Dec Q&A 2024: Applying prevention-oriented risk formulation in a fictitious Defence case example

Information and Prevention-Oriented Risk Formulation

• Long-term risk factors: History of trauma, unknown biological father history, harsh parenting, prior concussion
• Impulsivity/Self-control: Gambling which has increased since separation causing financial strain, increased alcohol use including recent binge drinking
• Suicidal Thoughts/Behaviors: No past attempts, recent onset of ideation, thoughts becoming more intense after seeing social media posts
• Preparation: Research on methods, practice of knot-tying, potential firearm access
• Stressors/Precipitants: Recent relationship breakdown, partner moved interstate and took car, loss of autonomy in transportation
• Symptoms: Jittery presentation, hunched posture, irritable mood, difficulty identifying protective factors
• Initial Engagement: Resistant ("didn't ask for any of this," "want to be left alone"), tenuous rapport

Risk status is higher than other members presenting with mental health concerns to the Health Centre because:

•  Preparation and research into means
•  Limited existing supports
•  Limited current engagement with assessment
•  Multiple acute stressors

Additional Points

• Risk status looks at the person’s risk in the context of the treatment setting or one being considered.
• In acute settings, clinicians often put more weight on acute stressors when considering risk status. 
• The preparatory behaviour and access to means would make this case a higher risk status than others with suicidal ideation at the health centre.
• The focus is on what helps communicate to the treatment team why additional support/review might be needed.

Risk state is higher than the member’s baseline because:  

• Recent relationship breakdown as key precipitant
• Intensification of thoughts after social media trigger
• Increased alcohol use and gambling
• Loss of practical supports (transportation)

Additional Points

• Risk state compares to the person's own baseline and history. 
• Even when risk status is similar to others in a given setting, risk state can still be higher than baseline to express that things are happening for someone at this moment that increases them compared to their baseline. 

Key Questions Raised in the Discussion

How do dynamic and more acute factors like preparation, access to means and research relate to risk status and state? 

In the SafeSide Framework, the line from enduring and dynamic factors goes to both risk status and risk state - it's not that enduring factors only go to status and dynamic only to state. Short-term or acute factors can influence both risk status and risk state. This means that there is flexibility to say someone's risk status is higher than others in a setting but their risk state might be similar to their baseline. 

How might you describe risk for a member who is struggling, where risk status might be higher than normal population and risk state is higher, but protective factors are meeting their needs?  For example, a member who’s partner died recently, leaving them with children to care for, but who has no intent to die by suicide and has a high support system. 

Even in this difficult situation, looking at all you know across the eight categories, you might not see the person as being at higher risk than others in the same setting. So you could say they have similar risk status to others in the same setting because, though there was an acute stressor, they also have strong protective factors and a strong support system. Similar risk status doesn't mean no intervention is needed, though - response planning remains important, with a focus on identifying foreseeable changes that could impact the person and developing contingency plans for those changes. 

Takeaway

Prevention-oriented formulation allows clinicians to clearly articulate specific risk factors and changes in risk over time, supporting more targeted interventions than broad risk categories. The approach emphasizes understanding both enduring and dynamic factors while maintaining focus on modifiable areas for intervention. The framework provides flexibility to consider context and multiple factors while maintaining clear communication about level of concern and needed responses.

Related Resources

Prevention-Oriented Risk Formulation Worksheet 
Risk formulation efficiency (10-min video refresher)
When does suicide ideation increase risk status and risk state? (4-min video refresher)