Risk assessment and management in crisis

It is recommended that a detailed risk assessment be undertaken in patients presenting in crisis. This should be carried out in an empathic and non-judgmental manner, taking account of risks to the patient but also identifying risks to others, including children and vulnerable adults. Patients’ crisis self-management plans, CPA plans and clinical crisis care plans should be used where available to assist with the risk management process.

Risk assessment should include

history
mental state
situation as well as systematic assessment of static and dynamic risk factors.

Structured tools such as STORM (Skills Training On Risk Management) may be helpful, see Appendix. STORM documentation and training can be found at the following link: STORM training

Clinically indicated positive risk taking following a risk-benefit analysis is an important component of the care and treatment of patients with personality disorder. While safety must always remain a primary consideration in such an analysis, it must be recognised that complete elimination of risk is impossible. Risk management decisions should as far as possible be made by the multidisciplinary team in collaboration with the patient.

It is important to recognise that, while the clinical team is responsible for providing a reasonable standard of care, the patient retains responsibility for their behaviour and the consequences of that behaviour. A patient with personality disorder should always be assumed to be a competent adult, able to make and responsible for their own choices, unless there are compelling reasons to think otherwise, for example severe mental state disorder. In good multidisciplinary working, clinical responsibility for risk management decisions belongs to the whole multidisciplinary team rather than any single clinician.

Community management of crisis

Most crises will not require the input of services and can be resolved by the resources available to the person in their social network. Self-help guides and information may be of value in supporting this process.

When involvement of mental health services is indicated by reason of risk, severity or frequency of crises, relevant community services include:

• Community Mental Health Teams
• Mental Health Assessment Unit for Inverness sector patients who present significant risk to themselves or others and who would otherwise be considered for admission to hospital.

Hospital management of crisis

Acute in-patient management should be considered with the guidelines on in-patient management in the ICP in mind. Admission to hospital should usually not be considered when other options are appropriate.

After resolution of the crisis

At the earliest opportunity, the assessor should arrange that all clinicians involved in the patient’s care are informed of the details of the crisis and the current treatment plan. In addition, the patient’s crisis self-management plan and the clinical care plan should be updated at the earliest possible opportunity.

Crises are likely to recur unless a patient’s situation changes or their ability to cope with their situation changes. A crisis can therefore become a useful opportunity to open the discussion about longer term care and treatment options for personality disorder.