Preventing the unpredicted: managing violence risk in mental health care.
ABSTRACT Using clinical judgment alone, mental health professionals cannot predict individual patient violence much more accurately than chance. Clinicians could improve their prediction of violence if they routinely used structured risk assessment instruments, but they don't; the use of such tools for screening is not currently the standard of care in the United States and is not commonly reimbursed by insurance. The author argues, however, that clinicians actually can predict and prevent violence if they consider their patients as a group from the perspective of public-health epidemiology. Optimizing treatment for all patients will help prevent violence by the few who pose a risk of violence, even when such patients are not identified in advance.
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ABSTRACT: Patients leaving forensic psychiatric settings on conditional discharge face the challenge of achieving successful community integration, which involves not re-offending, adjusting to the local community and building support networks. Aftercare and monitoring of patients by workers ostensibly assists with integration, but is often dominated by concerns about risks to the public. Risk is seen to emanate from individuals, with steps taken to ensure intensive monitoring and, if necessary, swift return to hospital. This article shows that workers and conditionally discharged patients have distinct views about risk in community living which are driven by contrasting values and priorities; and that some of these differences are associated with the provision of care itself. A discursive analysis of accounts, drawn from 59 interviews with patients and workers, demonstrates that fears about deviant status weigh most heavily for the individual leaving hospital. Aftercare, with its focus on intensive regular visits by nurses, social workers, police and voluntary agencies, works to ‘unmask’ the person to the wider community, setting them apart as needing supervision. Discharged patients express unease that this unmasking undermines their attempts to begin new lives. Their concern suggests that significant iatrogenic risk arises from aftercare. Workers are not indifferent to this issue, but are themselves subject to public safety imperatives which require surveillance and control of individuals deemed risky. Community integration has the potential to be an important mediator in future risk behaviours. However, managing intensive aftercare without allowing for its wider visibility may jeopardise its achievement.Health Risk & Society 08/2012; 14(5):465-482. · 1.13 Impact Factor
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ABSTRACT: Firearms injuries place a unique burden on America in terms of lives lost (31,000/year), disability (70,000 nonfatal injuries/year), and economic costs ($174 billion in 2010). The purpose of this study was to examine psychiatric residency directors' perceptions of firearm access issues of the mentally ill. In late Fall 2012 and early Spring of 2013, a three-wave mailing was used to survey the membership of the American Association of Directors of Psychiatric Residency Training (N = 129). Due to the homogenous small sample size descriptive statistics were calculated to describe the responses. A total of 72 (56 %) directors responded. Almost 1 in 4 (23.6 %) thought that access to firearms by the seriously mentally ill should not be prohibited. The majority (91.7 %) supported closing the background check loophole. The majority (54.2 %) also believed that singling out the mentally ill as a group of "banned purchasers" adds to the stigma of the mentally ill (54.2 %) but a plurality (44.4 %) did not believe reporting the mentally ill to authorities would result in the mentally ill avoiding treatment. The current method of reducing access by the mentally ill to firearms is perceived by psychiatric residency directors as ineffective and burdensome to the mentally ill.Journal of Community Health 04/2014; 39(2):322-326. · 1.28 Impact Factor
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ABSTRACT: OVERVIEW Mass murder, the killing of four or more victims at one location within one event, is a rare and catastrophic phenomenon. 1 The prevalence of firearms, media coverage, and increasing awareness of the subject has led to speculations about the influence of a western cultural script being played out. 2,3 In the case of mass murder, the play is an appalling tragedy in which the main themes are a wounded ego, revenge, and infamy. Western influences aside, mass killings are not new. News media tend to suggest that the era of mass public killings was ushered in by Charles Whitman atop the University of Texas at Austin tower, and thereafter became "a part of American life" in subsequent decades. 4 In contrast, research indicates that the news media Disclosures: Dr Knoll has nothing to disclose.