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Involuntary Certification

Scott Woodside, LL.B, MD, FRCPC Centre for Addiction & Mental Health. Involuntary Certification. Involuntary Certification. Outline Factors considered in determining whether to admit or discontinue a Form 1 Risk for violence against self or others Lack of competence to care for oneself.

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Involuntary Certification

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  1. Scott Woodside, LL.B, MD, FRCPC Centre for Addiction & Mental Health Involuntary Certification

  2. Involuntary Certification • Outline • Factors considered in determining whether to admit or discontinue a Form 1 • Risk for violence against self or others • Lack of competence to care for oneself

  3. Risk for Violence . . . • Multi-faceted construct • Nature: what kind of violence • Severity: how serious • Frequency: how often • Imminence: how soon • Likelihood: probability of violence occurring

  4. ER Assessment of risk for violence: • Statistical measures best for estimating long-term risk of violence but impractical in ER • Have to rely on clinical indicators of risk in deciding whether to certify or not • Clinicians actually reasonably good at identifying risk of violence over short-term (hours to days)

  5. Indicators of increased risk for violence: (Kaplan & Sadock) • Expressed intent to harm • Presence of a victim • Frequent/open threats • Concrete plan • Access to instruments of violence • Previous history of violence/loss of control • Chronic anger/hostility • Callous/lack of compassion • Views self as victim • Anti-authority • Childhood abuse/deprivation • Early loss of parent • Conduct Hx • Reckless driving

  6. Indicators of risk for violence (HCR-20) – structured approach • Historical Factors (Fixed/Static): • Previous violence (frequency/severity) • Young age (under 20) • Relationship instability (unstable/conflicted intimate R/S) • Employment problems (unstable pattern) • Substance use problems (serious impairment) • Major mental illness • Psychopathy (PCL-R or PCL-SV score) • Early maladjustment (serious conduct problems or victimization) • Personality disorder (any non-psychopathic disorder) • Prior supervision failure

  7. Indicators of risk for violence (HCR-20) cont’d • Clinical Factors (dynamic/current): • Lack of insight (Dx or need for Tx) • Negative attitudes (procriminal/antisocial/ pessimistic/anti-authority) • Active sx of MMI (disturbance of thought, affect, perception) • Impulsivity (Behavioural, cognitive, affective) • Unresponsive to treatment (resistant or refractory) • Especially important re: imminence

  8. Indicators of risk for violence (HCR-20) cont’d • Risk Management Factors (dynamic/future): • Plans lack feasibility (no plans, unsuitable, unrealistic) • Exposure to destabilizers (weapons, substances, victims) • Lack of personal support (personal, emotional) • Noncompliance with remediation (cannot, will not comply with Tx) • Stress (serious psychosocial stressors, fragile)

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