Is this risk assessment adequate for a patient with preoccupation with a past relationship potentially undermining their current marriage?

Risk Assessment Inadequacy

This risk assessment is inadequate because it fails to systematically evaluate for intimate partner violence (IPV), which is a critical safety concern when marital conflict and instability are present, and it lacks structured assessment of suicide risk, homicide risk, and specific safety planning despite identifying relationship distress as the primary concern.

Critical Missing Elements

Absence of IPV Screening

The assessment identifies "marital conflict and instability" as a risk factor but does not document whether validated IPV screening was performed. 1 The CDC categorizes marital conflict and instability as a relationship-level risk factor for IPV, yet this assessment makes no mention of:

• Physical, sexual, or psychological harm within the current marriage 1
• Fear of partner or controlling behaviors 1
• Use of validated screening instruments such as HITS, HARK, STaT, or WAST, which have sensitivities ranging from 81-100% and specificities from 86-99% 1

The preoccupation with a past relationship combined with current marital distress creates a context where IPV risk assessment is clinically indicated, as marital difficulties are an established risk factor for violence. 1

Inadequate Suicide Risk Assessment

The assessment states "low indication of risk of harm to self" without documenting:

• Specific inquiry about suicidal ideation, intent, plan, or means 1
• Assessment of depression, anxiety, or substance abuse, which are associated with both marital distress and self-harm risk 1, 2
• History of prior suicide attempts or self-injurious behavior

Marital distress and relationship problems are associated with increased rates of depression, anxiety, and suicidal behavior. 1, 2 A conclusory statement about "low risk" without documented systematic inquiry is insufficient.

Inadequate Homicide/Violence Risk Assessment

The phrase "low indication of risk of harm to others" lacks:

• Specific questions about violent thoughts, fantasies, or plans toward the spouse or others 1
• History of violent behavior or legal involvement 3, 4
• Access to weapons 4
• Substance use patterns, which increase violence risk 1, 3

Additional Assessment Gaps

Contextual and Historical Factors Not Addressed

The assessment should document:

• Adverse childhood experiences in either partner, which predict marital violence 3
• History of dating violence or violence in prior relationships 3
• Attachment patterns (particularly avoidant attachment in husbands), which predict relationship dysfunction 5
• Chronic role strain and external stressors affecting the marriage 5
• Emotional intimacy levels, as lower intimacy predicts relationship problems 5

Quality of Life Impact Underestimated

The assessment minimizes potential morbidity by focusing only on "stability and intimacy" without addressing:

• Mental health consequences of unresolved relationship distress, including depression, anxiety, and substance abuse 1, 2
• Physical health impacts of chronic relationship stress 1
• Functional impairment in work, parenting, or social domains 6

Recommended Structured Approach

To make this assessment adequate, the clinician must:

1. Administer a validated IPV screening tool (HITS, HARK, or STaT) to both partners separately if possible 1

2. Conduct systematic suicide risk assessment including direct questions about ideation, intent, plan, means, prior attempts, and protective factors 1

3. Assess violence risk with specific questions about violent thoughts toward spouse, history of violence, weapon access, and substance use 3, 4

4. Document pre-marital and childhood risk factors including adverse childhood experiences, dating violence history, and prior relationship patterns 3

5. Evaluate current mental health status for depression, anxiety, substance use, and other psychiatric disorders 1, 2

6. Assess relationship functioning including emotional intimacy, conflict management patterns, and support provision/receipt 5, 6

Common Pitfalls to Avoid

• Assuming absence of physical violence means low risk: Psychological abuse and coercive control are forms of IPV that may not involve physical contact 1
• Accepting patient reassurance without structured inquiry: Many IPV victims do not spontaneously disclose due to fear, shame, or reprisal 1
• Failing to interview partners separately: Joint interviews may prevent disclosure of abuse 1
• Overlooking the link between marital distress and mental health morbidity: Relationship problems significantly impact depression, anxiety, and substance use 1, 2