This post is by guest blogger Anna Fialkowska
Risk during therapy is something that has to be considered on a regular basis. Whilst it is not always apparent, it is something that therapists need to be aware of and understand. However, it is also something that is useful for us all to consider with our loved ones, especially if they are vulnerable, and to consider how best we might support others who may be in crisis or at risk.
What is risk?
Risk is defined as “the chance that any activity or action could happen and harm you” (RCOG, 2008). Very few aspects of our lives are zero risk, and it is always important to consider risk when caring for those with mental health difficulties. The BPS Division of Clinical Psychology (BPS, DCP, 2016) defines three concepts that help us to define and minimize risk:
- Risk assessment – ensuring risk is defined, examined and discussed
- Risk prevention – putting things in place to stop risk increasing
- Risk management – when met with risk, knowing how to manage it
Risk in clinical practice and types of harm
Whilst anyone can be at risk at anytime, it is important to consider what risk might entail. We should ask ourselves who is at risk? Are people at risk to themselves, to others or from others? Abuse can also vary greatly in its presentation, from physical, emotional and sexual abuse to neglect and radicalization. The national confidential inquiry into suicide and safety in mental health in England, NI and Scotland (2021) gives a lot of very useful information about who is most at risk and provides statistics to indicate which populations can be most at risk. It also goes further into groups based on COVID-19 risk factors considering ethnic group and living status. These statistics vary by age, location, marital status, employment status and a number of other different factors. This is important to understand as it was found that a majority of those who completed suicides had not contacted mental health services ever in their lives or in the year leading up to the death. The highest risk group were those diagnosed with affective (mood) disorders (almost 50%). Other major risk factors were found as being male, unmarried, unemployed, people with a history of self-harm and those living alone.
What use are history and statistics?
The statistics help to show that there is overrepresentation in a number of certain clinical and demographic groups and knowing these can help to prevent, manage and reduce risk. It is important to consider systemic issues also in regard to racism and biases within certain systems. Early life experiences and coping are also important to consider (such as early years trauma) as these can be good indicators of future risk. Understanding the past, as well as different risk presentations helps further with risk mitigation. For example, some risk presentations are more common for certain mental health conditions compared to others, such as spending money and debt (Bipolar Affective Disorder BPAD), physical health crisis (Eating Disorders, self-harm/suicide) and disorders of overcontrol vs. under control. It is important to consider what is static and what is dynamic in a persons life. For example, if housing has been precarious in the past, or someone has a history of drug use it is important to consider these things, even if a person is not presenting issues with these problems in the present. Both past and present are extremely important to consider when managing risk.
How is risk managed?
As well as statistics, history and current presentation, it is also important to consider risk to wellbeing such as poor sleeping, eating issues, alcohol use, specific acts of harm, social isolation and subjugation of own needs. Protective factors are extremely important also, and these are defined as factors which reduce the risk of harm. These can include a supportive family and friends, hobbies, social groups, therapist input and relaxation exercises. If people only have one of these protective factors, this can still be a concern, especially if some people find that a relationship can provide protection at times but is also a source of stress at others. Motivation can be an issue for those who are low in mood and so encouragement or supporting those at risk to engage is vital and the first step in prevention. How can you reestablish these and build protective factors?
Risk management plan
At first, we want to try and protect those at risk, if this is not possible, then we want to go ahead and try to reduce the risk as much as possible. Risk assessments should be individualised and based on a psychological formulation. There are many types of therapy which can help to reduce risk, such as Dialectical Behaviour Therapy, distress tolerance skills of self-soothing, grounding people back in reality, encouraging others to engage in meaningful activities or simply providing positive, non-judgmental support to your friend or family member. It is also important to encourage those at risk to consider these factors and to move quickly out of that area if they feel the urge to self-harm or feel at risk of poor mental health. Crisis planning in advance can be an important task to undertake. These plans belong to an individual and can be passed to care givers or support networks when desired by therapists. However, useful questions for an individual to consider may include:
- What am I like when I am feeling well?
- Indicators that things are breaking down (crisis looming and warning signs)
- Indicators that I am in crisis and need others to help keep me safe
- What does safe feel like and what makes me feel unsafe?
- What things help me stay safe and well
- Support from others such as increased levels of contact, childcare support, medication
- What other people can do that is helpful when I am in crisis?
- What I can do to help myself when in crisis?
- What I have not found helpful when I am in crisis?
Conclusion
As has been mentioned, protecting vulnerable people from harm is something we can all consider, whether a healthcare professional or not. The best thing we can do is be supportive and available to those most vulnerable in our lives, and to encourage them to be open when they are struggling. Consider that risk factors may not always be obvious without the above statistics, being prepared and understanding the signs of risk are extremely important.
About Anna Fialkowska
Anna Fialkowska has worked within the field of mental health dysfunction and cognitive rehabilitation over the last six years. Her main areas of research include the development of behaviour change interventions, the impact of stress on individuals’ physical health and the effect of chronic conditions on psychological well-being.
References
Royal College of Obstetricians and Gynaecologists (2008) Presenting Information on Risk. Doi: Understanding how risk is discussed in health care | RCOG
National Confidential Inquiry into Suicide and Safety in Mental Health ANNUAL REPORT: ENGLAND, NORTHERN IRELAND, SCOTLAND AND WALES 2021. Healthcare Quality Improvement Partnership (HQIP). Doi: display.aspx (manchester.ac.uk)