What You Will Learn
Elements of, and requirements for, Risk Assessment
Procedures for responding to identified risks
Precautions for reporting risks and behavior
Your Duty to Warn
Elements of a Crisis Plan and when to use it
Elements of a Relapse Prevention Plan and when to use it
What is a WRAP and how to use it
Risk Assessment
At intake, and during each update to the Assessments for adults, you will be asked to assess current risks and describe plans for managing them. For adults receving ARMHS or Case Mangement, you'll find this on the summary page of the Adult FA.
For anyone receiving Behavioral Health Home services, the risk assessment is part of the Health and Wellness Assessment.
For children you will conduct a brief risk assessment using the Child and Family Safety and Crisis Assessment Plan.
With each progress note you write, you'll be asked to assess these same risks. The list includes:
- > Suicidal ideation
- > Threats of or behavior indicating potential self harm
- > Threats of or behavior indicating potential harm to others
- > Threats to safety in current relationships, social and interpersonal risk, or behavior that may prompt harm from others
- > Disorientation, wandering
- > Substance abuse presenting imminent risk of harm to self
- > Self neglect in basic needs, medication, personal care, etc.
- > Risky behavior or impulsivity that could result in injury or illness, or financial loss (e.g. gambling, sexual encounters)
- > Vulnerability to financial exploitation
- > Unmanaged health problems presenting imminent risk
- > Imminent risk of incarceration
- > Current, or imminent risk of, unmet basic needs (housing, clothing, food, safety, health care)
- > Imminent risk of loss of job or basic financial supports
- > Other
How to Respond When You Perceive or Identify a Risk
Of course, if an individual's, or others' safety or health is in immediate danger, call 911 immediately. And take steps to ensure your safety and the safety of others. Then call your supervisor when the situation is under control.
When the risk you perceive during services is not an emergency, document that you've identified a risk using the add-on to your progress note: Safety or Health Risk Identified. Contact your supervisor for guidance and inform others who work with the individual of the risk.
When the risk you identify is the result of an Incident, (see our Incident Reporting Policy and Procedure here), complete an Incident Report, and use the add-on to your progress note: Incident Report Filed.
Precautions About Reporting
Some of what you learn about behavior and activities and behavior of the people you serve is protected by psychotherapist-client privilege. (By extension, laws about psychotherapist-client privilege apply to you via the licensed professional who supervises you.) This is a very subtle and important concept.
Internal reports are just that: internal. They do not reach others beyond our own walls. However, reporting to persons outside of our agency, the disclosure of past criminal behavior by somemone you serve is protected by psychotherapist-client privilege. There are exceptions to limitations on revealing protected information. These include the following.
Adult in Need of Protection/Maltreatment
You are required to make a maltreatment report (Adult in Need of Protection in some cases. These include:
- When a client makes credible threats of serious self-harm, with a plan and means
- When you learn that a client is being exploited or abused
- When you learn or suspect that a client may be maltreating others
Read the Reporting Maltreatment Of Vulnerable Adults or Children chapter of this guide for more information and seek guidance from supervisors in these cases.
Duty to Warn
Duty to Warn refers to the responsibility of a mental health practitioner to inform third parties or authorities if a client poses a threat to another identifiable individual. Normally, ethical guidelines require that mental health practitioners keep information revealed during therapy strictly private. When you learn of a credible threat to health and safet of others, seek guidance on reporting and your duty to warn individuals threatened.
Crisis Response Planning
Helping the people you serve develop plans to prevent and respond to crises is a vital and important responsibility. Everyone you serve should have either a Crisis Response Plan or a Relapse Prevention Plan.
A Crisis Response Plan identifies:
- Behaviors that are warning signs that I am not doing well
- Other warning signs that I am beginning to not do well
- Other behaviors that I exhibit when I am in crisis
- What I can do to help myself
- Signs that I need help from others
- What I don't want people to do
- What I want people to do when I am in crisis
- In a crisis, other ways I may also need help
Develop a Crisis Plan with the people you serve in a natural, person-centered interview style.
Relapse Prevention Planning
Relapse Prevention Planning is a process for writing a plan that defines how a person will maintain stability. Relapse Prevention Plans are for individuals who have achieved a certain level of stability and success and are making plans for how to maintain this stability. The Relapse Prevention Plan details:
- Key support people
- Coping Skills
- Daily Maintenance Plan
- Triggers
- Early Warning Signs
- When Things Are Breaking Down
- Crisis Response
Develop Relapse Prevention Plans with persons who have successfully moved beyond the need for Crisis Response Plans because they have acheived a certain level of stability and are looking to maintain.
WRAP Planning
Visit mentalhealthrecovery.com to read about WRAP. You will learn there that the WRAP, the Wellness Recovery Action Plan, is "now recognized by the Federal Substance Abuse and Mental Health Service Administration (SAMHSA) as an evidence-based practice." You will find, on this website, several free downloadable resources and much valuable information about WRAP.
At Accend, we recognize WRAP as a best and evidence-based practice. This resource is available as a resource in our Treatment Library, and the WRAP booklet is one resource we ask all providers to purchase.
We encourage you to use WRAP with all of the people you serve and especially as a part of intentional discharge planning.
We will reimburse you for the expense of this booklet for use with the people you serve.
WRAP is an advanced competency-based training.
Crisis and Recovery Maintenance Planning in the Adult Functional/Health and Wellness Assessment
The Adult FA/HWA has a page for Crisis and Recovery Maintenance Planning. You have several options on this page. The assessment begins with this question:
Which of the following are true about Crisis or Recovery Maintenance Plans?
- I currently have a Crisis or Recovery Maintenance Plan I developed in another form or template
- My Crisis or Recovery Maintenance Plan follows
- I want to develop a Crisis or Recovery Maintenance Plan as a part of my services in the next few months
- I currently have a Crisis or Recovery Maintenance Plan, but want to update it
- My brief Crisis Plan follows
If you have already developed a Crisis Prevention Plan or Relapse Prevention Plan using a Tabs template, you can indicate this and the values will populate into the FA. If you have used another template, like a WRAP, you'll be prompted to indicate where this plan is stored and who can access it.
If the person indicates they would like to develop a Crisis or Recovery Maintenance Plan as a part of services, a brief text box narrative asks you to make a formal plan. This populates into the rationale for objectives in the Symptom Management and Mental Health Services domains.
"My brief Crisis Plan follows" is the least desirable option for a high-quality assessment. When selecting this option, you will see the prompt: "I would still like to make a more complete Crisis Management or Recovery Maintenance Plan." Encourage the individual to agree to developing a more complete plan. When the individual agrees, record that as an Action Item in the clients file labeled with the Action element "Safety." Make immediate plans to work on this task. You might also consider making it a Treatment outcome. Get started immediatley and mark the Action Item complete and/or the treatmen toutcome accomplished when the plan is written.
This guide is a living document. We want to improve it with your help. Do you have questions? Found a typo? Find yourself wanting more information? Please send us your thoughts about anything in this chapter by tapping on the link below.
December 28, 2022:
Chapter reviewed. Link to WRAP updated. Options available in the FA/HWA for development of a crisis plan updated to match current template. References to related guides added in introduction.
Instructions for using Action Items for plans to develop Crisis Response or Recovery Maintenance plans added.
Language on reporting in cases of Adult in Need of Protection and Abuse or Exploitation clarified.
