival and coping beliefs
- Responsibility to family
- Child related concerns
- Fear of suicide
- Fear of social disapproval
- Moral objections
• You are the reason, if there is no other reason for living (Carl
Rogers – Unconditional Positive regard)

29. Scenario 2
Ingrid is a woman in her mid 20s that lives alone. She has
an extended trauma history and ongoing comorbid
depression and anxiety. When she feels hopeless and
overwhelmed she has tried on two occasions to kill herself
by taking a large number of benzodiazepine pills and
drinking alcohol. Ingrid has a 2 year old daughter who
currently lives with Ingrid’s mother. Ingrid currently reports
that she does not want to die as she wants to see her
daughter grow up.
1. Identify Ingrid’s level of risk of suicide/self harm
2. Develop a safety plan to manage her current risk

30. Scenario 3
Barwon is a 17 year old man from rural Victoria who has
recently been moved to live with family in Melbourne after
multiple family difficulties. He presents with symptoms of
depression and anxiety, and is a daily user of cannabis and
occasionally uses methamphetamine on the weekends with
peers Barwon has never lived in an urban environment and
is struggling to fit in with his peers at his new school. . Last
weekend Barwon attempted to ‘train surf’ as a dare and fell
onto the train tracks.
1. Identify Barwon’s level of risk of suicide or self-harming
behaviours
2. Identify appropriate interventions (in session) and
referral pathways

31. Documentation
Health Records Act 2001
• Legal obligation to document thoroughly all information
recorded during or following an interaction with a
patient/client.
• All notes pertaining to the client and recorded by a
psychologist (psychologist's records) are to be
maintained as confidential information as required by
both relevant national and state legislation and the
Australian Psychological Society Code of Ethics.

32. Documentation
Privacy Act 1988 and amendments - Access to records
Confidentiality of patient records and protocols to protect anonymity are
observed, unless:
• The health, wellbeing, or safety of the patient/client is threatened by
the behaviour of the patient/client (suicide/self-harm)
• There is a direct and imminent threat to the health, wellbeing, or
safety of another person who identity is known caused by the
behavior of the patient/client (harm towards others)
• The health, wellbeing, or safety of the patient/client is directly
threatened by another person (harm from others)
Legislation permits the right to provide access to the information to
those who must be involved to protect the patient/client or the
threatened person.

33. Documentation
Coroners Act 2008
• The usual obligation to maintain confidentiality regarding
patient information under the Health Records Act 2001
(Vic) and the Privacy Act 1988 (Cth) does not apply to
requests for information by someone acting on behalf of
the coroner.
• Hence, if health care providers are requested by the
coroner (or a police member acting on their behalf) to
give any information or assistance for the purposes of a
coronial investigation they must provide it.

34. Documentation
Guidelines
• Document all steps used (clinical interview, consult with
peers, supervisor etc.) to establish risk
• Document all pre-disposing risk factors
• Document all population-based risk factors
• Detailed assessment of the precipitants of the person’s
suicidal crisis
• Exploration of factors maintaining distress
• Mental state examination
• Current risk assessment (severity and reasons why)
• Short-term safety management plan
• Medium-Long term treatment plan/referral avenues

35. Question Time?
Contact details:
Dr Gemma Russell
Clinical Psychologist
Director of Clever Minds Psychology
director@clevermindspsychology.com.au
Telephone: 0435854205
Fax: 03 86922708