Violence Risk Management

1. Violence RiskManagement Jack Rozel, MD, MSL

2. Conflicts of Interest • Current Research Funding – NIMH • Past Research Funding – Alexza*, Janssen • Past Conference/Travel – Alexza, Eli Lilly, Janssen, Wyeth Ayerst • Past Speakers’ Bureaus – Pennsylvania ACLU • Past Stock Holdings – Johnson & Johnson, United Health (both sold in 2006)

4. Agenda for today • A practical approach to violence risk management • Elucidating the violence history and other risk factors • Duties to 3rd parties

5. There is more in the handout,and more handouts at the website: www.acutechildpsychiatry.com/emergency

6. What does psychiatry know about violence?

8. Factors Affecting Predictability • Time Span – hours, weeks, months, lifetime? • Common vs. Rare events • Amount of collateral information • Environmental Variables (and control) – known, unknown, unknowable

9. The problem of prediction & assessment Prediction is very difficult, especially about the future. Niels Bohr

10. Predicting cold weather and snow is easier to do correctlyin Rochester than in Rio

11. Risk Management Model(Harm Reduction) • Some outcomes and behaviors may be inevitable • Minimize adverse outcomes when behavior occurs • Limit access to lethal means (Tylenol, handguns) • Rapid response when behaviors occur

12. Factors Risk Factors Protective Factors Dynamic Factors Static Factors

13. Risk & Protective Factors:Clinical Priorities • Dynamic Risk Factors • Develop a strategy to fix them • Dynamic Protective Factors • Identify and support them • Increased caution when they change or fail

15. Risk Management & Treatment Planning • Target behavior – Suicide, violence, sexually dangerous behavior • Identify Dynamic Risk Factors • Strategy to correct/change each one • Check in plan

16. Risk Management Grid

17. Risk Management: Violence Risk

18. Clinical Evaluation of Violence

19. Risk Factors for Violence • Recent Acts or Intent > Ideation or Fantasy • Past history of violence, esp. with an identified target • Explicit threats > implicit threats • More specific plan (esp. with “evasive” features) • Limited coping mechanisms, supports or resources (or loss thereof) • Recent increase in psychosocial stressors • Impulsivity • Substance use (esp. alcohol, cocaine, speed) • Untreated/under-treated mental illness • Suicidality, hopelessness

20. Risk Factors • Male > Female in the community • Male = Female in inpatient settings • Generally • SUD + Major Psychiatric Disorder • SUD alone • No SUD/psychiatric disorder • Psychiatric disorder • Psychiatric patients are victims > perpetrators

21. Do not confuse category with scale

22. Psychosis & Violence • Command Hallucinations • Recognized/known voice • Specific command • Congruent delusion • History of acting on commands • Delusions • Mood / hallucination congruent • Loss of control • Persecutory delusions • Jealous delusions • With preservation of organized behavior

24. Experience and Violence • Past history of violence • Past use of weapons • Military history • Branch, MOS • Combat experience • Criminal (legal) history • Violent or drug crimes? • Gang / organized crime / hate group involvement?

25. Major psychiatric disorders often … • Impair concentration, focus and ability to persist with tasks or activities • Impair reality testing especially relating to consequences and responses of others • Impair energy, motivation and interest

26. Spot the risk factors…

27. Always ask about weapons Prior use Current access Practice and experience Fantasies and favorites

28. What your charge nurse wants you to know about prn’s

29. Tricks of the trade • Overmedication vs. Aggression? • The default is VP and PRNs • Read the chart (use what worked before) • Know the pharmacokinetics • Know the interactions • TID or QID – not Q8h or Q6h • An emergency is the wrong time to have a debate or discussion

31. Duties to Third Parties The protective privilege ends where the public peril begins.

32. Tarasoff v. Board of Regents (II) • Poddhar was recognized by the therapist to pose an imminent risk to Tarasoff • The therapist attempted – and failed – to have Poddhar involuntarily admitted • Poddhar stabbed and killed Tarasoff • Tarasoff’s family sued University / counseling center for damages • Dismissed and appealed

33. Legal & Policy Context • No general duty to third parties • Confidentiality and privilege of clinical material • Confidentiality as essential element to therapy • APA submitted amicus curiae brief opposing duty to warn: “The end of psychotherapy”

34. The Tarasoff “Standard” • Duty to take reasonable steps • To protect • Identifiable third parties • Foreseeable • Serious harm • If dereliction of this duty directly causes damages then there may be a tort…

35. A duty to protect:not a duty to warn

36. Tarasoff was a California case… There is no binding or applicable • Federal case • Federal law • New York case • New York law And the APA Code of Ethics remains vague

37. New York Confidentiality Law • Warning a potential victim or LEO of “serious and imminent danger” • A permissible breach of confidentiality • Protects the therapist from a breach of confidentiality claim by the patient

38. “Nothing in this paragraph shall be construed to impose an obligation upon a treating psychiatrist or psychologist to release information pursuant to this paragraph”

40. MacDonald v Clinger (1982) • Dr. MacDonald breached Clinger’s confidentiality by disclosing information to Clinger’s wife • “Disclosure of confidential information … could be justified by an overriding concern … [such as] a danger to the patient, the spouse or another person” • Breach of confidentiality may be permissible in certain situations

41. Purdy v. Public Adm. Westchester (1988) • An elderly and infirm nursing home resident drove and struck and killed Purdy. The staff of the nursing home knew of her inability to drive safely • No duty because there was no legal authority to interfere with the behavior of a voluntary patient in the absence of an obvious emergency • Nonspecific dangerousness does not create a duty for voluntary patients

42. Wagshall v. Wagshall (1989) • During a contentious breakup, the Wagshalls’ marital therapist was concerned about potential violence and arranged for firearms to be removed. 8 Months later, the wife killed the husband • Any duty to control the behavior of a voluntary outpatient is limited, especially 8 months after the end of treatment. • No duty to warn when the victim is aware of the danger.

43. Ellis v Peter (1995) • Ellis, the wife of Dr. Peter’s patient, contracted TB. Dr. Peter was unaware the patient had TB. • Peter had no duty to warn or protect Ellis when he was unaware of the risk

44. AMA Opinion 5.05 • When a patient threatens to inflict serious physical harm to another person or to him or herself and there is a reasonable probability that the patient may carry out the threat, the physician should take reasonable precautions for the protection of the intended victim, which may include notification of law enforcement authorities

45. The practical Tarasoff duty • Foreseeable • Serious harm • To a person or class of persons • Who is identified, or reasonably identifiable • We have a duty • To take reasonable steps to protect • Which may include warning • And can certainly include commitment

46. Bottom Line • Assess for violence risk • Manage identified dynamic risk factors • Take reasonable steps to prevent imminent and serious harm • Document, document, document! www.acutechildpsychiatry.com/emergency