Self-Harm and Violence: Towards Best Practice in Managing Risk in Mental Health Services
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A Victorian government resource providing information and advice on designing and caring for people with dementia in residential aged care settings. While there is no single prescribed standard of care or clinical approach for situations involving suicide and self-harm, Working with the suicidal person recommends a series of general practices and principles to guide the assessment and management of people at risk.
The ultimate judgement must be made by the attending clinician, based on their experience, the clinical presentation and the assessment and management options available at their health service.
Although risk factors cannot identify suicidal individuals with any certainty, they can alert a clinician to take particular care in assessing an individual. There is a wide range of factors that can influence suicide risk, from mental illness or physical ill-health to abusive relationships, stressful life events such as unemployment or bereavement, or a history of suicidal thoughts. There are several general principles for mental health staff to consider in the assessment and management of people at risk of suicide.
Good communication and listening are vital to establish rapport with a person, to validate their feelings and to discuss difficult issues with them in an empathetic way. Clinicians are encouraged to ask a person directly: Are you thinking about suicide? Talking about suicide will not encourage a person to take action — it will actually decrease their risk because it lets them know they are able to talk about it with you. Clinicians should find out if they have made any preparations for death, such as giving possessions away or saying goodbye to loved ones.
If a suicide attempt has been made, ask about any precipitating events, whether it was impulsive or premeditated, and whether they sought help beforehand. It is very important to gain information, not only from presenting individuals but from their friends, family, caregivers or medical records, which can help gauge their level of risk and determine appropriate clinical options. Clinicians should take particular care to ensure that pertinent information is accurately documented and passed on to other staff to ensure a consistent approach and prevent adverse outcomes.
Keeping a person safe and comfortable while they are waiting for an assessment is paramount, and any restrictions of their liberty must be kept to an absolute minimum. For acutely suicidal people, assessment should be made immediately. Intoxication should not delay an assessment, as it can increase impulsiveness and the risk of self-injury in the short term. The practical quick guide, Working with the suicidal person, Rapid suicide-risk assessment at emergency department triage , provides a useful list of pointers and questions to assist clinicians during the key stages of a risk assessment.
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Self-Harm & Suicide Issue - Foreword from the Editor - ACAMH
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