Domain 2 - Risk of Harm (Primary Domain)

Overview

An initial assessment should include an evaluation of risk to determine a person’s potential for harm to self or others. Results from this assessment are of fundamental importance in deciding the appropriate level of care required.

Recent Australian and international evidence indicates that risk prediction is a flawed, imprecise, and misleading activity in mental healthcare that contributes to both over and under prediction of risk. This domain is not about predicting the individuals that are likely to attempt or complete suicide or other forms of harm, rather this domain guides evaluation of risk to inform the most appropriate response and/or referral. This domain is focussed on examining:

  • suicidality – current and past suicidal ideation, attempts,
  • self-harm (non-suicidal self-injurious behaviour) – current and past,
  • severe symptoms that pose a danger to self or others, and
  • self-neglect that poses a risk to the person’s safety.

The PHQ-9 (item 9) and the EPDS (item 10) include specific items relating to suicide or self-harm risk. If these tools are used, revisit the scores for these items to assist rating this domain.

PRACTICE POINT

Risk of harm must be considered in the context of information gathered on the other 7 domains- information gathered across the other 7 domains (e.g., if the person is experiencing loneliness, or significant environmental stressors) is very important in evaluating harm

Scoring

0 = No identified risk in this domain – no descriptors apply

1 = Low risk of harm

  1. No current suicidal ideation but may have experienced ideation in the past (with no previous intent, plan, or attempts).
  2. May have engaged in behaviours in the past that posed a risk to others but no current or recent instances.
  3. Occasional non-suicidal self-injurious acts in the recent past and not requiring surgical treatment.

2 = Moderate risk of harm

  1. Current suicidal ideation, without plan or intent. But may have had intent, plans, or attempts in the past unrelated to current episode or current life stressors.
  2. Current or recent behaviours that pose a non-life-threatening risk to self or others.
  3. Frequent non-suicidal self-injurious acts in the recent past and not requiring surgical treatment.

3 = High risk of harm

  1. Current suicidal ideation with intent and history of suicidal attempts. No plan or strong reluctance to carry out plan, strong protective factors, and a commitment to engage in a safety plan including involvement of family, significant others, and services.
  2. Current or recent life-threatening self-harm or dangerous behaviours to self or others.
  3. Clearly compromised self-care ability to the extent that indirect or unintentional harm to self is likely. This includes indirect harm to self - associated with conditions such as anorexia nervosa.
  4. Frequent non-suicidal self-injurious acts in the recent past and requiring surgical treatment.

4 = Very high risk of harm

  1. Current suicidal intention with plan and means to carry out. Few or no protective factors.
  2. Long term history of repeated and life-threatening self-harm or dangerous behaviour to self or others that is prominent in the person’s current presentation.
  3. Evidence of current severe symptoms (e.g., hallucinations, avoidant behaviour, paranoia, disordered thinking, delusions) with behaviour that poses an imminent danger to self or others.
  4. Extremely compromised self-care ability to the extent that the person is in real and present danger and experiencing harm related to these deficits.