Hello and welcome. I'm Shireen Khan, Senior Director of Workforce and Organizational Development at Thresholds, Illinois' oldest and largest provider of community mental health services and social work expert for SMI Advisor. I am pleased that you are joining us for today's SMI Advisor webinar, A Clinician's Guide to Violence Risk Assessment in Persons with Serious Mental Illness. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now I'd like to introduce you to the faculty for today's webinar, Dr. Deb Pinals and Dr. Charles Scott. First, Dr. Charles Scott. Dr. Scott is Chief of the Division of Psychiatry and the Law Forensic Psychiatry Fellowship Training Director and Professor of Clinical Psychiatry at the University of California Davis Medical Center in Sacramento, California. He is board certified in General Psychiatry, Child and Adolescent Psychiatry and has added qualifications in Forensic Psychiatry and Addiction Psychiatry. Dr. Scott is a past president of the American Academy of Psychiatry and the Law, the AAPL, and is also a past president of the Association of Directors of Forensic Psychiatry Fellowships. He has served as a member of the AAPL National Task Force to develop guidelines for the evaluation of criminal responsibility and competency to stand trial. Dr. Scott is one of four National AAPL Forensic Psychiatry Review Course Faculty Instructors and in 2008 received the AAPL Award as the most outstanding Forensic Psychiatry Fellowship Program Instructor in the United States. And second, we have Dr. Deb Pinals. Dr. Debra Pinals serves as the Director of the Program in Psychiatry, Law and Ethics and as a Clinical Professor of Psychiatry at the University of Michigan Medical School. She is a Clinical Adjunct Professor at the University of Michigan Law School. She also is a Medical Director of Behavioral Health and Forensic Programs for the Michigan Department of Health and Human Services. She is board certified in Psychiatry and Forensic Psychiatry and is a board certified in Addiction Medicine. From 2008 to 2016, she was the Assistant Commissioner of Forensic Services and between 2012 and 2014, she was the Interim State Medical Director for the Massachusetts Department of Mental Health. During her career, she has been a Clinical Psychiatrist in Community Mental Health, Inpatient Settings, Forensic and Correctional Facilities, Emergency Rooms and Court Clinics. Thank you so much for leading today's webinar and I'll turn it over to you Dr. Pinals and Dr. Scott. Great, thank you so much for that very nice introduction and it is a pleasure to be here on SMI Advisor. Neither I nor Dr. Scott have any financial relationships or conflicts of interest to report. Today we're going to be talking about violence risk assessment and our hope is that upon completion of this activity, you will be able to describe some of the challenges clinicians face in considering violence risk assessment, discuss studies that have examined the relationship of serious mental illness and violence and describe clinical approaches to violence risk assessment and risk mitigating interventions. We're going to start with the first objective, describing challenges clinicians face in considering violence risk assessment. Violence risk assessment is actually quite common and a necessary component of clinical work in mental health, regardless of the context in which one works, emergency rooms, inpatient medical floors, inpatient psychiatric units, outpatient clinics or in specialized assessments for civil commitment, risk of harm to third parties like tear us off, stalking, fire setting, sex offending kinds of work or release from forensic hospitals. We find ourselves in situations where patients may present and we are under the responsibility of doing violence risk assessments. It's not that patients with serious mental illness are extremely dangerous and we've talked about this in other kinds of webinars, but nonetheless, it is an important component of clinical work. There are many clinical challenges in doing these violence risk assessments. For example, in an emergency room setting, there is the need to work quickly. You may not have all the data that you wished you had and you have to figure out whether this person needs to be hospitalized, even involuntarily, or whether they can be discharged safely to their home or community-based setting. There may be limited training that you feel that you have in conducting a violence risk assessment. There are ever-evolving research and risk assessment tools that are discussed in the literature. Of course, when we talk about violence risk assessment, there's a lot of trepidation because of fears of bad outcome and liability. Nobody wants the patient that they saw to be somebody who goes out and harms somebody else. Although we're getting better and better at suicide risk assessment, the conversation about violence risk assessment is less common. We're hoping that by going through today's webinar, you will feel more comfortable with this task of violence risk assessment. By going to our next objective, we're going to discuss studies examining the relationship of serious mental illness and violence to help you understand some of that context. First of all, it's always important to realize that there's a great deal of stigma that comes with serious mental illness. We have to be aware of it even in ourselves as mental health professionals. In a poll that was published in 2013 in the New England Journal of Medicine, people were asked about whether they thought individuals with mental illness were more dangerous than not. Of the people polled, and this was just lay people being polled, about half who responded felt that people with mental illness were not just more dangerous, but were by far more dangerous than those without mental illness. A third of people didn't even want to work with people. Only a third of people, excuse me, only a third of people were willing to work with people with mental illness, which meant that two-thirds were not. Many didn't favor insurance coverage that was on par with medical coverage. Only 60% of people wanted to see more spending on mental health treatment. While that's good that the majority did want to see that, that means that 40% of people didn't. We have a lot to overcome in terms of stigma when it comes to people with mental illness and violence. Next slide. Well, if we look back at the literature, it's really important to think about how far we've come in understanding the role of serious mental illness and violence. This early study by Jeff Swanson and colleagues looked at the epidemiologic catchment area surveys and found, and published in 1990, found that compared to people with no disorders, people with serious mental illness were not the people that were most at risk for reporting violence within the last year. It was individuals with substance use, including alcohol use or other drug use and dependence, that were much more significantly likely to report violence within the prior year. Now, it's not that people with serious mental illness didn't have some increased risk, but they weren't the most at risk. We're going to go through this a little bit further in looking at other studies. The most methodologically sound study to date was published in 1998 by Hank Steadman and colleagues, and it was known as the MacArthur Violence Risk Assessment Study, and it's still relevant today. This study tracked people, about 1,000 people who were discharged from civil psychiatric hospitalization, acute psychiatric units, across three cities, and they followed patients every 10 weeks for one year. They were tracking them for whether they engaged in violence, and the way they tracked them every 10 weeks is they would ask the individual themselves whether they had engaged in violence. They would look at agency records, such as arrest records and hospitalization records, as well as speaking to a collateral source. They would ask the individual to identify a collateral source who knew them well, to say whether that individual was violent or not during the 10 weeks prior. And then what they did was they defined violence, which many studies hadn't done previously. They defined violence as either battery resulting in injury, weapon use or sexual assault, or other aggressive acts, battery without injury. Oftentimes, prior studies subsumed both in one category, and thus you couldn't distinguish between what was really the violence that we're really worried about versus lower level acts, other aggressive acts that might generate some worry, but not as much as certainly violence contributing to injury or involving weapons. And there's some key points that I think are still relevant today. First of all, agency records alone underestimated violence by a factor of six. That's really interesting because it's really important to look at agency records and prior hospital records, and we certainly recommend that from a risk management perspective. However, it may not tell the full story. The other important nugget was that self-report actually provided the highest proportion of data. In other words, asking patients about their history of violence has a high yield. Medical sources also provide a more robust picture with each source of information being additive. So in other words, asking the patient, looking at other records, and maybe talking to somebody who knows the patient would be a way of triangulating the information, getting the most information for you to do your assessments. Also, the rate of violence varied across follow-ups in time, but the time period before and just after discharge seemed to be the greatest risk period, which tells us a lot about the importance of doing careful discharge planning because people might still have a period of instability. Other key findings from this study showed that co-occurring substance use was a major risk factor for violence, and that mental illness alone is not a homogeneous category. When they looked at one-year prevalence rates of violence, the most significant group were those that were found to have other mental disorders, like personality disorders, combined with substance use, whereas people with major mental disorder, i.e. people with serious mental illness, without substance use were in the lowest risk category. If you combined substance use, that risk jumped up, and it is true that people with major mental disorders are at higher risk for having substance use disorders, but we need to think about substance use as a major contributor to violence in our society. In another study, the NISARC data study, Albogan and Johnson reported out of over 34,000 subjects that the incidence of violence was significantly higher for people with mental illness, but only for those with co-occurring substance use disorders, so we see the same theme. They also found that there were other factors associated with violence that were reported more commonly by people with mental illness, and so this is very relevant, but they involved the history of past violence, juvenile detention, the history of trauma in childhood, physical abuse, and even parental arrest records, as well as the concomitant substance use and the perception of threat. Age, sex, and income were also correlated with violence, and contextual factors like recent divorce, unemployment, or victimization. Trauma and violence becomes a major theme. We know that PTSD symptoms can predispose youth towards impulsive violence, and PTSD, especially in combination with substance use or comorbid other psychiatric conditions, may increase the risk of violence among veterans, so paying attention to those trauma histories can also help us as we do those violence risk assessments. So what are the summary points from the violence research? Most persons with mental illness are not violent. Most violence is not caused by persons with mental illness. Substance use is a major risk factor for violence, but that said, there is a small relationship between violence and mental illness where the relative risk is about three to five times the general population, and substance use with mental illness increases the risk more than either alone. Trauma is a risk factor that needs further study but should also be taken into account. Now we're going to go to objective three, which is looking in depth at clinical approaches to violence risk assessment and risk mitigating interventions. So first things first. When we are looking at violence risk assessment, it's important for clinicians to feel safe. If you are feeling unsafe in a patient encounter, it's important that you seek help. Maximize safety and comfort for both the patient and the interviewer so that you can do a proper assessment. That may mean that you want to bring an observer in the room, even in an outpatient clinic. Also you want to be aware of what options you have for safety and security. If weapons are revealed during a clinical contact, you need to have a strategy for seeking assistance. You want to try to avoid small rooms, which can make people more stressed during interviews, so having more space for people to feel like they have some opportunity to get up and to leave. Also, you want to consider strategies during your patient encounter about communicating concerns if the patient appears agitated or threatening and how to end the interview if agitation escalates. I really recommend that people have such strategies kind of mapped out in their mind and that they practice scenarios so that they know how to keep themselves safe. Most clinical encounters, of course, are going to be safe, but you want to just plan for those situations where it may get escalated. Also remember that your job is not to predict risk. We're not soothsayers. Chance prediction can be better than chance in short term, but you're really going to have a hard time if you think your job is just predicting risk. There's false positive rates that are going to be high. In other words, we tend to overpredict risk. We overpredict violence. The more we're looking at dangerousness, any behavior that could be construed as dangerous, even something that doesn't create serious harm, will create a tendency towards overpredicting violence risk. What we really want to move to is violence risk assessment, which is looking at contextual variables that look at the magnitude, imminence, likelihood, and frequency that somebody might engage in violence, which has increased utility as we look at clinical treatment planning and deciding level of care needs for individuals who may need to be hospitalized or may be able to be safely supported in the community. As we look at guided clinical interviews, we're going to look at demographic variables, often things that are not going to be changeable, historical variables, also not changeable, and then situational factors as well as clinical factors that are able to be changed through treatment interventions. Demographic risk factors that place people at increased risk of violence include being in the late teens and early 20s. In general, males more than females, except when we're talking about serious mental illness, where we may see an equalizing effect of being male or female in terms of the risk of violence. Lower socioeconomic status, lower IQ, employment instability, and residential instability can contribute to increased risk of violence. We also know that, again, trauma is a major factor to pay attention to. Individuals who've had adverse childhood experience and early behavioral problems can be more at risk for later behavioral problems, even as adults. This is when controlled for race, gender, and ethnicity. In other words, it's those early childhood experiences that contribute potentially to greater risk, even as adults. Historical factors are also important to take into account. Past violence is a strong predictor of future violence, but not everyone will have a past history of violence who you might be worried about. However, you do want to pay attention to those individuals with a past history of violence. For example, risk factors might include the age at first offense. The younger, the early offending, and the pattern and frequency of violence that's happened in the past may be something to consider as you're looking at this individual's escalated risk in the future. Also the degree of harm towards others. Individuals who have engaged in serious violence in the past where others have been harmed are at risk for doing so in the future. You want to assess what their history was like. Why was it like this? What were the feelings and reasoning behind the violence? What were their life circumstances at the time? Maybe their life circumstances have completely shifted. Were there weapons involved? And weapons can involve firearms. They may involve bats, other types of knives, things like that. And so you really want to understand what their history is with weapon use. So what was the result of the violent act? Were they incarcerated? Were they hospitalized? Was there planning involved? Or was it more of an impulsive violent response? All of that can help you understand what is increasing this person's risk and what strategies might be able to be put in place in terms of risk mitigation. Now, very often a violence risk assessment today includes just one single question. Are you having any thoughts about hurting or killing others? And often clinicians are awkward in asking that. And they're more than happy when they hear a no answer and then they can move on. It is the most frequently asked violence risk question, but it may not yield the full risk picture. So I would encourage you to think about violence screening questions that can help give you a little bit of a broader brush that will then help you understand whether you need to delve further. And Dr. Scott will be going over more details, especially with people with serious mental illness. But in general, some of the violence screening questions might be, do you ever have thoughts about hurting someone else? That's what I said before. What's the most violent thing you've ever done? Is there anyone you hold a grudge against? How would you describe your temper? Is there anything or anyone that is making you afraid? Do you carry any type of weapon for protection? Have you ever had to use it or come close to using it? You can see that these are broad, open-ended questions that allow for dialogue without shame to help understand what's going on for this person in terms of their violence potential. Situational factors are other things that we have to pay attention to. What are the current stressors that somebody might be feeling? What social supports do they have that might be mitigating and help them refrain from violence? If they have preoccupation with certain types of victims, is this someone that can overcome those victims? If they're having some thoughts about harming, let's say, a family member who might be at risk, is that individual aware? What is their size and what is their strength? Does the person have weapons and means to engage in violence with those weapons? Is there any way to think about means reduction like we do for suicide risk? What about substance use? Is substance use a big factor for this individual? And if so, what is that availability? And for somebody with a history of violence, are there situational factors that sound very familiar to prior circumstances in which violence ensued, in which case we want to think about what can be done to, again, mitigate and change those circumstances for that individual and help them change it themselves. Clinical risk factors might include looking at symptoms of major mental illness, which Dr. Scott will get into, personality factors, which the MacArthur study pointed to as well as being relevant to violence risk, and then their mental health history. If their mental health history was associated with agitation, aggression, or violent behavior, what is their treatment adherence and response? Have they been hospitalized? Do they have a prodromal symptom pattern, something I spend a lot of time talking to patients about who've engaged in violence to understand are there ways that we can identify safety planning so that if their prodromal symptom pattern starts to emerge, like difficulty sleeping, getting tons of energy, then we can sort of pay attention to that more closely. Their substance use history, and again, the relationship between the past violence and their mental health and substance use is going to be very important to delineate. A clinical examination that goes beyond a general mental status examination would look at does this person engage in violent fantasies, and if so, how much of their time is spent in violent fantasies? Do they have negative attitudes, sort of antisocial attitudes where they really don't care about harming others? It doesn't bother them. Again, access to weapons and suicidal thoughts. Sometimes these two are linked, suicide and violence. What about their level of irritability, their level of anger about a particular issue, their likelihood of engaging in an impulsive act, level of fear and suspiciousness can contribute to violence, whether it's delusional or not, and you'll hear more about that later. What's their insight and judgment about their current condition and their current risk for violence? Again, their current treatment, are they adhering to treatment? Is the treatment effective? If they're not adhering, why not? Are they having side effects from medications and because they don't like the medicines, they don't take the medicines? Are there ways to adjust that? What about hallucinations and delusions, a complex area in violence risk assessment that Dr. Scott will talk about next? All of these things are going to be relevant in the clinical examination of violence risk assessment. With that, I'll turn it over to Dr. Scott. All right. Thank you so much Dr. Pymance for that outstanding review of the literature, looking at both situational and historical factors for violence. What I'd like to do now in the next several minutes is drill down into some of the most common psychotic symptoms we see in individuals with serious mental illness and correlate the published literature about which symptoms and what type of symptoms in your patients are associated with an increased risk of violence. Let's start off with one of the most common psychotic symptoms and that's command auditory hallucinations. For purposes of our webinar, this is defined as an auditory hallucination that provides some type of directive to the individual. And this is important because about half of patients with hallucinations will actually experience a command auditory hallucination. So now I'm going to pose to you the question, if you were asked in your clinical work, what factors increase the risk of acting on a command to harm others? What might be the answers you could provide and also use to help screen your patients? So let's start. The first that's been noted in the literature is if the person experiences the command hallucination as a very powerful voice, that may result in a subjective loss of control with feelings of powerlessness and helplessness. So you would definitely inquire about how they perceive the voice and the strength of the voice as it relates to them. Second, you would ask, does the voice direct you in some way with a command hallucination? And if you follow the directive, will that benefit the individual? For example, the person might feel that their suffering will diminish or there'll be some other emotional benefit if they follow the command. So you would ask, do you think that if you act on the command, it'll help you in any way? Next is having something known as a mood congruent delusion. And as you know, a delusion is a fixed false belief and a mood congruent delusion is going to be a delusion that's consistent with a person's reported mood. And so I want to pose to you this example. Imagine a man who loves his wife dearly. He's very depressed and he starts to hear a voice telling him to kill his wife. He's having a serious command auditory hallucination. That alone may not increase the risk, but if he started to have the delusion that his wife has been taken over by an exterior or a force, or it may be some type of syndrome where someone else has invaded her body and is no longer his wife, he is much more likely to act on that delusional belief if it is consistent with the content of the auditory hallucination. And again, he has that mood congruent delusion. So you would ask if someone has a command auditory hallucination, do you have any other beliefs that are either bothering you or that you're experiencing that relate to what the voice is telling you to do? The fourth evidence-based factor that increases the risk of acting on the command hallucination is if the individual is also experiencing some type of negative emotion. So there's an increased risk if the person feels symptoms of anger and anxiety or sadness related to the voice. But if the voice calms them or provides them some sort of sense of happiness, there may actually be a decreased risk. So here again, you can ask very specific questions for your risk formulation. So we've learned probably from day one as a psychiatrist, it's important to ask a person, how does that make you feel? And no more important situation than that of a person having a command auditory hallucination. All right. So if you had a screening checklist for really important questions, and you could do this either in the emergency room setting, inpatient setting, in your outpatient clinical setting, have the person describe the voice. Ask them if the voice tells them to do anything. Do they feel they have to obey? Have they tried to escape it? Have the voices actually stopped them from doing something they might've done? Here you're looking at, do they actually take actions or stop doing something based on a command auditory hallucination? So they do have influence by the voice. And then finally, again, how does the voice make them feel? So just try to summarize some of this. If you were going to look at this little vignette, I want you to just try to identify as many specific risk factors from this man. He's a 24-year-old male. He has voices telling him to harm a staff member. He relates that the voice makes him feel scared, that he thinks he will die if he does not obey them, that the staff member has been taken over by a satanic force, and that he would be granted special powers if he does what the voice tells him to do. Here you can see there are numerous specific risk factors to acting on this command hallucination. And those would be, he experienced it as a command, powerful voice. He has a delusion about the staff member. He feels frightened by the voice. And by acting on the voice, he'll have safety, and therefore this will benefit him. This is someone that you would identify as a particular high risk for even more acute violence based on all of these risk factors. Now that we've covered auditory hallucinations, I want to cover one of the more specific symptoms associated with violence in individuals with serious mental illness, and those are delusions. Is there a link between delusions and violence risk or not? And this has been studied for several years. So in one of the earlier but classic studies, Wesley et al noted that people who had these persecutory delusions, feelings of paranoia, did have associated higher aggression. And this is one of the first time that the term threat control override delusions appeared in the literature. And I'm going to explain what this term means in some detail. And basically, if you have kind of a fear or paranoia, you feel threatened, or you feel someone's controlling your behavior, those types of delusions were noted here to increase the risk. So in learning and researching further about these type of delusions, this was later defined as those delusions that cause feelings of personal threat or pathological thoughts with override self-control. So back in the 1990s, I know that we were instructed to investigate both aspects of feeling threatened and aspects if the person felt these kind of control override components. So what are threat delusions again? This is belief that one is being threatened in some way, and that could be that they're being poisoned, that someone's out to harm them, that someone's following them. And in the ECA study mentioned earlier by Dr. Pinos, this was one type of delusion that was actually studied. And in this study, they noted that patients with threat control override symptoms were twice as likely to be assaultive compared to those that did not have these delusions. But curiously, the MacArthur study also mentioned by Dr. Pinos did specifically look in further detail about this one particular type of symptoms amongst others that they studied. And here is Paul Appelbaum. He published one of the key articles from the study. And remember, this was looking at 1,000 individuals who had been civilly committed. They were at three different sites. They were then followed prospectively into the community over a 12-month period. And during the follow-up times for that year, one of the specific symptoms that they looked at were threat control override delusions. And in contrast to the earlier literature I've already presented, this study did not find that these types of delusions increased the risk of violence. So now what are you supposed to do as an examiner? You've got this mixed research, if you will, and you just want to do a great job for your patients. So when this finding came out, this researcher, this is Anthony Maiden. He's an excellent forensic psychiatrist from London. And he questioned whether or not the MacArthur study really disproved this issue of threat control override and violence. First of all, he said, the sample greatly underrepresented delusional disorder. Remember that the people that were studied in the MacArthur study were those who were felt safe enough to be released into the community. So individuals that may have had the more concerning delusions may not have been represented in the sample study. He noted that this was not a forensic sample. It was a civilly committed sample, but not forensic patients. And again, that the most dangerous patients were likely not released. So he wasn't confident that threat control override delusions didn't still carry a weight in the violence risk assessment. All right. So finally, we had someone who wanted to solve this riddle about these threat control override delusions. And it comes out of the Netherlands in a study known as the Netterlof study. So this was a large cross-sectional multicenter study, and they wanted to try to find the definitive answer, are threat control override delusions related to aggression, yes or no? So they had a sample of about 124 patients. And you can see that this was truly a sample of individuals that we would say meet criteria for a serious mental illness. All had either a form of schizophrenia or a smaller group, 1% had delusional disorder. And they developed a questionnaire. And in this questionnaire, they identified six specific threat symptoms. And this included, is someone trying to poison me, make me ill, plot to ruin me? Do they have evil intentions against me, follow me, or drive me insane? They had eight control symptoms. And this was looking at, is there some sort of external force determining my actions? Or are there people trying to control my movements? Can people insert thoughts in my head? Are my thoughts determined by an external force? Can others read and determine my thoughts? Can others insert thoughts in my mind? Do other people have control over me? And is my life determined by someone other than me? So what was the outcome? Here they did find that threat control override symptoms were significant and were correlated with an increased risk of aggression. However, when they studied the two separately, so they looked just at the threat symptoms, and when they took out the control override symptoms, it was really those threat symptoms alone that accounted for that increased risk of aggression. So I think my take-home point for all of you for this is that it's still probably important to screen for control override, but it's particularly important that you look at that filling of paranoia or threat. So that persecutory delusion as an increased risk has proven true even 20 years later in later outcome studies. So some basic clinician screening questions you can do, you know, have you thought about taking action based on the delusion? So if a person acts on a delusion that indicates that they're more influenced by it, so have they started to have an action plan, and then have they taken an action? Did they not do something because of a delusional belief? So for example, if they were going to go out and do their grocery shopping for the day, but they were so paranoid that they did not, that would be an example of how their behavior was impacted by the delusional belief, which is concerning because they aren't able to have independent judgment of the delusion. You can ask them what percentage of time they think about the delusion and have them describe how this has impacted their life. And then finally, if you want a screening question for the control override aspect, you could ask if they have any concerns that someone or something has been taken over by another person or entity. So that gets back to that delusional belief that may involve kind of a catgrass syndrome as well, sort of like we talked about with auditory hallucination. So the last slide I'm going to talk about before I turn this back over to Dr. Pinos is a very recent study that was looking specifically at individuals with severe or serious mental illness and their violence, but who ultimately were found not guilty by reason of insanity. So what this means is they had such a violent act that it did get the attention of the criminal justice system, but later they were adjudicated not guilty by reason of insanity. So they were interested, are there proximal risk factors? So they were looking at days to a week, and those individuals with SMI who ultimately were found not guilty by reason of insanity. Here again, they found that the independent risk factors for acute, severe, or fatal violence was the three I just mentioned to you and we've spent some time on, command hallucinations, experiencing threat control override symptoms, and again, that catgrass syndrome where the person who was the target of the violence, the perpetrator believed that they had been invaded or taken over by someone else. So you now know specific risk factors for each of these subcomponents of symptoms that can further screen and improve your violence risk assessment. So I'm going to turn this now back over to Dr. Pinos. Thanks, Dr. Scott. All right. So now you've heard a lot of information about some of the clinical symptoms and risk factors and some of the research that's been done related to serious mental illness and violence, and it still probably is a confusing landscape. I want to talk a little bit about structured assessments and violence risk because you read a lot about them in the literature if you've been paying attention to this specific area, which may not be your specific area. So I want to give you a little bit of familiarity about these instruments. So first of all, there is something called the psychopathy checklist. It comes in multiple versions and it is a tool that is used, but really more commonly used in forensic settings or correctional settings and only for very specific purposes. It's also used a lot for research. Psychopathy is not the same as antisocial personality disorder, and that's an important thing to think about. And so psychopathy is a major predictive variable for future violence, but it is a personality type that does not reflect changes in treatment, generally speaking. Psychopathy is a term that we often hear in clinical settings used in an inappropriate way. And so it's an important thing for you to realize that to diagnose or label somebody as having psychopathy, it really does require a formalized assessment that can only be done with very specific training. The components of psychopathy include some components that look like antisocial personality disorder. They may look like narcissistic personality disorder. They may even have features of borderline personality disorder, but it's a very different construct that combines a variety of different elements. So that's not something that's typically going to come up in general clinical work. So that's just something to keep in mind. The other thing you may hear about are these violence risk assessment tools. Now I can tell you working in forensic hospitals, we are very familiar with these. We use them. Some state systems will use them as a routine. Some will use them on an ad hoc basis when they think the clinical case warrants this type of assessment. And there's a variety of models that are out there, and I just highlight three of them here for you. One is the violence risk appraisal guide, which really looks kind of in an actuarial way. It defines certain risk factors, and once you've plugged them in, you are able to calculate that individual's likelihood of engaging in risk over a certain period of time. The HCR 20 version 3 is sometimes called an aid memoir, and it is utilized often more clinically. It includes historical, clinical, and risk management variables that one examines and rates, and then develops a risks construct for the individual. And in version 3, it also asks you to utilize scenario-based planning to understand what would be the context in which a patient would engage in more risk or which context could help you mitigate risk. The iterative classification tree method of the COVR, which was developed out of that early MacArthur study, is a computerized version that would allow people to plug in variables and then determine from those variables, predetermined variables from the MacArthur data, whether an individual is high or low risk. What's important about any of these tools is that even if you're using them, that they don't really make those clinical determinations, and they don't line up with who needs to be brought into the hospital, who can go to a partial hospitalization program, who can return home. That still requires a clinical judgment, and again, in most settings, these aren't going to be used except for in specialized settings. Now, more and more emergency rooms are doing screening tools for suicide risk, for example, and other clinical settings are bringing in screening instruments for suicide risk. You will see some emergency room contacts, for example, looking at short-term predictors of violence risk, like the DASA and other types of tools that we're not really emphasizing here, because what we really wanted you to take from this webinar is really a way of understanding how to evaluate the patient, how to talk to the patient, and how to understand how symptomatology may or may not play a role in risk. And again, just to emphasize the point that we were talking about before from the literature, there are going to be those factors that really can't be changed by clinical intervention. We call those static risk factors. That's going to be the person's age, their violence risk with change over time, again, with the early 20s being a time of higher risk, and historical events that can't be changed. The dynamic risk factors are those that can be changed or modified. For example, if a patient that you're seeing has those symptoms of psychosis, those can be modified through treatment. If they have a history of trauma, you can't take away their history of trauma and how that impacted their brains as they were developing if it happened in early childhood. However, you can work with the patient to modify their irritability and modify their focus on negative ideation. What we really want to do is identify those dynamic risk factors and then link treatment to them to mitigate risk and help the patient in a supported way to reduce their risk of harm so that they can go on to achieve their best potential with the least likelihood of victimizing others. It's also important to think about treatment in a broad sense. When we think about biopsychosocial treatments, we don't want to forget medications, of course, which can treat the symptoms that Dr. Scott was describing. In this study that was published in the American Journal of Psychiatry in 2021, they looked at 99 patients with schizophrenia who were physically assaulted. These patients were randomly assigned to Clozapine, Olanzapine, Haloperidol for a 12-week trial. Then they looked at these individuals and looked at also their early histories of whether they had conduct disorder as children. What they found is that for the patients with schizophrenia with conduct disorder, Clozapine seemed to be the optimal treatment. I know that you can learn more information about Clozapine through SMI Advisors Clozapine information, which provides you with robust details about Clozapine prescribing. That's something that we really want to emphasize. There may be patients that with the right pharmacology can also have their violence risk reduced. It's not that every patient needs Clozapine, but you may find those that can benefit from that type of treatment. We really want to look from a biopsychosocial perspective to help reduce violence risk. With that, I'm going to conclude our presentation portion of this webinar and turn it over to the SMI Advisor support team. Thank you both for such an interesting and informational presentation. Before we shift into the Q&A, I want to just take a moment and let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events. Complete mental health rating scales, and even submit questions directly to our team of SMI experts. Download the app now at smiadvisor.org slash app. We have several questions, so we'll get to a couple. We have about 10 minutes left. First question is, can you talk a little bit more about the relationship between substance use and violence? Are there substances in particular that are more prone to violence, and is it during intoxication or withdrawal? Hey, Deb. Yeah, I'm happy to start off, and I know Dr. Pinos will have a lot to add as well. So I think in general, a couple of substances that represent the larger prevalence of violence because it's so more commonly used would be alcohol and then stimulants. So about 50%, if you look at arrest rates of crimes, alcohol is involved. And it's because it's a more commonly used substance, one, and it does cause disinhibition. Stimulants are also a significant risk, and there's a good bit of literature even trying to distinguish a chronic long-term stimulant-induced psychosis such as that of methamphetamine from even schizophrenia. So although there may be an increased risk in the intoxication phase, you have irritability, intoxication, paranoia, some individuals can have a rather long-sustained methamphetamine-induced psychosis, and as a result, they may have lingering paranoia, delusions, hallucinations that extend beyond the point of intoxication alone. More recently, and we presented, I think, a webinar a few weeks ago, was looking at the relationship of even cannabis to violence. And whereas many people traditionally felt that cannabis products might reduce violence or keep people calm, what's quite clear, I think, from a large group of literature for individuals with serious mental illness is that with those groups, cannabis increases the risk of psychotic symptoms coming back. They may have their own independent risk for psychosis, and it's particularly important that when you're taking a substance use history for all substances, and now particularly for cannabis as well, to know the type of product they're using, the frequency, the duration, and if they can describe any of the methods of administration. There are certain substances that do have a withdrawal phase, some increased risk of violence. So think about an alcohol delirium, for example, that would be more kind of a medical or organic delirium, but they can have agitation and aggression. So that is one particular withdrawal syndrome associated with an increased risk. And I'll now let Dr. Pinos add her comments. Now, I think you did a great job answering, Dr. Scott, and I think we should move on to another question. That was a great answer. I agree with everything you said. That sounds good. Thank you for that. Another question that we have, and there's actually probably two parts to this, but it's related to hospitalization. So is there a difference between risk of violence and either risk of harm or dangerousness? In a lot of states, it's indicated that hospitalization can occur, involuntary hospitalization, if somebody is at risk of harm to others or a danger to others. So what is the difference between violence and those, or does it mean the same thing? And then I'll ask the second part about hospitalization. Can you just say the very beginning of that question again? I'm trying to give a good answer. Yeah. It's basically wondering if the risk of violence is the same as the risk of harm to others or dangerousness, depending on which state you're in, it's called either risk of harm to others or dangerousness to others. Yes. Okay. So what I think the questioner is asking about is the statutory definition that allows for involuntary hospitalization. And some states do use the word danger. Some say risk of harm to others. And states have variable definitions about the language. It might mean failure to hospitalize would lead to a likelihood of serious harm. Some states look at imminence of the harm. Some states will look at the severity of the harm. I would say that in general, obviously you have to follow your statute and make sure if you're involuntarily hospitalizing someone that you're not operating outside your mental health laws. At the same time, I think clinically, certainly if you're in an emergency room and you're making a determination about whether somebody needs to be hospitalized or you're in an outpatient clinic and you're concerned, we often have a low index of suspicion maybe, or a low threshold. Because we do still tend to overpredict risk. And we're often, if we're worried that somebody's going to hurt somebody, we don't make a magic formula of, you know, is it only going to be that they're going to really harm them with serious injury? We look at whether there's anything that can be put in place in the community that would offer a lesser restrictive alternative. And we always want to offer voluntary hospitalization as well, which means that the person just needs treatment and then they can come into the hospital. But those laws, risk of harm usually means risk of violence. That's usually what they're alluding to. And I don't know if Dr. Scott has any other words of wisdom on that point. Just real brief. And so if you happen to work in a forensic setting, you definitely, I agree with Dr. Pinos, are going to have to know your state statute. They vary greatly. And so for example, in California, for offenders with a mental disorder, they actually say to hold and detain them past their period of normal commitment, you have to show that they're going to be a substantial risk of physical harm to others. And they now have also included individuals with a pedophilic disorder. Physical harm to others includes if they've had a history of inappropriately touching a child less than 14. So it can vary greatly between state of how they define harm or danger. Great. Thank you. And so some of the assessments, the risk assessments that went over today, do they indicate low, medium, or high level of risk? Or is there one that you would recommend to determine the level of risk so then a determination about hospitalization or alternative plan could be made? So some of them will make a distinction, low, medium, or high risk. Many of them will. Some will give percentages of risk over periods of time. But again, one of the challenges is that none of them are equal to what your statute allows for hospitalization or what the clinical risk should be. For example, working in a forensic hospital, we see people that are at chronic risk of harm, but we still discharge them because their risk for that period of time has been mitigated sufficiently as long as their support's in place. Anybody that you are worried about that may score low on a risk of harm may still score high enough that you think that they need to be hospitalized. So a lot of hospitals or clinics will have their own rubric or use basically some kind of rubric, some analysis, for example, in the medical record, where you really just want to document why you're making the determination that you're making. And some will have a formula that will say, if these factors are there, then put them at medium. If these factors are not there, say that the individual is at low risk. So it'll really depend on your clinical system. Hi, and this is Dr. Scott. Yeah, I would add to that, in an acute setting, like an emergency room, or even if you're discharging someone from an inpatient unit, some of these instruments take a lot of time to score, to do thorough chart reviews, and so it may not be practical. One thing that is very practical, though, that's true across all the instruments is one factor that stands out as most correlated with your risk assessment for violence, and that's a past history of violence. And so, again, that screening question and learning either from family or from the patient in an acute setting about past history of violence would be important to document and to review. And then the flip side is, some of the instruments that may be more actuarially based might predict the person is at a low risk, but in a clinical setting, imagine that a man is brought into your emergency room, the police had to break down a door, he was holding a gun to his wife about to shoot her, but you score the history instrument, and in his case, if he had no prior history and no other substance use or other risk factors, he might score very low on that particular instrument, but obviously, in the acute setting, you would say he's very high. So it's always a balance of clinical judgment, incorporating the instruments where appropriate. Great. I'll probably squeeze one final question in, and it is about the factors that we as clinicians or providers do that can contribute to violence. So whether it can be a medication we prescribe or in our interactions, they use the word iatrogenic, which I was not familiar with. So are there any iatrogenic factors that may contribute to violence, and how could we minimize these as providers? Do you want to take that, Charles, first? Yeah. So I would say if a person has a history of a substance use disorder, and that's either exacerbated or worsened their symptoms, or if they even have an independent, let's say have an alcohol use disorder, and you're prescribing a medication that's known to facilitate relapse, perhaps they may have a chronic pain issue, or you're giving a particular medicine for anxiety but may have an addictive component, that is something you would need to take careful consideration of, because that could then facilitate the risk factor of violence of substance use. That would be my major. And then the other thing is if a person is non-adherent to their medication, you really should think about more depo forms of the medicine, because noncompliance with medicine is a key component to violence. So an iatrogenic cause would be if you fail to recognize that, when that could have helped. Yeah. And the only other thing I would say is that some medicines can cause restlessness, agitation, akathisia. So just monitor for those side effects, because that can lead people to just be in distress that can just heighten their irritability. Thank you so much. That's all the time we have questions for today, so we apologize if we weren't able to get to everybody's. But if you do have follow-up questions about this or any topic related to evidence-based care for SMI, our clinical experts are now available for online consultations. Any mental health clinician can submit a question and receive a response from one of our SMI experts. Consultations are free and confidential. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. Today's initiatives cover a broad range of topics, from school-based mental health through the opioid epidemic. Thank you for joining us, and thank you very much to our two presenters. Until next time, take care. Thank you for participating in today's free course from SMI Advisor. We know that you may have additional questions on this topic, and SMI Advisor is here to help. Education is only one of the free resources that SMI Advisor offers. Let's briefly review all SMI Advisor has to offer on this topic, and many others. We'll start at the SMI Advisor website and show you how you can use our free and evidence-based resources. SMI Advisor's mission is to advance the use of a person-centered approach to care that ensures people who have serious mental illness find the treatment and support they need. We offer several services specifically for clinicians. This includes access to education, consultations, and more. These services help you make evidence-based treatment decisions. Click on consult request and submit questions to our national experts on bipolar disorder, major depression, and schizophrenia. Receive guidance within one business day. It only takes two minutes to submit a question, and it is completely confidential and free to use. This service is available to all mental health clinicians, peer specialists, and mental health administrators. Ask us about psychopharmacology, recovery supports, patient and family engagement, comorbidities, and more. You can visit our online knowledge base to find hundreds of evidence-based answers and resources on serious mental illness. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Harvard, Emory, NAMI, University of Texas at Austin, and more. Browse by key topics or search for a specific keyword in the search bar. Access our free education catalog to find more than 100 free courses on topics related to serious mental illness. You can search the education catalog by topic, format, or credit type to find courses that fit your needs. SMI Advisor also offers live webinars each month that let you learn about evidence-based practices and participate in live Q&A with faculty. Check out our education catalog often to find new courses and earn continuing education credits. For individuals, families, friends, people who have questions, or people who care for someone with serious mental illness, SMI Advisor offers access to resources and answers from our national network of experts. The individuals and families section of our website contains an array of evidence-based resources on a variety of topics. This is a great place to refer individuals in your care for information about their conditions. They can choose from a list of important questions that individuals who have SMI typically ask. SMI Advisor worked with experts from the National Alliance on Mental Illness to develop these important questions and many of the resources in this section. Watch videos on important topics around SMI, such as what to know about a new diagnosis. They can also find dozens of fact sheets, infographics, and links to other important resources. To access even more evidence-based resources for individuals and families, visit our online knowledge base. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Mental Health America, National Alliance on Mental Illness, and more. Browse by key topics and select View All to uncover a list of resources on each topic. SMI Advisor offers a smartphone app that lets you access all of the same features on our website in an easy-to-use, mobile-friendly format. You can download the app for both Apple and Android devices. Submit questions, browse courses, and access clinical rating scales that you can use in your practice with individuals who have SMI. SMI Advisor also created My Mental Health Crisis Plan, a smartphone app that helps individuals in your care to create a crisis plan. The app is available on both Apple and Android devices. It helps people prepare in case of a mental health crisis. They can make their treatment preferences known and specify who should be contacted and who should make decisions on their behalf. The app even guides individuals through the process to turn their crisis plan into a psychiatric advance directive. Thank you for your interest in SMI Advisor. You can access our free education, consultations, and more on smiadvisor.org at any time.

violence risk assessment

serious mental illness

webinar

mental health

auditory hallucinations

delusions

substance use

dynamic risk factors

thorough assessments

clinical judgment