How to Coach Yourself and Others Empowering Coaching And Crisis Interventions | страница 176

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4. Assessing Risk of Harm to Self or Others
About 80% of all suicides are committed by men. Yet suicidal attempts and parasuicidal behavior (nonfatal
self-injurious behavior with clear intent to cause bodily harm or death; Welch 2001) are more prevalent among
women.
The greatest predictor of eventual suicide is prior suicidal attempts and deliberate self-harm inflicted with no
intent to die (Joe et al. 2006).
While substance dependence and PTSD are associated with self-harm and suicidal behavior (Harned et al.
2006), the most frequent diagnoses associated with suicide are mood disorders, specifically depressive episodes
(Kessler et al. 1999).
Considering the prevalence of suicides, suicidal attempts, self-injurious behavior, and depression, employing
safety screenings should be a standard practice. From the outset, clinicians should specifically ask the client and
anyone else who is providing information whether the client is in immediate danger and whether they have any
immediate intention to engage in violent or self-injurious behavior. If the answer is “yes,” the clinician should
obtain more information about the nature and severity of the thoughts, plan, and intent, and then arrange for an
in-depth risk assessment by a trained mental health clinician. The client should not be left alone.
No tool is definitive for safety screening. Clinicians should use safety screening tools only as an initial guide
and proceed to detailed questions to obtain relevant information. In addition, care is needed to avoid
underestimating risk because clients that are using substances may also engage in self-injurious behavior. For
example, a woman who is intoxicated might seem to be making empty threats of self-harm, but all statements
about harming herself or others must be taken seriously. Overall, individuals who have suicidal or aggressive
impulses when intoxicated are more likely to act on those impulses; therefore, determination of the seriousness
of threats requires a skilled mental health assessment, plus information from others who know the client very
well. Screening tools and procedures in evaluating risk are discussed in depth in TIP 50 Addressing Suicidal
Thoughts and Behaviors in Substance Abuse Treatment (CSAT 2009a).
Substance abuse treatment programs need clear mental health referral and follow-up procedures so that clients
receive appropriate psychiatric evaluations and mental health care. The American Association of Community
Psychiatrists (AACP) developed the Level of Care Utilization System for Psychiatric and Addiction Services
(LOCUS) that evaluates clients along six dimensions and defines six levels of resource intensity. It includes an
excellent tool for helping the counselor determine the risk of harm (AACP 2000).
The potential risk of harm most frequently takes the form of suicidal intentions, and less often the form of
homicidal intentions. The scale has five categories, from minimal risk of harm to extreme risk of harm. It is
available at www.comm.psych.pitt.edu/finds/LOCUS2000.pdf and can be easily adapted for use in treatment
facilities.

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