Domain 2 - Harm (Primary Domain)

Overview

This domain is focused on:

  • Suicidality – current and past suicidal ideation, intent, planning, and attempts.

  • Intentional, non-suicidal self-harm – current and past.

  • Impulsive, dangerous, or risky behaviours with the potential for psychological or physical harm to self or others (consider and include risks associated with the use of alcohol and other drugs).

  • The psychological or physical harm caused by abuse, exploitation, or neglect by others.

  • Unintentional harm to self, arising from symptoms or self-neglect.

The IAR for older adults includes the harm from others in domain 2 because there are direct implications for the intensity of mental health response an older adult at risk of or experiencing harm from others is likely to require. Placing harm from others in another domain (e.g., domain 6) does not carry the same weight within the logic that underpins the recommendations about a level of care. Note that the presence of external stressors (e.g., family violence) is rated at domain 6, but the degree of harm arising from those stressors is rated separately at domain 2.

PRACTICE POINT - evaluating harm associated with suicidal thoughts, impulses, or behaviours

This domain must be considered in the context of information gathered across the other seven domains. Information gathered across the other seven domains (e.g., severe symptoms, impulsivity, use of substances, environmental stressors, recent changes, and degree of engagement with helping resources) is especially important when evaluating harm.

The IAR-DST is not a suicide risk assessment or risk formulation tool. If an individual expresses suicidal thoughts or impulses or displays suicidal behaviours, a risk formulation compatible with local or state-based protocols (e.g., Towards Zero, Connecting with People) is indicated.

A risk formulation generally involves:

Determining risk status through consideration of static factors such as a history of psychiatric illness, family history of suicide, history of abuse, and history of suicidal behaviour.

Exploring risk state through consideration of recent suicidal behaviours, current symptoms and stressors, and engagement with helping resources. Comparing the current risk state to the person’s “baseline” and “worst-point” states. Exploring the risk state includes building an understanding of the:

  • Nature of the suicidal thoughts (frequency, intensity, speed of onset, persistence, intrusiveness)

  • Perception of the future (hope, alternatives to suicide)

  • Degree of planning

  • Degree of preparation

  • Ability to resist thoughts of suicide

Considering the resources available to the person and foreseeable changes that might exacerbate risk.

A suicide risk formulation may need to happen urgently. If this is the case, refer to localised urgent assessment and care pathways.

PRACTICE POINT - safety planning

If indicated, a safety plan can be an important resource to develop with a patient. There are templates and guidance for developing a safety plan available online from mental health service providers and systems.

PRACTICE POINT - elder abuse

The World Health Organisation defines elder abuse as ‘a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person.’ Elder abuse includes financial, physical, psychological, emotional, and sexual abuse or neglect. Users of the IAR Guidance and IAR-DST for older adults must understand and be aware of elder abuse, and what to do if an older adult discloses elder abuse (or if elder abuse is suspected). More information about elder abuse is available through the Australian Human Rights Commission.

1800 ELDERHelp (1800 353 374) is a free call number that automatically redirects callers seeking information and advice on elder abuse with the existing phone line service in their jurisdiction.

Scoring

0 = No concerns about harm

1 = Previous but no current concerns about harm

  1. No recent or current suicidal ideation, but has experienced ideation, plans, or intent in the past. No recent history of suicide attempts but may have made attempts in the past. Demonstrates future-oriented thinking and has strong protective factors.

  2. Occasional non-suicidal self-injurious acts in the recent past and not requiring any medical treatment.

  3. May have engaged in past behaviours that posed a risk to self or others, but no current or recent instances.

  4. Currently at low risk of harm from abuse, exploitation, or neglect by others.

2 = Some current concerns about harm

  1. Current suicidal ideation, without plan or intent but may have had plans, intent, or suicide attempts in the past. Demonstrates future-orientated thinking and has strong protective factors.

  2. Frequent non-suicidal self-injurious acts in the recent past and not requiring any medical treatment.

  3. Current or recent behaviours that pose a non-life-threatening risk to self or others.

  4. Currently at some risk of harm from abuse, exploitation, or neglect by others.

  5. Frequent lapses in self-care that may lead to harm.

3 = Significant current concerns about harm

  1. Current suicidal ideation with a plan, but no current intent or a strong reluctance to carry out a plan. May have a history of suicide attempts. Strong protective factors and a commitment to engage in a safety plan, including the involvement of family, significant others, or services.

  2. Recent suicide attempt (within past 12 months) but no current ideation, intent, or plan.

  3. Frequent non-suicidal self-injurious acts in the recent past and requiring medical treatment.

  4. Recent or current impulsive, dangerous, or risky behaviours that pose a risk of harm to self or others, or that have had or are likely to have a serious negative impact.

  5. Serious medical risks and/or complications associated with a mental illness.

  6. Significant risk of, or recent experience of, abuse, exploitation, or neglect by others.

  7. Clearly compromised self-care ability that is ongoing to the extent that indirect or unintentional harm to self is likely.

4 = Very significant current concerns about harm

  1. Recent suicide attempt (within the past 12 months) or current suicidal ideation, with intent, typically with a plan and means to carry out the plan. Few or no protective factors. Limited or no future-orientated thinking.

  2. History of life-threatening self-injurious acts that are prominent in the current presentation.

  3. There is evidence of current severe symptoms (e.g., hallucinations, avoidant behaviour, paranoia, disordered thinking, delusions, impulsivity, disinhibition) with behaviour that is likely to present an imminent or unpredictable danger to self or others.

  4. Extremely compromised self-care ability to the extent that there is a real and present danger of the person experiencing harm related to these deficits.

  5. Life-threatening medical risks and/or complications associated with a mental illness.

  6. Other signs or indicators of imminent risk of serious harm to themselves or others.