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VIOLENCE IN
CLINICAL
PSYCHIATRY
Proceedings of the 9th European Congress on
Patrick Callaghan - Nico Oud - Johan Håkon Bjørngaard
Henk Nijman - Tom Palmstierna - Joy Duxbury
Violence in Clinical Psychiatry
Design and production: DM Creatieve Communicatie. The Netherlands. www.dmcreatief.nl
Prof. Patrick Callaghan
Mr. Nico Oud, MNSc
Prof. Johan Håkon Bjørngaard
Prof. Henk Nijman
Prof. Tom Palmstierna
Prof. Joy Duxbury
Editors
Violence in Clinical Psychiatry
Proceedings of the
9th European Congress on
Violence in Clinical Psychiatry
22 – 24 October 2015
Crowne Plaza Copenhagen Towers
Ørestads Boulevard 114 – 118
DK-2300 Copenhagen S, Denmark
4
© 2015 Kavanah, Dwingeloo & Oud Consultancy, Amsterdam
Publisher KAVANAH
Eemster 2
7991 PP Dwingeloo
The Netherlands
info@kavanah.nl
www.kavanah.nl
Oud Consultancy & Conference Management
Hakfort 621
1102 LA Amsterdam
The Netherlands
Telephone: +31 20 409 0368
Telefax: +31 20 409 0550
conference.management@freeler.nl
www.oudconsultancy.nl
ISBN 978-90-574-0144-2
All Rights Reserved.
No part of this publication may be produced, stored in a retrieval system or
transmitted in any form or by any means, electronic, mechanical, photocopying,
recording, scanning or otherwise, without the permission in writing of the copyright
owner (Oud Consultancy & KAVANAH) and the concerned author.
5
Preface
Welcome to ‘Wonderful Copenhagen’. Denmark’s vibrant, friendly, multicultural
capital hosts the 9th European Congress in Violence in Clinical Psychiatry. This year’s
event is co-organised with the European Network for Training in the Management of
Aggression (ENTMA08) and the European Violence in Psychiatry Research Group
(EVIPRG); it is also a World Psychiatric Association (WPA) co-sponsored meeting.
This year’s Congress theme: ‘Advancing Knowledge; transforming practice’ showcases
the potential of research, education and practice innovations to transform the delivery
and organisation of psychiatric services to prevent, minimise and better manage violence
in clinical psychiatry. We are delighted to have attracted a host of international scholars,
academics, clinicians, managers, policy makers, those using psychiatric services, and
delegates.
Contemporary evidence-based health and social care prioritises the judicious use of
best available evidence, ethical care, shared decision-making with service users and
their representative agents, emphasises human aspects of care with strong service user
choice and preferences based upon sound interpersonal skills. This is evident in the
quality of presentations at this year’s Congress. They provide an invaluable resource to
commissioners of mental health and intellectual disability services, educators, and those
shaping national and international policies in violence in clinical psychiatry.
As usual the Congress takes an interdisciplinary approach encompassing a range of
themes relevant to violence research, education and practice. As usual the Congress
focusses on clinically relevant and practically useful interdisciplinary scientic and
practical knowledge with regard to interventions aimed at treating and reducing violent
behaviour of psychiatric patients, forensic patients and challenging behaviour in persons
with intellectually disability. For the rst time we will discuss through a “meeting of
minds” debate with service users how we can close the gap between the rhetoric of
evidence and the reality of everyday practice.
Once again we welcome some of the leading international scholars who are at the
forefront of thinking on violence in clinical psychiatry and beyond. Risk assessment
and prediction of violence remains a popular, yet challenging eld of research. Dr Jay
P Singh will examine international perspectives and share evidence on the current state
of the art in this area. Dr Singh (and other’s) recent work has challenged the scientic
reliance of ROC curve analysis and the AUC as the standard techniques to establish
reliable predictors of violence and anti-social behaviour.
6
The clinical outcome of risk assessment and prediction sometimes leads to involuntary
detention for those deemed at risk to themselves or others. Dr Soren Bredkjaer, Deputy
Director of Psychiatry in the Zealand region of Denmark will discuss his national work
addressing involuntary hospitalisation and treatment.
A practising clinical psychologist and academic professor in the North of England,
Professor John Taylor is a familiar presence at the Congress. This year we are delighted
he will present his recent advances using cognitive behavioural interventions in treating
anger and aggression in people with intellectual disabilities.
Towards the end of the last century, the American novelist Tom Wolfe predicted the 21st
Century would be the century of cognition. Increasingly the Congress has welcomed
the contribution of neuroscience to how neuro-cognitive systems inuence violence
and aggression. The task this year falls to Dr James Blair, Chief of the Unit on Affective
cognitive Neuroscience at the US National Institute of Mental Health. He will examine
the neuro-biology of antisocial behaviour/psychopathy in relation to violence.
Ultimately, the primary purpose of violence research, education and practice in clinical
psychiatry is the improvement of care and treatment to people using psychiatric
services. Dr Julie Repper, Director of Improving Recovery through Organisational
Change (ImRoC) in the UK is an international expert on recovery-focussed mental
health practice, a leading mental health researcher, and a long-time user of mental
health services. Dr Repper will provide a challenging and thought provoking service
user perspective on violence and mental health. She will also contribute to the Congress’
‘meeting of the minds’ debate.
Two presentations come from the Congress’ co-organisers. In the rst, Dr Tillman
Steinert a renowned researcher into violence in clinical psychiatry and a long standing
member of EVIPRG will present the latest research on violence in clinical psychiatry. In
the second, Dr Brodie Patterson, Chair of ENTMA08 will present recent advances into
education and training in the management of violence.
In addition to the outstanding keynote papers the Congress offers a rich selection of
concurrent sessions, symposia, poster presentations as well as a stimulating debate from
presenters in all continents. What better setting than Northern Europe’s premier capital
for three days debating contemporary issues in research, education and practice about
violence in clinical psychiatry. En varm velkomst til alle!
Professor Dr. Patrick Callaghan,
School of Health Sciences, University of Nottingham, UK
7
Supporting Organisations
The Congress organisation committee cordially thanks the following organisations for their
support:
• ENTMA08
• European Violence in Psychiatry Research Group (EViPRG)
• Altrecht Aventurijn
• CONNECTING, partnership for consult & training
• Karolinska Institute
• British Institute for Learning Disabilities (BILD)
• World Psychiatric Association (WPA)
Section on Art and Psychiatry
Section on Psychiatry and Intellectual Disability
Section on Stigma and Mental Illness
• St. Olavs Hospital, Trondheim University Hospital
• The University of Nottingham
• The Mandt System
• The Psycho-Fysical Consultants
• Kudding & Partners B.V.
• Friends Hospital
• National Institute for the Prevention of Workplace Violence, Inc
The Scientific Committee
Prof. Tom Palmstierna (Sweden) (chair)
Prof. Henk Nijman (Netherlands) (chair)
Prof. Johan Håkon Bjørngaard (Norway)(abstract review manager)
Prof. Patrick Callaghan (UK)(editor)
Prof. Seamus Cowman (Ireland)
Prof. Sabine Hahn (Switzerland)
Prof. Stål Bjørkly (Norway)
Prof. Tilman Steinert (Germany)
Prof. Richard Whittington (UK)
Prof. Dirk Richter (Switzerland)
Ass. Prof. Lars Kjellin (Sweden)
Dr. Mojca Dernovsek (Slovenia)
Dr. Brodie Paterson (UK)
Prof. Joy Duxbury (UK)
Dr. Denis Ryan (Ireland)
Dr. Mary E. Johnson (USA)
Dr. Roger Almvik (Norway)
Dr. Liselotte Pedersen (Denmark)
Dr. Marie Trešlová (Czech Republic)
Dr. Rok Tavcar (Slovenia)
Dr. Hulya Bilgin (Turkey)
Mr. Bart Thomas (Belgium)
8
The Organisation Committee
Henk Nijman (Netherlands) (chair)
Tom Palmstierna (Sweden) (chair)
Joy Duxbury (UK)(chair on behalf of the EViPRG)
Brodie Paterson (UK)(chair on behalf of ENTMA08)
Patrick Callaghan (UK) (main editor of the proceedings)
Johan Håkon Bjørngaard (Norway)(abstract review manager)
Nico Oud (Oud Consultancy – Congress Organiser)(Netherlands)
Local Organization Committee
Liselotte Pedersen (Denmark)
Henrik Møller
Bjarne Vejgaard
Ronald Vestergaard (ENTMA08 Representative)
Niels Knudsen
General scientific remark
Occasionally the congress organization receives queries – especially from academic
institutions – regarding the procedure for the selection of abstracts to be presented at
the congress. Each abstract is submitted for peer review to members of the International
Scientic Committee. Each abstract is anonymously adjudicated by at least three members
of the committee. Abstracts are evaluated according to the following criteria:
• relevance to the conference theme,
• interest to an international audience,
• scientic and/or professional merit,
• contribution to knowledge, practice, and policies, and
• clarity of the abstract
Following the evaluation of each submission, the Organization Committee assesses the merit
of each individual abstract and deliberates on the acceptance, the rejection or – occasionally –
on provisional acceptance pending amelioration of the abstract. On applying this procedure,
the Organization Committee endeavors to do justice to all submitters and to the Congress
participants, who are entitled to receive state of the art knowledge at the Congress.
In total we did receive 290 abstracts from 43 different countries worldwide, of which 44
(16%) were rejected, 30 (11%) were withdrawn mainly due to nancial reasons or not getting
funding in time, and 38 (14%) were not included in the program and the proceedings due to
not registering after all or not paying the fees in time. Together with the special workshops
and the keynotes in total 190 presentations from 30 different countries worldwide were
presented.
9
Content
Chapter 1 – Keynote speeches................................................................... 29
Chapter 2 – Special Debate: “Meetings of the Minds” ....................................... 47
Chapter 3 – Epidemiology and nature of violence............................................ 48
Chapter 4 – Role of Post-Traumatic Stress Disorder (PTSD) & violence.....................83
Chapter 5 – Trauma informed care & practice ................................................89
Chapter 6 – Assessment of risk, prevention & protective factors ........................... 96
Chapter 7 – Examples of humane safe & caring approaches in and reduction
of restrictive practices.............................................................166
Chapter 8 – Neurobiological approaches and pharmacological therapies ..............216
Chapter 9 – Application of new technology (media – social networks –
information technology – e-learning – virtual environment) ................223
Chapter 10 – Advances in psychological therapies ...........................................231
Chapter 11 – Service users and family perspectives..........................................245
Chapter 12 – Race, gender, cross-cultural & ethnicity perspectives.........................257
Chapter 13 – Ethical, human rights and legal perspectives..................................261
Chapter 14 – Sexual offending & violence .....................................................287
Chapter 15 – Specific populations forensic.....................................................295
Chapter 16 – Specific populations intellectually disabled ....................................321
Chapter 17 – Specific populations child & adolescent ........................................331
Chapter 18 – Specific populations elderly / dementia .......................................342
Chapter 19 – Training and education of interdisciplinary staff..............................344
Chapter 20 – Other related themes .............................................................402
Index of Names........................................................................................440
Index of Keywords ....................................................................................443
Announcement .........................................................................................447
Supporting Organisations............................................................................448
10
Content.....................................................................................................9
Chapter 1 – Keynote speeches ..........................................................29
Restraint Reduction. Remembering but not repeating. ...........................................29
Dr. Brody Paterson (UK)
Reduction of restraint use in Denmark – what have we learned?............................... 31
Søren Bredkjær (Denmark)
Medical Director, Psychiatry in Region Zealand
Coercive Treatment in Psychiatry: Ethical Aspects .................................................32
Prof. Tilman Steinert (Germany)
International Perspectives on Violence Risk Assessment..........................................35
Jay P. Singh, PhD
Coercion in Psychiatry: A User Perspective ......................................................... 40
Julie Repper RGN RMN Ba(Hons) MPhil PhD
Understanding and Treating Anger and Aggression in Adults with Intellectual
and Developmental Disabilities....................................................................... 41
Prof. John L. Taylor, Northumbria University and Northumberland, Tyne & Wear NHS
Trust, UK.
A cognitive neuroscience approach to violence ....................................................46
James Blair (USA)
Chapter 2 – Special Debate: “Meetings of the Minds” ....................47
Meeting of the minds: closing the gap between violence research, education
and practice .............................................................................................47
Chapter 3 – Epidemiology and nature of violence ...........................48
Patient and Visitor Violence in a South Indian hospital...........................................48
Mr. Peter Lepping (Wales)
The Nature of Violence: Strategies for Violence Prevention ......................................49
Sylvia McKnight (USA)
11
From Psychomotor Therapy for Psychiatric Patients to Suicide Prevention through
Adapted Physical Activity and Sports Participation ............................................... 57
Herman Van Coppenolle, Svetlana Belousova & Ejgil Jespersen (Belgium)
Prevalence and risk factors of violence by psychiatric acute inpatients:
A systematic review and meta-analysis.............................................................58
Giovanni de Girolamo, Laura Iozzino, Clarissa Ferrari, Matthew Large & Olav Nielssen
(Italy)
Observational study of aggression and violence and its subsequent coercive
measures on Indian psychiatric wards ..............................................................60
Bevinahalli N Raveesh, Tom Palmstierna, Vijay Danivas, Shivanna Punitharani,
Kundapur S Ashwini, Handithavalli Gowrishree & Peter Lepping (India)
Aggressive behavior in autism spectrum disorders preschool children with or
without Attention-Deficit/Hyperactivity Disorder ..................................................62
Chen Chen, Jianjun Ou & Weixiong Cai (China)
Which are the clinical characteristics of psychiatric patients with an history of
violence behavior? An in-depth assessment of a prospective cohort in Italy .................. 63
Giovanni DeGirolamo, Valentina Candini, Viola Bulgari, Laura Iozzino, Chiara Buizza,
Clarissa Ferrari, Paolo Maggi, De Francesco & Giuseppe Rossi (Italy)
The half halfway: reduction of seclusion in Dutch psychiatry between 2007
and 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Eric Noorthoorn, Yolande Voskes, Wim Janssen, Niels Mulder, R. van de Sande, A. Smit,
Henk Nijman, A. Hoogendoorn, A. Bousardt & Guy Widdershoven (Netherlands)
Violent Recidivism of Mentally Ill Offenders: A Long-term Follow-Up Study................... 68
Susanne Bengtson & Jens Lund (Denmark)
Predictors of violence among German forensic in-patients....................................... 69
Jan Querengässer, Sebastian Harttung, Jan Bulla, Klaus Hoffmann, Thomas Ross
(Germany)
Transforming clinical practice in the management of acute behavioral
disturbance in an Acute Psychiatric Unit ............................................................74
Vincent Drinkwater (Australia)
Use of restraint and open-area seclusion in Norwegian mental health services
for adults.................................................................................................75
Maria Knutzen, Martin Bjørnstad, Stål Bjørkly, Astrid Furre & Leiv Sandvik (Norway)
Aggression towards staff: trends from an intensive treatment program in the
Netherlands .............................................................................................77
Nienke Kool & Tony Bloemendaal (Netherlands)
Factors associated to repetitively assaultive psychiatric inpatients..............................78
Didier Camus, Valérie Moulin, & Mehdi Gholam Rezae (Switzerland)
12
Violence, crime, sexual behaviors and use of crack cocaine in a Brazilian
inpatient sample ........................................................................................ 80
Sandra Cristina Pillon, Alessandra Diehl, Manoel Antônio dos Santos, G Hussein Rassool
& Ronaldo Laranjeira (Brazil)
Factors influencing the Advance directive among psychiatric inpatients from
India: A prospective study.............................................................................81
Guru S Gowda, Eric Noorthoorn, Channaveerachari NaveenKumar, Philip Sharath,
Raveesh Benvinahalli Nanjegowda, Peter Lepping & Suresh Bada Math (India)
Chapter 4 – Role of Post-Traumatic Stress Disorder (PTSD)
& violence ...........................................................................................83
The effect of trauma focused treatment on violent risk: the integration of
theoretical perspectives and clinical practice ....................................................... 83
Ellen van den Broek & Renate Reker (Netherlands)
The Need for Specialized Support Services for Nurse Victims of Physical Assault
by Psychiatric Patients .................................................................................85
Lois Biggin Moylan, Marybeth McManus & Meritta Cullinan (USA)
Chapter 5 – Trauma informed care & practice .................................89
Dream experiences in patients who experienced the comatose state: a clinical-
qualitative approach...................................................................................89
Tatiane Maria Angelo Catharini, Thiago Calderan & Mário Eduardo Costa Pereira (Brazil)
Witnessing violence: What are the experiences of psychiatric nurses? ........................ 91
Dave Jeffery (UK) (Member of ENTMA)
Trauma Informed Teamwork: Understanding the Dynamics of the Trauma
Histories of Caregivers................................................................................. 92
Bob Bowen (USA)
Chapter 6 – Assessment of risk, prevention & protective factors ....96
Violence and aggression against staff in mental health work: Consequences and
effective management ................................................................................. 96
Brian Littlechild (UK)
13
From scale to scenario: Old method but new development in risk assessment
research? ...............................................................................................100
Stål Bjørkly (Norway)
Reducing violence by implementing BVC and SOAS-R in forensic clinical practice ..........101
Johan Christian Clasen, Liselotte Mattison, Kelly Nielsen, Katrine Christiansen & Liselotte
Pedersen (Denmark)
The use of the HCR-20 in Forensic Medium Security Units in Flanders:
Clinical value?..........................................................................................103
Inge Jeandarme, Claudia Pouls, Jan De Laender, T.I. Oei & Stefan Bogaerts (Belgium)
Brøset Violence Checklist: Risk Assessment of Violence in Psychiatric Care – From
Evidence to Everyday Practice .......................................................................104
Dorte Graulund Olsen & Sabina Renee Beldring (Denmark)
Violent Behavior and risk of recidivism of violence among patients living in
psychiatric residential facilities ......................................................................106
Giovanni de Girolamo (Italy)
What is the evidence for factors protective against violence in an intellectually
disabled population?..................................................................................108
Juliet Hounsome & Richard Whittington (UK)
Protective factors for violence risk in boys and girls: the SAPROF – Youth Version..........110
Michiel de Vries Robbé & Vivienne de Vogel (Netherlands)
Anger, Violent Fantasies, and Violent Behavior among Discharged Psychiatric
Patients..................................................................................................112
Raymond W. Novaco, University of California, USA
Michael Russell, Pennsylvania State University, USA
John Monahan, University of Virginia, USA
Anger, violent images and physical aggression among male forensic inpatients............114
Stine Bjerrum Moeller, University of Copenhagen
Matthias Gondan, Department of Psychology, University of Copenhagen
Raymond W. Novaco, University of California, Irvine
Young nurses and experiences of aggression: a qualitative content analysis ................118
Karin Anne Peter, MScN, RN, Prof. Dr. Sabine Hahn, PhD, CNS, RN, Applied Research
& Development in Nursing, Division of Health, Bern University of Applied Sciences,
Switzerland.
Introduction of a Conducted Electrical Weapon to Control Violence in a Hospital
Setting...................................................................................................122
Jeffrey Ho (USA)
Gender-Responsiveness in Corrections: Estimating Female Inmate Misconduct
Risk Using the Personality Assessment Inventory (PAI)...........................................123
Jonathan Sorensen, Megan Davidson & Thomas Reidy (USA)
14
Coercion decisions: Event sequences of aggression, seclusion and enforced
medication in a sample of admission and specialized treatment wards for adults
and the elderly.........................................................................................124
Marlies Snelleman-Van der Plas, Peter Lepping, Lia Verlinde, Willem Snelleman, Adriaan
Hoogendoorn, Henk van den Berg & Eric Noorthoorn (Netherlands)
Coercion decisions, event sequences of aggression, seclusion and enforced
medication before and after a policy change .....................................................126
Lia Verlinde, Eric Noorthoorn, Willem Snelleman, Marlies Snelleman-Van der Plas, Henk
van den Berg & Peter Lepping (Netherlands)
Interventions in a Finnish psychiatric admission ward after the assessment of
violence risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128
Jenni Kaunomäki, Markus Jokela, Raija Kontio, Tero Laiho, Eila Sailas & Nina Lindberg
(Finland)
Response Crisis Intervention Model for Conflict Management: Fidelity Scale in
Psychiatric Care........................................................................................130
Remko den Dulk, Eva Heijkants, Ishany Balder, Antonia Bauer, Eva Hoogstins, Steven
Nooter, Loubna Ouifak. & Elizabeth Wiese (Netherlands)
Staff’s attitudes towards aggression in psychiatry ...............................................135
Milou M. H. Mik, Ingrid L. Malan, Erik J. E. Janssen, Bas E. A. M. Kooiman, Roos E. D. X.
Middelkoop, Stefanie Poelman, Jeppe de Lange & Elizabeth Wiese (Netherlands)
Experiences with the Response Crisis Intervention Model for Conflict
Management: The Safety Team......................................................................139
Kyra L. J. Smeets, Nicole Ligthart, Ien Albers, Ibtissam Benali, Dorien de Hoop, Victoria
O’Callaghan, Lisa Rückwardt, Toon van Meel & Elizabeth Wiese (Netherlands)
Presenting GRIP®: a Grouped Risk-assessment Instrument for Psychiatry, for
aggression, suicide and fire setting.................................................................143
Cornelis Baas & Carla De Bruyn (Netherlands)
Understanding antisocial behaviors: Antisocial personality traits involving
sensation seeking and callousness..................................................................145
Saima Eman (UK)
Validation of the Novaco Anger Scale – Provocation Inventory (Danish) with
Non-Clinical, Clinical, and Offender Samples.....................................................146
Stine Bjerrum Moeller¹, Raymond W. Novaco²,
Vivian Heinola-Nielsen³, Tine Wøbbe³, and Helle Hougaard4
¹Psychiatric Center Capital Region, North of Zealand, Denmark
²University of California, Irvine, USA
³Psychiatric Center Capital Region, Sct. Hans, Denmark
4Psychiatric Center Capital Region, Ballerup, Denmark
Validity and Reliability of the Chinese Version on Perception of Aggression Scale
(POAS) in health care workers ......................................................................150
Wai Kit Wong & Wai Tong Chien (China)
15
Predictive validity of lipids for violence after discharge from an acute psychiatric
ward.....................................................................................................152
Bjørn Magne S Eriksen, Stål Bjørkly, Ann Paerden & John Olav Roaldset (Norway)
Nurses’ perception of factors contributing to patient aggression – findings from
Slovak mental health clinical areas .................................................................153
Martina Lepiešová, Jana Nemcová, Martina Tomagová, Ivana Bóriková, Juraj Čáp &
Catarína Žiakováína (Slovakia)
A review of the relationship between Emotional Intelligence and psychopathic
traits: is the EI construct a mediator between aggression and psychopathy? ................155
Maria Gutierrez-Cobo, Rosario Cabello & Pablo Fernandez-Berrocal (Spain)
Developing a psychiatric intensive care unit and effects observed on the
incidence of violence ..................................................................................157
Halldora Jonsdottir, Eyrun Thorstensen & Bryndis Berg (Iceland)
Reducing aggression among chronic psychiatric inpatients through nutritional
supplementation ......................................................................................158
A. Schat, A.A.M. Hubers, J.M. Geleijnse, O. van de Rest, W.B. van den Hout, J.P.A.M
Bogers, C. Mouton, A.M. van Hemert & E.J. Giltay (Netherlands)
Incidences of violence in psychiatric inpatient care as described by staff.....................160
Lars Kjellin, Susanna Törnqvist, Lars-Erik Warg & Veikko Pelto-Piri (Sweden)
Violence prevention and organizational values: Views from management and
staff in three types of psychiatric inpatient care .................................................162
Ulrika Hylén, Karin Engström, Veikko Pelto-Piri, Lars Kjellin & Lars-Erik Warg (Sweden)
Risk predictions of physical aggression in acute psychiatric wards: accuracy,
determination and suggested control interventions ..............................................164
Suna Uysa & Hulya Bilgin (Turkey)
Chapter 7 – Examples of humane safe & caring
approaches in and reduction of restrictive practices ......................166
How a 24/7 Single point of entry service (SPOE) can increase access to Mental
Health Services (MHS) ................................................................................166
Ian McLauchlan (New Zealand)
No coercion without care!............................................................................167
Minco Ruiter & Petra Schaftenaar (Netherlands)
Safety in MIND’: Cross-organizational training to improve patient safety in crisis
and restraint............................................................................................169
Natalie Hammond, Karen Wright & Ivan McGlen (UK)
16
Treatment of heavily disruptive patients: A Dutch model for complex care...................171
Elvira van Wirdum & Martijn Helmerhorst (Netherlands)
Reducing the use of restrictive practices in Forensic Psychiatry – a case study
illustration ..............................................................................................174
Liselotte Mattison, Kelly Nielsen & Katrine Christiansen (Denmark)
Professional behavior and attitudes to ‘get in control’...........................................175
Sophie de Valk & Petra Schaftenaar (Netherlands)
Music listening as anxiety management in intensive psychiatry ...............................177
Helle Nystrup Lund & Lars Rye Bertelsen (Denmark)
The Forensic Clinical Specialist Initiative: transforming practice by enhancing
skills in risk minimization.............................................................................178
Patrick Seal (Australia)
De-escalation processes in mental health settings – a co-operative inquiry project . . . . . . . . . 180
Lene Lauge Berring, Liselotte Pedersen & Niels Buus (Denmark)
Implementation of a Crisis Intervention Model in a psychiatric clinic: The
Response Method as an answer to reduce restraint and seclusion at Emergis
Zeeland over seven years ...........................................................................182
Loubna Ouifak (Netherlands)
Violence and Restraint reduction SPSP–Mental Health/East London Foundation
NHS Trust: Culture, Attitude, Data...................................................................184
Johnathan MacLennan, Andy Cruikshank & David Hall (UK)
Client participation 3.0 ...............................................................................186
Mauro Vittali & Renske De Jong (Netherlands)
Creating safety: Client centered care or unit centered care?....................................188
Isabelle Jarrin, Anne Marie Brown, Annette McDougall, Andrea Rosner & Bonita Fanzega
(Canada)
Emotion Regulation through Sensory – Gardening: Managing Aggression of
Adult Psychiatric Patients in an Inpatient Unit.....................................................190
Susan Rappaport, Leilanie Marie Ayala, Aimee Levine-Dickman, Nancy Wicks, Era Hawk,
Curtis Boelke, Anna Kurtz & Jennifer Alcaide (USA)
Restraint Reduction – What Works? – A review of the Literature and Research
Relating to the use of Restrictive Practices in Healthcare settings and how these
might be implemented in practice...................................................................192
Christopher Stirling & Colin Dale (UK)
Sensory rooms in acute psychiatric care: primary and secondary violence
prevention ..............................................................................................194
Anna Björkdahl (Sweden)
17
Implementing the Six Core Strategies (6CS) to reduce physical restraint in the
UK: The ‘REsTRAIN YOURSELF’ project .............................................................195
Joy Duxbury, Fiona Jones, John Baker, Mick McKeown, Richard Whittington, Gill
Thomson, Paul Greenwood & Soo Downe (UK)
Normalizing the Environment: The Appearance of the Emergency Department
Safe Rooms.............................................................................................197
Michael Polacek & Dana Hart (USA)
High and Intensive Care in Psychiatry: a validity study of the HIC-monitor ..................200
Laura van Melle, Yolande Voskes, Eric Noorthoorn, Roland van de Sande, Yolanda Nijssen,
Niels Mulder & Guy Widdershoven (Netherlands)
High and Intensive Care: a new vision on mental health care in Dutch psychiatry..........201
Yolande Voskes, Laura van Melle, Tom van Mierlo, Frits Bovenberg & Niels Mulder
(Netherlands
Extreme Coercion and recovery journeys in a high secure hospital: stories of
recalcitrance, resistance and cooperation .........................................................202
Mick McKeown, Mark Chandley, Fiona Jones, Karen Wright, Joy Duxbury & Paul Foy
(UK)
Co-productivity – a cross agency partnership for education and skills acquisition:
the TEAM course (‘Teaching Effective Aggression Management’)...............................204
Karen Wright, Iain Harbison & Tiffany Sinclair (UK)
Can implementing a Quiet Room reduce the use of mechanical restraints? ..................205
Stella Bonde, Lena Rasmussen & Lene Lauge Berring (Denmark)
1on1-support to reduce seclusion and to improve care .........................................207
Petra Schaftenaar & Minco Ruiter (Netherlands)
Setting the stage for a new approach to coercive interventions in Belgian Mental
Health Care.............................................................................................209
Frieda Matthys, Chris Bervoets (Belgium)
Introducing the Safewards-model in adolescent psychiatry of HUH in Finland ..............211
Anja Hottinen, Silva Autio, Jenny Herrala & Nina Lindberg (Finland)
A participatory approach to develop tools for post-seclusion and/or restraint
review. ..................................................................................................213
Marie-Hélène Goulet, Caroline Larue (Canada)
A sensory based approach to preventing violence in a closed ward – Project
‘New Paths’ ............................................................................................215
Roland Westerlund, Katarina Nenadovic, Karen Jurlander & Annick Francoise Parnas
(Denmark)
18
Chapter 8 – Neurobiological approaches and
pharmacological therapies ..............................................................216
Efficacy and safety of Medical Cannabis Oil (MCO) in aggression and agitation
due to Alzheimer’s dementia: an open label, add on, pilot study..............................216
Assaf Shelef1, Yoram Barak1, Uri Berger2, Diana Paleacu1, Shelly Tadger1, Igor Plopsky1
and Yehuda Baruch3,4
1 Abarbanel Mental Health Center, Bat-Yam,Israel and Sackler Faculty of medicine,
Tel-Aviv University, Tel-Aviv,Israel
2 Department of Psychology, Bar-Ilan University, Ramat-Gan , Israel
3 OneWorldCannabis Ltd.
4 Gertner institute for epidemiology and health Policy research
Chapter 9 – Application of new technology (media – social
networks – information technology – e-learning – virtual
environment) .....................................................................................223
Using Technology to Prevent Coercive Practices in Inpatient Mental Health
Setting: A Canadian Specialty Mental Health Setting Lens ......................................223
Ian Dawe, Sanaz Riahi, Philip Klassen & Ilan Fischler (Canada)
Co-Creating new tools for good practices in recovery and high secure healing
environments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .225
Erik Kuijpers & Alwin Verdonk (Netherlands)
Quantifying Violent Episodes on Psychiatric In-Patient Units: How to Collect
and Analyze High Frequency Problem Behaviors for Clinical Interventions by
Leveraging Electronic Medical Records.............................................................229
John Boronow, Barbara Charen, Jaqueline Williams-Porter, Christopher Borleis, Annie
Verghese & Josh Nohe (USA)
Chapter 10 – Advances in psychological therapies .......................231
Violence Reduction with Equine-Assisted Group Psychotherapy – A controlled
study in long term psychiatric inpatients...........................................................231
Jeffry Nurenberg & Steven Schleifer (USA)
19
Self-wise, Other-wise, Streetwise (SOS) training: a novel intervention to reduce
victimization in psychiatric patients with substance use disorders: a randomized
controlled trial..........................................................................................235
Marleen M de Waal1,2), Martijn J Kikkert1), Matthijs Blankers1,3), Jack JM Dekker1,4), Anna E
Goudriaan1,2)
1) Department of Research, Arkin Mental Health Care, Klaprozenweg 111, 1033 NN
Amsterdam, The Netherlands
2) Academic Medical Center, Department of Psychiatry, Amsterdam Institute for Addiction
Research, University of Amsterdam, Amsterdam, The Netherlands
3) Trimbos Institute, Da Costakade 45, 3521 VS Utrecht, The Netherlands
4) Vrije Universiteit Amsterdam, Department of Clinical Psychology, Amsterdam, The
Netherlands
Victimization in depressed patients: Prevalence rates and the description of an
intervention study .....................................................................................237
C. Christ, S.C. Meijwaard, M. Kikkert, D.J.F. van Schaik, R. Van, C.L.H. Bockting, J.J.M.
Dekker &
A.T.F. Beekman (Netherlands)
Anger Treatment for Forensic Patients: Stress Inoculation Module .............................240
Raymond W. Novaco, University of California, USA
John L. Taylor, Northumberland, Tyne & Wear NHS Trust & University of Northumbria, UK
Anger Treatment Therapist Training Level Effects with Forensic Intellectual
Disability Patients......................................................................................242
John L. Taylor, Northumberland, Tyne & Wear NHS Trust & University of Northumbria, UK
Raymond W. Novaco, University of California, USA
The Use of Cognitive Behavioral Therapy in Treating Patients with DSM–5
Intermittent Explosive Disorder ......................................................................243
Michael McCloskey, Alexander Hamilton, Alexander Puhalla, Lauren Uyeji, Anne Knorr &
Daniel Kulper (USA)
Is It More Than Just the Play? The Influence of Therapeutic Catharsis-Seeking,
Personality Differences, Self-Construal and Social Capital ......................................244
Hye Rim Lee, Eui Jun Jeong & Ju Woo Kim (South Korea)
Chapter 11 – Service users and family perspectives ...................... 245
“My daddy has an illness in his mind”, Children as next of kin................................245
Anne Kristine Bergem (Norway)
Subjective Perception of Coercion in Persons with Mental Disorder in India .................247
Bevinahalli N Raveesh, Peter Lepping, Soumithra Pathare & Joske Bunders (India)
20
Risk, Gain, Liability and Hope: Integrating and Training Family Members in the
Treatment Planning and Implementation Process When Aggression History is
Present ..................................................................................................249
Bob Bowen (USA)
Self-determination and the use of coercion and restraint – People with
intellectual disability ..................................................................................252
Kim Berge & Karl Elling Ellingsen (Norway)
Violence towards family caregivers by mentally ill relatives – results of a
German online survey ...............................................................................255
Christian Zechert, Beate Lisofsky & Caroline Trautmann (Germany)
Chapter 12 – Race, gender, cross-cultural & ethnicity
perspectives ...................................................................................... 257
Gender differences in victimization and the relation to personality disorders and
MID: Results from a multicenter study in forensic psychiatry ...................................257
Vivienne de Vogel & Anouk Bohle (Netherlands)
How Gender of Staff and Patient may Impact the Incidence and Management of
Aggression in Forensic Psychiatric Units ...........................................................260
Ms. Marie Gold (Canada)
Chapter 13 – Ethical, human rights and legal perspectives ...........261
Decision-making capacity ............................................................................261
Peter Lepping & Bevinahalli N Raveesh (UK)
Prevalence of decision-making capacity in psychiatric patients compared to
medical patients .......................................................................................262
Peter Lepping, Thushara Stanly & Jim Turner (UK)
Coercive Measures in a High Secure Hospital: Attitudes and Experiences of Staff
and Patients in England ..............................................................................263
Ada Hui (UK)
Coercive measures in cases of actual danger to others? Ethical aspects of the
current German debate on coercion in psychiatry ...............................................265
Jakov Gather & Jochen Vollmann (Germany)
21
Children’s rights versus parental rights in involuntary admission of minors to a
psychiatric unit for children and adolescents in Germany – new developments in
jurisdiction and legislation ...........................................................................266
Michael Bruenger (Germany)
Violence in media and aggressive behavior: the difficulties of establishing a
debate ..................................................................................................267
Maria Teresa Ferreira Côrtes (Brazil)
Coercive measures in the treatment of drug-dependent patients...............................268
Katrin Forstner / Mareike Wakolbinger / Karin Bruckmüller
Workplace Violence (WPV) – the Emergence and Jurisdiction of a Social Problem..........273
Soa Wikman (Sweden)
Getting it Right, Getting it Wrong: Ethical Tensions in Decisions Related to
Seclusion Use...........................................................................................275
Isabelle Jarrin & Marie Edwards (Canada)
Legislation and coercive methods in Psychiatric Clinic in Romania – a five years
follow-up study ........................................................................................277
Adriana Mihai, Paula Sarmasan, Alex Mihai, Elle Tifrea, Katalin Birtalan & Emese
Muresan (Romania)
Judicial reactions on violence in clinical psychiatry ..............................................278
J.M. (Joke) Harte a b & M.E. (Mirjam) van Leeuwen c
a The Netherlands Institute for the Study of Crime and Law Enforcement (NSCR),
Amsterdam, The Netherlands
b VU University, Department of Criminal Law and Criminology, Amsterdam, The
Netherlands
c University of Applied Sciences Inholland, program Nursing, Amsterdam, The Netherlands
Dealing with Psychiatric Patient Violence in Private Clinical Treatment –
Professional and Ethical Dilemmas..................................................................282
Suzana Roitman & Ronit Kigli (Israel)
How violence is imagined in psychiatry: a philosophicalper-spective on violence
andtrauma..............................................................................................283
Daniel Nicholls, School of Nursing & Midwifery, University of Western Sydney, Australia
Chapter 14 – Sexual offending & violence ..................................... 287
Does Psychological Treatment of Pedophiles’ work? A Meta-Analytic Review of
Treatment Outcome Studies ..........................................................................287
Pål Grøndahl, Cato Grønnerød & Jarna Soilevuo Grønnerød (Norway)
22
The compulsory notification of violence against women in Brazilian public
policies and academic production ..................................................................288
Mariana Pedrosa de Medeiros & Valeska Zanello (Brazil)
Impact of context on attributions of rape victim culpability: Are online dating
victims blamed more?.................................................................................292
Graham Tyson, Melanie Lucas, Paola Castillo (Australia)
Revenge and forgiveness after victimization: Differences between violent
offenders and male students from various educational settings................................293
Coby Gerlsma (Netherlands)
Chapter 15 – Specific populations forensic .....................................295
Forensic Assertive Community Treatment (ForACT): an essential integrated
cooperation with key-partners (illustrated by ForACT The movie)..............................295
Diana Polhuis, Rene Mooij, Harry van Putten & Jaap Keijzer (Netherlands)
‘Fight, Flight or Freeze’ – I’m fighting! The application of EMDR in a group based
violence reduction treatment programme..........................................................297
Rachel Worthington (UK)
Dissociation and Violence-Fools Venture Where Angels Fear To Tread........................298
Julian Gojer, Adam Ellis & Monik Kalla (Canada)
The role of (forensic mental health) nurses and group workers in the reduction of
violence and aggression..............................................................................299
Petra Schaftenaar (Netherlands)
Toxicology in Suicides and Homicide-Suicides ....................................................300
Carrie Carretta, Ann Burgess & Michael Welner (USA)
Risk management and reduce of recidivism through relational care in a forensic
psychiatric hospital....................................................................................301
Petra Schaftenaar & Ivo van Outheusden (Netherlands)
Development of the therapeutic relationship in music therapy with forensic
psychiatric inpatients – a mixed method case study .............................................302
Britta Frederiksen (Denmark)
ADHD & delinquency: double trouble?.............................................................304
Rosalind van der Lem & Marijn DuPrie (Netherlands)
Change management in juvenile forensic psychiatry aiming at the prevention of
violence and the improvement of treatment outcome ............................................306
Michael Bruenger (Germany)
23
Extensive Hostile Interpretation Bias Regarding Emotional Facial Expressions
among Forensic Psychiatric Outpatients ...........................................................308
Danique Smeijers, Mike Rinck, Erik Bulten, and Robbert-Jan Verkes (Netherlands)
The Early Recognition Method used to identify precursors of aggression in prisoner .......313
Frans Fluttert, Gunnar Eidhammer, Christine Friestad, Kari Yngvar Dale, Stål Bjørkly &
Åse-Bente Rustad (Netherlands)
Is fire-setting performed in adolescence associated with future diagnoses of
schizophrenia/schizoaffective disorder?...........................................................315
Annika Thomson, Jari Tiihonen, Jouko Miettunen, Matti Virkkunen & Nina Lindberg
(Finland)
The Forensic Patient in the Psychiatric Hospital – Dealing with Patient Violence
during Court Ordered Examination in a Psychiatric Department ..............................317
Ronit Kigli, Hilik Levkovich, Avigdor Mizrachi & Moshe Kotler (Israel)
Violence against psychiatric inpatients in forensic psychiatric hospital setting...............319
Mari Leskinen, Anssi Kuosmanen & Hannele Turunen (Finland
Chapter 16 – Specific populations intellectually disabled ..............321
From integrated diagnostics to integrated treatment: the results of the
cooperation between a treatment facility for people with intellectual disabilities
and a forensic ward ..................................................................................321
Diana Polhuis & Hans Kruikemeier (Netherlands)
Meeting the sexual identity needs of people with intellectual disabilities: could
this have a role in managing aggression?.........................................................324
Liz Tallentire, Trainee Clinical Psychologist, Lancaster University Doctorate in Clinical
Psychology, University of Lancaster, Lancaster, UK
Dr Ian Smith, Senior Clinical Tutor & Lecturer in Research Methods, Lancaster University
Doctorate in Clinical Psychology, University of Lancaster, Lancaster, UK
Dr Paul Withers, Head of Psychological Treatment Services, Calderstones Partnership
NHS Foundation Trust, Whalley, Clitheroe, Lancashire, UK
Sarah Morrow, Assistant Psychologist, Newhaven (Fieldhead Hospital), South West
Yorkshire NHS Foundation Trust, Wakeeld, UK
Characteristics of aggressive behavior in people with intellectual disabilities and
co-occurring psychopathology.......................................................................327
Kim van den Bogaard, Henk Nijman & Petri Embregts (Netherlands)
24
The relation between team climate, attitude towards external professionals
and attitude towards aggression of staff working with clients with intellectual
disabilities and aggressive behavior ...............................................................329
M.H. Knotter1.,2, G.J.J.M. Stams2, X.M.H. Moonen2.,3., & I.B. Wissink2.
1. De Twentse ZorgCentra, Den Alerdinck 2, 7608 CM Almelo, The Netherlands
2. University of Amsterdam, Nieuwe Prinsengracht 130, 1018 VZ Amsterdam, The
Netherlands
3. Hogeschool Zuyd, Nieuw Eyckholt 300, 6419 DJ Heerlen, The Netherlands.
Chapter 17 – Specific populations child & adolescent ................... 331
Prevalence of Physical Restraint in Psychiatric Treatment and Research Unit for
Ado-lescent Intensive Care (EVA) ....................................................................331
Janne Virta (Finland)
Healthcare support network to families involved in domestic violence against
children and adolescents in Brazil ..................................................................333
Diene Monique Carlos, Maria das Graças Bomm Carvalho Ferriani,
Elisabete Matallo Marchesini de Pádua, Lygia Maria Pereira da Silva &
Michelly Rodrigues Esteves (Brazil)
How to effectively reduce coercive measures in an inpatient unit of child &
adolescent psychiatry – a ten years’ overview of Pfalzinstitut C & A Psychiatry/
Klingenmuenster, Germany ..........................................................................337
Michael Bruenger (Germany)
The relationship between media violence exposure and aggressive behavior of
children and adolescents .............................................................................338
Maria Teresa Ferreira Côrtes (Brazil)
Psycho-pathology of victims and bullies in school violence ....................................339
Sun Mi Cho, Yun Mi Shin, Eun Ha Jung (Korea)
Associations among parental education, inhibitory control and aggressive
behavior in children...................................................................................340
Maria Gutierrez-Cobo, Rosario Cabello & Pablo Fernandez-Berrocal (Spain)
Different clinical courses of children exposed to a single incident of psychological
trauma: a 30-month prospective follow-up study ................................................341
Bung Nyun Kim & Soon-Beom Hong (South Korea)
25
Chapter 18 – Specific populations elderly / dementia .................. 342
Prevalence of violence and health personnel’s experience with violence from
elderly residents in nursing homes..................................................................342
Rita Helme (Norway)
Chapter 19 – Training and education of interdisciplinary staff .....344
The Interaction Skills Training Programs: Improving Cooperation through
Effective Interactions ..................................................................................344
Jan Boogaarts & Bas van Raaij (Netherlands)
Therapeutic communication provided by nurses in general hospital – common or rare? ..346
Marie Treslova & Jaroslav Pekara (Czech Republic)
Communication Skills Training for Healthcare Workers as a technique to reduce
patient perpetrated violence – A Randomized Controlled Trial .................................349
Maria Baby, Nicola Swain & Chris Gale (New Zealand)
Using the Rock & Water method in the treatment of forensic psychiatric patients
and in educating staff.................................................................................355
Erik Timmerman & Ernst Janzen (Netherlands)
Van der Hoeven Kliniek, Utrecht, The Netherlands
Maintenance of the staff’s conflict preventive competencies ....................................359
Line Juul Christensen & Nethe Plenge (Denmark)
Can physical activities reduce the use of coercive measures? ..................................361
Anne Naested & Lene Lauge Berring (Denmark)
Sex and violence: a topic for all medical and health care professionals......................363
Heidi Siller, Women’s Health Centre, Medical University of Innsbruck, Austria
Susanne Perkhofer, University of Applied Sciences Tyrol, Austria
Martina König-Bachmann, University of Applied Sciences Tyrol, Austria
Margarethe Hochleitner, Women’s Health Centre, Medical University of Innsbruck, Austria
The experiences with violence and prevention of violence in The Prague
Emergency Medical Service in years 2004 – 2014...............................................367
Jaroslav Pekara, Zdenĕk Schwarz & Alan Mejstřik (Czech Republic)
Staff training and violence prevention in coercive care institutions: A newly
revised program in Sweden .........................................................................372
Caroline Björck, Karl Glifberg, Mikael Malmberg, Carina Moen & Gunilla Nötesjö
(Sweden)
26
Work ethics and active communication: The leader on the floor ...............................377
Baidur Karlsson (Iceland) (member of ENTMA)
Training staff to manage challenging behavior and violence - does staff safety
effect the ability to de-escalate?.....................................................................378
Pal-Erik Ruud (Norway)(member of ENTMA)
A Model of continuous professional development for instructors in the
management of aggression & violence ............................................................380
Donal Mc Cormack & Kevin McKenna (Ireland)(members of ENTMA)
Developing the Role of Clinical Nurse Educator for Behavioral Health ........................383
Timothy Meeks (USA)
How to train ourselves to assess the risk of violence ?...........................................387
Anthony Djurkov (New Zealand)
Violence in health and social care settings training resource package:
A multicenter evaluation study.......................................................................388
Joanne Skellern, Tibor Ivanka & Marie Treslova (UK)
How we train staff to avoid violence in forensic milieu therapeutic environments ..........390
Thor Egil Holtskog (Norway)
SIMBA – a staff education and training programme in forensic milieutherapeutic
environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .394
Mr Thor Egil Holtskog (Norway)
Education Experiment: Short Time Education – Long Time Results for PracticePaper ........396
Jaroslav Pekara, Marie Trešlová, Lidmila Hamplová
Staff Training for the Management of Violence: Incorporating Staff Attitudes and
Self-Efficacy in Clinical Training .....................................................................400
N. Aasdal & T. Wøbbe (Denmark)
Chapter 20 – Other related themes .................................................402
Professional Commitment and Intent-to-Leave: A moderated effect of violence
prevention climate.....................................................................................402
Yuan-Ping Chang & Hsiu-Hung Wang (Taiwan)
Violence and Mental Illness from an US Perspective .............................................404
Murali Rao (USA)
27
A Pilot study examining instinctive and natural body movements during
simulated assaults: developing a new approach to physical intervention skills in
health and social care settings ......................................................................408
Richard Luck, John Parkes & Phil Smith (UK)
Comparing the effect of non-medical mechanical restraint preventive factors
between psychiatric units in Denmark and Norway .............................................410
Jesper Bak, Vibeke Zoffmann, Dorte Maria Sestoft, Roger Almvik, Volkert Dirk Siersma, and
Mette Brandt-Christensen (Denmark)
Decision-Making Factors Influencing Mental Health Nurses in the Use of
Restraint: An Integrative Review ....................................................................412
Sanaz Riahi (Canada)
A Phenomenological Exploration of ‘Last Resort’ in the Use of Restraint .....................414
Sanaz Riahi (Canada)
The issue of patient aggression against nurses in Slovak clinical practice . . . . . . . . . . . . . . . . . . . .416
Martina Lepiešová, Martina Tomagová, Ivana Bóriková, Katarína Žiaková, Mária
Zanovitová, Juraj Čáp
Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Institute of
Nursing, Slovak Republic
Victimisation in adults with severe mental illness: prevalence and risk factors ..............420
Liselotte de Mooij, Martijn Kikkert, Nick Lommerse, Jaap Peen, Sabine Meijwaard, Jan
Theunissen, Pim Duurkoop, Anna Goudriaan & Henricus Van (Netherlands)
‘My parent died in this psychiatric hospital in 1936, 1944, 1947’ – Sons,
daughters and grandchildren inquiring after decades of incertitude. How can we
answer to their questions in Germany nowadays?...............................................422
Michael Bruenger (Germany)
The Impact of Value Incongruence between Employees and their Workplaces
within Psychiatric Inpatient Units: Preliminary data related to perceived
psychosocial factors...................................................................................424
Lars-Erik Warg & Ulrika Hylén (Sweden)
Staff and caregiver attitude on coercion in India .................................................426
Bevinahalli N Raveesh, Peter Lepping, Soumithra Pathare & Joske Bunders (India)
Analysis of Nurses Experiencing Anger toward their Patients at work........................427
Naoko Shibuya & Risa Takahashi (Japan)
WECARE - Addressing Mental Health Staff Burnout Through Organizational
Culture ..................................................................................................428
Bob Bowen (USA)
Rethinking Debriefing: A structure for aligning constituents and process .....................432
Kevin McKenna (Ireland)(member of ENTMA)
28
Psychopathy: Defining the Diagnostic Construct ..................................................433
Daniël L. Janssen, Bachelor of Arts Graduate at University College Roosevelt, Utrecht
University, the Netherlands
Elizabeth B. P. Wiese, Associate Professor of Psychology at University College Roosevelt,
Utrecht University, the Netherlands
Clinical features of Methamphetamine – induced Psychosis inpatients........................437
Seyed Mohammadrasoul Khalkhali Shari, Reza Ahmadi, Azam Hamidi, Homa Zarrabi,
Kiomars Naja, Robabe Soleimani & Somaieh Shokrgozar (Iran)
Who becomes violent, who is victimized, and who becomes both after discharge
from emergency psychiatry? ........................................................................439
John Olav Roaldset, Stål Bjørkly (Norway)
Index of Names........................................................................................440
Index of Keywords ....................................................................................443
Announcement 10th European Congress on Violence in Clinical Psychiatry ..................447
Supporting Organisations............................................................................448
29
Chapter 1 – Keynote speeches
Restraint Reduction. Remembering but not
repeating.
Keynote speech
Dr. Brody Paterson (UK)
“Progress, far from consisting in change, depends on retentiveness. When change is absolute there
remains no being to improve and no direction is set for possible improvement: and when experience is not
retained, as among savages, infancy is perpetual. Those who cannot remember the past are condemned
to repeat it.” 1
Introduction
The use of restraint whether in the form of seclusion, mechanical restraint or physical holding has been
the subject of debate for much longer than many practitioners realise. A truly exhaustive overview of the
diversity of that debate is beyond the scope of this discussion that must of necessity be selective. The aim
of this presentation will essentially be to summarise what as Santayana observed we should remember
from our past both historical and somewhat more recent in order to ensure we make real progress as
opposed to delivering mere change.
The early years of this century have seen the re-emergence of a restraint reduction movement in services
for people with mental health needs. Such initiatives are in historical terms very far from new and have
featured in many calls to reform the treatment of those experiencing mental distress over epochs. Soranus
of Ephesus2 a Greek physician who practiced in the town of the same name some 2000 years ago disagreed
with punishment as a means of treatment but accepted that on occasion restraint was necessary stressed
that servants who restrained must use their hands and not clubs. Persian physicians such as Rhazes (865-
925), a senior doctor in Baghdad the location of the rst known mental health ward advocated talking
therapies and rejected the use starvation, ogging and fetters.
Ascribing the origins of restraint reduction to later developments in the works of Pinel in France, Tuke
and Connolly (an Irishman) in the UK would therefore be a mistake. Such initiatives were driven by
ideological, philosophical and religious belief systems that viewed approaches based on punishment as
counterproductive and restraints as something to be avoided wherever possible. Tuke a quaker rejected
the dominant discourse that “fear (is) the most effectual principle to reduce the insane to orderly conduct”
in favour of “A system which, by limiting the power of the attendant” made it in “his interest to obtain
the good opinion of those under his care”. Connolly (1856) one of the foremost UK critics of mechanical
restraint was however less concerned regarding the ethical principles involved than with the difculties be
encountered in preventing its misuse. As Bowers writing somewhat more recently (2005) notes restraint
is not intrinsically a punitive intervention but it can be used in a punitive way. Exposes of poor practice
involving allegations of the over use of restraint may therefore shock but should never surprise us. The
potential for corrupted cultures of care to develop which are characterised by the misuse of physical
intervention is a product of processes so powerful that services must continually guard against them.
Recent debates between supposed and actual advocates of restraint elimination and those who are
fundamentally arguing that its ethical justication lies in its ultimate necessity to ensure safety for both
service users and staff echo essentially echo versions of an argument recorded over centuries. Calls made
by some to completely eliminate their use entirely have evoked dissent and reminders that mental health
practitioners must sometimes face and manage grave risks. Current debates regarding the desirability of
eliminating prone restraint physical intervention procedure once common in the UK have trod much the
same ground as those advocating the elimination of mechanical restraint in the 19th century. It may seem
tempting therefore to agree with the observation of the anonymous author of Ecclesiastes that there is after
all nothing new under the sun.
30
Nothing however could be further from the truth in that whilst such arguments may in some respects
be unoriginal in tenor this does not render them unimportant quite the contrary. They remain as vital
as ever they were and the nature of the current debate is different in several key respects from those
which have preceded it. This generation have rediscovered restraint reduction in an era in which the
bio-chemical discourses that have dominated psychiatry for some decades have been challenged by the
narratives of recovery and increasingly of trauma. They have rediscovered restraint reduction in an era
of evidence based practice and with access to computing power unimaginable to our predecessors. They
have rediscovered restraint reduction in an era where service user voices must be heard in the planning and
delivery of services that are subject to levels of audit and demands for accountability almost unimaginable
to previous generations.
This context has allowed many of the tenets of the pro restraint camp to be robustly tested. One consequence
has been that the old shibboleth that has underpinning the use of restrictive interventions over the many
centuries i.e. safety has been undermined by a series of research studies. These have revealed an astonishing
variation in the nature and frequency of the use of restrictive interventions used. They also uncovered that
the use of restrictive interventions has sometimes posed severe and even even fatal risk to consumers and
practitioners.3 Faced with such ndings practitioners, researchers and policy makers across the globe have
increasingly become engaged with the question of how to deliver safe and therapeutic services in which
restrictive interventions are minimised. A consensus has emerged suggesting that it is only through deep
change informed by root cause analyses that restraint reduction can be delivered. Multiple reviews of
successful initiatives have suggested they must be systemic, multidimensional and whole organisational4.
A series of complex interventions have now been developed, tested and disseminated that have delivered
reduction.5,6 Multiple studies have conrmed that services can often signicantly reduce the frequency and
level of restrictiveness of their interventions without compromising staff safety. The root causes of the
corrupted cultures that can develop within mental settings can be identied and addressed.7
Signicant challenges remain amongst which is how do we ensure that the insights generated by such
research become sufciently embedded in mainstream thinking to resist what will be inevitable regression
to the mean. A tendency in this instance inevitably fostered by the discourses that spur the overuse of
restraint which will never truly go away.8 We may though be forgiven for celebrating practicing at a time
when we can at least aspire towards proving that old radical Thomas Szasz wrong. Those familiar with his
oeuvre will remember his famous or perhaps infamous observation that non-coercive psychiatry was an
oxymoron, a conceptual impossibility.9 We may never be able to completely eliminate the use of restrictive
interventions but the ambition to do so has already taken some services on a quite incredible journey in
which some old and unspoken assumptions have been foregrounded and challenged. We have on the very
long journey the discussion presented here has touched upon sometimes forgotten that control where
it may be necessary must rest, as it should in a family, in demonstrating that the person receives more
help, more compassion, more love, more understanding and more encouragement then he will encounter
elsewhere.10 This above all is something we must strive not only to remember but to consistently deliver.
References
1 Santyana. G. (1905) The Life of Reason, or the Phases of Human Progress, New York, Charles Scribner’s Sons.
2 Keyser, P.T., & Irby-Massey, G.L. (2008). The encyclopedia of ancient natural scientists: the Greek tradition and its many
heirs. New York, NY: Routledge
3 Duxbury, J., Aiken, F., Dale, C. (2011) Deaths in custody: the role of restraint. Journal of Learning Disabilities and
Offending Behaviour. 2(4)178 - 189
4 Scanlan J.N. (2010) Interventions To Reduce The Use Of Seclusion And Restraint In Inpatient Psychiatric Settings: What
We Know So Far A Review Of The Literature, International Journal Of Social Psychiatry 56(4), 412–423.
5 National Registry of Evidenced-Based Programs and Practices. (2012). Six Core Strategies to prevent conict and
violence: Reducing the use of seclusion and restraint. National Association of State Mental Health Program
6 Bowers L et al. (2015) Reducing conict and containment rates on acute psychiatric wards: The Safewards cluster
randomised controlled trial. International Journal of Nursing Studies 52(9),1412-1422.
7 Paterson B., McIntosh I.,Wilkinson D., McComish S. and Smith I. (2013) Corrupted cultures in mental health inpatient
settings. Is restraint reduction the answer? Journal of Psychiatric and Mental Health Nursing. 20(3):228-35
8 Paterson B., Bowie V., Miller G. and Leadbetter D (2009) Reframing the problem of violence towards mental health
nurses - A work in progress? ,International Journal of Social Psychiatry. 56(3), 310-320.
9 Szasz T. (1961) The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, Hoeber and Harber, New York.
10 Millham et al. 1981 (cited in Social Work Services Inspectorate for Scotland 1997)
31
Reduction of restraint use in Denmark – what
have we learned?
Keynote speech
Søren Bredkjær (Denmark)
Medical Director, Psychiatry in Region Zealand
Abstract
Restraint and seclusion have been used in many countries and across service sectors for centuries. Restraint
use in the treatment of mental illness has long been a controversial practice in Denmark. Regulatory
agencies, licensing organizations and professional and advocacy groups have called for reduction of
restraint use. With the recent and increasing recognition of the harm associated with these procedures,
efforts have been made to reduce and prevent restraint use.
In the last ten year, projects (The National Breakthrough Series Collaborative) in psychiatric departments
in Denmark have reduced and prevented restraint use by implementing the breakthrough method. There
has been a lot of success for each of the projects but the results have not been implemented at a national
level and the gures for restraint on a national level have not changed in the last decade.
In 2014, the Danish Ministry of Health made a partnership with each of the ve regions responsible
for all the psychiatric departments in Denmark to reduce the use of restraint with 50 % before 2020.
The National Board of Health has established a task force that has standardized ways to dene, register,
measure, follow, and supervise restraint and violence so it is possible to make the inter-facility and inter-
regional comparisons. The National Board of Health now publicly reports restraint rate, average duration,
and frequency by facility and region every sixth month.
The regions are implementing the best practices to reduce restraint from the National Breakthrough Series
Collaborative and elements from the Sixth Core Strategies in reducing and preventing the use of restraint.
Leadership commitment is essential to begin and sustain this work of reducing and preventing restraint.
32
Coercive Treatment in Psychiatry: Ethical Aspects
Keynote speech
Prof. Tilman Steinert (Germany)
Introduction
Should a person not have the right to refuse treatment, and the right to keep one’s illness? This is obviously
the case in somatic diseases such as cancer, coronary heart disease or diabetes. Nobody would be forced
to accept a diabetes diet, drugs for increased blood pressure or chemotherapy or even surgery for cancer,
even if there is a considerable risk of deterioration of health status or even death. Most people will
intuitively judge this attitude as ethically appropriate. But why should a person with schizophrenia or
mania then be forced to take medication against his or her will? Is there any difference? We come closer
to an understanding if we consider a patient with post-operative delirium after surgery. The 85-year-old
women with acute inammation of the gall bladder has consented to cholecystectomy after comprehensive
information. But in a delirious state after the operation she wants to remove infusions with antibiotics
(which she calls poison) and go home, saying she has to go to work and she supposes to be in a “madhouse”
with bad people around her. Most people will intuitively feel that it would not be fair to let this patient
go home as this would have a deleterious outcome. The key aspect of this scenario is that this patient is
suffering from a somatic disease, but also from a mental state (delirium) which impairs her ability to make
reasonable decisions. This increases the liability of carers - health care staff in the present case - to take
responsibility for her. An ethical framework is required to achieve a sound theoretical reasoning for such
cases.
Principle-based ethics
According to principle-based ethics (Beauchamp and Childress 2009, there are four fundamental ethical
principles in medicine: respect for the patient’s autonomy, benecence, non-malecence, and justice.
Essentially, coercive treatment is a severe violation of patient’s autonomy. Furthermore, coercive
treatment can impose harm on the patient due to short-term and long-term medication side effects and
psychological distress. On the other hand, withholding treatment can cause deterioration of mental health
and social exclusion up to involuntary detention in case of severe behaviour disorders in consequences
of untreated mental illness. Withholding treatment for the most seriously ill (who lack insight into illness
and into treatment) would be a violation against the principle of justice. These considerations show that
the adoption of principle-based ethics to the case of coercive treatment is in most cases not a solution but
a rst approach to a reasonable discussion.
Insight and capacity to consent
Balancing the four principles of medical ethics, there is only one good reason to justify violations of
patient’s autonomy: a weakening of this autonomy through severe illness. Severe mental disorders such as
psychoses and organic brain disorders can impair insight and capacity to consent. The concept of capacity
to consent is different from legal capacity. It is always related to a concrete situation. Patients need to
understand relevant information, need to be able to relate that information to their personal situation, and
need to be able to make a balanced decision. If a patient does not understand that he suffers from psychosis
but understands that he suffers from pneumonia, he may be able to consent to therapy with antibiotics but
not to therapy with antipsychotics. In this case it might be justied to transfer the decision on antipsychotic
treatment to someone else (a relative, a guardian, a judge or combinations of these) according to a dened
and fair procedure. However, it would not be justied that the decision lies on the doctor alone, except for
cases of emergency.
Is untreated psychosis a danger to one’s health?
Psychiatrists certainly would answer this question with “yes”, but why? Results on the level of brain
structure are inconclusive in this regard. However, mental disorders frequently manifest themselves as
behavioral disorders. Behaviour driven by psychotic experience can be so strange and dangerous that it
frequently leads to social exclusion – from involuntary detention in a psychiatric hospital up to seclusion,
restraint, and detention in forensic psychiatry. Loss of social inclusion really is a severe damage of psycho-
social health.
33
If coercion is necessary, should coercive treatment or other coercive measures be preferred from an ethical
point of view?
This question is very important and it has been answered in opposing directions in different countries.
In some countries, most clearly in the Netherlands, the position has been held that treatment is more
invasive and a greater violation of patient’s autonomy than ‘pure’ freedom-restrictive measures such as
detention, seclusion, and restraint (Steinert et al. 2014). However, the consequence was an excessive use of
seclusion which has then led to reconsiderations of such policies resulting in less restrictions to involuntary
medication. In other countries, most clearly in the UK, the position has been held that coercive treatment is
just treatment in the patient’s best interest so that the aspect of coercion in treatment received rather little
attention in research and practice. In recent years, there has been some empirical research on the use of
different coercive interventions and patients’ views on them. One denite answer is that not all patients
need and prefer the same, as in all other areas (Veitkamp et al. 2008, Georgieva et al. 2012, Steinert et al.
2013). Concerning the use of different coercive interventions and successful strategies to avoid or replace
them, ethical positions need to be supported by the ndings of empirical research.
Conflict with the UN position on human rights
The ideas outlined so far are well accepted among ethicists and psychiatrists and nd themselves more
or less in the legislations of many developed countries. However, in 2013, a special report to the Human
Rights Council of the United Nations (UN 2013) caused considerable concerns among psychiatrists. In this
report, all coercive treatment and use of coercive measures in mentally ill people is called ill-treatment and
even torture. The idea of lack of capacity and treatment in the patient’s best interest is explicitly addressed
as not justied in this report. It relates to the UN Convention of Rights of Persons with Disabilities which
does not include any concept such as lack of capacity.
Danger to others: additional ethical conflicts
Coercive treatment may be justied if it is carried out in order to improve the patient’s health or to avoid
harm from her or him. In many cases, and in most cases of psychotic disorders, dangerous behaviour is
due to the disorder. If so, treatment of the disorder is appropriate to improve also the dangerous behaviour.
In these cases, coercive treatment might be justied under several conditions, because it is also in the
patient’s best interest. In some cases, however, medication is not in the interest of the patient but only
or primarily in the interest of others. This applies if psychoactive drugs are used against a patient’s will
primarily for the purpose of controlling aggressive or other undesired behaviour and not for the treatment
of an underlying mental disorder. No drugs are approved for this purpose, their application would be
off-label anyway. Such kind of application of drugs cannot be called ‘treatment’ because it is not in the
patient’s interest. It should be considered as unethical. A subsequent question is whether mental health
professional should be obliged to care for dangerous people who do not prot from treatment which can
be offered by mental health services.
Ethical concern in involuntary outpatient treatment
In the countries where it is in use, involuntary outpatient treatment has been introduced primarily to
ascertain antipsychotic maintenance therapy, preferably with depot antipsychotics, for people with poor
insight into illness and treatment and frequent relapses. Under antipsychotic treatment, most of these
individuals recover and regain capacity to consent. But, if they have capacity, it cannot be ethically
justied to use coercion to apply the next depot medication. This could cause serious concern not only for
people with mental illness but for civil rights in general. Where does it happen elsewhere in democratic
societies that people who have not committed a crime are forced to undergo a medicalised dangerousness
management against their will?
Conclusion
Mental health professionals and policy makers who are concerned with aspects of coercive treatment need
continuous ethical reections based on philosophy as well as research evidence.
References
Beauchamp TL, Childress JF (2009). Principles of Biomedical Ethics. 6th ed. New York: Oxford University Press
Georgieva I, Mulder CL, Whittington R (2012) Evaluation of behavioral changes and subjective distress after exposure to
coercive inpatient interventions. BMC Psychiatry 12:54
34
Steinert T, Birk M, Flammer E et al. (2013) Subjective distress after seclusion or mechanical restraint: one-year follow-up of
a randomized controlled study. Psychiatr Serv 2013; 64; 1012-1017
Steinert T, Noorthoorn EO, Mulder C (2014) The use of coercive interventions in mental health care in Germany and the
Netherlands. A comparison of the developments in two neighboring countries. Front Public Ment Health 2:141
United Nations (2013) Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or
punishment, Juan E. Méndez. Human Rights Council, 22nd session, 1.2.2013. http://www.hr-dp.org/les/2013/10/28/A.
HRC_.22_.53_Special_Rapp_Report_.2013_.pdf
Veitkamp E, Nijman H, Stolker J et al. (2008) Patients’ preferences for seclusion or forced medication in acute psychiatric
emergency in the Netherlands. Psychiatr Serv 59: 209-211
Correspondence
Prof. Dr. med. Tilman Steinert
Centres for Psychiatry Suedwuerttemberg
Ulm University, Clinic for Psychiatry and Psychotherapy I
Medical Director
Director of Education and Research
Weingartshofer Straße 2
88214 Ravensburg
tilman.steinert@zfp-zentrum.de
35
International Perspectives on Violence Risk
Assessment
Keynote speech
Jay P. Singh, PhD
Keywords: violence, risk assessment, forensic, crime, innovation
Acknowledgements: This paper was published as “Five Opportunities for Innovation in Violence Risk
Assessment Research” in Volume 1, Issue 3 of the Journal of Threat Assessment and Management.
Over the past 30 years, the development of structured instruments to aid in the evaluation of violence
(including sexual violence) risk has become a cottage industry. There are now literally hundreds of
available risk assessment tools and a large research literature suggesting their superior reliability and
predictive validity over unstructured clinical judgments (Singh, Serper, Reinharth, & Fazel, 2011). With
over 40 systematic reviews and meta-analyses on the topic (Singh & Fazel, 2010), and an average of 17
new risk assessment articles being published each month (Global Institute of Forensic Research, 2014), it is
important to take a step back from this fast-moving train and examine possibilities for research innovation.
The present article provides an overview of ve opportunities for innovation in risk assessment research.
Recommendation 1:
Move beyond the idiographic vs. nomothetic controversy and start focusing
on the nomothetic vs. nomothetic controversy
Over the past seven years, much research and commentary has focused on the issue of whether actuarial
risk assessment tools can reliably apply group-based estimates of recidivism risk to individuals (e.g.,
Cooke & Michie, 2010; DeMatteo, Batastini, Foster, & Hunt, 2010; Hart, Michie, & Cooke, 2007; Scurich,
Monahan, & John, 2012). This has come to be known as the “idiographic versus nomothetic” controversy.
What seems to have been forgotten is that there is only a need for research in this area if practitioners
are actually assigning group-based probabilities to individuals (e.g., “Mr. X has a Y% probability of
recidivating in Z years”). But only a minority of practitioners are doing so. Indeed, according to recent
survey evidence (Singh, 2013b), a large majority of clinicians communicate risk in a categorical (e.g., “Mr.
X is at low/moderate/high risk”) or dichotomous manner (e.g., “Mr. X is dangerous”).
Abandoning actuarial risk assessment tools based solely on the argument that group-based estimates are
not applicable to individuals is a slippery slope. By this logic, most research ndings should be disregarded,
as the preponderance of scientic investigations attempt to make conclusions about individuals based on
group-level ndings. Consider the public health problems that would result from disregarding widely-
used medical screening tests such as mammograms or prostatic-specic antigen tests due to their use of
normative cut-off thresholds to inform decisions about individuals.
In the end, what is worrying in the actuarial risk assessment literature is not so much that group-based
estimates cannot be applied to individuals, but rather that group-based estimates appear to not be applicable
to groups. Two meta-analyses in the past year have found that rates of recidivism in groups judged to be
at “high risk” by both sex offender (Singh, Fazel, Gueorguieva, & Buchanan, 2013) and violence risk
assessment tools (Singh, Fazel, Gueorguieva, & Buchanan, 2014) vary so much that practitioners simply
cannot assume manual-based probabilistic estimates of recidivism risk to be true. These large reviews
found that sexual recidivism rates in “high risk” groups were higher in younger samples assessed by
actuarial instruments when conviction was the study outcome, and violent recidivism rates in “high risk”
groups were higher in samples with fewer men where an SPJ tool had been administered to a population
with overall higher recidivism rate. And recent primary research has conrmed that even when replication
studies match the sample and design characteristics of normative investigations closely and follow
manual-based protocols exactly, group-based recidivism rates still do not hold (Rossegger, Endrass, Gerth,
Urbaniok, & Singh, 2014; Rossegger, Gerth, Singh, & Endrass, 2013).
This nomothetic versus nomothetic quandary is more concerning than the idiographic versus nomothetic
debate, as a main benet of actuarial instruments over alternative risk assessment approaches is the
production of probabilistic estimates of group-based recidivism. And if these estimates do not hold for
36
different risk groups or risk scores (cf. Helmus, Thornton, Hanson, Babchishin, & Harris, 2012), then it
could be argued that the actuarial approach has a difcult road ahead in forensic mental health.
Recommendation 2: Move beyond discrimination validity
In the context of structured risk assessment, predictive validity refers to the ability of an instrument to
predict the likelihood of an adverse outcome (Singh & Petrila, 2013). This form of construct validity
can be divided into two equally important components: discrimination and calibration (for a primer see
Singh, 2013a). Consistent with a diagnostic approach, discrimination refers to the ability to retrospectively
detect whether recidivists were judged to have been at higher risk than non-recidivists. Consistent with a
prognostic approach, calibration refers to the ability to prospectively predict whether individuals judged to
be at higher risk are more likely to recidivate. Given that risk assessment in practice relies inherently upon
conditions of uncertainty, the calibration component of predictive validity is perhaps more relevant. But
calibration performance indicators are reported in less than a third of risk assessment predictive validity
studies, with the general reasoning being that discrimination indicators are less inuenced by outcome
prevalence rates and, hence, easier to compare across studies (Singh, Desmarais, & Van Dorn, 2013). This
said, both discrimination and calibration validity should arguably be established before implementing an
instrument in practice.
As Bayesian thought is currently in vogue in the eld (e.g., Harris & Rice, 2013; Beauregard &
Mieczkowski, 2009; Wollert, 2006), it may be that the time has come to explore advancing the statistical
methodology used in the eld to take into consideration the issue of outcome prevalence rather than
to systematically sweep this issue under the proverbial rug. For example, instead of providing readers
with receiver operating characteristic (ROC) curves, predictiveness curves could be constructed (Pepe
et al., 2008). Rather than publishing areas under the ROC curve (AUC), probabilistic AUCs could be
reported (Shiu & Gatsonis, 2008). Should researchers wish to combine both discrimination and calibration
in a single performance indicator, the Brier score and its various decompositions could be calculated
(Rubach, 2010).
Recommendation 3:
Move beyond using comparisons against chance
Risk assessment researchers have a number of statistical methods at their disposal when measuring
predictive validity. Many of these methodologies – including correlation, regression, and ROC curve
analysis – incorporate null hypothesis signicance testing (NHST). NHST is a statistical method by which
the likelihood of a research hypothesis being “true” is evaluated (Carver, 1978). The conventional null
hypothesis in the behavioral sciences is chance. However, there are no practitioners whose alternative
to using a risk assessment tool is simply ipping a coin (and if there are, please alert me so malpractice
charges can be brought forth). As a eld, we cannot be content to rely on methods of statistical testing that
lack practical meaning.
The ideal comparison against which to compare the performance of risk assessment tools would be
unstructured clinical judgments. However, to recommend that case-control study designs be used when
clinical guidelines suggest that structured assessments are preferable to unstructured evaluations would
be unethical. An alternative would be to use routinely available pieces of information that would likely
drive unstructured clinical judgments as a proxy. Recent research has shown that simple models composed
of just three pieces of routinely available information (age, sex, and criminal history) produce rates of
discrimination validity similar to widely used risk assessment scales (Fries, Rossegger, Endrass, & Singh,
2013; Buchanan & Leese, 2006; Fazel, Singh, Doll, & Grann, 2012). This transition would mean that the
p-values produced by commonly used statistical packages, which assume a null hypothesis of chance,
would no longer be reported. Rather, predictive validity estimates produced by tools versus routinely
available demographic information would be compared using established statistical tests such as the
Steiger (1980) z-test or the Pearson-Filon (1898) z-test for differences in correlations, the Breslow-Day
(1987) χ2 test for differences in odds ratios, or the DeLong-DeLong-Clarke-Pearson (1988) χ2 test for
differences in AUCs. In interpreting the ndings of these tests of differences, it should be remembered that
statistical signicance – no matter how it is calculated – does not necessarily mean practical importance,
and smaller p-values do not necessarily mean stronger relationships (Glinger, Leech, & Morgan, 2002).
37
Recommendation 4:
Move beyond using rules-of-thumb to justify claims of predictive validity
There is little question that the AUC is the most commonly used performance indicator in predictive
validity studies of risk assessment tools. In their systematic review of predictive validity methodology,
Singh, Desmarais, and Van Dorn (2013) found that AUCs were frequently labelled as small, moderate, or
large in terms of their magnitude. The usefulness of such rules-of-thumb is predicated upon there being
some agreement in the eld as to what ranges of AUCs constitute small, moderate, and large effect sizes.
But there is no such agreement. Both the Singh review and an overview by Mossman (2013) – the clinical
researcher who introduced the eld to ROC curve analysis in the 1990s – have concluded that there is
too much variability in rules-of-thumb for them to be practically useful. Rather than relying on rules-
of-thumb, AUCs should be interpreted for readers using a standardized denition (e.g., “The probability
that a randomly selected recidivist had a higher risk classication than a randomly selected non-recidivist
was X%”). Surprisingly, such a straightforward interpretation is provided in a minority of studies. Also,
it is important to note that risk assessment tools that perform well at identifying recidivists but poorly
at identifying non-recidivists can produce the same AUCs as tools that perform well at identifying
non-recidivists but poorly at identifying recidivists (cf. Singh, Grann, Lichtenstein, Långström, & Fazel,
2012). Hence, statements that an instrument should be used in practice solely because the AUCs it produces
are comparable with those of other instruments should be read with due caution.
Recommendation 5:
Move beyond assuming incidents of recidivism occurred after index offenses
The use of criminal registers to detect incidents of recidivism is commonplace in predictive validity
studies of risk assessment tools (Singh, Grann, & Fazel, 2011). Though much has been written on the
potential drawbacks of relying solely on register-based outcomes like charges or convictions (e.g., Davies,
Clarke, & Duggan, 2004; Monahan et al., 2001), comparatively little attention has been paid to the closely
related issue of pseudo-recidivism. Pseudo-recidivism refers to new charges or convictions handed down
after an index offense precipitated by incidents occurring before that index offense (Quinsey, Harris, Rice,
& Cormier, 2006).
Consider the following situation: Mr. X is charged with threatening to his father-in-law with a knife and
is released on bail. The next day he gets into an argument at a local bar, a confrontation that ends in Mr.
X murdering the bartender. He is summarily convicted of second-degree murder and incarcerated in the
state penitentiary. Upon admission to the facility, a risk assessment tool is administered with hopes of
establishing the likelihood of future harmful behavior. Six months later, Mr. X goes to court to face the
charge of threatening his father-in-law and is convicted. Is this new conviction an act of recidivism? No –
the new conviction was for an incident that occurred before the index offense. But if researchers interested
in the predictive validity of the administered risk assessment tool rely solely upon conviction outcomes
without cross-referencing date-of-offense information, then their ndings concerning the utility of the tool
will be biased. It is important to control for this issue of pseudo-recidivism to ensure that outcomes rates
are as accurate as possible.
Concluding Remarks
The most important aspect of risk assessment research can be summed up in a single word: transparency.
Consumers of research – be they other researchers, practitioners, or policymakers – need to know exactly
how an instrument was tested and on whom in order to judge whether ndings are applicable to their
particular context. Consensus-based guidelines for what should be routinely reported in risk assessment
research have recently been established (Singh, Yang, Mulvey, & the RAGEE Group, 2015), offering a
promising way forward. With high hopes for the eld, what must be advocated when it comes to structured
risk assessment is neither nihilistic cynicism nor unfettered optimism, but rather objective and respectful
scientic caution. Risk assessment tools are not panaceas, but they do represent a signicant improvement
in psychometric performance over unstructured approaches.
Conflicts of interest
The author is occasionally hired as an expert for giving talks or workshops about risk assessment.
Typically, this is done as part of the author’s regular university duties but depending on the nature of the
task and constituents, such activities are sometimes commissioned with remuneration.
38
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Singh, J. P., Serper, M., Reinharth, J., & Fazel, S. (2011). Structured assessment of violence risk in schizophrenia and other
disorders: A systematic review of the validity, reliability, and item content of 10 available instruments. Schizophrenia
Bulletin, 37, 899-912. doi:10.1093/schbul/sbr093
Singh, J. P., Yang, S., Mulvey, E., & the RAGEE Group. (2015). Reporting standards for risk assessment predictive validity
studies: The Risk Assessment Guidelines for the Evaluation of Efcacy (RAGEE) Statement. Law & Human Behavior,
39, 15-22. doi:10.1037/lhb0000090
Steiger, J. H. (1980). Tests for comparing elements of a correlation matrix. Psychological Bulletin, 87, 245-251.
doi:10.1037/0033-2909.87.2.245
Wollert, R. (2006). Low base rates limit expert certainty when current actuarials are used to identify sexually violent predators:
An application of Bayes’ theorem. Psychology, Public Policy, & Law, 12, 56-85. doi:10.1037/1076-8971.12.1.56
Correspondence
Global Institute of Forensic Research
11700 Plaza America Drive
Suite 810
Reston, VA 20190, USA
jaysingh@gifrinc.com
40
Coercion in Psychiatry: A User Perspective
Keynote speech
Julie Repper RGN RMN Ba(Hons) MPhil PhD
Abstract
Violence in Clinical Psychiatry has long focused on why, how, when and how often patients are violent
towards staff. Whilst this has often been done sympathetically in order to improve the experience of
patients and thereby reduce the likelihood of them being violent, neither the violence perpetrated by
psychiatry (Clarke, 1964) nor the perspectives of people who use services have been explored in such
detail. It is only when both sides of this story are fully understood that both can be brought together to
coproduce more harmonious, less restrictive, recovery focused services.
I have used acute psychiatric services on and off for nearly 40 years and so I am aware of how it feels
to be rendered powerless and voiceless by people who don’t appear to hear my distress, who don’t seem
to try to understand what I am saying, who offer glib responses when faced with my desperation, who
effectively minimise my despair and who label it rather than listening. Such utter powerlessness – an
absolute conviction that I can’t cope, am not being heard, am unable change things - is unbearable and so it
inevitably turns into that seering high pitched pain that can only be relieved by doing something that makes
a difference, that stops the burning pain. This might be harming oneself or it might result in someone or
something else. For me, and others like me, it is called coping with an unbearable situation. For you this
is Violence in Clinical Psychiatry.
In this paper I want to go beyond my own experiences to describe the feelings, beliefs, and explanations
for violence that have been narrated by people who use mental health services. I will then draw on recent
research and practice based evidence about coproduction, shared decision making, joint crisis plans,
negotiated safety plans and collaborative care planning to propose processes that bring together the
experiences, roles, relationships and skills of both people who use services and people who staff those
services in order to nd solutions and negotiate agreements that reduce violence and promote recovery.
Correspondence
Julie Repper
Julie.Repper@nottshc.nhs.uk
41
Understanding and Treating Anger and
Aggression in Adults with Intellectual and
Developmental Disabilities
Keynote speech
Prof. John L. Taylor, Northumbria University and Northumberland, Tyne & Wear NHS Trust, UK.
Introduction
During 2013-2014 there were 30,574 admissions to NHS facilities (including high security hospitals) in
England under the Mental Health Act (MHA) 1983 (Health & Social Care Information Centre, 2014). Of
the 29,116 detentions under civil sections of the act during this period 2.5% were categorised as having
an intellectual disability (ID). However of the 1,317 criminal detentions under court and prison disposals
during the corresponding period, just over 6% were categorised having an ID. Assuming a normal
distribution, the proportion of people in the general population with IQ scores under 70 is approximately
2.5%. Thus it appears that more than double the expected number of people with ID are being detained
in NHS facilities under criminal sections of the MHA 1983. However, the evidence that people with ID
commit more crime than others is highly equivocal.
It is not clear whether people with ID commit more crime than those without ID or, in fact, whether the
nature and frequency of offending by people with ID differs from that committed by offenders in the
general population. A policy of deinstitutionalisation has been implemented across the western world since
the mid-1970s and has had a signicant effected on services for people with ID who offend or engage in
offending-type behaviour. For example, most large hospital facilities for people with ID in the UK would
have had wards dealing with patients exhibiting this type of behaviour. Such people are now more likely
to be living in community settings where their offending and offending-type behaviour is more visible and
subject to scrutiny by the criminal justice system.
Prevalence and Impact of Anger and Aggression
In the Northgate, Cambridge and Abertay Pathways (NCAP) project O’Brien et al. (2010) reported on the
offence characteristics of 477 adults with ID referred to ID services in three regions of the UK during a
12-month period because of antisocial or offending behaviour. They found that aggression (physical and
verbal) accounted for over 80% of the antisocial and offending behaviour referred. Research on several
continents has found high rates of aggression amongst people with ID – with much higher rates for those
living in institutional and secure forensic facilities than for those residing in community settings (see
Table 1). The impact of aggression is signicant in a number of ways for people with ID and those who
provide support and services to them. Aggression has been shown to be the main reason for individuals in
this client group to be prescribed antipsychotic and behavioural control drugs (Aman et al., 1987), despite
there being little or no evidence for their efcacy (e.g. Brylweski & Duggan, 1999; Tyrer et al, 2008); and
it is the primary reason for people with ID to be admitted or re-admitted to institutional settings (Lakin et
al., 1983).
While it is neither necessary nor sufcient for aggression to occur, anger has been shown to be strongly
associated with and predictive of violence in men with ID and offending histories (Novaco & Taylor,
2004). Thus anger has become a legitimate therapeutic target. The treatment of anger and aggression using
cognitive-behavioural interventions has been extensively evaluated with a range of clinical populations
(see Taylor & Novaco, 2005 for a review). One potential advantage of cognitive behavioural anger
treatment over interventions based on applied behaviour analysis, is that self-actualisation through the
promotion of portable and internalised control of behaviour is intrinsic to the skills training components
of these approaches (Taylor, 2002). Further, there is evidence from studies in non-disability elds that
for a range of psychological problems the effects of cognitive-behavioural treatments are maintained and
increase over time compared to control conditions (Taylor & Novaco, 2005).
Cognitive Behavioural Anger Treatment
Willner (2007) reviewed nine controlled studies involving people with ID that compared cognitive
behavioural treatment for anger control problems with wait-list control conditions. Most of these
42
interventions were based on the treatment approach developed by Novaco (1975) that incorporates
Meichenbaum’s (1985) stress inoculation paradigm. All of these studies reported signicant improvements
on outcome measures for those in treatment conditions that were maintained at 3 to 12-month follow-up.
Nicoll et al. (2013) systematically reviewed 12 studies of cognitive behavioural treatment for anger in
adults with ID published between 1999 and 2011. Nine studies were included in a meta-analysis that
yielded a large uncontrolled effect size (average ES = 0.84).
Taylor and colleagues have evaluated individual cognitive-behavioural anger treatment with detained male
patients with mild-borderline ID and signicant histories of violence in a linked series of studies (Taylor et
al., 2005; Taylor et al., 2002; Taylor et al., 2004). The 18-session treatment package included a six-session
broadly psycho-educational and motivational preparatory phase; followed by a 12-session treatment phase
based an individual formulation of each participant’s anger problems and needs, following the classical
cognitive-behavioural stages of cognitive preparation, skills acquisition, skills rehearsal and then practice
in vivo. These studies showed signicant improvements on self-reported measures of anger disposition,
reactivity and imaginal provocation following intervention in the treatment groups compared with scores
for the control groups, and these differences were maintained for up to four-months following treatment.
Figure 1 shows the effects of anger treatment over a routine care control group on the Novaco Anger Scale
(Novaco, 2003), a reliable and valid self-report measure of anger disposition, as reported by Taylor et al.
(2005).
Reductions in Aggressive and Violent Behaviour
The impact of these anger interventions on aggressive behaviour, including physical violence, has been
investigated empirically on only a few occasions. Allan et al. (2001) and Lindsay et al. (2003) reported
reductions in violence following a group intervention in case series of 6 women and 6 men respectively
with violence convictions living in the community. In a larger study involving 47 people with ID and
histories of aggression, Lindsay et al. (2004) showed that following a community group anger intervention
14% of participants had been aggressive during follow-up, compared with 45% of people in a control
condition.
Taylor et al. (in press) described an evaluation of the impact of the cognitive behavioural anger treatment
described earlier (e.g. Taylor et al., 2005) on aggressive and violent behaviour by offenders with ID living
in secure forensic hospital settings. Incident data were collected retrospectively from hospital case notes
over a 24-month period. The data collected were organised into four assessment intervals: Time 1 = 7-12
months pre-treatment; Time 2 = 0-6 months pre-treatment; Time 3 = 0-6 months post-treatment; and Time
4 = 7-12 months post-treatment. The participants in this study were 44 men and 6 women referred by their
clinical teams for anger treatment on the basis of their histories of aggression and/or current presentation.
The total number of aggressive incidents fell from 856 in the12-months before treatment to 561 in the
12-month period following. This represents a reduction after treatment of 34.5%. The total number of
physical attacks against staff and patients fell from 319 in the12-months before treatment (Time 1 = 128;
Time 2 = 191) to 153 in the 12-month period following treatment (Time 3 = 93; Time 4 = 60). This
represents a reduction after treatment of 55.9%. The reductions in the mean number of physical attacks
from Time 2 pre-treatment to Time 3 and Time 4 post-treatment were statistically signicant.
Importantly, in an extension of this study, Novaco and Taylor (2015) demonstrated that the reduction in
physical assaults was associated with measured reductions in anger over the course of treatment as indexed
by several anger measures validated for use with this population.
Conclusions
Aggression and violence by people with ID is a signicant problem for patients, staff and service-providers,
and is amplied in inpatient secure services. Antipsychotic medication is the most common treatment for
aggression in people with ID despite the absence of an adequate evidence base with this population (e.g.
Tsiouris, 2010; Tyrer et al., 2008). The evidence base for cognitive behavioural anger treatment for people
with ID has been growing steadily over the last two decades.
These interventions can be effective in the treatment of offenders with ID and histories of aggression and
violence in terms of improvements on self-report and informant anger dependent measures. However,
there has been little evidence available to show that treatment gains on measures anger disposition,
reactivity and control are associated with reductions in aggressive and violent behaviour. The results
of recent research shows that incidents of aggressive behaviour directed at others, including physical
assaults, reduce signicantly for detained patients with ID in the 12-month period following delivery of a
43
case-formulated, individual cognitive behavioural anger intervention compared with the 12-month period
prior to treatment commencing.
Further, the reduction in physical assaults was associated with measured reduction in anger over the course
of treatment, indexed by multiple self-rated anger psychometric scales with validated use for this patient
population. Importantly, reduction in patient anger over the course of treatment as rated by staff in their
ward observations was also signicantly associated with the decline in assaults from pre-treatment to post-
treatment. Overall, the results provide support for the rationale that case-formulated cognitive behavioural
anger treatment has clinical value in reducing patient violence.
References
Allan, R., Lindsay, W.R., Macleod, F. & Smith, A.H.W. (2001). Treatment of women with intellectual disabilities who have
been involved with the criminal justice system for reasons of aggression. Journal of Applied Research in Intellectual
disabilities, 14, 340-347.
Aman, M. G., Richmond, G., Stewart, A. W., Bell, J. C., & Kissell, R. (1987). The Aberrant Behavior Checklist: Factor
structure and the effect of subject variables in American and New Zealand facilities. American Journal on Mental
Deciency, 91, 570-578.
Brylewski, J. & Duggan, L. (1999). Antipsychotic medication for challenging behaviour in people with learning disability.
Journal of Intellectual Disability Research, 43, 360-371.
Health & Social Care Information Centre (2014). Inpatients formally detained in hospitals under the Mental Health Act 1983,
and patients subject to supervised community treatment: Annual report, England, 2013/14. Author.
Lakin, K. C., Hill, B. K., Hauber, F. A., Bruininks, R. H., & Heal, L. W. (1983). New admissions to a national sample of public
residential facilities. American Journal on Mental Retardation, 88, 13-20.
Lindsay, W. R., Allan, R., MacLeod, F., Smart, N. & Smith, A.H.W. (2003). Long-term treatment and management of violent
tendencies in men with intellectual disabilities convicted of assault. Mental Retardation, 41, 47-56.
Lindsay, W. R., Allan, R., Parry, C., Macleod, F., Cottrell, J. Overend, H. & Smith, A.H.W. (2004). Anger and aggression
in people with intellectual disabilities: Treatment and follow-up of consecutive referrals and a waiting list comparison.
Clinical Psychology and Psychotherapy, 11, 255-264.
Meichenbaum, D. (1985). Stress Inoculation Training. Oxford: Pergamon Press.
Nicoll, M., Beail, N., & Saxon, X (2013). cognitive behavioural treatment for anger in adults with intellectual disabilities: A
systematic review and meta-analysis. Journal of Applied Research in Intellectual Disabilities, 26, 47-62.
Novaco, R.W. (1975). Anger control: The development and evaluation of an experimental treatment. Lexington, MA: Heath.
Novaco, R. W. (2003). The Novaco Anger Scale and Provocation Inventory (NAS-PI). Los Angeles: Western Psychological
Services.
Novaco, R. W. & Taylor, J. L. (2004). Assessment of anger and aggression in male offenders with developmental disabilities.
Psychological Assessment, 16, 42-50.
Novaco R.W. & Taylor, J.L. (2006). Cognitive-behavioural anger treatment. In M. McNulty & A. Carr (Eds.), Handbook of
adult clinical psychology: An evidence based practice approach (pp. 978-1009). London: Routledge.
Novaco, R.W. & Taylor, J.L. (2015). Reduction of assualtive behaviour following anger treatment of forensic hospital
patients with intellectual disabilities. Behaviour Research and Therapy, 65, 52-59.
O’Brien, G., Taylor, J.L., Lindsay, W.R., Holland, A.J., Carson, D., Steptoe, L., et al. (2010). A multi-centre study of adults
with learning disabilities referred to services for antisocial or offending behaviour: Demographic, individual, offending
and service characteristics. Journal of Learning Disabilities and Offending Behaviour, 1, 5-15.
Taylor, J.L. (2002). A review of assessment and treatment of anger and aggression in offenders with intellectual disability.
Journal of Intellectual Disability Research, 46 (Suppl. 1), 57-73.
Taylor, J.L. & Novaco, R.W. (2005). Anger treatment for people with developmental disabilities: A theory, evidence and
manual based approach. Chichester: Wiley.
Taylor, J.L., Novaco, R.W. & Brown, T. (in press). Reductions in aggression and violence following cognitive behavioural
anger treatment for detained patients with intellectual disabilities. Journal of Intellectual Disability Research.
Taylor, J.L., Novaco, R.W., Gillmer, B.G. & Robertson, A. (2004). Treatment of anger and aggression. In W.R. Lindsay, J.L.
Taylor & P. Sturmey (Eds.), Offenders with developmental disabilities (pp. 201-219). Chichester: Wiley.
Taylor, J.L., Novaco, R.W., Gillmer, B.T., Robertson, A. & Thorne, I. (2005). Individual cognitive-behavioural anger
treatment for people with mild-borderline intellectual disabilities and histories of aggression: A controlled trial. British
Journal of Clinical Psychology, 44, 367-382.
Taylor, J.L., Novaco, R.W., Gillmer, B. & Thorne, I. (2002). Cognitive-behavioural treatment of anger intensity among
offenders with intellectual disabilities. Journal of Applied Research in Intellectual disabilities, 15, 151-165.
Taylor, J.L., Novaco, R.W., Guinan, C. & Street, N. (2004). Development of an imaginal provocation test to evaluate
treatment for anger problems in people with intellectual disabilities. Clinical Psychology & Psychotherapy, 11, 233-246.
Tsiouris, J. A. (2010). Pharmacotherapy for aggressive behaviours in persons with intellectual disabilities: Treatment or
mistreatment? Journal of Intellectual Disability Research, 54, 1-16.
Tyrer, P., Oliver-Africano, P. C., Ahmed, Z., Bouras, N., Cooray, S., Deb, S., et al. (2008). Risperidone, haloperidol, and
placebo in the treatment of aggressive challenging behaviour in patients with intellectual disabilities: a randomised
controlled trial. The Lancet, 371, 57-63.
Willner, P. (2007). Cognitive behaviour therapy for people with learning disabilities: focus on anger. Advances in Mental
Health and Learning Disabilities, 1(2), 14-21.
44
Table 1: Studies of Prevalence of Aggression amongst People with ID
NLocation
Prevalence (%)
Community Institution Forensic
Tyrer et al. (2006) 3065 England 16 - -
Taylor et al. (2004) 782 England 12 - -
Hill & Bruininks (1984) 2491 USA 16 37 -
Harris (1993) 1362 England 11 38 -
Sigafoos et al. (1994) 2412 Australia 10 35 -
Smith et al. (1996) 2202 England -40 -
Novaco & Taylor (2004) † 129 England -47
McMillan et al. (2004) † 124 England - - 47
Note. †These studies involved detained inpatients with offending histories. The prevalence concerns physical assaults post-admission.
Figure 1. Mean Novaco Anger Scale Total scores over Time. ANCOVA (WAIS-R IQ as covariate) F(1,33)
= 4.74. p < .05, r = .35
Figure 2. Total Physical Attacks Over 24 Months. ANOVA (log10), F(1,49) = 11.23, p = .002, r = 0.43.
45
Correspondence
Professor John L. Taylor
Northumbria University
Room H018, Coach Lane Campus-East
Benton, Newcastle upon Tyne, NE7 7XA, UK,
john.taylor@ntw.nhs.uk
46
A cognitive neuroscience approach to violence
Keynote speech
James Blair (USA)
The cognitive neuroscience approach with respect to psychiatry involves considering not only which neural
regions are dysfunctional in a patient population but also what functional impairments are consequences
of this neural dysfunction. This paper takes the cognitive neuroscience approach to the study of violence.
The rst thing to note is that violence/aggression is not a homogeneous behavior. A distinction can be
drawn between instrumental and reactive aggression. Instrumental aggression is aggression committed to
achieve a goal; e.g., acquiring another individual’s money. As such, instrumental aggression is like any
other form of instrumental behavior. What is interesting is that few individuals typically use instrumental
aggression to achieve their goals. This relates to a desire to avoid the negative consequences of engaging
in instrumental aggression. Importantly, the distress of another individual is a particularly salient negative
consequence of instrumental aggression. The amygdala is a core component of a circuit that orchestrates
responding to the distress of others. The level of a patient’s dysfunction in their amygdala responsiveness
to the distress of others predicts their level of instrumental aggression. It also predicts their level of
callous-unemotional traits (reduced guilt and empathy), the core emotional component of psychopathy.
Reactive aggression is aggression committed in response to threat, social provocation and frustration.
Considerable work with animals has identied a circuit that includes the amygdala, hypothalamus and
periaqueductal gray and which organizes the response to threat. Distal threats induce freezing but as they
grow closer they induce ight and, if very close, ghting. Work with animals indicates that the greater the
activity of the amygdala, hypothalamus and periaqueductal gray, the greater the likelihood that reactive
aggression will be displayed. Recent fMRI work has shown that this network shows a response to threat,
social provocation and frustration in humans also. Importantly, individuals who selectively show an
increased risk for reactive aggression show heighted responsiveness of this circuitry to threat and social
provocation relative to healthy individuals.
Aggression, including even reactive aggression, is typically a chosen behavior. Human reactive aggression
paradigms such as the Taylor Aggression Paradigm involve participants choosing a response to provocation.
Reinforcement-based decision-making, choosing actions based on the rewards and punishments associated
with them, involves a series of neural regions including ventromedial frontal cortex, dorsomedial
frontal cortex and anterior insula cortex. Ventromedial frontal cortex is particularly responsive to the
reinforcement associated with an action. This region shows increased responding when a participant is
choosing a behavior as a function of the reward associated with that choice. Decient responding within
this region should be associated with poorer response choices. These will include poorer modulation of
aggressive responses. In line with this, recent fMRI work reveals that patients showing heightened levels
of aggression show reduced modulated ventromedial frontal cortex activity when retaliating to another
individual’s social provocation. Notably, the level of failure in modulation predicts the level of reactive
aggression shown by the individual in the community.
Dorsomedial frontal and anterior insula cortices are particularly important when choosing to avoid
particular behavioral choices. Importantly, they show increases in activity as a function of the poverty of
the choice. The more a behavioral choice is associated with punishment, the greater the activity in these
regions should a healthy individual make that choice. However, recent fMRI work reveals that patients
showing heightened levels of aggression show reduced modulation of dorsomedial frontal and anterior
insula cortices as a function of anticipated punishment in decision-making paradigms. Moreover, this work
reveals that the greater this impairment, the greater the levels of antisocial behavior symptoms shown by
the patients.
In summary, the proposed paper will consider four core neuro-cognitive systems involved in emotional
responding and reinforcement-based decision-making and show how these, when dysfunctional, increase
the risk for aggression and antisocial behavior.
47
Chapter 2 – Special Debate:
“Meetings of the Minds”
Meeting of the minds: closing the gap between
violence research, education and practice
In debate with service users form the UK and Denmark
Violence in clinical psychiatry remains a major health care issue in many parts of the world. Research
and education on the prevention, minimisation and management of violence in this setting is extensive
and ongoing. In line with most research and educational initiatives, it remains a formidable challenge to
translate these activities into better care for people using psychiatric services. This session will debate how
we close the gap between violence research and education, and clinical practice.
Co-production is a method, approach and philosophy to deliver health and social scare services that uses
an egalitarian and reciprocal approach between people delivering services and those receiving them. It has
been shown to produce better and sustained outcomes for service users. It can be summed up by the phrase
‘nothing about you, without you’. Using this approach, academics, clinicians and service users will debate
with conference delegates what value violence research and education has for improving the experience of
people using mental health services where violence is present.
Topics that we will explore during this session include the role and presence of mental health service users
working collaboratively with violence researchers and educators in the design and delivery of research and
education, the possibilities and pitfalls in working with service users in violence research and education,
the issues and concerns that service users have with violence research and education, and how researchers
and educators address these and whether discourses around violence research and education disempowers
service users and impedes the translation of research and educator into better services.
Presenters
Professor Patrick Callaghan, UK - Moderator
Dr Julie Repper, UK – Discussant
Odile Poulsen, Denmark – Discussant
48
Chapter 3 – Epidemiology and nature
of violence
Patient and Visitor Violence in a South Indian
hospital
Paper
Mr. Peter Lepping (Wales)
Keywords: patient and visitor violence, India
Background
Patient and visitor violence (PVV) towards staff is common across health settings. It is has negative effects
on staff and treatment provision. There is very little data from the developing world.
Aims
We examined the prevalence of PVV in India in a government run hospital and a Missionary hospital in
South India and made comparisons with existing data.
Methods
We administered an abbreviated version of the Survey of Violence Experienced by Staff
(SOVES-A) in English in Mysore on medical and psychiatric wards in two different hospitals that serve
an underprivileged area.
Results
249 staff participated. 16% of staff in psychiatric wards was subjected to some form of PVV in the past
4 weeks which is lower than in the developed world. Fifty-seven percent of staff on medical wards
experienced PVV which is similar to the developed world. Patients and Visitors were almost equal sources
of this violence. Verbal abuse was more common than threats and physical assaults. Training in aggression
management may be a protective factor.
Conclusion
PVV is a signicant problem in India, especially on medical wards. Aggression management training may
be a way to reduce the prevalence of PVV. PVV on psychiatric wards may be reduced because of the fact
that a relative is routinely present at all times when a patient gets admitted to a psychiatric unit.
Educational Goals
• Expand knowledge of prevalence of violence in hospital settings outside Europe
• Compare PVV data
Correspondence
Mr. Peter Lepping
BCULHB, Centre for Mental Health and Society (Bangor University) and Mysore MC&RI
Ffordd Croesnewydd
LL13 7TD Wrexham, Wales (UK)
peter.lepping@wales.nhs.uk
49
The Nature of Violence: Strategies for Violence
Prevention
Workshop
Sylvia McKnight (USA)
Keywords: Risk factors, Anger, aggression, agitation, violence, psychiatric illness, organic mental
illness, assessment, early intervention, de-escalation, violence prevention initiatives, safety, mental health,
wellness and recovery.
Abstract
Violence in healthcare facilities is a prominent global concern. To prevent violence it is necessary to have an
organized plan of action against violence. It is vital to learn where violence originates and then to develop an
organized interventional plan to prevent violence. This article analyzes the origins (causes and risk factors)
of violence and delineates the process and development of an evidence based violence prevention plan
designed to negate violence risk factors and prevent violence in mental health facilities. Specic techniques
are presented for prevention and de-escalation of aggression to prevent violence. Strategies are determined
for development and implementation of effective violence prevention plan utilizing holistic evidence based
interventions to prevent/reduce violence in mental health facilities for a safe and therapeutic environment
for everyone. Implications for practice are strategies for best practice in safety and violence prevention.
Environmental, patient and caregiver interventions for prevention of aggression and violence in mental health
facilities is delineated as well as psychosocial management of aggressive behavior for safety in the healthcare
environment. An effective violence prevention educational plan is presented for holistic applications for
decreasing violence in psychiatric facilities promoting mental health, wellness and recovery.
Introduction
Violence is a prominent global healthcare concern. Violence permeates every aspect of our culture,
including mental health care organizations (Liss & McCaskell, 1994; Cole, 2005). Every year one in four
mental health nurses suffers a disabling injury from patient violence (Simon & Tardiff, 2008; Findorff et
al, 2004;Franz et al, 2010). An essential safety strategy for violence prevention is the development and
implementation of an organized violence prevention plan for mental health care facilities. A violence
prevention plan decreases violence and assists to maintain a safe and therapeutic environment for everyone.
This article describes the process of the development of an evidence based violence prevention plan with
interventional strategies effective to prevent/reduce violence in mental health facilities. The violence
prevention plan developed is based on violence origins (causes) and prevention of violence, focusing
interventional strategies to prevent the phenomenon of violence promoting safety, health, wellness and
optimal recovery outcomes.
Background
To prevent violence it is necessary to learn where violence originates (Demeo,1991; Pinker, 2011;
Copeland-Linder, Lambert, & Lalongo, 2013;Sapolsky, 2007; Littrell & Littrell,1998).Violence is dened
as an outburst of physical force that abuses, injures or harms another individual or object (Sunderland,
1997). Appropriate organized healthcare response to the phenomenon of violence requires recognition that
violence originates from multiple causes. There is robust evidence that origins of violence is associated
with patient risk factors, environmental risk factors, caregiver (nursing and mental health staff) risk factors
and that in most cases violence is predictable (Distasio, 1994).
Method
The process of developing an evidence based violence prevention plan begins with researching the
violence risk groups of patient, environment and caregiver for risk factors associated with violence as well
as researching effective strategies to negate each violence risk factor and prevent violence (Bowers et al,
2009). Extensive research was completed utilizing multiple data bases such as PubMed and CINAHL from
years 1989 to 2014. The research identied denitive risks for violence (Findorff et al, 2003). After each
group’s risk factors is identied then strategies and an interventional plan is developed from best practice
to reduce/eliminate each risk for violence.
50
Patient violence risk factors
Literature review on patient risk factors for violence indicates there are primary groups that are associated
with increased risk of violence. The rst high risk group for violence are those individuals with a diagnosis of
psychosis such as schizophrenia or bipolar disorder (Hodgins, 2008). The second high risk group is organic
patients with neurological or medical disorders such as brain injury, dementia, organic brain syndrome,
alcohol or drug intoxication, infections, delirium or degenerative diseases of brain. The last high risk group
for violence is personality disorders such as borderline personality disorders known for poor impulse control
(Umhau, Trandem, Shah, & George, 2012). Mental instability increases the risk of directed violence toward
others. Indicators for primary motivation for violence include 1) disordered impulse control, 2) psycopathy
and 3) symptoms of psychosis (Simon & Tardiff, 2008). The presence of delusions or command hallucinations
with violent content is an indicator of greatly increased risk of violence in that individual.
Environmental violence risk factors
Environmental risk factors may contribute substantially to the risk of violence. Research suggests that
environmental factors such as levels of stimulation can affect the risk for violence. Environmental factors
of excessive external stimuli such as noise or physical activity is associated with violent behavior. An
environment that is devoid of therapeutic groups and activities contributes to boredom and also increases
risk of violence. Changing environments such as during renovation may increase risk of violence (Chou,
Kaas, & Richie, 1996). A major contributing environmental factor is lack of unit structure and a predictable
schedule. The most common times for inpatient violence are at meal times when patients have eating
utensils and during shift change (Johnson & Delaney, 2007; Lehmann, McCormick, & Kizer, 1999).
Caregiver violence risk factors
Evidence based research on caregiver violence risk factors indicates caregiver characteristics greatly
contribute to the risk factors for inpatient violence. The educational level of the caregiver staff impacts
risk of encountering violence. Staff members that attend education on violence prevention reduce their
risk of becoming a victim of violence (Chou, Lu, & Mao, 2002). Caregivers work experience and attitude
effect the risk of a violent encounter staff (Simon & Tardiff, 2008; Lanza, 1991).
Analysis
The violence prevention plan is developed in a three domain framework of patient, environment and
caregiver. The violence risk factors were delineated and separated by each domain. After the risk factors
were divided the violence prevention interventional strategies were also separated by patient, environment
and caregiver. Each risk factor was then paired with the most effective interventions to negate each violence
risk factor. The educational interventions were then structured into an interventional framework that formed
the violence prevention educational plan. The completed violence prevention plan is listed in gure 4. The
interventional plan is implemented as an organized structured plan to reduce inpatient violence.
Patient factors admission risk assessment for safety
To address patient risk factors for violence it is necessary to understand that violence is a common reason
for psychiatric evaluation and admission to a mental health facility. Over 10% - 40% of mental health
admissions are to address aggression and violence issues (Swanson, 1994; Singh, Fazel, Gueorguieva
& Buchanan, 2014). Research indicates violence prevention begins the rst day a patient is admitted
with an effective risk assessment (American Psychiatric Association (APA), 2008; Gately, & Stabb, 2005;
Haggard-Grann, Hallqvist, Langstrom, & Moller, 2006). Strong clinical admission assessment is one of
the most vital interventions to prevent healthcare violence (Singh, Fazel, Gueorguieva, Buchanan, 2014).
It is imperative that an efcient violence prevention plan include a risk assessment on admission as a
critical part of a comprehensive mental health assessment. Violence prevention includes professionals
routinely assess, document and monitor dynamic risk factors for violence (Singh et al, 2012; McKnight,
2011). An admission risk assessment based on Joint Commission recommendations is listed in Figure 1.
Risk assessments increase staff awareness and safety to anticipate and potentially prevent aggression and
violence (Hamrin et al, 2009; Johnson & Delaney, 2007). It is important to include risk factors for assault
and violence in the initial evaluation of the patient and ongoing (Abderhalden et al, 2008). Vital assessment
also includes identifying the situations which trigger a patient’s violent response. The admission assessment
on violence triggers is seen in Figure 2. The assessment assists in identifying precursors to violence that
may be diminished or eliminated from the environment to prevent episodes of violence or self harm until
the patient becomes emotional stable (Chabora, Judge-Gorney, & Grogan, 2003).
51
Figure 1 – Admission Risk Assessment
Danger to Self or Others: Yes
No
Homicidal Thoughts ____________________________________________
Homicidal Plan ____________________________________________
Homicidal Intent ____________________________________________
Homicidal Means ____________________________________________
Suicidal Thoughts ____________________________________________
Suicidal Plan ____________________________________________
Suicidal Intent ____________________________________________
Suicidal Means ____________________________________________
Figure 2 – Admission Assessment of Violence Triggers
Do any of the following render you emotionally upset, stressed or agitated/violent?
Touch
Shouting/Loud Noise
Physical Force
Restraints
Derogatory Name Calling
Television
Uniforms
People Crying
People Angry
Isolation
Threats
Other ____________________________________________________________
A de-escalation assessment is an important part of an admission assessment to prevent violence. An
example of a de-escalation assessment is seen in Figure 3. The purpose of the de-escalation assessment is
to obtain information on personal preferences of interventions that are effective in calming the individual
to prevent harming behaviors. It is important to integrate all the assessment factors into the treatment plan.
Figure 3 – De-escalation Assessment
Do any of the following activities assist you to calm when under stress?
Watching TV
Going for a Walk
Deep Breathing Exercises
Working with Puzzles/Games
Time Alone/Quiet Time
Physical Activity
Medication
Speaking to Family, Friends or Staff
Reading a Book, Bible or Magazine
Taking a Nap
Music
Warm Blanket
Other _____________________________________________________
52
Caregiver Factors De-escalation Training for Violence Prevention
Evidence based research indicates that early intervention and de-escalation training of mental health staff
greatly reduces the risk of violence (Chabora, Judge-Gorney, & Grogam, 2003; United States Department
of Health and Human Services, 2007). Figure 3 lists therapeutic de-escalation techniques to reduce/
eliminate agitated states and prevent risks for violence. Adequate acuity based stafng is important as
staff need to be available to intervene at the rst sign of agitation to prevent violence (Biancosino et
al, 2009). Focus on elements of treatment plan to prevent violence, eg. de-escalation, prn medication,
special observation one-to-one, and coping skills development (Timko et al, 2012). If these least restrictive
alternatives fail the last resort for violence prevention is seclusion or application of a physical restraint
per hospital policy.
Caregiver factors minimizing personal risk
The literature review indicates that staff education and training in interpersonal skills is effective for
improving safety and violence prevention. Education and training programs in communication skills
of empathy, listening, and low expressed emotion to role model calmness greatly reduces the risk of
patient violence (Rice, Harris, Varney, Quinsey, 1989). Provide staff with clinical supervision to review
interactions with patients such as debrieng to review techniques to prevent future violence.
As a professional interacting with patients daily it is important to implement strategies to decrease personal
risk for encountering violent behavior. For safety utilize nonthreatening body language. Respect the
patient’s personal space when interacting (Umhau et al; Sifford-Snellgrove, Beck, Green, & McSweeney,
2012). Choosing to leave the door open while conversing is important for personal safety. Remember to
never become isolated with an agitated person.
Environmental factors changing healthcare culture
Research suggests that hospital environments affect patient behavior in either a positive or negative
manner. Promoting a healing environment with therapeutic activities will benet in reducing episodes of
violence. It is important to reduce and mitigate risk during times of transition. It is vital staff be available
for therapeutic intervention and de-escalation even during shift change (Hamrin, Lennaco & Olsen, 2009).
Create comforting and calming physical environments (Felgen, 2004). Encourage staff to increase time
staff spend on the unit observing, assessing and interacting with patients to encourage therapeutic rapport
and prevent violence.
Environmental factors improving milieu structure
Environmental interventions for violence prevention include a unit culture that provides meaningful and
predictable unit activities. Unit activities and groups with structure and schedules posted and given to
patients as well as consistency in rules and staff roles is benecial (Adamson, Vincent & Cundiff, 2009).
Promote peer advocates as mentors and facilitators of patient centered care (Henry, Miller-Johnson,
Simon, & Schoeny, 2006). Plan a conict resolution group to voice and air issues before open conict
erupts. Introduce an anger management group to assist in self control of aggressive impulsive behavior.
An exercise group is benecial to release endorphins which are the bodies natural calming hormones to
restore homeostasis.
Environmental factors safety in milieu control
The hazardous item search is important to maintain a safe therapeutic milieu for everyone (Damon,
Matthew, Sheehan, Uebelacker, 2012). All patients and belongings are searched for hazardous items when
entering a mental health unit (Rice, Harris, Varney, Quinsey, 1989). A very careful head to toe body pat
search and a metal detector scan is completed for prevention of dangerous items entering the secure unit.
Environmental factors psychosocial management of aggression
One of the most vital interventions for management of aggression to prevent violence is direct
communication between patient, provider and staff (APA, American Psychiatric Nurses Association
and National Association of Psychiatric Health Systems, 2007). To facilitate communication minimize
any sensory decits by providing eyeglasses and a hearing aid (Sifford-Snellgrove, Beck, Green &
McSweeney, 2012; Negley & Manley,1990). Emphasize patient strengths and the hope of recovery. Offer
creative treatment combinations to promote holistic healing and violence prevention.
53
Figure 4 Violence Prevention Plan
Violence prevention plan
Violence Risk Domains Violence Prevention Interventions & Strategies Rationale
Patient Factors - Risk assessment on admission
- Mental Health Assessment (hx violence, substance/
ETOH abuse, psychosis)
- Early intervention and de-escalation
- Patient education (group therapy, recovery groups,
psycho-education, activity therapy, cognitive behavioral
therapy, anger management, conflict resolution group,
community groups, coping with symptoms groups,
medication groups, and stress management groups) for
coping skills development
- Peer mentors for support
- Provide patient with other outlets for stress and anxiety
(exercise, listening to music, talking to a friend or
staff member, attending support groups, participating
in sports)
- Direct communication with caregivers and provider
- Decrease environmental stimulation
- PRN (when needed) medication
- Special observation one-to-one
- When interpersonal and pharmacologic interventions fail
last resort is seclusion and restraint
- Helps nurse/provider identify triggers for aggression,
factors that can mitigate or reduce risk of anger and
physical aggression especially with early intervention
- Early intervention with de-escalation techniques greatly
improves chances of successful de-escalation
- Patient education to develop coping skills, learn systemic
and effective approaches to dealing with and mastering
tough life situations/problems.
- Peer mentors for social support and as positive role
models of recovery
- Alternative means of channeling aggression and angry
feelings can assist to decrease anxiety and stress and
allow for calming
- Clear lines communication to establish trust & rapport,
verbalization of feelings may assist to resolve issues.
- Stimulating environment may increase levels of anxiety
- Medications reduce immediate aggression and anxiety to
prevent escalation to violence
- Patients at high risk for violence require close
observation to prevent harm to self or others
- Hospital protocols are clear & well written on when
to implement as a last resort when least restrictive
measures have failed to ensure safety of patient and
others
Environmental Factors - Create caring and healing, calm therapeutic
environments
- Ward design for optimal observation
- Mitigate risks during times of transition
- Educational posters on unit teaching healthy appropriate
behavior
- Stagger shifts so they overlap to maximize staff
availability
- Staff dining with patients during meal time to develop
rapport and
observing for safety
- Provide group & activity schedules
- Hazardous item search
- Decrease/prevent long lines
- Control access to entrances and exits
- Therapeutic music and television
- Implement group therapy, psycho- education groups,
recovery groups,
activity therapy and exercise groups
- Provide predictable, safe, orderly & respectful
environment
- Activities & groups during days, evenings, weekends and
during shift changes
- Keep environmental stimulation to a minimum (e.g.,
lower lights, decrease noise, calm milieu or take patient
to a another area
- Environments with a calm safe therapeutic environment,
safe staffing levels, meaningful activities and group
therapy decrease harmful stimuli and promote optimal
recovery outcomes.
- Increased stimulation increases patients anxiety level
which leads to increased agitation and aggression risks
54
Caregiver Factors - Caregiver Mental Health Learning Needs Assessment to
identify educational gaps for education and competency
development
- De-escalation & Violence prevention training
- Crisis Intervention Training
- Management of aggressive behavior
- Conflict resolution training
- CPI (crisis prevention institute) or PMDB (prevention &
management of disruptive behavior) training
- Therapeutic & Interpersonal Communication skill
development
- Intervene early and de-escalate
- Offer availability to talk
- Encourage verbalization of issues and precipitating
events
- Introduce yourself
- Call patient by his/her proper name and Mr. or Mrs.
- Develop listening skills
- Acknowledge, validate & encourage individual to discuss
feelings
- Show respect in words and interactions
- Remain calm, non-confrontational & never shout
- Role model calmness
- Nonthreatening body language
- Debrief
- Increase time observing and assessing patients in milieu
- Maintain reliability and consistency &-Adequate personal
space
- Minimize personal risk (open door, short hair, post
earrings, avoid objects around neck)
- Acuity based staffing
- Education & training in early therapeutic intervention,
risks, communication skills and techniques of
de-escalation as well as violence prevention reduces risks
of encountering violence.
- Verbalization of feelings in a non threatening
environment can diffuse an agitated state
- Develops therapeutic rapport and shows respect
which reduces risk of aggression
- Calm matter of fact approach can help interrupt cycle
of violence
- Discussing events can lead to better understanding and
decreases emotional impact as well as may prevent
future aggressive or violent acts
- Early intervention may prevent aggressive response to
command hallucinations or delusions
- Essential for developing trust and therapeutic rapport
- Know well the units safety precautions for
staff as well as patient safety to prevent injury
- Providing adequate staff availability for observation,
monitoring and early intervention with de-escalation
decreases risk of violence.
Discussion
The violence prevention plan suggested in Figure 4 addresses the critical areas of violence origins
for effective strategies to prevent violence in mental health facilities for safe holistic care. A violence
prevention plan addressing the holistic risk factor domains of patient, caregiver, and environment are
effective as an organized method to reduce/prevent healthcare violence. The violence prevention plan
suggested is comprehensive and therapeutic, educating and implementing best practice in violence
prevention for a safe healthcare environment.
The disadvantage of the violence prevention plan is it implements comprehensive change. The complete
implementation of the plan takes several months of tiered education and training in violence techniques
as well as environmental changes. The plan introduces effective patient assessment as well as staff and
patient education. Environmental changes are extensive to create a caring and healing environment for
recovery oriented care. The nursing and mental health staff education suggested for violence prevention is
in-depth and requires educational time off the units for training.
The major advantage of the violence prevention plan is it empowers holistic applications for safety.
Healthcare violence has more than one point of origin. Holistic applications utilizing the framework
of patient, environment and caregiver comprehensively addresses the multiple origins of violence for
effective interventions and strategies to prevent/reduce violence in mental health facilities.
Conclusion
Violence in mental health facilities is preventable with early assessment and interventional strategies for
safety. Violence prevention plans targeting the causes of inpatient violence will greatly improve safety
55
for all individuals in the therapeutic mental health care environment. Safety is improved with holistic
application of interventions focused on the patient, caregiver and environment risk factors to prevent
violence. Holistic applications for violence prevention will greatly benet everyone and is truly the future
of safe mental health care. Implementation of a violence prevention plan will improve care and provide
a safe therapeutic mental health environment. Research is needed into advanced application of violence
prevention plans into all healthcare environments. The violence prevention plan is versatile, improves
safety, and can provide optimal recovery outcomes, improving the lives of vulnerable populations
promoting health, wellness, and recovery.
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Educational Goals
• Develop and Implement evidence based strategies for violence prevention
• Implement therapeutic violence prevention principles for healthcare facilities
Correspondence
Ms. Sylvia McKnight
University of Alabama
P. O. Box 371
76643 Hewitt, Texas
USA
Smcknight541@gmail.com
57
From Psychomotor Therapy for Psychiatric Patients
to Suicide Prevention through Adapted Physical
Activity and Sports Participation
Paper
Herman Van Coppenolle, Svetlana Belousova & Ejgil Jespersen (Belgium)
Keywords: psychomotor therapy, suicide prevention, adapted physical activity, sports participation
Abstract
We started-up psycho-motor therapy in Europe in 1965 and promoted it world-wide through European and
Erasmus Mundus Master courses for 600 international students in Adapted Physical Activity. In this way
we had good therapeutical results with psychotic, depressive and anorexia nervosa patients.
However we wanted to use Adapted Physical Activity and Sports Participation not only as Therapy but
also as life-saving suicide prevention tool. Literature research showed indeed the protective value against
Suicide of Adapted Physical Activity and Sports Participation. Participation in Exercise and Sports resulted
in more physical self-esteem, better social relations and less suicidal ideation
Starting from these hopeful research data we can assume that an individualized sports program could
have a protective and Suicide prevention effect. We are now researching this in the University of Southern
Denmark in Odense and in the University of St. Petersburg in Russia. If we are able to demonstrate this
preventive effect we will have contributed to reduce one of the most important international problems in
many countries: suicide.
Educational Goals
• Demonstrate the positive effect on reducing the number of suicides though Adapted Physician Activity
and Sports Participation
Correspondence
Mr. Herman Van Coppenolle
Faculty of Kinesiology and Rehabilitation Sciences KU Leuven
Beekstraat
3070 Kortenberg
Belgium
herman.vancoppenolle@faber.kuleuven.be
58
Prevalence and risk factors of violence by
psychiatric acute inpatients: A systematic review
and meta-analysis
Paper
Giovanni de Girolamo, Laura Iozzino, Clarissa Ferrari, Matthew Large & Olav Nielssen (Italy)
Keywords: Violence, inpatient unit, schizophrenia, substance use, lifetime history of violence, meta-
analysis.
Background
Physical violence in acute psychiatric wards is a major problem, not only because of the potential for injury
to patients and staff, but also because of the counter therapeutic effects of both violence and measures to
prevent violence.
However there is wide variation in the reported rates of violence in mental health care settings, which
might be due to real differences in the rates of violence between wards, differences in the denition of
violence, differences in the duration of measurement and methods of data collection, and variations in the
level of under-reporting of aggressive incidents by mental health care workers
Aims
The aims of this study was to use systematic meta-analysis in order to estimate the pooled rate of violence,
in terms of period prevalence, in acute psychiatric wards, and to examine the characteristics of the
participants, and aspects of the studies themselves that might explain the variation in the reported rates of
violence (moderators)..
Methods
Studies were identied by searching the electronic databases Cumulative Index to Nursing and Allied
Health Literature (CINAHL), Scopus and Pubmed. Queries were limited to articles published in all
languages between January 1995 and December 2014 and reporting data on violence in acute psychiatric
wards of general or psychiatric hospital in the 31 countries classied as “high-income countries” by the
World Bank.
Results
Of the 23,972 inpatients described in 35 studies, the pooled proportion of patients who committed at least
one act of violence was 17% (95% condence interval (CI) 14-20%). Studies with higher proportions
of male patients, involuntary patients, patients with schizophrenia and a history of alcohol use disorder
reported higher rates of inpatient violence.
Conclusion
The ndings of this study suggest that as many as 1 in 5 patients admitted to acute psychiatric units commit
an act of violence. Factors associated with levels of violence in psychiatric units are similar to factors
that are associated with violence among individual patients (male gender, diagnosis of schizophrenia,
and substance use and lifetime history of violence). Establishing the risk factors for violence in acute
psychiatric inpatients may enable researchers and clinicians to devise strategies to prevent and manage
violence in psychiatric wards.
Educational Goals
1. To present rates of violence in different mental health care settings;
2. To examine the characteristics of the participants, and aspects of the studies themselves that might
explain the variation in the reported rates of violence
59
Correspondence
Mr. Giovanni de Girolamo
IRCCS St John of God
Pilastroni, 4
25125 Brescia
Italy
gdegirolamo@fatebenefratelli.it
60