More than four years ago, the Institute for Community Living (ICL) extended its focus on risk assessment and intervention to provide staff with additional tools and strategies to support integrated and coordinated assessment and intervention of and for clinical risk. The purpose of the model is to facilitate communication, supports and a culture of mutual responsibility across disciplines and organizational boundaries to create a comprehensive and cohesive system that emphasizes integrated care and preventive interventions.
Risk and risk-taking behaviors are unfortunately as applicable to youth as they are to adults. According to the Center for Disease Control (CDC), in 2009, 13.8% of the high school students surveyed seriously considered suicide, and 6.3% attempted suicide. Further, 5.6% of students surveyed had carried a weapon on school grounds on at least one of the thirty days preceding the survey, and 7.7% had been threatened with a weapon on school property. Risk taking behaviors of others, up to and including suicide, are rarely solitary acts—at the very least, they impact family members, friends and even the broader communities in which people live. For example, in the same CDC survey, 28.3% of students rode in a car with someone who had been drinking at least one of the thirty days preceding the survey, and 5% had not attended school on at least one day out of concern for their safety either at school or on the way to or from. According to the Citizens Committee for Children, in East New York, one of the areas in which ICL operates both a clinic and services in schools, there were over 1000 juvenile misdemeanor and/or felony arrests in 2006.
In 2008, the New York State/New York City Mental Health-Criminal Justice Panel Report and Recommendations were published with guidelines for standards of care and screening for risk of violence in mental health clinics. ICL built upon this guidance in the development of an initial and ongoing assessment process to identify areas of potential danger to self and/or others. The goal of this ongoing work is to develop systems that assist staff in collecting the pertinent data and helping them to convert the data to clinically relevant information regarding factors that indicate the potential for risky behavior. Supervisory staff and clinical training and consultation can then be provided to staff to support work with consumers around identification of triggers and subsequent intervention strategies, including both in-house and linkage services, e.g., urgent clinic treatment visits, mobile crisis teams and in-patient hospital services.
In ICL’s four community- and school-based clinics and on-site school services throughout Brooklyn, risk assessment begins at the initial interview with client. As the clinician completes the psychosocial interview, there are very structured and purposeful questions relating to risk. These pertain to legal involvement, abuse / trauma assessment, witness to violence or victim of such, anger management issues, history of fire-setting, use of / access to weapons, as well as adherence to prescribed medication routines. At the conclusion of the psychosocial assessment, a clinician will consider information from this process, as well as the mental status exam and other pertinent information to determine a level of risk for the incoming client.
When a client is identified as at high clinical risk, a summary of risk factors is forwarded to the clinician’s supervisor for review. It serves as a trigger for ongoing discussion and possible outreach for further consultation. A case conference may be convened involving family members, clinical specialists, other self-identified supports and other individuals with systems, regulatory, medical or other expertise pertaining to the situation.
The clinical risk assessment process is ongoing—it needs to be assessed at every session, particularly with youth who may not be in control of the situation, and for whom impulsivity, fluctuating emotions and large-scale issues that could easily challenge adults, are the norm. When youth are involved, the issues are always more complex, and the terrain is changing. We are currently reviewing the child and adolescent clinic assessment process to ensure that we remain current with emerging risk factors, such as cyber-bullying, as well as continue to focus on more traditional areas, such as drug and alcohol use, possession of weapons, gang involvement and others.
Concurrently, clinicians have continued to participate in an ongoing monthly training on best practice interventions, spanning from those specific to risk assessment and intervention to ongoing treatment, and family work.
It is the intent of the clinical risk initiative that we will have a better opportunity to identify those clients at risk and to facilitate a more comprehensive system of ongoing support, follow-up and monitoring. However, nothing is stagnant—as we continue to evolve this process, the field will continue to develop, and new areas of risk, as well resource, will emerge.