Educational Approaches Using Simulation for Psychiatric Risk Assessment: a Scoping Review

OBJECTIVE

The ability to assess a patient's risk of harm to self or others is a core competency for mental health clinicians which can have significant patient outcomes. With the growth of simulation in medical education, there is an opportunity to enhance education outcomes for psychiatric risk assessment. The purpose of this study was to determine how simulation is used to build competency in risk assessment and map its educational outcomes.

METHODS

The authors conducted a systematic scoping review using the Arksey and O'Malley framework. Electronic database searches were conducted by an academic librarian. Studies published before August 2022 which described simulation activities aimed at training clinicians in suicide, self-harm, and/or violence risk assessment were screened for eligibility.

RESULTS

Of the 21,814 articles identified, 58 studies were selected for inclusion. The majority described simulations teaching suicide risk assessment, and there was a notable gap for building competency in violence risk assessment. Simulation utility was demonstrated across emergency, inpatient, and outpatient settings involving adult and pediatric care. The most common simulation modality was patient actors. A smaller subset implemented technological approaches, such as automated virtual patient avatars. Outcomes included high learner satisfaction, and increases in psychiatric risk assessment knowledge, competency, and performance.

CONCLUSION

Simulation as an adjuvant to existing medical curricula can be used to teach risk assessment in mental health. Based on the results of our review, the authors provide recommendations for medical educators looking to design and implement simulation in mental health education.

The Quality of Violence Risk Formulation and a Quasi-Forensic Mental Health Training Experiment

Objectives

The study was aimed at measuring the impact of training on forensic case formulation in mental health and to provide more evidence on the reliability of the TEC-F.

Method

Nine psychiatrists and six psychologists from various Latin American countries participated in a quasi-pedagogical experiment. The quality of formulations was independently and blindly measured pre- and post-intervention with the TEC-F and the assignment of two standard vignettes was also randomly manipulated. Quality mean differences and instrument reliability indicators were calculated.

Results

The values of intraclass correlation coefficients were 0.92; 0.94; 0.83; 0.93 and 0.95 and the values of Cronbach's alpha coefficient were 0.83; 0.94; 0.63; 0.77 and 0.93, for the dimensions transparency, specificity, communication, reasoning and for the total TEC-F respectively. The results of the 19-day test-retest were excellent. The mean TEC-F total quality pre-course was 31.4 and the mean post-course, 38.4 (p = 0.003 and p = 0.001 for group test and paired test respectively).

Conclusions

The pedagogical intervention produced a significant improvement in the quality of the expert’s formulations. The study added evidence supporting the TEC-F reliability.

Violence Risk Assessment in the Emergency Department

INTRODUCTION

Workplace violence is a prevalent problem in health care, with mental health and emergency departments being the most at-risk settings. The aim of this evidence-based practice project was to pilot use of a violence risk assessment tool, the Broset Violence Checklist, to assess for risk of type II violence and record the interventions that nurses chose to implement to mitigate the situation. Additionally, reports made to the hospital reporting system were tracked and compared to previous reporting frequency.

METHODS

Following staff education, nurses were instructed to complete checklists for all patients who have a score of 1 or higher, which indicates the presence of at least 1 high-risk behavior, and continue hourly scoring until the score returned to 0 or the patient was dispositioned. The number of incidents recorded, time of day, scores, interventions applied to mitigate violence, and change in scores after interventions were evaluated. The number of Broset Violence Checklist scoring sheets submitted and reports made via the hospital reporting system were compared.

RESULTS

Incidents were most frequent from 11 am until 3 am. The highest scores occurred in the late evening and early morning hours. There were significantly more incidents captured with the use of the Broset Violence Checklist as compared to the hospital reporting system. Incidents significantly associated with higher scores included providing comfort measures, addressing concerns, and applying restraints.

DISCUSSION

The Broset Violence Checklist was used successfully in the emergency department setting to identify behaviors associated with violence. Under-reporting to the hospital report system was identified in this project, consistent with reports in the literature. Specific interventions were not associated with a decrease in Broset Violence Checklist scores.

Feasibility and Utility of Different Approaches to Violence Risk Assessment for Young Adults Receiving Treatment for Early Psychosis

This pilot study examined violence risk assessment among a sample of young adults receiving treatment for early psychosis. In this study, thirty participants were assessed for violence risk at baseline. Participants completed follow-up assessments at 3, 6, 9 and 12 months to ascertain prevalence of violent behavior. Individuals were on average 24.1 years old (SD = 3.3 years) and predominantly male (n = 24, 80%). In this sample, six people (20%) reported engaging in violence during the study period. Individuals who engaged in violence had higher levels of negative urgency (t(28) = 2.21, p = 0.035) This study sought to establish the feasibility, acceptability, and clinical utility of violence risk assessment for clients in treatment for early psychosis. Overall, this study found that most individuals with early psychosis in this study (who are in treatment) were not at risk of violence. Findings suggest that violent behavior among young adults with early psychosis is associated with increased negative urgency.

Violence risk assessment for young adults receiving treatment for early psychosis

AIM

Although the absolute risk of violence is small for individuals with mental illnesses, a specific subgroup of individuals who appear to be at increased risk for violence includes young people experiencing emerging or early psychosis. Prior research has identified risk factors for violence in this population, though no prior studies using a formal risk assessment tool have been identified. This study used the Historical Clinical Risk Management-20, version 3 (HCR-20) to identify risk of future violence among a sample of young adults with early psychosis and relevant predictors of risk unique to this population.

METHODS

The HCR-20 was administered to a sample of young adults with early psychosis (N = 53) enrolled at one OnTrackNY site, part of a statewide program providing early intervention services to young adults presenting with a first episode of non-affective psychosis. A Confirmatory Factor Analysis (CFA) was conducted to explore the relative importance of the HCR-20 items for this population.

RESULTS

The average age of participants was 21.9 years (SD 3.6 years) and most were male (69.8%, n = 37). Most patients were assessed to be at low risk for future violence based on the Case Prioritization summary risk rating (67.9%, n = 36). The CFA identified 4 items that were not of relative predictive value in identifying the risk of violence in this sample: history of substance use (item H5), history of major mental disorder (item H6), living situation (item R2), and personal support (item R3).

CONCLUSION

This study presents a formal approach to assessing violence risk in a population at elevated risk of violence, demonstrates the feasibility of using a standardized risk assessment tool in early intervention services, and identifies factors of particular importance associated with predicting violence in this population. Future research should implement violence risk assessment with a structured tool such as the HCR-20 and assess its accuracy in predicting future violent behavior in this setting.

Assessment of violence risk in 440 psychiatric patients in China: examining the feasibility and acceptability of a novel and scalable approach (FoVOx)

BACKGROUND

Violence risk assessment is a routine part of clinical services in mental health, and in particular secure psychiatric hospitals. The use of prediction models and risk tools can assist clinical decision-making on risk management, including decisions about further assessments, referral, hospitalization and treatment. In recent years, scalable evidence-based tools, such as Forensic Psychiatry and Violent Oxford (FoVOx), have been developed and validated for patients with mental illness. However, their acceptability and utility in clinical settings is not known. Therefore, we conducted a clinical impact study in multiple institutions that provided specialist mental health service.

METHODS

We followed a two-step mixed-methods design. In phase one, we examined baseline risk factors on 330 psychiatric patients from seven forensic psychiatric institutes in China. In phase two, we conducted semi-structured interviews with 11 clinicians regarding violence risk assessment from ten mental health centres. We compared the FoVOx score on each admission (n = 110) to unstructured clinical risk assessment and used a thematic analysis to assess clinician views on the accuracy and utility of this tool.

RESULTS

The median estimated probability of violent reoffending (FoVOx score) within 1 year was 7% (range 1-40%). There was fair agreement (72/99, 73% agreement) on the risk categories between FoVOx and clinicians' assessment on risk categories, and moderate agreement (10/12, 83% agreement) when examining low and high risk categories. In a majority of cases (56/101, 55%), clinicians thought the FoVOx score was an accurate representation of the violent risk of an individual patient. Clinicians suggested some additional clinical, social and criminal risk factors should be considered during any comprehensive assessment. In addition, FoVOx was considered to be helpful in assisting clinical decision-making and individual risk assessment. Ten out of 11 clinicians reported that FoVOx was easy to use, eight out of 11 was practical, and all clinicians would consider using it in the future.

CONCLUSIONS

Clinicians found that violence risk assessment could be improved by using a simple, scalable tool, and that FoVOx was feasible and practical to use.

The Rapid Risk of Violence Screen (RROVS): a Brief Violence Risk Screening Tool for People in a Community Behavioral Health Setting

The Rapid Risk of Violence Screen (RROVS) is a brief screening tool that is designed for use in community-based behavioral health service settings to identify people who may need comprehensive violence risk assessment. This study examined the association between the RROVS total score and future criminal justice involvement including violent offenses. Results from this study suggest that the RROVS screening tool has predictive validity as it is associated with later criminal justice involvement with a violent offense. The RROVS may be a helpful tool for community-based behavioral health providers to screen incoming clients for violence risk to inform whether additional assessment for violence potential is warranted.

Clinical risk management in High-Security Forensic Psychiatry Residences. Protecting patients and health professionals: perspectives and critical issues of the Law 81/2014

The Italian Law n. 9/2012 provided the Italian Regions with a new decisional role by demanding the management/rehabilitation of prisoners judged as partially/fully mentally ill to care and protection delivered by the psychiatric services of the Regional Health Service. Healthcare has to be guaranteed by the so-called High-Security Forensic Psychiatry Residences (Italian: Residenze per l'Esecuzione delle Misure di Sicurezza: REMS) and by community mental health centres. Ensuring patients' and professionals' health and safety is a complex issue which requires effective strategies to cope with several structural, technological, and organisational problems. The present paper summarises the historical evolution of the Italian laws towards the development of the High-Security Forensic Psychiatry Residences in Italy, focusing specifically on the Tuscany Region situation. The paper also presents the key issues emerging after the implementation of the Law 81/2014 which complemented the Law 9/2012. Since these reforms included the need for assessing to what extent the patient may be considered as a danger to society and for ensuring the safety of National Health Service (NHS) professionals, they underscored the importance of a preventive use of specific clinical governance tools aimed to reduce risk of adverse events. The present work has the strength of proposing a new, evidence-based scientific approach to the implementation of assessment and care pathways in High-Security Forensic Psychiatry Residences.

Moral cognition, the missing link between psychotic symptoms and acts of violence: a cross-sectional national forensic cohort study

BACKGROUND

People with schizophrenia are ten times more likely to commit homicide than a member of the general population. The relationship between symptoms of schizophrenia and acts of violence is unclear. There has also been limited research on what determines the seriousness and form of violence, such as reactive or instrumental violence. Moral cognition may play a paradoxical role in acts of violence for people with schizophrenia. Thoughts which have moral content arising from psychotic symptoms may be a cause of serious violence.

METHOD

We investigated if psychotic symptoms and moral cognitions at the time of a violent act were associated with acts of violence using a cross-sectional national forensic cohort (n = 55). We examined whether moral cognitions were associated with violence when controlling for neurocognition and violence proneness. We explored the association between all psychotic symptoms present at the time of the violent act, psychotic symptoms judged relevant to the violent act and moral cognitions present at that time. Using mediation analysis, we examined whether moral cognitions were the missing link between symptoms and the relevance of symptoms for violence. We also investigated if specific moral cognitions mediated the relationship between specific psychotic symptoms, the seriousness of violence (including homicide), and the form of violence.

RESULTS

Psychotic symptoms generally were not associated with the seriousness or form of violence. However, specific moral cognitions were associated with the seriousness and form of violence even when controlling for neurocognition and violence proneness. Specific moral cognitions were associated with specific psychotic symptoms present and relevant to violence. Moral cognitions mediated the relationship between the presence of specific psychotic symptoms and their relevance for violence, homicide, seriousness of violence, and the form of violence.

CONCLUSIONS

Moral cognitions including the need to reduce suffering, responding to an act of injustice or betrayal, the desire to comply with authority, or the wish to punish impure or disgusting behaviour, may be a key mediator explaining the relationship between psychotic symptoms and acts of violence. Our findings may have important implications for risk assessment, treatment and violence prevention.

Interventions following a high violence risk assessment score: a naturalistic study on a Finnish psychiatric admission ward

BACKGROUND

Patient aggression and violence against staff members and other patients are common concerns in psychiatric units. Many structured clinical risk assessment tools have recently been developed. Despite their superiority to unaided clinical judgments, staff has shown ambivalent views towards them. A constant worry of staff is that the results of risk assessments would not be used. The aims of the present study were to investigate what were the interventions applied by the staff of a psychiatric admission ward after a high risk patient had been identified, how frequently these interventions were used and how effective they were.

METHODS

The data were collected in a naturalistic setting during a 6-month period in a Finnish psychiatric admission ward with a total of 331 patients with a mean age of 42.9 years (SD 17.39) suffering mostly from mood, schizophrenia-related and substance use disorders. The total number of treatment days was 2399. The staff assessed the patients daily with the Dynamic Appraisal of Situational Aggression (DASA), which is a structured violence risk assessment considering the upcoming 24 h. The interventions in order to reduce the risk of violence following a high DASA total score (≥4) were collected from the patients' medical files. Inductive content analysis was used.

RESULTS

There were a total of 64 patients with 217 observations of high DASA total score. In 91.2% of cases, at least one intervention aiming to reduce the violence risk was used. Pro re nata (PRN)-medication, seclusion and focused discussions with a nurse were the most frequently used interventions. Non-coercive and non-pharmacological interventions like daily activities associated significantly with the decrease of perceived risk of violence.

CONCLUSION

In most cases, a high score in violence risk assessment led to interventions aiming to reduce the risk. Unfortunately, the most frequently used methods were psychopharmacological or coercive. It is hoped that the findings will encourage the staff to use their imagination when choosing violence risk reducing intervention techniques.

Risk assessment for patient perpetrated violence: Analysis of three assaults against healthcare workers

Workplace violence in healthcare settings is a complex topic with many different environments in which aggression is sometimes expressed by patients toward those entrusted with providing their healthcare. The assessment of violence risk in a nursing home containing many patients with organic brain syndrome is quite distinct from assessment in forensic psychiatric units, inner city emergency rooms, or outpatient pain clinics. Three cases are presented that are composite summaries of actual assaults which took place across different hospital settings, all within an urban Midwestern city in the United States: (1) an emergency department; (2) a psychiatric emergency services (PES) center; (3) a short stay (typically 72 hours to 5 days) civil psychiatric inpatient unit. These case studies exemplify specific risk factors that violent patients have, depending upon the specific healthcare setting where the patient presents. Research is cited relevant to all three case studies and how one should assess their risk. Lastly, the complexity of this issue is highlighted by a brief discussion of the pitfalls entailed in profiling ``the dangerous patient.'' It is demonstrated that when violence is expressed by a patient toward a healthcare provider, it is usually a maladaptive response, one in which characteristics of that setting and behavior of those who work within it must be carefully considered when determining what factors precipitated the patient's violent act.

Stalking and Violence

The three widely known stalker classifications assist in categorizing stalkers, which allows for better management of violence risk. Although 80% of stalking is done by men, women also engage in stalking, and their violence risk should not be underestimated. Juvenile stalkers do exist and juvenile stalking is also associated with violence. Clinicians can become a victim of stalking and may become victims of stalking by proxy, a special type of stalking behavior where the stalker involves other people or agencies to communicate with or track their victim. A careful stalking violence risk assessment is essential in the intervention and risk management process.

Childhood animal cruelty, bestiality, and the link to adult interpersonal violence

Animal cruelty has been a concern of the legal and psychiatric communities for many years. Beginning in the early 1800s, state legislatures in the United States established laws to protect the basic safety and security of animals in their jurisdictions. Legislatures have differed in opinion on the animals to receive protection under the law and have instituted differing penalties for infractions of anti-cruelty measures. In the 1960s, the psychiatric community took notice of childhood animal cruelty as a potential risk factor for violent acts against humans. Since that time there has been increasing evidence that children who engage in animal cruelty may be at increased risk of interpersonal offenses in adulthood. Less is known about children and adults who engage in bestiality and the potential risk that these individuals may pose for interpersonal sexual or nonsexual violent acts. We review the legal status of animal cruelty in the United States, summarize the history of psychiatric interest in and research of animal cruelty, describe current knowledge regarding the link between animal cruelty and violence, and propose a novel classification scheme for individuals who engage in bestiality to assist forensic psychiatric examiners in determining the risk that such behavior poses for future interpersonal offending.

[Forensic assessment of violence risk]

Over the last 20 years there have been steps forward in the field of scientific research on prediction and handling different violent behaviors. In this work we go over the classic concept of "criminal dangerousness" and the more current of "violence risk assessment". We analyze the evolution of such assessment from the practice of non-structured clinical expert opinion to current actuarial methods and structured clinical expert opinion. Next we approach the problem of assessing physical violence risk analyzing the HCR-20 (Assessing Risk for Violence) and we also review the classic and complex subject of the relation between mental disease and violence. One of the most problematic types of violence, difficult to assess and predict, is sexual violence. We study the different actuarial and sexual violence risk prediction instruments and in the end we advise an integral approach to the problem. We also go through partner violence risk assessment, describing the most frequently used scales, especially SARA (Spouse Assault Risk Assessment) and EPV-R. Finally we give practical advice on risk assessment, emphasizing the importance of having maximum information about the case, carrying out a clinical examination, psychopathologic exploration and the application of one of the described risk assessment scales. We'll have to express an opinion about the dangerousness/risk of future violence from the subject and some recommendations on the conduct to follow and the most advisable treatment.

Neuroprediction, Violence, and the Law: Setting the Stage

In this paper, our goal is to (a) survey some of the legal contexts within which violence risk assessment already plays a prominent role, (b) explore whether developments in neuroscience could potentially be used to improve our ability to predict violence, and (c) discuss whether neuropredictive models of violence create any unique legal or moral problems above and beyond the well worn problems already associated with prediction more generally. In "Violence Risk Assessment and the Law", we briefly examine the role currently played by predictions of violence in three high stakes legal contexts: capital sentencing ("Violence Risk Assessment and Capital Sentencing"), civil commitment hearings ("Violence Risk Assessment and Civil Commitment"), and "sexual predator" statutes ("Violence Risk Assessment and Sexual Predator Statutes"). In "Clinical vs. Actuarial Violence Risk Assessment", we briefly examine the distinction between traditional clinical methods of predicting violence and more recently developed actuarial methods, exemplified by the Classification of Violence Risk (COVR) software created by John Monahan and colleagues as part of the MacArthur Study of Mental Disorder and Violence [1]. In "The Neural Correlates of Psychopathy", we explore what neuroscience currently tells us about the neural correlates of violence, using the recent neuroscientific research on psychopathy as our focus. We also discuss some recent advances in both data collection ("Cutting-Edge Data Collection: Genetically Informed Neuroimaging") and data analysis ("Cutting-Edge Data Analysis: Pattern Classification") that we believe will play an important role when it comes to future neuroscientific research on violence. In "The Potential Promise of Neuroprediction", we discuss whether neuroscience could potentially be used to improve our ability to predict future violence. Finally, in "The Potential Perils of Neuroprediction", we explore some potential evidentiary ("Evidentiary Issues"), constitutional ("Constitutional Issues"), and moral ("Moral Issues") issues that may arise in the context of the neuroprediction of violence.