Navigating Risks: From Professional Curiosity To Safeguarding Oneself And Others

Editor's note: This text-based course is a transcript of the webinar, Navigating Risks: From Professional Curiosity To Safeguarding Oneself And Others, presented by Tania Sofia Nogueira, MSc, HCPC – UK, COT – UK, ACSS – PT.

Learning Outcomes

• After this course, participants will be able to identify the meaning of clinical risk in mental health.
• After this course, participants will be able to recognize types of risk.
• After this course, participants will be able to list principles of good practice involved in conversations about safety/risk assessment.

Introduction

In our roles, we all are responsible for looking out for the well-being of our clients, family, and friends, providing support whenever we sense they may need it. This support can truly make a difference in their lives. I sincerely hope this webinar will enhance our understanding and skills regarding how simple conversations can save lives.

As a diverse group, our perspectives on risk are shaped by our unique backgrounds. Today's discussion will delve into sensitive topics that may have personal relevance for some of our colleagues. If at any point you feel the need, please don't hesitate to step away from the session momentarily. You can also contact me or other colleagues for support following the webinar.

This session is designed as an introductory level, with the goal of enabling participants to identify the concept of clinical risk in mental health, distinguish between different types of risk, and outline the principles of good practice in conversations about safety and risk assessment. Let's approach any input shared during this process nonjudgmentally, as our goal is to learn collaboratively.

Polls (In the live session)

Poll #1: What comes to mind when you think about risk?

What words and types of examples come to your mind when considering risk? Some of the answers include fall risk, stress, danger to self and others, trauma safety, exposure to danger, childhood disability, unwanted outcomes, etc. 

Poll #2: How comfortable are you talking about risk (e.g., suicide, abuse) with your clients:

A.Totally comfortable

B. I can, but feels awkward

C. I avoid it

D. I think it is not my job to talk about that

Think about your experience and how comfortable and confident you are discussing risk. If you are still studying, consider how comfortable you are talking about risk with your family and friends, for example. There is no right or wrong answers. We are here to learn with each other. Most of the audience answered the second option, "I can but feels awkward." That answer was followed by "totally comfortable" at 24%. 

Poll #3: What might be some barriers to being professionally curious?

I see mentions of burnout, stigma, healthcare regulations, patient personalities, personal biases, management policies, time constraints, cultural factors, fear, peer pressure, workplace regulations, and concerns about loss.

Thank you all for your valuable contributions.

Why This Session?

• People at potential risk are encountered across occupational therapy (OT) practice settings. (1, 2, 3)
• Risk factors can arise from various stressors such as chronic pain/health conditions, school/work environment, grief, financial problems, or family conflicts. (1, 2, 4)
• OTs are in a position to identify those who are emotionally struggling. (1, 2, 3, 5)
• OTs can play an important role in working directly with clients throughout the risk continuum, from identifying eventual risks to supporting clients to find more meaning in life through occupation. (1, 2, 3, 5, 6)

The purpose of this session is to underscore the importance of being vigilant about risks, including suicidal ideation, across all practice settings, not just within mental health contexts. Risks can manifest from various stressors such as chronic pain, physical or mental health conditions, school or work environments, and family conflicts. As occupational therapists, we are uniquely positioned to recognize individuals experiencing emotional distress. We interact with clients during vulnerable moments in their lives, often within their own environments, addressing deeply personal questions and concerns.

The critical question arises: Do we possess the confidence, knowledge, and skills to effectively address these risks? Occupational therapists play a crucial role in working directly with clients along the risk continuum, from identifying potential risks to assisting clients in finding greater meaning in life through engagement in meaningful occupations.

Professional Curiosity

Professional curiosity is a fundamental trait all humans share, serving as a powerful bond between individuals. In healthcare, curiosity distinguishes between simply going through the motions and genuinely engaging with our clients. It's essential to recognize that every individual interacting with children, potentially vulnerable adults, or families plays a crucial role. Safeguarding, encompassing actions taken to promote welfare and prevent harm, is a collective responsibility.

Within this framework, the concept of professional curiosity emerges. Before delving into its definition, let's examine a case study to illustrate its application.

Case Study #1

• During a conversation about family life, Jane makes the following reference:
  • “My 1 year old daughter takes baths with her father.”
• What are your first thoughts?

Upon hearing the statement above, various thoughts may arise among different individuals. Some colleagues may not perceive any issue with the statement, while others might raise concerns about safeguarding. Some may question whether Jane is referring to her father, while others might not have considered that possibility.

These diverse reactions highlight the importance of maintaining professional curiosity. Rather than making assumptions, it's crucial to inquire further and understand the context behind Jane's statement. Asking questions can clarify and ensure that potential concerns are addressed appropriately.

1. What is it? ^{(7, 8, 9, 10)}

• Understanding a client’s situation more fully;
• Combination of looking, listening, asking direct questions, checking out, and reflecting on information received;
• Not accepting a single set of details you are given at face value;
• Checking/crossing information from different sources/moments to gain a better understanding;
• Testing out professional hypothesis and not making assumptions.

Professional curiosity is characterized by being respectfully inquisitive, engaging in skilled observation, active listening, and thoughtful questioning. It entails not taking information at face value but delving deeper to gain a comprehensive understanding. This involves cross-referencing details from various interactions and refraining from making assumptions based on initial impressions or narratives.

2. Why is it important? ^{(7, 10)}

• Fuel sustaining our humanism;
• More comprehensive data collection;
• Learning opportunity – client-oriented;
• Facilitates finding the best available answers for the client/family » improves decision-making;
• Underlies a habit of obtaining follow-up;
• It can promote reciprocal trust, engagement and health outcomes;
• Ensures continuous professional development.

Adopting a curiosity-based approach is essential for several reasons. Firstly, curiosity fosters a desire to understand more, enhancing patient-centered care by facilitating a deeper exploration of the client's history, concerns, and contextual factors. This approach leads to improved findings and observations, enabling better-informed decision-making.

Furthermore, curiosity is a continuous learning opportunity centered around the client's needs and experiences. It encourages follow-up and ongoing engagement, promoting better health outcomes over time. Additionally, embracing curiosity ensures ongoing professional development, as it motivates individuals to reflect on their thoughts and actions, driving continuous improvement in practice.

What can an absence of professional curiosity lead to? ^{(7, 8, 9, 10)}

• Missed opportunities to identify less obvious indicators of vulnerability or significant harm;
• Working based on assumptions made in our interactions with clients may be incorrect.

If we fail to embrace professional curiosity, we risk overlooking less apparent signs of vulnerability or significant harm in our clients. Relying solely on assumptions, we may misinterpret situations and make incorrect judgments.

It's common to respond to what's immediately visible, but it's crucial to cultivate curiosity to delve deeper beyond surface impressions. To nurture our curiosity, we can actively listen, ask probing questions, and seek additional information to better understand our client's circumstances.

3. What supports it? ^{(7, 10)}

• Maintaining an open mind – this includes being willing to think the unthinkable;
• Thinking about what you don’t know;
• Being curious;
• Understanding what the life of that person is like on a day-to-day basis;
• Exploring the meaning behind symptoms and unusual statements;

Maintaining an open mind is crucial in professional practice. While it's natural to want to believe the best of a family, it's equally important to remain objective and consider all possible issues affecting their lives. This mindset allows us to think critically about the evidence presented and explore what we don't yet know.

Professional curiosity involves being inquisitive about individuals' daily experiences and challenges, enabling us to gain a deeper understanding of their lives beyond what may be immediately apparent.

• Exploring implications of the client’s emotions and beliefs;
• Asking questions and thinking ‘outside the box’;
• Considering the unpredictability of an evolving disorder or new presentation;
• Looking out for disguised compliance;
• Challenging the information received;
• Identifying concerns;
• Exploring every possible indicator of risk, abuse, or neglect;
• Making connections.

Exploring the deeper meaning behind symptoms and unusual statements is essential in understanding clients' emotions and beliefs. This involves asking probing questions and thinking creatively to consider the unpredictability of evolving disorders or new presentations. Reflecting on a poignant case from my early career underscores the importance of recognizing risk factors, even in seemingly routine situations.

In this case, a client's suicide following surgery highlights the unpredictability of human behavior and the potential risks associated with significant life changes. Despite thorough preparation by the hospital team, the client's distress over perceived changes to their body led to a tragic outcome. This emphasizes the need to remain vigilant for disguised compliance, where clients may superficially engage with services to avoid suspicion.

To effectively address risk, it's crucial to challenge received information, identify concerns, and explore every possible indicator of risk, abuse, or neglect. Making connections and delving deeper into clients' experiences can help uncover hidden risks and prevent tragic outcomes.

4. Barriers to Curiosity ^{(7, 8, 10, 11)}

4.1. How do we overcome barriers? ^{(7, 10, 11, 20)}

• Acknowledge/recognize difficulties (e.g., lack of confidence, fear, etc.);
• Ask for help – this could be by talking to your manager or in supervision;
• Seek opportunities to develop your practice and understanding;
• Get prepared - understand the purpose of the contact and any previous worries or concerns;
• Be confident in saying that you will find out.

Structural barriers, such as time pressure and workload, can impede our ability to effectively address concerns and provide support. This includes challenges related to administrative tasks, unfamiliarity with internal policies, and limited knowledge of available services in the local area. Additionally, working in environments with a target-driven culture may further exacerbate these barriers.

Relational barriers may arise from our interactions with clients, where overwhelming amounts of information or an overly optimistic outlook can obscure concerning signs. Similarly, becoming overly invested in the progress of caregivers may detract from our focus on the individual's well-being, particularly in cases involving children.

Personal barriers, rooted in human experiences, can also hinder our professional practice. Fear of conflict, lack of confidence in addressing sensitive topics, or feeling unequipped to navigate difficult conversations may limit our effectiveness. Unconscious biases or prejudices against certain individuals or groups can further complicate matters.

To overcome these barriers, it is crucial to acknowledge and recognize the difficulties we face. Seeking support through group supervision can provide a safe space to discuss findings, observations, and judgments, fostering collective learning and growth. Actively seeking learning opportunities and familiarizing ourselves with the purpose of our interactions with clients can enhance our preparedness.

Maintaining confidence in acknowledging uncertainties and committing to finding answers during conversations with clients can build trust and facilitate meaningful dialogue. Embracing a collaborative approach to problem-solving and remaining open to learning and growth are essential in overcoming these barriers and delivering effective care.

Risk (Mental Health)

1. What is it? ⁽¹²⁾

• Anything that can result in harm
• Why have this always in mind?
  • To work with clients towards achieving the best possible outcomes for them and others
• How to act on it?
  • Identify and consider what common risks the population you work with present » Risk Factors
  • Look at how risks can be reduced and managed safely
  • Risks are not static » Require regular review

In mental health practice, clinical risk encompasses anything that may lead to harm, whether it be harm to oneself, to others, or from others. It is crucial for health professionals to be cognizant of these risks, as they can manifest across various stages of life and impact individuals' well-being. Understanding and identifying common risk factors within the population we serve is essential. These factors may include demographics, health conditions, behaviors, and socioeconomic circumstances contributing to heightened risk.

Once identified, developing strategies to reduce and manage these risks effectively is imperative while promoting client empowerment. This may involve providing information, facilitating awareness sessions, and connecting clients with local resources and support services. It is important to acknowledge that while risks cannot be entirely eliminated, adopting a proactive approach and regularly reviewing risk factors with clients can help mitigate potential harm.

By actively addressing clinical risks and implementing appropriate interventions, occupational therapists can achieve the best possible outcomes for their clients while ensuring the safety and well-being of all involved.

2. Types of Risk ^{(12, 13)}

• Risk to Self
  • Self-harm, suicide ideation and attempt, sensory seeking/risk-taking behavior, self-neglect
• Risk from Others
  • Different types of abuse
• Risk to Others
  • E.g., Anti-social behavior, violence, aggression

It is essential to consider all forms of risk together, as clients who present one type of risk may also be vulnerable to others. For instance, individuals at risk of harm to themselves or from others may also be susceptible to exploitation by others. 

We will now delve into these risk categories, using case studies to cultivate our professional curiosity skills and deepen our understanding of risk assessment and management in mental health contexts. Through these case studies, we aim to enhance our ability to effectively identify, assess, and address various types of risk.

Risk to Self

1. Self-Harm (SH) ^{(14, 15)}

• Also referred to as self-injurious behavior or self-directed violence.
• Intentional behavior, not socially accepted, which leads to the destruction or injury of body tissue without major physical injury, performed with or without conscious suicidal intention. 
• Subtypes:
  • Suicidal self-injury
  • Non-suicidal self-injury (NSSI)
  • Self-harm with unclear intent

Self-harm behavior encompasses actions that result in the destruction or injury of the body, performed either with or without conscious suicidal intent. It is essential to differentiate self-harm from socially accepted practices like tattoos or piercings. There are three primary types of self-harm behavior: suicidal self-injury, non-suicidal self-injury, and self-harm behavior with unclear intent. Examples of self-harm behavior include cutting, burning, or otherwise injuring oneself. Understanding these behaviors is crucial for effective risk assessment and intervention in mental health settings.

Case Study 2

• You are working with John, 16 years old, who reports having a headache. This morning, he has taken 6 paracetamols, which have made no difference.
• Is there anything that makes you feel worried?

Working with John, a 16-year-old reporting a persistent headache despite taking medication, raises concerns. Firstly, his age indicates the need to involve his family or carers in his care. Additionally, the intent behind taking six paracetamol tablets is unclear. Further conversation is necessary to understand the dosage, timing, and circumstances surrounding the medication intake. It's important to inquire about any alcohol consumption or additional substances taken and whether he has sought any support. If his family or carers are unaware, it's crucial to establish an action plan with John. This plan should involve informing his carers and seeking medical advice due to the risk of overdose and potential liver damage.

2. Suicide ^{(15, 16, 17)}

• Self-inflicted death with evidence (explicit or implicit) that the act was intentional;
• People of all genders, ages, and ethnicities can be at risk for suicide.
• Avoid using terms such as “committing suicide,” “successful suicide,” or “failed suicide” when referring to suicide and suicide attempts.

Moving on to the topic of suicide, it's crucial to understand its gravity and impact. Suicide is a significant cause of death globally, with one suicide occurring approximately every eleven minutes in the United States alone. It's important to use respectful language when discussing suicide, avoiding terms like "committing suicide" and instead opting for phrases like "died by suicide" or "lost their life to suicide." This helps reduce the stigma and blame associated with the act. When addressing suicide, it's essential to consider suicide ideation, intent, and attempts as distinct aspects of the phenomenon.

2.1. Suicide Ideation (SI) ⁽¹⁵⁾

• Often called suicidal thoughts or ideas.
• Range of contemplations, wishes, and thoughts of serving as an agent of one’s own death.
• Heterogeneous presentation - varies in intensity, duration, and character; fluctuating pattern
  • Active SI
  • Passive SI
• Many people experience ideas or thoughts of suicide. This does not mean that they will actually attempt to take their own life.

Suicidal ideation, often referred to as suicidal thoughts or ideas, varies widely in intensity, duration, character, and severity. Active suicidal ideation involves a conscious desire to engage in self-harming behaviors, with the intent for death to occur as a consequence. In contrast, passive suicidal ideation entails a general wish to die without a specific plan for self-harm. It may manifest as fleeting wishes for never waking up or indifference to accidental death. It's important to note that many individuals experience such thoughts without intending to act on them, but they should always be taken seriously.

2.2. Suicide Intent (SI) ⁽¹⁵⁾

• Subjective expectation and a desire for a self-destructive act that would end in death.

Suicide intent is a desire to kill oneself without or with a specific plan that is fully or partially worked out by the person who has the intent to carry it out.

2.3. Suicide Attempt (SA) ⁽¹⁵⁾

• Self-injurious behavior with a non-fatal outcome accompanied by evidence (explicit or implicit) that the person attempted to die.

A suicide attempt is a self-injurious behavior with a nonfatal outcome, indicating evidence that the person has tried to die. In 2021, in the USA alone, approximately 12.3 million adults reported having suicidal thoughts, 3.5 million adults made a plan for suicide, and 1.7 million adults attempted suicide.

Keep in Mind ^{(18, 19, 20)}

• Conversational signs
  • Escape: “I can’t take this anymore.”
  • No future: “What’s the point? Things are never going to get any better.”
  • Guilt: “It’s all my fault. I’m to blame.”
  • Alone: “I’m on my own. No one cares about me.”
  • Damaged: “I’ll never be the same again.”
  • Helpless: “Nothing I do makes a bit of difference.”, “It’s beyond my control.”
  • Talking about suicide or death

Attention to conversational signs that may trigger our professional curiosity is important. Signs such as expressions of wanting to escape, feelings of hopelessness or guilt, loneliness, helplessness, or even joking references to suicide or death should prompt further exploration and understanding of their underlying meaning. These cues provide opportunities to delve deeper into the conversation and offer support where needed.

• Behavioral signs
  • Disengagement from services; refusing help
  • Quitting previously important activities
  • Loss of interest in personal hygiene or appearance
  • Major changes to sleeping patterns and eating habits
  • Withdrawal from family and friends
  • Putting affairs in order
  • Uncharacteristic risk-taking or recklessness
  • Prior suicidal behavior; self-harming
  • …

Behavioral signs can also serve as important indicators of potential risk. When individuals disengage from services, refuse help, withdraw from activities, neglect personal care, exhibit out-of-character risk-taking behavior, or have a history of previous suicidal behavior and self-harm, these behaviors heighten the risk for suicide. Recognizing and responding to these signs is crucial in providing appropriate support and intervention.

• Feelings
  • E.g., Hopelessness, Worthlessness, Powerlessness, Disconnection, Isolation, Loneliness, Anger, etc.

There is also the expression of hopelessness, worthlessness, powerlessness, loneliness, anger, etc.

Case Study 3

• At Christmas, someone you know whose dad passed away tells you:
  • “I am missing my dad. He has been in my mind a lot… I want to be with Dad.”
• How would you respond?

In response to the individual expressing their longing for their deceased father during the Christmas season, my initial reaction was to consider the context of the holiday and the natural inclination to reminisce about loved ones. However, upon reflecting on the person's background and previous conversations, which revealed various risk factors such as homelessness, family issues, and past trauma, I realized the importance of probing further.

I asked the individual what they meant by wanting to be with their father and if they had any plans to end their life. This led to the revelation that they had access to a razor blade and experienced feelings of fear. Recognizing the situation's urgency, I offered support and discussed options for managing their distress.

I also raised concerns with the team at the homeless center and ensured that the individual received medical assistance. By addressing the person's immediate needs and providing them with support, we were able to take steps toward ensuring their safety and well-being.

3. Sensory Seeking Behavior ^(21,22)

• When a person engages in a specific behavior to regulate their nervous system.
• People may not intend to hurt themselves, but those behaviors can put them at risk of harm.
• Self-injuries are linked to sensory seeking or self-stimulating behavior (e.g., skin-picking, pulling out hair, or jumping off swings when high).
• Can be prevalent in people with neurodevelopmental issues.

Sensory-seeking behavior involves individuals engaging in specific actions to regulate their nervous system, often without the intention of causing harm but potentially putting themselves at risk. Examples include skin picking, pulling out hair, or engaging in risky activities like jumping off swings at great heights. These behaviors can be particularly prevalent in individuals with neurodevelopmental issues.

Keep in Mind ^{(21, 23)}

• All behavior is communication;
• Consider/think about the function of the behavior;
• Pay attention to the situation before, during, and after the behavior (e.g., behavior diary);
• Choose empathy over problem-solving;
• Build alternative (sensory) experiences.

It's important to recognize that all behavior communicates something, including sensory-seeking behavior. We can better support individuals by paying attention and understanding the underlying need or message behind such actions. For instance, someone engaging in sensory-seeking behavior might be doing so to fulfill a sensory need or alleviate boredom. In such cases, using a behavioral diary to track patterns and identify triggers can be helpful. Additionally, we can work with individuals to develop alternative sensory experiences that meet their needs in safer ways. For example, I recently assessed a 69-year-old woman who shared that she finds calmness in seeing her own blood dripping from her hand, leading her to occasionally cut her wrist. This underscores the importance of empathizing with such behaviors and exploring healthier coping strategies.

4. Risky/Impulsive Behavior ⁽²⁴⁾

• It can be another way that people put themselves at risk.
• E.g., Carrying/using a weapon, unprotected sex, shoplifting, gang involvement, drug dealing, reckless driving, children running away, etc.
• Harmful sexualized behavior
  • Behavior developmentally inappropriate that can be harmful or abusive;
  • E.g., Watching porn, sending/receiving unwanted sexual images, exposure in public, touching others without consent, sexual contact with animals, etc.

Risky and impulsive behavior can significantly increase the likelihood of individuals putting themselves at risk. This can manifest in various forms, such as carrying and using weapons, involvement in gangs, children running away from home, and engaging in harmful sexualized behavior. Harmful sexualized behavior encompasses actions that are developmentally inappropriate, potentially harmful, or abusive, including behaviors like watching pornography at a young age or engaging in early sexual activity.

In addressing these concerns within occupational therapy practice, it's essential to consider sexual activity and intimacy as integral aspects of daily living. This prompts reflection on how extensively we address these topics in our practice and how we might initiate these discussions if they are not already part of our approach.

One way to begin is by adopting a professionally curious stance, particularly when working with groups vulnerable to harmful sexualized behavior, such as teenagers or individuals with disabilities. We can inquire about their understanding of personal information, privacy boundaries, online activities, and perceptions of healthy relationships through open-ended questions and exploratory conversations. This approach encourages individuals to reflect on their behaviors and beliefs, fostering awareness and facilitating the development of healthier attitudes and practices regarding sexuality and intimacy.

5. Self-neglect ⁽²⁵⁾

• Intentional or unintentional behavior by a person that threatens their own health and safety.
  • E.g., Failure to eat/drink, failure to maintain personal hygiene and home environment, noncompliance with treatment, hoarding, etc.
• Eating Behaviors
  • E.g., Restricting food, vomiting, over-exercise to avoid weight gain, hiding/hoarding food, binge-eating, over-eating

Self-neglect presents another risk to oneself, although it's not always straightforward to address, particularly in less severe cases. This risk can stem from various factors, including physical and mental health conditions and brain injuries that may impact motor or cognitive abilities, energy levels, and attention span. Self-neglect manifests when individuals refuse or fail to meet their basic needs, such as eating, drinking, complying with treatment, or maintaining their living environment.

Behaviors associated with self-neglect, such as eating disorders or substance misuse, are viewed as indirect forms of self-harm and can lead to significant harm if left unaddressed. For instance, unhealthy eating habits, especially in teenagers who may hide food in their rooms or exhibit signs of binge eating, can serve as early indicators of potential self-harm risks. Therefore, it's crucial for occupational therapists to approach these issues with professional curiosity, particularly when working with populations prone to such behaviors, to explore and address unhealthy patterns effectively.

Case Study #4

• You are doing an initial assessment over the phone with a client in the afternoon. They tell you they are in their bedroom. You ask them how is weather where they live. The client answers, “I have no idea.”
• How would you progress the conversation?

In this case study, during an initial assessment conducted over the phone in the afternoon, the client's response about not knowing the weather raised a red flag. Given the context of the COVID-19 lockdown and the lack of access to clinical information, I shifted the focus of the conversation to explore this statement further. I began by acknowledging the challenges of lockdown and delved into questions about the client's living situation, accommodation, and living arrangements. It was revealed that the client lived in shared accommodation and kept their room dark.

Upon further exploration, the client disclosed struggling with low mood, racing thoughts, fear of going outside, loss of appetite, and signs of self-neglect. Recognizing the severity of the situation, I obtained consent to raise concerns with the council for a welfare check and shopping delivery. However, as the situation persisted, a referral to a mental health team was necessary to provide the client with the support and intervention they required.

Risk From Others

Risk from others, specifically abuse, is a prevalent issue across societies and encompasses intentionally harmful actions, causing physical, psychological, or social harm to individuals.

1. Types of Abuse ^{(26, 27)}

• Physical abuse
• Emotional abuse
• Domestic violence
• Sexual abuse
• Financial abuse
• Modern slavery
• Discriminatory abuse
• Organizational abuse
• Neglect

Abuse can manifest in various forms, as outlined in the presentation slide. To provide some context, recent statistics from the Child Maltreatment 2022 report indicate that there are over half a million victims of child abuse and neglect in the US, with nearly 2,000 children estimated to have died from abuse and neglect. While it's beyond the scope of this webinar to delve into all types of abuse, I will focus on three main types, starting with neglect, which accounts for 74% of victims, according to the report.

1.1. Neglect ^{(26, 27)}

• When people are not provided with their basic needs
• E.g., Living in an unsuitable living environment, being left alone, wearing unwashed clothing, not being brought to or missing school/medical appointments
• People with a disability, more complex needs, or are in a care system/asylum seekers are known to be at greater risk of neglect.

Neglect occurs when individuals are deprived of their fundamental needs, such as being left unsupervised, and not being taken to essential appointments like school or medical check-ups. It's important to note that individuals with disabilities, especially those with complex needs in care systems, are particularly vulnerable to neglect.

1.2. Bullying and Cyberbullying ^{(28, 29)}

• Bullying » Unwanted aggressive behavior(s) by another youth or group of youths, that involves an observed or perceived power imbalance, and is repeated or is highly likely to be repeated. 
  • Takes different forms in real-life
    • Physical + Verbal + Relational
• Cyberbullying » Bullying through social media
  • Includes: threatening or abusive text messages, shaming through vídeos, trolling

Bullying, both in traditional and cyber forms, remains a significant issue affecting many individuals, with statistics revealing alarming rates of victimization among students and teenagers. Traditional bullying encompasses physical aggression, verbal harassment, and spreading rumors, while cyberbullying extends these behaviors into the online realm, including through social media platforms. Vulnerable groups such as teens, young women, LGBTQ+ youth, and certain racial or age demographics are particularly susceptible to cyberbullying.

For professionals working with these populations to maintain a professional curiosity and delve deeper into their online experiences. Exploring topics such as their online safety knowledge, interactions on social media, instances of being tagged in distressing posts or videos, and experiences with blocking or being blocked can shed light on potential risks they face, especially within specific demographics.

1.3. Modern Slavery ^{(26, 27, 28)}

• Exercising unjustifiable influence or forcing a vulnerable individual to perform services for the benefit of others.
• Sex trafficking (use of force, fraud, or coercion to compel another person to engage in a commercial sex act)
  • Child sex trafficking
• Forced labor
  • Domestic servitude, forced child labor, child soldiering, bonded labor, or debt bondage

The issue of modern slavery, encompassing sex trafficking and forced labor, remains a grave concern globally. According to the Global Slavery Index released in 2023, alarming figures indicate that on any given day in 2021, there were 1.1 million individuals living in modern slavery within the USA alone. Forced labor can manifest through various forms of exploitation, including debt manipulation, confiscation of identification documents, and control over access to basic necessities such as food, transportation, or housing. This underscores the importance of ongoing efforts to combat modern slavery and protect the rights and dignity of those affected.

Keep in Mind (18)

• Pay attention to indirect verbal hints:
  • E.g., “My boss keeps bothering me.”; “My brother doesn’t let me sleep,” etc.
• Give opportunities to disclose by explaining your reasons for asking those questions:
  • E.g., Explaining that it is common and lots of people experience it, so it’s normal for you to be asking

It's crucial to remain vigilant regarding indirect verbal hints that may indicate risk from others. For instance, if a client mentions, "My boss keeps bothering me," it's essential to provide opportunities for them to disclose further by clarifying the reasons behind your questions. You can explain that discussing different forms of abuse is a routine part of the assessment process, aiming to ensure their well-being and safety. This approach encourages openness and may facilitate the disclosure of potentially harmful situations.

• Examples of questions:
  • Has anyone close to you made you feel frightened?
  • Does anyone close to you control you or force you to do things?
  • Has anyone close to you ever hurt you physically, like hit, pushed, or choked you?
  • Has anyone stopped you from getting food, clothes, medication, or medical care?
  • Has anyone stopped you from being with people you want to be with?
  • Has anyone forced you to sign papers against your will?
  • Has anyone talked to you in a way that made you feel ashamed or threatened?
  • Has anyone taken money belonging to you?

During assessments or conversations with individuals, it's crucial to address various forms of abuse sensitively and effectively. To ensure comprehensive coverage, I often use carefully crafted questions tailored to different types of abuse. For instance, I might inquire if anyone close to them has made them feel frightened or threatened or if someone, intentionally or unintentionally, has physically hurt them. Similarly, I explore experiences related to financial exploitation, emotional abuse, sexual harassment, and other forms of mistreatment. By asking about specific scenarios, such as being prevented from socializing with desired individuals or experiencing coercion into unwanted activities, I create a safe space for individuals to share their concerns. It's essential to accompany these questions with explanations for their purpose, reassuring individuals that discussing such sensitive topics is common and necessary. I aim to build trust and encourage disclosure through empathetic and nonjudgmental communication, facilitating access to support services and interventions tailored to each person's needs.

Case Study #5

• Your friend Anna works as an OT in physical rehab. She tells you about a client who calls her sweet names, is very motivated to attend sessions (e.g., arrives early), sometimes offers chocolates that she shares with everyone, and has requested to start having OT sessions in her last slot for no particular reason.
• What thoughts cross your mind?

Upon hearing about Anna's situation with her client, several thoughts come to mind, particularly considering the client's behavior. While Anna may not initially perceive any issue or discomfort, it's crucial to recognize the potential red flags and implications of the client's actions. The client's behavior, such as calling Anna sweet names, offering chocolates, and requesting sessions for no apparent reason, could indicate fixation or obsession.

Given the escalation of the situation, where the client started attending sessions outside of their scheduled appointments and waiting for Anna in the car park, there are clear signs of unwanted and obsessive behavior. In such cases, addressing the situation promptly and appropriately is essential to ensure Anna's safety and well-being.

The prevalence of stalking among healthcare professionals, as indicated by studies, underscores the importance of taking such incidents seriously. Despite the social acceptability of certain behaviors like offering gifts or making phone calls, when these actions become persistent and unwanted, they can constitute stalking and pose risks to the healthcare provider's safety.

It's not uncommon for healthcare professionals to feel ashamed or blame themselves for triggering such behaviors. However, it's crucial to recognize that stalking is not the victim's fault and to take necessary steps to address the situation, such as involving management or seeking support from appropriate channels. By prioritizing Anna's safety and well-being, appropriate measures can be taken to mitigate the risks posed by the client's behavior.

Risk to Others

Risk to Others ⁽¹²⁾

• Abuse or neglect of dependents
• Anti-social behavior
  • E.g., Theft, fire-setting, or vandalism
• Intimidation and threats
• Aggression - behavior intended to cause physical or psychological harm to another person
• Violence - an extreme form of aggression that has an intentional injury as its primary goal
• Property damage

When assessing risk to others, it's crucial to consider a range of potential behaviors that could harm or endanger others. This includes forms of abuse or neglect of dependents, antisocial behaviors such as vandalism, intimidation, and threats, as well as aggression, violence, and property damage.

To effectively explore the risk to others, it's important to ask targeted questions that can reveal underlying issues or concerns. For example, understanding how individuals express negative emotions can provide insights into coping mechanisms and potential risk factors. By acknowledging that feelings of anger or frustration are normal and exploring how individuals manage these emotions, we can better understand any potential risks they may pose to others.

Taking a comprehensive approach to risk assessment involves probing into various aspects of an individual's behavior and emotional state to identify any potential warning signs or red flags. This allows healthcare professionals to intervene early and implement appropriate measures to mitigate the risk of harm to others.

Keep in Mind

• Examples of questions:
  • Have you ever had thoughts of harming others?
  • Have you ever been aggressive/violent?
  • Have you ever been involved with the police?
  • What happened?
  • What were you thinking and feeling at the time?
  • What have your thoughts been since?
  • How do you feel about it now?
  • Who has been affected by this?
  • How have they been affected?

Before delving into specific questions, I find providing examples of behaviors associated with expressing negative emotions helpful. For instance, I may mention screaming, slamming doors, punching walls or people, throwing objects, breaking items, or making threats. By presenting these examples, individuals may better understand the range of behaviors that can indicate underlying emotional distress or potential risk to others.

Following this, I like to ask open-ended questions encouraging individuals to reflect on their experiences and behaviors. For instance, I might ask, "How do you typically cope with anger or frustration?" or "Have you ever felt the urge to engage in behaviors like those we discussed?" These questions help to gauge the individual's self-awareness and provide insight into their coping mechanisms.

Additionally, in assessing risk to others, I often inquire about past interactions with law enforcement. This can offer valuable information about previous instances of aggression or violence and potential patterns of behavior that may pose a risk to others. By considering a range of factors and engaging in open dialogue, we can better assess and address the risk of harm to the individual and others.

Professional Curiosity and Risk

Let's link professional curiosity to risk and how that translates practically.

1. Get Professionally Curious ^{(7, 10, 30)}

• Look
• Listen
• Ask

Maintaining a professional curiosity involves a multifaceted approach encompassing observation, listening, and questioning. Each of these elements plays a crucial role in understanding the needs and circumstances of individuals and families.

Observation is the first step in this process. It entails carefully observing the environment and the behavior of the client or family members during interactions. By observing their demeanor, body language, and interactions with others, one can discern subtle cues indicating underlying issues or concerns. It's essential to look for signs of distress, inconsistencies between verbal and nonverbal communication, or behaviors that deviate from the norm.

Listening is equally important. Listening to what clients or family members express allows for a deeper understanding of their perspectives, emotions, and challenges. Paying attention to the content of their speech, tone of voice, and emotional nuances can provide valuable insights into their experiences and needs. Listening without judgment is essential, validating their feelings and concerns while remaining empathetic and attentive.

Questioning serves as a means to delve deeper into the issues and clarify any uncertainties. Open-ended questions encourage clients to express themselves more fully, facilitating a more comprehensive understanding of their circumstances. By asking probing questions in a supportive and non-threatening manner, one can clarify any discrepancies or concerns arising during observation and listening.

Overall, maintaining a professional curiosity involves integrating observation, listening, and questioning into one's practice seamlessly. By honing these skills and applying them sensitively and effectively, practitioners can better identify risks, address concerns, and provide meaningful support to those they serve.

Keep in Mind ^{(7, 10, 31)}

• Disclosures about risk may come in a non-verbal form – e.g., writing a letter, or story, or drawing a picture.
• Risk can be evident in a behavioral form – people can behave in ways that they hope will alert someone to a problem.
• If you know the person well, it may also be a general sense that ‘something is not quite right.’
• If you don’t feel confident speaking to a person yourself, seek support from a colleague/manager.

Nonverbal cues can be powerful indicators of underlying issues or risks, especially when individuals struggle to express themselves verbally. Behaviors such as drawing pictures, engaging in pretend play, or displaying changes in body language can provide valuable insights into their emotional state and experiences.

It's crucial for professionals to trust their instincts and pay attention to their intuition when they sense that something may be amiss, even if it's not explicitly communicated. These subtle cues may signal underlying distress, discomfort, or risk that warrants further exploration and intervention.

Furthermore, if a practitioner feels uncertain or unequipped to address concerns directly with the individual, seeking support from colleagues or supervisors is essential. Collaboration and consultation with peers can provide additional perspectives and insights, helping to ensure that appropriate steps are taken to address the identified risks and support the individual effectively.

By remaining vigilant and responsive to verbal and nonverbal cues, professionals can better identify and address risks, ultimately promoting the well-being and safety of those under their care.

2. How do you open up a conversation? ^{(7, 11, 30)}

• Be aware about resources available in community
• Choose an appropriate time and space, without distractions
• Ask where they are and who they are with (calls)
• Show you care:
• I’m worried about you. I’m wondering if we can talk about what’s troubling you?
• You’ve seemed really (down/sad/angry/unhappy) lately. Can we talk about this?
• I want to check in with you because you haven’t seemed yourself lately.

Starting a conversation about sensitive topics such as mental health or potential risks requires delicacy and empathy. It's not always easy, but it's crucial to create a safe and supportive environment where the person feels comfortable opening up.

One key aspect is timing and setting. Choosing the right time and place is essential. Ensuring privacy and minimal distractions allows for a focused and uninterrupted conversation. Whether in person or over the phone, finding a moment when both parties are relaxed and receptive is crucial.

Expressing genuine concern is paramount. Starting with a statement like, "I've noticed that you seem a bit down lately," or "I'm worried about you," shows that you care and are attentive to their well-being. It's essential to use non-judgmental language and avoid making assumptions about their situation.

Asking open-ended questions encourages the person to share their thoughts and feelings freely. Questions like, "How have you been feeling lately?" or "Is there anything on your mind that you'd like to talk about?" allow them to express themselves at their own pace.

Active listening is key throughout the conversation. It involves giving your full attention, validating their emotions, and reflecting back on what they say to show understanding and empathy. It's essential to listen without interrupting and to respect their perspective, even if it differs from your own.

Offering support and resources is important. Letting them know that you're there for them and providing information about helplines, support groups, or mental health services can empower them to seek help if needed. However, respecting their boundaries and comfort level is crucial throughout the conversation.

By approaching the conversation with empathy, sensitivity, and a genuine desire to help, you can create a safe space for the person to open up and receive the support they need.

• Be patient » Slow down, go at their pace
• Use open questions as instructions to gather information – TED (tell, explain, describe)
  • What is happening for you?
  • How is this affecting you?
  • How long have you been feeling this way?
• Let them know you are listening
• Show you understand
  • Reflect back on what they’ve said to check your understanding
  • Use their language to show their experience
  • Check their understanding of the words they are using to describe their feelings/experience

When engaging in conversations about sensitive topics, it's crucial to approach them with patience, empathy, and a willingness to listen. The TED acronym - Tell, Explain, Describe - serves as a helpful guide for facilitating meaningful discussions.

Firstly, encourage the person to tell their story, allowing them to express themselves openly and without judgment. Use open-ended questions to prompt them to explain their feelings, thoughts, and experiences in more detail. This creates a safe space for them to share their perspective and helps to deepen understanding.

Additionally, incorporating scaling questions can be beneficial for gauging the intensity of their emotions and assessing their current state. For instance, asking them to rate their feelings on a scale of one to ten provides valuable insight into their level of distress or discomfort.

Active listening is paramount during these conversations. Respect pauses and silences, reflect back on what the person has shared to ensure comprehension and acknowledge their emotions and experiences. It's essential to use appropriate language for their age and understanding and to clarify any terms or concepts they may find confusing.

Avoid accepting the initial response at face value and delve deeper to uncover the underlying emotions and concerns. Rather than offering immediate advice or solutions, focus on validating their feelings, expressing empathy, and offering support. Let them know you're there to listen, understand, and assist them in any way you can. This approach fosters trust, builds rapport, and promotes a collaborative effort toward finding solutions and addressing their needs.

• Validate their experience/behavior
  • Helps to normalize what they are going through and encourages discussion
  • Respond in a non-judgemental way
• Be compassionate
  • I can see this is worrying you.
  • What would you like to happen next?
  • I may not understand your feelings, but I care about you and want to help!
  • How can I best support you right now?
  • Thanks for sharing this experience with me…

Validation is crucial in creating a supportive environment where individuals feel comfortable expressing themselves openly and honestly. By acknowledging and normalizing their experiences, validation encourages discussion and fosters understanding and empathy.

One approach to validation is framing questions in a way that acknowledges common experiences and emotions. For example, stating, "We know that many young people try to hurt themselves because they have these really big emotions they don't know how to express. Is that something you have experienced?" This approach reassures the individual that they are not alone in their struggles and allows them to share their experiences.

Compassion is another essential component of validation. Expressing empathy and concern, such as saying, "I can see this is worrying you. How can I best support you?" demonstrates genuine care and a willingness to assist. Even if you may not fully understand their emotions, expressing a sincere desire to help can significantly affect how they feel supported.

Ultimately, validation communicates to individuals that their feelings are valid and deserving of attention and support. By employing compassionate language and demonstrating understanding, we can create an environment where individuals feel heard, respected, and empowered to share their thoughts and experiences.

• Instill hope
  • You are not alone in this. There are people/services available
  • I don’t have any special training in helping people with experiences like yours, but I can give you contact details of services that can help…
  • It is because of experiences like yours that these organizations are involved in this work.
• With children
  • You were very brave to tell me. I’m proud of you.
  • I believe you.
  • This was not your fault. You did nothing wrong.
  • What’s happened is not OK.
  • I am here for you and will help you.

Instilling hope is vital to supporting individuals facing difficult situations or experiencing distress. By offering reassurance and information about available resources, we can empower them to seek help and navigate their challenges effectively.

One powerful way to instill hope is by letting individuals know they are not alone. We acknowledge their strength and resilience by affirming their courage in sharing their experiences. Saying phrases like "You are not alone" and "You are very brave in telling me" communicates understanding and support, helping them feel validated and heard.

Additionally, it's important to emphasize that their situation is not their fault. Assuring them that what has happened is not okay and expressing a commitment to helping them sends a clear message of advocacy and support. By offering assistance and guidance, we demonstrate our dedication to their well-being and affirm their right to safety and support.

We must be honest about our limitations if concerns or issues are raised that we may not feel equipped to address. We ensure they receive the assistance they need by acknowledging gaps in our expertise and offering to connect them with specialized services or resources. Contact details for relevant services or organizations can empower individuals to access additional support and assistance tailored to their needs.

2.1. What to do next? ^{(6, 31)}

• If a serious risk seems imminent:
  • Liaise with the relevant emergency support services
• If there is no imminent risk:
  • Focus on the thing that person is struggling with
    • What has been the hardest thing?
    • What needs to happen to put things right?
    • What do you need now?
• Explore alternatives/expand options to solve that specific issue
  • Support them to identify a resolution.

After we have this conversation, what we do next? If there is a serious imminent risk, we need to liaise with the relevant emergency service and don't need consent from them. If there is no imminent risk, we must understand what needs to happen to put things right and what the client needs. It is about exploring with them options to solve the specific issue.

• Agree on a specific action plan » Agree to a follow-up;
• Discuss a safety plan involving interests/occupations, significant people, and available support.
  • Connect people at risk to mental and physical healthcare » Offer contact details of support services;
  • Offer individual and group-based supportive interventions;
  • Offer opportunities that bring people together;
  • Promote (re-)engagement in meaningful activities/occupations/roles.
• Take care of yourself

After the conversation, agreeing on an action plan with the individual is essential. This may involve setting specific steps to address their concerns and ensuring their safety. It's also important to arrange follow-up sessions to review the action plan and discuss a safety plan if required.

As time progresses, supporting the individual in connecting with healthcare services becomes vital. This may include facilitating access to individual or group interventions tailored to their needs. Additionally, offering opportunities for them to connect with others and reengage in meaningful activities can benefit their well-being and recovery.

Throughout this process, it's crucial to prioritize self-care. Taking time to rest, process emotions, and discuss feelings with a trusted person is essential for maintaining personal well-being. Adhering to internal policies and procedures is also important to ensure appropriate protocols are followed to effectively support the individual.

3. Suicide Risk – A Closer Look ^{(17, 18, 19, 20)}

• It should always be taken seriously.
• People experiencing suicidal ideation may find it difficult to access appropriate services.
• Engagement of the person is crucial.
• Asking direct questions about suicide does not prompt a person to start to think about harming themselves » Questioning about suicide both facilitates and develops engagement.

Conversations about suicide demand sensitivity and seriousness. Engaging with individuals experiencing suicidal thoughts is crucial, considering the challenges they may face in accessing support. Despite concerns, research indicates that discussing suicide directly does not escalate the risk of suicidal ideation. Thus, approaching the topic directly and with compassion is essential, ensuring the person feels understood and supported in their struggles.

Approaching discussions about suicide with empathy and understanding is paramount. Beginning with statements acknowledging the commonality of dark thoughts during periods of struggle can help create a supportive atmosphere. Seeking permission before delving deeper into the conversation empowers the individual and respects their autonomy.

Once permission is granted, gently probing about the nature of their thoughts allows for a better understanding of their experiences. Encouraging them to share specific examples can provide clarity. When discussing suicidal ideation, it's crucial to frame questions sensitively, ensuring clarity while maintaining compassion. Similarly, with children, questions should be adapted to their comprehension level, focusing on feelings of being a burden or thoughts of self-harm to gain insights into their emotional well-being.

When addressing the presence of suicidal thoughts, it's crucial to delve deeper to understand the severity and potential risk. Asking about the existence of a plan, including specifics about when and where the individual envisions taking their life, can provide valuable insights. Inquiring about any preparations made or means available for carrying out the plan is essential for risk assessment.

Equally important is understanding what factors currently prevent the individual from acting on these thoughts, as these protective factors can be leveraged to instill hope and support resilience. Additionally, exploring any substance misuse, such as alcohol or drugs, can help assess and mitigate risk, as these factors can exacerbate suicidal ideation.

Taking into account any history of previous suicide attempts or self-harm behavior is crucial, as it indicates an increased risk. It's important to reassure the individual that experiencing these thoughts does not equate to madness and that coping strategies and support are available. Following the conversation, appropriate action should be taken based on the level of risk, whether that involves liaising with emergency services in cases of imminent danger or agreeing on an action plan for ongoing support and intervention.

Keep in Mind ^{(18, 20)}

When discussing suicide or addressing suicidal thoughts, it's important to avoid certain behaviors and language that could be harmful. Firstly, it's crucial not to shy away from using the word "suicide." Openly acknowledging and discussing suicide can foster a more supportive and understanding conversation.

Additionally, refrain from using guilt-inducing or threatening language, such as suggesting that one's actions would ruin others' lives if they died by suicide. Such statements can exacerbate feelings of shame and may further isolate the individual.

Avoid dismissing the person's thoughts as mere attention-seeking or cries for help. Instead, take their feelings seriously and provide empathetic support and understanding.

Expressions like "Why didn't you tell me?" can invalidate and place undue pressure on the individual. Instead, focus on offering support and assistance without judgment.

Lastly, refrain from offering false reassurances or minimizing the severity of the situation. Acknowledge the uncertainty and emphasize the importance of seeking help and support from qualified professionals.

OT Intervention for Suicide (2, 6, 17, 31)

• Prevention – OTPs reduce factors that contribute to suicide
  • E.g., Working with populations at risk; enhancing protective factors (re-engagement in occupations)
• Intervention – OTPs increase the safety of people with negative thoughts
  • E.g., Offering immediate attention, guiding to proper services
• Postvention – OTPs support people who attempted suicide or who lost someone by suicide
  • E.g., Re-engagement in meaningful roles/occupations

Occupational therapists (OTs) play a crucial role in supporting various populations at increased risk of suicide. Through a preventive approach, OTs can identify risk factors and work to mitigate them while enhancing protective factors for individuals experiencing suicidal thoughts. This involves being professional couriers and facilitating open conversations about mental health concerns. Additionally, OTs can assist individuals in developing safety plans and provide information about local services for ongoing support.

In postvention efforts, OTs can support individuals who have attempted suicide or those who have lost someone to suicide. This support may involve helping them reintegrate into meaningful roles and occupations, fostering a sense of purpose and connection, and providing holistic care to promote overall well-being.

Case Studies

Let's move on to a few other case studies.

Case Study #6

• Chris is 2 years old and has been attending OT for 3 months. Mother always drops off and collects the child, however, this week an unknown person has been dropping off. You’ve noticed that Chris has been unsettled and that mum doesn’t chat so much at collection time.
• Who would you talk to and what questions you could ask?

In this scenario, there are several concerning factors: Chris appears unsettled, there has been a change in the mother's behavior, and an unknown person has been dropping him off at OT sessions. To address these concerns, speaking with the mother and the unknown person would be important.

When talking to the mother, questions could include inquiring about any recent changes at home, asking how Chris has been behaving outside of OT sessions, and expressing observations about his unsettled demeanor. Additionally, confirming the identity and relationship of the unknown person would be crucial.

When speaking to the unknown person, introducing oneself and politely inquiring about their relationship with Chris would be appropriate. This conversation could provide valuable information about the individual's role in Chris's life and whether they have been authorized to drop him off at OT sessions.

Continued observation of Chris's behavior and interactions can also provide insight into ongoing concerns and help inform the next steps in addressing the situation.

Case Study #7

• ‘I feel like I'm in a constant battle with myself everyday. I look in the mirror, and I absolutely despise what I see. I’m more accepting of people doing me dirty because no one could ever hate me more than I hate myself. It’s horrible, and I would not wish it on anyone! I just wanna wake up and be happy with who I am, physically and mentally.’
• What catches your attention in this statement?

The email from the client highlights several concerning points and some positive aspects. 

Firstly, the fact that the client is reaching out and sharing their feelings is a positive sign. It shows that they are willing to open up and seek support, which can be protective in addressing their struggles.

However, the language used in the email, particularly the statement "I absolutely despise what I see" and feeling more accepting of mistreatment from others due to self-hatred, raises concerns about the client's self-esteem and mental well-being. It suggests that they may be experiencing significant distress and negative self-perception, which could impact their overall mental health and quality of life.

Additionally, the client's desire to wake up and be happy with themselves physically and mentally indicates a strong motivation for improvement and a willingness to work on their well-being.

In responding to the email, it's essential to acknowledge the client's feelings and express empathy for their struggles. Offering support and encouraging them to explore further resources and options for assistance can help them take steps towards achieving their goal of happiness and self-acceptance.

Case Study #8

• A 9-year-old girl you work with tells you she will spend the summer at her grandparents’ home in Somalia. She talks about a big celebration that will take place.
• What would you do?
• If you want to know more about Female Genital Mutilation: https://endfgmnetwork.org/

The situation described raises concerns about the possibility of the nine-year-old girl being at risk of female genital mutilation (FGM), particularly if she is planning to spend the summer in Somalia, where FGM prevalence is high. Given the cultural and social factors associated with FGM, it's crucial to approach the situation sensitively and tactfully.

As an occupational therapist, it's essential to prioritize the safety and well-being of the child. One approach could involve engaging in a conversation with the girl's family to gather more information about their cultural beliefs and practices, particularly regarding FGM. Questions could be asked to understand the family's perspective on traditions, celebrations, and values regarding FGM.

It's important to approach the discussion with cultural sensitivity and without judgment, recognizing that FGM is deeply rooted in cultural norms and beliefs. Educating the family about the potential physical and psychological harms of FGM, as well as the legal implications in countries where it is prohibited, may be necessary.

Additionally, connecting the family with resources and support services that can provide further education, counseling, and assistance in navigating cultural and legal complexities related to FGM is crucial. Ultimately, the goal is to ensure the safety and well-being of the child while respecting the cultural context in which the family operates.

Case Study #9

• You start working with a teenager, born female, who has begun identifying themselves as male. They have been diagnosed with ASD. They are homeschooled, as a consequence of the bullying they experienced while in school. They shared with you their wish to change their gender, and their frustration about the waiting times, adding that ‘half of the people waiting for an appointment at the Gender Clinic kill themselves.’
• How would you approach?

In approaching the teenager in this case study, it's crucial to consider the various risk factors at play, including age, gender identity concerns, frustration with service waiting times, and the diagnosis of autism spectrum disorder (ASD). The history of bullying victimization and isolation through homeschooling further complicates the situation and underscores the need for a sensitive and comprehensive approach.

Given the vulnerabilities associated with ASD, such as difficulty in seeking help and rigid thought patterns, it's important to approach the topic of suicide with caution and sensitivity. Instead of directly asking about suicidal thoughts, it may be more appropriate to first assess the teenager's current level of functioning and well-being. This can involve exploring their daily activities, sleeping patterns, and personal care routines to gain insight into their mental and emotional state.

Building rapport and trust with the teenager is essential, creating a safe space for open communication. Using empathetic and nonjudgmental language, such as acknowledging their frustration with waiting times and validating their feelings, can help foster a supportive environment.

Asking open-ended questions about their gender identity journey and their experiences with bullying can encourage the teenager to share their thoughts and feelings more openly. It's important to listen actively and validate their experiences while offering reassurance and empathy.

Providing psychoeducation about suicide risk factors and protective factors, tailored to their level of understanding, can empower teenagers to recognize warning signs and seek help when needed. Additionally, connecting them with appropriate mental health resources and support services, including those specialized in gender identity issues and autism, is essential for addressing their unique needs and promoting their well-being.

Case Study #10

• You are working with an adult who needs a carer to help them in their day-to-day life. They tell you:
  • ‘I don’t like my carer anymore.’
• What steps could you take?

Finally, our last case study. You are working with an adult who needs a carer to help them in their day to day life. They tell you I don't like my carer anymore. What steps could you take? Remember what you already know about a client, what are their circumstances? Try to understand who is the carer, what has happened for the client to feel like that, what they would like to happen in these regards, and how you can help them.

Summary

Today, we delved into clinical risk, encompassing anything that could lead to harm. We discussed various types of risk, including risk to self, such as self-harm behavior, risk to others, including aggression, and risk from others, which can involve different forms of abuse.

We emphasized the importance of maintaining professional curiosity, which involves looking, listening, and asking questions to better understand a client's situation. Being open-minded and attentive to unusual statements is crucial in identifying potential risks.

A significant focus was placed on suicide awareness and prevention. We explored how anyone can be at risk of suicide and discussed the importance of recognizing conversational, behavioral, and emotional signs. Additionally, we highlighted the role we can play in making a difference through intervention and support. As we move forward, let's apply these principles to our treatments.

Remember, be respectfully nosy. Thanks for attending.

Exam Poll

1) A barrier to curiosity can be...

A. Structural

B. Relational

C. Personal

D. All of the above 

The answer is D, as they are all barriers to professional curiosity. 

2) What is an example of a risk to others?

A. Self-harm

B. Aggression   

C. Suicide ideation

D. Self-neglect

Today, we have spoken about risk to self, risk to others, and risk from others. For a risk to others, the correct answer is aggression.

3) Which is a TRUE statement about suicide?

A. People of all genders, ages, and ethnicities can be at risk for suicide.   

B. It is ok to say committed suicide.

C. Suicide is an unintentional act.

D. Suicide is not a self-inflicted death.

People of all ages, genders, and ethnicities can be at risk for suicide, so A is the correct answer.

4) What is a behavioral sign of suicide?

A. Disengagement from services

B. Loss of interest in personal hygiene

C. Uncharacteristic risk-taking

D. All of the above

All of the above are behavioral signs of suicide (Answer D).

5) Which is not a component of being professionally curious?

A. Looking

B. Telling   

C. Listening

D. Asking

The correct answer is B. We are not here to tell them anything or to make assumptions.

References

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