Presented Association For Academic Psychiatry Oct. 16-19, 2013

After the Violence

At

Virginia Tech, Aurora & Newtown:

Violence Prevention Program

for

Psychiatric Outpatient Departments

(Online Supplementary Materials Only)

Robert E. Feinstein, M.D.

University of Colorado School of Medicine

Professor of Psychiatry

Vice Chair for Education Quality & Safety

University of Colorado Hospital Psychiatry Outpatient Department

Practice Director-Robert E. Feinstein, M.D.

(303) 815-6934

Violence Prevention Program

for

Psychiatric Outpatient Departments

The 8 voluntary modules in the Violence Prevention Program include:

  1. Situational Awareness/ Creating a Safe Environment
  2. Violence De-escalation Training
  1. Violence Risk Assessment Training and Documentation Tools
  1. Violence Safety Discharge Planning Checklist
  2. Legal Issues and Violence: Tarasoff, Mental Health Certifications, Confidentiality
  1. Shots Fired on Campusvideo/discussion:
  2. If possible, attend a live viewing with a Police officer and Faculty member;Video may be obtained from the Center of Personal Protection and Safety: shots-fired-on-campus57
  1. 2011 Violence Threat Simulation Video- Watch our 10 min. video of the 2011 Violence Threat Simulation Exercise. The video is designed to help one decide if he/she wants to participate in an upcoming live simulation exercise (available from the author).
  1. Violence Threat Simulation Exercise

Experiential in nature, this 4 hour simulated experience is designed to help prepare staff forwhat to do in the event of a threat, physical act of violence, or shooting.

In addition, all staff can voluntarily obtain additional violence prevention training by attending courses, if available at your institution:

1) Management of Aggressive Behavior

2) Personal Safety and Crime Prevention Course

3) Crisis Prevention Institute@

Epidemiology of Violence

  • Intimate Partner Violence (IPV) in the U.S., 20091
  • 1 in 4 women & 1 in 7 men experienced severe physical IPV
  • Sexual Violence in the U.S., 20091
  • 1 in 4 women & 1 in 71 men raped in their lifetime
  • 1 in 6 women & 1 in 19 men stalked in their lifetime
  • LGBT Middle & High School Violence ages 13-21 (7,000 students surveyed), 2009
  • 8 out of 10 LGBT students verbally harassed
  • 4 out of 10 physically harassed
  • 6 out of 10 felt unsafe
  • 1 out of 5 physically assaulted
  • Elder Maltreatment
  • Data from 5,777 respondents
  • 1 year prevalence - 4.6% for emotional abuse; 1.6% for physical abuse; 0.6% for sexual abuse; 5.1% for potential neglect; & 5.2% for current financial abuse by a family member
  • 1 in 10 respondents reported emotional, physical, or sexual mistreatment or potential neglect in the past year
  • Most consistent correlates of mistreatment across abuse types were low social support & previous traumatic event exposure
  • Child Maltreatment, 2011
  • 676,000 children abused & 1,545 child abuse deaths
  • Youth Homicides, 2010
  • 4,828 deaths: 2nd leading cause of death for ages 10-24 (86% male; 14% female)
  • School Violence, 2011 (grades 9-12)
  • 12% in a physical fight/year
  • 5.9% didn’t go to school in preceding 30 days for fear of violence
  • 5.4% carried a weapon (gun, knife, club) once in preceding 30 days
  • 7.4% injured by a weapon once or more in last 12 months
  • Patient & Visitor Violence (PVV) in General Hospital3
  • Patients more violent than visitors
  • 9%-25% staff experienced verbal aggression each year
  • 5%-21% physicians assaulted each year
  • 100% Nurses and 24-57% physicians experienced aggression/violence from patients each year
  • 33% of psychiatrists assaulted at-least once each lifetime
  • 72%-96% psychiatric residents verbally threatened
  • 35%-56% psychiatric residents physically assaulted
  • Mass Violence Possibly Attributed to Patients with Psychiatric Illness
  • Columbine, 1999; Virginia Tech, 2007; Fort Hood, 2009; Tucson (involving Gabby Giffords, 2011; Aurora, 2012; Sandy Hook, 2012
  • .3% risk of patients with schizophreniahaving homicidal hallucinations or delusions, or substance abusersshow a slight increase of violence compared to general population; the risk for patients with schizophrenia who commit homicide is most mediated by co-morbid substance use
  • More common – people with severe mental illnesses, schizophrenia, bipolar disorder or psychosis - 2.5x more likely to be attacked, raped or mugged than general population

References

  1. Child maltreatment CDC
  2. Hahn S, Hantikainen V, Needham I, Kok G, Dassen T, Halfens RJ.Patient and visitor violence in the general hospital, occurrence, staff interventions and consequences: a cross-sectional survey.J Adv Nurs. 2012 Dec;68(12):2685-99.
  3. National Intimate Partner and Sexual Violence Survey. Center for Disease Control (CDC) 2009.
  4. LGBT Violence
  5. Youth Violence National Center for Injury Prevention and Control (CDC) 2011

Behavioral Phases of Violence
Phase / Observed Patient Behavior / Suggested Intervention
Quiet/Calm Phase / Relaxed, alert, fully conscious, good self-care normal
social interactions / Observe all patients at a distance for 30 sec.
Psychomotor-Phase Anxiety/Agitation
(Non-aggressive and non-verbal with
some violence risk)
Mild approach-avoidance behaviors / Physical movement
(e.g. tapping feet or restless)
Psychic agitation
(e.g. patient describes anxiety or confusion when asked)
Approach-avoidance behavior (e.g. patient approaches staff with a vigilant or paranoid manner; then walks away) / Express empathy, support; make non-judgmental, non-confrontational inquires or statements (“How can I help?”)
Keep a relaxed body stance, hands visible, good eye contact. Sit/stand at 45angle topatient
a) Set expectations: when patient will be seen; how long b) Validate patient’s experience.
c) Understand patient’s current situation
d) Offer food/fluids, blanket if appropriate
Medications:
Atypical antipsychotic (e.g. olanzapine etc. for psychosis; lorazepam forand anxiety or alcohol withdrawal)
Early Verbal Phase
Mild verbal Aggression
(Moderate risk) / Expression of
annoyance or anger / Use LEAP
(Listen, Empathize, Affirm, Partner)
Listen:
Ask what’s happened
“Tell me about it.”
Empathize:
Describe the person’s feeling “You look upset or angry.”
Affirm/Validate:
“I’m sorry this happened;
I’m sorry you feel this way”
Partner
d) Ask how you can help
e) Suggest a solution
f) Thank patient for telling you how he/she feels
Late Verbal Phase
High Verbal Aggression
(Higher risk) / Arguing, questioning authority; insistent, defensive, yelling, or cursing;increase of approach–avoidance behaviors / Use non-threating, directive, commanding, calm & firm statements;use few words
(e.g. “Sit down! Calm down!)
Can use counter-projective statements (e.g. describe patient’s feelings & how they’re directed toward others not present)
Maintain a safe distance of 1.5 leg lengths to avoid getting hit; Sit/stand at 45 angle to avoid squaring off or being hit
Call security prn
Violent patients may need a time out; may need to end the interview
Offer food, cool fluidsblanket, as appropriate
Voluntary medications (same as psychomotor agitation)
Violent Phase
Physical Aggression
(Highest risk) / Aggressive Action
(e.g. throwing things) or violence / Use a show of force with staff
Use security/Police personnel
Use involuntary medications
(as above in psychomotor agitation)
Seclusion or physical restraints prn
Post-Violence Phase / Patient may fear punishment or retaliation of feeling guilty or ashamed / Reassure patient that there will be no punishment
Review alternative coping styles to prevent future episodes

YudofskySC, Silver JM, Jackson W, et al. The Overt Aggression Scale for the objective rating of verbal and physical aggression. Am J of Psychiatry 1986;143:35-39.

Questions for Interviewing Violent Patients

  • What was your most recent act of aggression or violence?
  • What were the precipitants or stressors for this episode?
  • How severe were the actions or violence?
  • What access & ways do you have to hurt others (guns, other weapons, etc.)?
  • Are substances involved when you become violent?
  • At what age did violent acts begin for you?
  • How frequently did those acts occur?
  • What are the common precipitants surrounding the acts?
  • Please describe any recurring pattern of escalation preceding or after the violence.
  • Have any violent actions resulted in arrests, legal actions, or incarceration?
  • Has there been a history of recklessness or other impulsivity?
  • What medical or psychiatric diagnoses do you have (associated with violence)?
  • Describe any family history of violence, child or elder abuse, or gang involvement.
  • How do you usually deal with stress?
  • Do you drink or use drugs when stressed?
  • Do you blame others for their problems?
  • Do you stop taking your medications when you’re feeling stressed?
  • Do you tend to think the worst will happen?
  • How do you tolerate psychological pain?
  • What has helped to tolerate stressful situations in the past?
  • What do you do to cope?
  • To ask for help, do you seek contact with family, friends, professionals, or programs?

Violence Risk Assessment Case:

Patient Role-Play

When role-playing this patient, please follow guidelines below.

Do not offer any info unless specifically requested (give reluctantly).

Patient Description

Your name: Joseph Perez. 43 yr. old immigrant from Cuba who speaks some English.

Brought in by police due to standing in front of a homeless shelter harassing those passing by. Asking for food, money & help; you were trying to buy alcohol.

Episodically without any stimuli you say, “Jesus wants me to kill.”

(If asked about saying, “Jesus wants me to kill” – act confused; don’t really acknowledge this… just get quiet and withdraw).

Act generally suspicious of others; often paranoid & psychotic; you like to drink alcohol.

Came to the U.S. via Miami from Cuba. In the U.S., originally staying with a 2ndcousin in Miami. However, when you couldn’t find a job or pay the rent,you became homeless and headed north. It took you 3 months to get to a northern city. During that time you stayed in motels, lived on the streets, in shelters, and you walked and hitched north.

Yesterday you stayed in a shelter for 1 night; during the day you were outside the shelter on the street. Because you were making such a commotion outside the shelter, a caseworker at the shelter called the police.

You were brought to the ER in handcuffs; given medications; after a single dose… the handcuffs were removed. Thereafter you’ve been mostly calm…occasionally threatening others with, “Jesus wants me to kill.” You are reserved, speakingonly with encouragement.

Only if specifically asked…. should you give these additional details:

1)You recently lived for 3 months in a nearby state

2)You live in an SRO and worked at odd jobs

3)Your landlord recently kicked you out 1 week ago

4)You have mild high blood pressure

5)You practice Santeria; a religion that is a mix of Catholic and African traditions

6)You have no family or friends

Violence Risk Assessment: Clinician Info & Tasks

Here is the only information you know about the patient.

Male in his 40s, named Joseph Perez.

Picked up by the police because he was harassing people on the street in front of a shelter. He stayed in the shelter for 1 night. Smells of alcohol. Police report tells you he was” drunk and crazy” pulling at people’s clothes, demanding money. He was somewhat incoherent, but also randomly yelling, “Jesus wants me to kill.”

Speaks primarily Spanish, but his English is adequate.

The police bring him into the ER in handcuffs and he goes into the holding area. Given 1 dose of medication; becomes calm and is released from handcuffs.

You are the 1st mental health professional to interview him. He is calm and you greet him in the interview room. Your job:

1)Interview and assess the patient

2)Formulate the crisis

3)Assess clinical violence risks

4)Assess the patient’s coping style

5)Screen for medical & neurological illness

6)Assess reality testing & defenses

7)Decide on the next step in your violence prevention treatment plan

Estimating Violence Risk
{Note: For best estimates of Violence Risks use both
1) Clinical History; 2) Risk Assessment Tools}
CLINICAL CORRELATES / EXAMPLES
History / Criminal record; childhood abuse/neglect; history of suicide attempts or self-mutilation; previous violence (e.g. Intimate Partner Violence IPV, Elder Abuse, Child Abuse) and/or other family violence
Age & Gender / Young (13-25 yrs. old)
Male
Psychiatric Factors / Active symptoms of psychiatric disorders (e.g. command auditory hallucinations; paranoid delusions; psychotic disorganization of thought, excitability)
Combination of serious mental illness and substance abuse
Personality disorders
Substance-related disorders, such as intoxication and/or withdrawal (IMPORTANT: Chronic alcoholism is more predictive of violence than immediate alcohol use; the greater the number of comorbid psychiatric disorders, the greater the rate of violence.)
Emotional Factors / Acting out behavior
Angry or rage full affects
Emotional lability
Irritability and/or impulsivity
Poor frustration tolerance
Limited/poor social supports
Social Factors / Low socio-economic status
Medication non-compliance
Delirium (e.g., HIV/acquired immune-deficiency syndrome)
Neuro-biologic Factors / Mental retardation
Neurologic diseases
Seizures; structural brain abnormalities

Violence & Suicide Assessment Scale (VASAScale)

Copyright 1986 Robert Feinstein & Robert Plutchik

Comprehensive Psychiatry Vol. 31, No 4 (July/August), 1990: pp. 337 – 343

Historical Clinical Risk (HCR-20)

Douglas K, Ogloff J, Nicholls T, et al. Assessing the risk for violence among psychiatric patients: HCR-20 violence risk assessment scheme and the psychopathy checklist: screening version. Journal of Consulting and Clinical Psychology 1999; 67:917-930.

Violence Prevention Safety Discharge Plan

(Write Down Your Violence Safety Discharge Plan)

Violence Prevention Safety Discharge Plan

Checklist

(To Be Reviewed Upon Discharge & 1 Week After Discharge)

☐Make sure the patient’s immediate environment is safe, without weapons or other

means to hurt others (e.g. bombs, etc.)

☐Review all current or new stressors expected at discharge; then 1 week later

☐Review early warning signs of increasing risk of violence (e.g. substance use,

isolation)

☐Review coping strategies the patient can use to diffuse their dangerous impulses

(e.g. relaxation techniques, exercise, distraction, etc.)

☐Using the ecological map, review all friends, family, etc. (and relevant contact info)

of people in the patient’s support network who can be called to help

☐Review the information on how to access and utilize a 24-hourcrisis hotline

☐Review use of medications to help control symptoms

☐Review need for follow-up psychotherapy or psychiatric programs to facilitate the

acquisition of new understanding, cognitive or interpersonal skills, or modification of

relationships

☐Review the names and contact info of specific mental health professionals or

programs (e.g. Alcoholic Anonymous) to be contacted for treatment and/or

psychotherapy

VIOLENCE PREVENTION SAFETY QUIZ 1

Instructions: Take no more than 10 min. to answer these questions. Make your response brief as ispossible.

Situational Awareness

1)When seeing patients in the outpatient setting (OPD), what is the first/easiest thing you can do to prevent violence?

2)Do you and all your rotating residents and faculty know their own office room numbers and locations? Why is this important?

3)Describe the set-up of your waiting room.

4)In your waiting room…for interviewing, do you also have several open, public, yet semi private spaces?

5)Do your office doors open into the room or out? Which is the safest way? Are they properly hung?

6)Do you have panic buttons in your outpatient department?

If yes… do you know how they work? Please describe.

7)Do you have a (PA) Public Address System?

If yes…how do you activate it?

8)Do you have a video surveillance system in your OPD?

If yes…do you know how to use it?

Do you know who is observing?

9)Does your OPD staff know where ALL the exits are located in your OPD?

Where do the exits lead you?

Stages of a Violent Episode

10) What are the 6 observable stages leading up to a violent episode?

Answer: 1) Observation; 2) Quiet phase; 3) psychomotor phase; 4) early verbal phase; 5) late verbal phase; 6) violent episode; 7) post-violence

11) What are the characteristics of the quiet phase?

12) What are the characteristics of the psychomotor agitated phase and how can

you intervene?

13) What are the characteristics of the early verbal phase and how do you intervene?

14) What 2 verbal intervention techniques can you use when a patient is loud, cursing,

threatening (in the late verbal phase) & about to lose control leading to an assault?

15) When do you ask for help if you have a feeling of potential violence?

Violence Risk Assessment

16) What is a Violence Risk Assessment?

17) Name One Violence Risk Assessment Tool.

18) Do you use a standardized Violence Safety Plan when releasing a patient?

19) What 4 important things should you document as part of your Violence Risk Assessment?

Legal Issues with Potentially Violent Patients

20) What are the Tarasoff Decisions?

21) What are the 2most important parts of the Tarasoff decisions?

22) Does your state have one, both, or neither of the Tarasoff (equivalent) obligations?

23) What is the general definition of imminent violence risk in your state? (Note: This is variable in different states).

24) What is the time frame for imminent violence risk?

25) What must/should you clinically do if violence risk is imminent? (Varies by state)

26) What are possible personal consequences to you if you fail to warn or protect?

27) What is your civil liability for overzealous warnings or protecting of others, or inaccurately predicting violence?

28) Can you be professionally censured or disciplined by a professional org. for causing harm to a person you warned or telling others of your violence prediction?

29) What are your state’s criteria for commitment, certification or mental health hold?

30) Who are the professionals in your state who may involuntarily commit a patient on a Mental Health Hold? How long does a Mental Health hold last?

31) In your state, after the initial Mental Health Hold, how long can a patient be held against their will?

32) What’s the next legal step after that time period?

Did you know the answers to all of these questions?

If yes… your environment is relatively safe.

If not…Make Your Environment Safer

Do a Safety Review &

Develop a Violence Prevention Program

VIOLENCE PREVENTION SAFETY QUIZ 2

Emergency Violence Prevention Preparedness

1)How do you reach the police/security in your outpatient setting? Do you want to contact the campus police or community police?

2)Does your OPD, hospital, university, etc. have a method for sending mass communications about emergency events? If yes, are you signed up?