Level of Care Utilization System (LOCUS)

Introduction

The Level of Care Utilization System or LOCUS tool has been designed by the American Association of Community Psychiatrists (2009) to allow staff who work on inpatient hospital environments with patients with psychiatric problems (such as emergency departments, psychiatric sections of general hospitals or in psychiatric hospitals) to determine the level of care that an individual should receive.

The LOCUS provides for six levels, ranging from the least intense (recovery maintenance, such as seeing a case manager once a month and having access to a 24-hour crisis line if needed) to the most intense (medically managed residential services such as being a hospital inpatient.)

Parameters

The LOCUS is based on a set of parameters that an individual is scored along. The level of care is determined based on the mix of parameters that each client has. These parameters are:

  1. Risk of Harm
  2. Functional Status
  3. Medical, Addictive and Psychiatric Co-morbidity
  4. Recovery Environment
  5. Treatment and Recovery History
  6. Engagement and Recovery Status

In most of these domains there are a number of states that are used to code the domain. For instance, “Risk of Harm” has five potential states from Minimal Risk of Harm to Extreme Risk of Harm. The exception is 4. Recovery Environment which has two subcomponents, Level of Stress and Level of Support.

The LOCUS manual provides detailed coding instructions to allow an individual to be assessed in a reliable, repeatable way.

Levels of Care

For each Level of Care, the manual provides for four categories, Care Environment, Clinical Services, Supportive Systems, and Crisis Stabilization and Prevention Services.

Care Environment describes where services are delivered and what facilities might need to be available. Clinical Services describes the type and number of clinical employees (nurses, etc.) and the types of therapies or treatments available. Supportive Services includes client access to things like case management, outreach and financial support, while Prevention Services include mobile crisis, crisis lines, and other access to services.

Scoring

Each of the levels includes specific individual scores required for a level, and also a composite score. The Composite Score overrides the individual scores to determine which level an individual is placed at if the Composite Score results in a more intense level of care.

Composite Scores

  • Level 1 – 10-13
  • Level 2 – 14-16
  • Level 3 – 17-19
  • Level 4 – 20-22
  • Level 5 – 23 – 27
  • Level 6 – 28+

Level 1 – Recovery Maintenance and Health Management

  • Risk of Harm: 2 or less
  • Functional Status: 2 or less
  • Co-morbidity: 2 or less
  • Level of Stress: Sum of Stress and Support less than 4
  • Level of Support: Sum of Stress and Support less than 4
  • Treatment & Recovery History: 2 or less
  • Engagement & Recovery Status: 2 or less

Level 2 – Low Intensity Community Based Services

  • Risk of Harm: 2 or less
  • Functional Status: 2 or less
  • Co-morbidity: 2 or less
  • Level of Stress: Sum of Stress and Support less than 5
  • Level of Support: Sum of Stress and Support less than 5
  • Treatment & Recovery History: 2 or less
  • Engagement & Recovery Status: 2 or less

Level 3 – High Intensity Community Based Services

  • Risk of Harm: 3 or less
  • Functional Status: 3 or less
  • Co-morbidity: 3 or less
  • Level of Stress: Sum of Stress and Support less than 5
  • Level of Support: Sum of Stress and Support less than 5
  • Treatment & Recovery History: 3 or less
  • Engagement & Recovery Status: 3 or less

Level 4 – Medically Monitored Non-Residential Services

  • Risk of Harm: 3 or less
  • Functional Status: 3 or less
  • Co-morbidity: 3 or less
  • Level of Stress: 3 or 4
  • Level of Support: 3 or less
  • Treatment & Recovery History: 3 or 4
  • Engagement & Recovery Status: 3 or 4

Level 5 – Medically Monitored Residential Services

  • Risk of Harm: If the score is 4 or higher – the client is automatically Level 5
  • Functional Status: If the score is 4 or higher – most clients are automatically Level 5
  • Co-morbidity: If the score is 4 or higher – most clients are automatically Level 5
  • Level of Stress: 4 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Level of Support: 4 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Treatment & Recovery History: 3 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Engagement & Recovery Status: 3 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity

Level 6 – Medically Managed Residential Services

  • Risk of Harm: If the score is 5 or higher – the client is automatically Level 6
  • Functional Status: If the score is 5 or higher – the client is automatically Level 6
  • Co-morbidity: If the score is 5 or higher the client is automatically Level 6
  • Level of Stress: 4 or more
  • Level of Support: 4 or more
  • Treatment & Recovery History: 4 or more
  • Engagement & Recovery Status: 4 or more

Given that there are a number of nuances in the exact scoring it’s recommended that an individual read or receive structured training in administration of the LOCUS. The LOCUS manual also provides a decision tree (not shown) to assist in making your determinations and a determination grid (shown below.)

Level of Care Determination Grid

LOCUS Level of Care Determination Grid

Research

Although the LOCUS is widely used, research is surprisingly limited.

The initial study validating the LOCUS was Sowers, George & Thomson (1999). Their study examined scores on the LOCUS and correlated them to expert decisions to see if the LOCUS matched that decision-making; their results indicated that it performed well in this function.

Kimura, Yagi & Toshizumi (2013) reviewed the LOCUS by comparing scores on it to the Global Assessment Scale (GAS) scores, a similar tool and examining the change of scores from admission to discharge. They found it a sensitive and effective tool for clinical use in Japan.

Ontario Shores, a large mental hospital in Whitby, ON implements the LOCUS along with the RAI tools as well.

References

American Association of Community Psychiatrists. (2009) LOCUS Level of Care Utilization System for Psychiatric and Addictions Services, Adult Version 2010. Retrieved on January 18, 2017 from http://cchealth.org/mentalhealth/pdf/LOCUS.pdf

Kimura, T., Yagi, F., & Yoshizumi, A. (2013). Application of Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) to Psychiatric Practice in Japan: A Preliminary Assessment of Validity and Sensitivity to Change. Community Mental Health Journal, 49(4), 477-491. doi:10.1007/s10597-012-9562-6

Sowers, W., George, C., & Thomson, K. R. (1999). Level of care utilization system for psychiatric and addiction services (LOCUS): a preliminary assessment of reliability and validity. Community Mental Health Journal, (6), 545.

Cite this article as: MacDonald, D.K., (2017), "Level of Care Utilization System (LOCUS)," retrieved on November 17, 2017 from http://dustinkmacdonald.com/level-care-utilization-system-locus/.
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Manage Stress Like a Marine

Military members salute

Introduction

Nobody knows stress management like the US military. Stress management has been recognized as an important part of ensuring an effective fighting force since the First World War. The US Marine Coprs manual MCRP 6-11C, “Combat and Operational Stress Control” (2010) is one part of this program.

Bite-sized takeaway: Know yourself and your team (whether that’s fellow Marines in a military environment or family and coworkers in a civilian enivronment) and be alert for any sudden, persistent or progressive change in their behaviour

Combat Stress Reactions

A combat stress-reaction (CSR) is the military equivalent to acute stress reaction, the state of agitation seen as a response to combat or other stressful or traumatic situations. These symptoms, if not properly managed, can lead to Post-Traumatic Stress Disorder (PTSD.)

The most common combat stress reaction symptoms include:

  • Slow reaction time
  • Difficulty with tasks and prioritizing
  • Excessive concern with minor issues
  • Indecision
  • Focus on familiar tasks
  • Loss of initiative

It can be hard to recognize when something is a normal reaction to battle or something that requires more intense medical or psychological support. One example given is that mild shaking while being fired upon or mortar rounds are incoming is very normal. On the other hand, intense shaking post-battle can be incapacitating and will require additional support.

Normal reactions to battle can include:

  • Perspiration
  • Chills
  • Nausea
  • Vomiting
  • Loss of appetite
  • Abdominal distress
  • Frequent urination
  • Incontinence

Dreams and flashbacks are one area that are commonly associated with PTSD. MCRP 6-11C notes that vivid battle dreams are a totally normal part of working through and processing combat experiences. Additionally, flashbacks are normal as long as they are recognized as flashbacks. These may become part of PTSD if the acute stress reaction is not managed but can be treated.

Some issues that may require more intensive support are stress-related blindness/deafness or partial paralysis. These can improve with reassurance from comrades, unit medical personnel or the batallion physician. As well, a reaction known as a panic run, where the service member rushes about without self-control or awareness (US Army, 1950) also requires evacuation for treatment.

Managing Combat Stress Reactions

If you need to, remove a soldier’s access to his weapon if he is experiencing combat stress reactions and you’re not sure he can keep himself safe. Additionally, give him simple tasks to do when not sleeping, eating, or resting. Strategies to manage combat stress reaction include:

  • Treating the service member close to the front (better outcomes happen when the service member is out of danger but still in theatre)
  • Utilize the BICEPS Model of Combat Stress Control
    • Brief (they should be out of the field no more than 3-4 days)
    • Immediate (treatment should be identified and started quickly)
    • Centrality (they should be treated out of hospital but close to the front)
    • Expectancy (the chain of command should have faith the service member will recover)
    • Proximity (keep the service member close to the rest of their unit so they can offer support)
    • Simplicity (the treatment should focus on the member’s return to duty)

Sleep Deprivation

Night time is the time to retain or gain the initiative, so it is common for operations to occur then. This increases the chance that sleep deprivation affects military member abilities to manage combat stress. Increasing circulation through activities like moderate exercise or drinking hot beverages may shorten start-up time after a short time sleeping.

After 36-48 hours of complete sleep loss, a minimum of 12 hours of sleep will be required to regain functioning. Keep watch for sleep drunkenness, which is the opposite (reduced functioning as a result of sleeping too much.)

Grief and Death

One area that many military members struggle with is grief and death. So-called open grieving, talking about grief and loss with comrades can help alleviate anxiety, whether this is a fear of the military member’s own death or survivor guilt from having lost friends and fellow military members on the battlefield.

Stress Management Techniques

It’s recommended that each service member know two stress management techniques: a slow or long one that can be used for deep relaxation and a quick one that can be deployed on-the-job.

Psychological Stress Management

Confidence is one of the strongest defences against stress. “If men can’t fight back, fear will overtake; as long as they can return fire they will not fear.”

Cognitive exercises include positive self-talk, visualization, rehearsal and meditation. Positive self-talk involves telling yourself that things will work out for you, rather than assuming and thinking the worst. Replacing bad self-talk with good self-talk can help increase your resilience.

Visualization is a cognitive technique that involves imagining good things. When you remember something that made you angry, your body reacts the same (your blood pressure rises and constricts), and you’re “right back there” mentally. By visualizing happy things, your blood pressure reduces and you find yourself more able to cope.

Rehearsal is similar to visualization but specifically involves yourself going over the tasks in your mind that you are about to perform. This helps to give you more confidence that you’re able to perform these tasks. Finally, meditation is a form of deep breathing and relaxation to improve one’s emotional state.

Physical Stress Management

Good nutrition and hydration is important. Remember the acronym HALT, the four items that make regulating our emotions more difficult (HALT is “Hungry, Angry, Lonely, Tired.”) If the service member only drinks when they are thirsty, they’ll become dehydrated.

Increasing your aerobic fitness increases your ability to handle stress

Mastering relaxation techniques allows you to reverse the combat stress process. Physical stress management techniques include deep breathing, and progressive muscle relaxation.

Breathing Techniques

Deep Breathing involves slow, deep inhaling. Deep breathe for 2-5 seconds, then exhale slowly over 2-5 seconds
Perform this exercise 5 times for a quick mind-clearing, or continuously at night to promote sleep. Diaphragmatic breathing (which is deep in the chest, as opposed to shallow) is especially helpful for stress control

Muscle Relaxation is a special form of relaxation where you concentrate on one muscle group at a time, tensing and relaxing your limbs in order to relax your entire body. The quick version involves tensing all your muscles simultaneously, holding this state for 15 seconds, letting your body relax, and shaking out all the tension.

The long version involves starting in your feet and working up, body part by body part until you reach your head, tensing and then relaxing the limbs.

Pre and Post-Deployment Reactions

New members to a unit are more likely to become casualties than experienced members. Keeping this in mind, experienced members can help mentor new ones to build resilience and support. “Startle reactions to sudden noise
or movement, combat dreams and nightmares and occasional problems with sleeping, and feeling bored, frustrated and out of place” wee all identified as being common after deployment, as the service member re-integrates into their community.

References

US Army. (1950) TM 8-240 Psychiatry in Military Law. Washington, DC: Department of the Army and the Air Force.

US Marine Corps. (2010) MCRP 6-11C, “Combat and Operational Stress Control”. Retrieved on September 5, 2016 from http://www.marines.mil/Portals/59/Publications/MCRP%206-11C%20%20Combat%20and%20Operational%20Stress%20Control.pdf

Cite this article as: MacDonald, D.K., (2017), "Manage Stress Like a Marine," retrieved on November 17, 2017 from http://dustinkmacdonald.com/manage-stress-like-marine/.
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Preventing Burnout on Crisis Lines

Introduction

Burnout is defined as a state of ineffectiveness comprising “emotional exhaustion, depersonalization, and reduced personal accomplishment.” (Maslach, 1982) It is a pervasive and frustrating state, accounting for a large portion of the turnover experienced in mental health services, including volunteer and paraprofessional organizations like crisis lines.

There are a number of models of burnout, but one stage model is presented below from Cherniss (1980) and reproduced in Kinzel & Nanson (2000):

Stage 1: Stress

Stress is the first stage of burnout, when an individual is functioning at a level that exceeds their optimal operating conditions. This could be because of internal factors (like wanting a promotion or being intensely devoted to work), external factors (like being given a larger caseload due to budget cuts) or interpersonal factors (like a negative relationship with a colleague or supervisor.)

Stage 2: Strain

When a person experiences strain, they have now operated in a state of stress long enough that they are reaching a point of emotional exhaustion. Their coping begins to be maldaptive and they often experience negative somatic or physical complaints like headaches.

Stage 3: Defensive Coping

In the final stage of burnout, an individual’s burnout begins negatively impacting their ability to take calls or otherwise perform their helpline work. There is a lack of empathy or concern for the callers and this may be accompanied by blaming the callers or detachment from the situation. At this stage

Causes of Burnout

There are a variety of causes of burnout. Some listed by Kinzel & Nanson (2000) include:

  • Nature of crisis calls
  • Negative emotions experienced during the calls like anger or guilt
  • Countertransferrence (being triggered by one’s own experiences while supporting another)
  • Repeat or regular callers creating a feeling of powerlessness or ineffectiveness
  • A lack of effective coping skills

Additionally Kinzel & Nanson note studies that revealed the presence of magical thinking (assuming the situation would get better on its own) and escape-avoidance coping skills were associated with an increase in burnout, along with detachment and personality responsibility.

Paradoxically, workers who were too involved (taking personal responsibility for callers) were more likely to experience burnout as were volunteers who were detached. The least likely to experience burnout is the crisis line worker who stays emotionally connected to a caller but also recognizes that their life is their life and it is not the worker’s responsibility to change it. (Mishara & Giroux, 1993)

Assessing Burnout

The Maslach Burnout Inventory (MBI; Maslach, C., Jackson, S.E., & Leiter, 1996) is the most common measure for assessing burnout. It is a 21-item scale that produces scores on three subscales: Emotional Exhaustion, Personal Accomplishment and Depersonalization.

Morse et. al. (2012) notes example cut-off scores for the three scales as follows “emotional exhaustion scores of at least 21, depersonalization scores of at least 8, and personal accomplishment scores of 28 or below” but with the caveat that those scores may be lower than necessary, artificially inflating the presence of burnout in mental health professionals.

Helpline managers will need to take the lead in determining whether their workers are experiencing symptoms of burnout. This may be witnessed in the quality of listened calls, in the comments made on call reports, or contacts that occur off the lines. For instance, volunteers who:

  • Started giving more advice to callers
  • Talked to staff about frustration with non-suicidal callers “wasting” distress line time
  • Missed shifts because of not being emotionally capable

These may be situations where you would recommend burnout prevention activities. Potential treatments for burnout are discussed more in-depth below, but in the helpline environment a leave of absence (LOA) from the lines for a while, increased self-care or decreased activity (e.g. limiting hours weekly or monthly) can help avoid burnout.

Treatments for Burnout

Smullens (2013), writing for Social Worker magazine notes a number of strategies including:

  • Stimulus control and counterconditioning. Stimulus control involves active decisions like not choosing to eat lunch at your desk or bringing a plant into the office while counterconditioning involves physical exercise, hobbies, or other diversions
  • Mental health treatment. Therapists should seek their own therapy when their personal issues interfere, and someone who is experiencing or worried about experiencing burnout is certainly under that category
  • Diversify. This refers to the idea of changing your responsibilities to give you non-clinical activities that help to refresh and restore you. For many social workers, this involves teaching, conferences, or other activities, but for heplline workers it can also involve becoming a leadership volunteer, serving on a non-profit Board or another form of volunteerism

Oser et. al. 2013) added to this with burnout prevention strategies including:

  • Coworker support. Being able to vent to colleagues who have a sense of what you’re going through and understand your organizational culture can be very helpful. Feeling like (or being) isolated without anyone to discuss concerns with can exacerbate feelings of ineffectiveness. This applies to helpline workers as well, who can make frequent use of debriefing
  • Clinical supervision. Supervision can also help reduce feelings of isolation and ineffectiveness by giving individuals an opportunity to identify maladaptive coping strategies or other issues that may lead to burnout

Research is continuing so hopefully in the future we have specific therapies designed for burnout and options; a number of individuals leave the helping professions each year because of burnout, which is obviously not ideal.

References

Bowden, G. E., Elizabeth Smith, J. C., Parker, P. A., & Christian Boxall, M. J. (2015). Working on the Edge: Stresses and Rewards of Work in a Front-line Mental Health Service. Clinical Psychology & Psychotherapy, 22(6), 488-501. doi:10.1002/cpp.1912

Cherniss (1980). Staff Burn-Out. Job Stress in the Human Services. Sage Publications.

Kinzel, A., & Nanson, J. (2000). Education and debriefing: Strategies for preventing crises in crisis-line volunteers. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 21(3), 126-134. doi:10.1027//0227-5910.21.3.126

Maslach, C. (1982). Burnout: The Cost of Caring. New Jersey: Prentice-Hall, Inc.

Mishara, B.L., Giroux, G. (1993). The relationship between coping strategies and perceived stress in telephone intervention volunteers at a suicide prevention center. Suicide and Life Threatening Behavior, 23(3).

Maslach, C., Jackson, S.E., & Leiter, M.P. (1996) Maslach Burnout Inventory (3rd ed.). Palo Alto, CA: Consulting Psychologists Press.

Morse, G., Salyers, M. P., Rollins, A. L., Monroe-DeVita, M., & Pfahler, C. (2012). Burnout in Mental Health Services: A Review of the Problem and Its Remediation. Administration and Policy in Mental Health, 39(5), 341–352. http://doi.org/10.1007/s10488-011-0352-1

Smullens, S. (2013) What I Wish I Had Known: Burnout and Self-Care in Our Social Work Profession. Social Worker. Retrieved on December 28, 2016 from http://www.socialworker.com/feature-articles/field-placement/What_I_Wish_I_Had_Known_Burnout_and_Self-Care_in_Our_Social_Work_Profession/

Cite this article as: MacDonald, D.K., (2017), "Preventing Burnout on Crisis Lines," retrieved on November 17, 2017 from http://dustinkmacdonald.com/preventing-burnout-on-crisis-lines/.
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Bereavement Risk Assessment Tool (BRAT)

Introduction

Bereavement Risk Assessment Tool (BRAT) Sample
Bereavement Risk Assessment Tool (BRAT) Sample

From September 2012 to April 2013, I had the pleasure of completing an 400 hour field placement with Durham Hospice (now VON Durham Hospice). During the first 200 hours (my first semester), I completed the Fundamentals of Hospice Palliative Care Course, learned how to perform psychosocial assessments and assisted in the facilitation of a Day Hospice group.

My second semester and final 200 hours, I completed an 8-week Bereavement Volunteer Peer Support Program that focused on the fundamentals of providing individual and group peer support to grieving individuals. That’s where I learned about this tool, the Bereavement Risk Assessment Tool (BRAT).

The BRAT was developed by Victoria Hospice Society to help “communicate personal, interpersonal and situational factors that may place a caregiver or family member at greater risk for a significantly negative bereavement experience” (Victoria Hospice Society, n.d.)

The version of the BRAT I worked with is the 2008 version, though the 2013 manual is available for purchase on the Victoria Hospice website.

Bereavement Risk Assessment Tool (BRAT) Items

The BRAT is organized into 11 domains for a total of 40 items. Each is scored on a yes/no basis and a risk level (unmitigated and mitigated.) The “unmitigated risk” level is the raw score from the first 10 domains, while the “mitigated risk level” takes into account the 11th domain. The domains are listed below, though the items themselves are not, out of respect for the author’s copyright:

  1. Kinship
  2. Caregiver
  3. Mental Health
  4. Coping
  5. Spirituality/Religion
  6. Concurrent Stressors
  7. Previous Bereavements
  8. Supports & Relationships
  9. Children & Youth
  10. Circumstances Involving the Patient, the Care or the Death
  11. Protective Factors Supporting Positive Bereavement Outcomes

Scoring the Bereavement Risk Assessment Tool

The BRAT is scored using an Excel sheet that automatically calculates the correct score and prepares the document for printing. Documentation information includes the date, the assessor and client’s names, an ID number (e.g. case/file number) and the name of the deceased.

Five Levels of Risk

  • Risk Level 1: No Known Risk
  • Risk Level 2: Minimal Risk
  • Risk Level 3: Low Risk
  • Risk Level 4: Moderate Risk
  • Risk Level 5: High Risk

Research Support for the Bereavement Risk Assessment Tool

The BRAT has received some, though very minimal, research exploration. Rose et. al. (2011) explored the inter-rater reliability of the BRAT and found it adequate (inter-class correlation of 0.68.) Qualitative responses indicated it was a useful tool for assessment of bereavement risk.

The lack of other published work significantly limits the usability of these tool in a research environment. Other reviews (e.g. this presentation by Bill Palmer) fail to identify the BRAT in a list of bereavement assessment tools which suggests it may not be well-known outside of the Canadian Hospice environment.

Other Bereavement Risk Assessment Tools

These tool recommendations come from Bill Palmer’s presentation:

  • Adult Attitude to Grief Scale (AAG)
  • Core Bereavement Items (CBI)
  • Grief Evaluation Measure (GEM)
  • Inventory of Traumatic Grief (ITG)
  • Texas Revised Inventory of Grief (TRIG)

Other Resources

References

Rose, C., Wainwright, W., Downing, M., & Lesperance, M. (2011). Inter-rater reliability of the Bereavement Risk Assessment Tool. Palliative & Supportive Care, 9(2), 153-164. doi:10.1017/S1478951511000022

Victoria Hospice Society. (n.d.) “Clinical Tools | Victoria Hospice Society” Retrieved on October 17, 2016 from http://www.victoriahospice.org/health-professionals/clinical-tools

Cite this article as: MacDonald, D.K., (2016), "Bereavement Risk Assessment Tool (BRAT)," retrieved on November 17, 2017 from http://dustinkmacdonald.com/bereavement-risk-assessment-tool-brat/.
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Biopsychosocial Model of Violence Risk Assessment

Introduction

Violence risk assessment is an important element of counselling and crisis intervention. Although in high-risk situations it can (and should be) performed by clinicians with specific training in violence risk, there may be situations where clinicians or others (corrections officers, private practice therapists, crisis line supervisors, etc.) need to have a understanding of the principles of violence risk assessment in order to respond appropriately.

Types of Violence Risk Assessment

There are three types of violence risk assessment, based on the way risk is estimated or “calculated.” The first is unstructured professional judgement. This is where the clinician merely listens to the client and makes their best judgement, based on their existing professional training. (Murray & Thomson, 2010) While some professionals made good predictions relative to others, some were very poor. It emerged that the reason for this disparity was that some clinicians considered factors relevant to violence while others did not. Unstructured professional judgement no longer stands up in court.

The second form of risk assessment is known as actuarial risk assessment. This is an entirely mathematical technique that examines what factors were present in offenders who later went on to commit violent crimes. (Brown & Singh, 2014) This is similar to the approach used in insurance to calculate the likelihood a person will die, and has the same flaw as that approach: you can determine over a large pool what percentage of individuals will be violent, but you risk ignoring salient risk or protective factors in an individual that may heighten or reduce their violence risk.

The final form of risk assessment is Structured Professional Judgement (SPJ; Falzer, 2013). SPJ attempts to merge the predictive ability of the actuarial approach with the flexibility of the unstructured approach by providing a list of evidence-based risk factors (elements that have been demonstrated to increase risk of violence) along with a coding or scoring method to generate a “Low”, “Moderate”, or “High” risk, and usually the freedom to modify the scoring for items or list additional contributing factors that entered into a clinician’s assessment.

Static vs Dynamic Risk Factors

Static risk factors are elements that are known to increase risk that are not changeable. An example of static risk factors for violence include sex and age. As a male, you will always have elevated risk of violence versus a female (Sorrentino, Friedman, & Hall, 2016), and as someone who is aged 18-24 you will always have a heightened risk of violence relative to someone older or younger. (Harris & Rice, 2007) There is nothing a clinician can do to change your age or sex.

On the other hand, other risk factors are called dynamic risk factors. These are factors that can be modified by the clinician or by the client (Public Safety Canada, 2010), such as one’s peer group, use of alcohol or stimulants, or access to a pool of victims.

Affective vs. Predatory Violence

Affective violence is also called impulsive or reactive violence. (Berg, 2014) This is violence that results from a threat, causes an individual to experience physiological arousal (heart racing, blood pressure increase, etc.) and then to strike back in a “fight or flight” response.

In contrast, predatory violence is more common among psychopaths and serial killers. This is violence that is not associated with an increase in physiological arousal or an identified threat. Instead, the predatory killer “stalks his prey” and then strikes without warning.

Biopsychosocial Model Items

This model comes from “Violence Risk and Threat Assessment” by Meloy (2000), but closely matches other models of violence risk.

Individual/Psychological Domain

  • Male
  • Age
  • Past History of Violence
  • Paranoia
  • Intelligence Below Average
  • Anger/Fear Problems
  • Psychopathy / Other Attachment Difficulties

Social/Environmental Domain

  • Family of Origin Violence
  • Adolescent Peer Group Violence
  • Economic Instability
  • Weapons History/Skill/Interest and Approach Behaviour
  • Victim Pool
  • Alcohol/Psychostimulant Use
  • Popular Culture

Biological Domain

  • History of CNS Trauma
  • Signs and Symptoms
  • Objective CNS Measures
  • Major Mental Disorder

Assessing Psychological Factors of Violence Risk

The elements in the psychological or individual domain cover static and dynamic items that relate to the person’s mental health and personal demographics. They include:

Men are up to 10x more likely to be involved in violence than women (Meloy, 2000; p.19); sex is a static variable. Significantly more crimes are committed before the age of 25 (Bureau of Justice Statistics, 2011), therefore age is an important static variable. Past history of behaviour is one of the most important future predictors of future violence. If the situations that led to violence in the past aren’t modified, we will find ourselves in them in the future, therefore Past History of Violence becomes an important static behaviour.

Other elements associated with increased violence risk include acute paranoia or a delusional state (Yang, 2008); this can cause them to genuinely believe they are in danger, and therefore Not Guilty by Reason of Insanity (NGRI) or Not Criminally Responsible (NCR). Someone in a paranoid state, with thought insertion or homicidal thoughts needs immediate psychiatric attention.

Below average intelligence and anger/fear problems are linked to the concept of affective violence above. Lower levels of intelligence are perhaps linked to violence in that people cannot think of responses quick enough to avoid violence (Freeman, 2012), and may find themselves unable to label or understand their emotions. Anger and fear problems cause an increase in violence by causing an individual to perceive threats where maybe none exists. It is the presence of these threats that causes affective violence (Helfgott, 2008)

Psychopathy and other attachment difficulties are associated with an increased risk of predatory violence. Psychopaths have difficulty perceiving empathy for others, and individuals who lack attachments may be able to cause those individuals pain without considering the impact their actions have on those people. (Brook & Cosson, 2013) A standardized assessment like the PCL-R (Hare Psychopathy Checklist–Revised; Hare, 2003) can be used to assess for the presence of psychopathy, with a score of 30 (out of 40) indicating psychopathy.

Assessing Social Factors of Violence Risk

Social factors of violence risk include those individuals that are around us who can model violent behaviour, and are caused by factors beyond mental health.

Family of origin violence (a static risk factor) and adolescent peer group violence (a dynamic risk factor) are both risk factors because of the ability of them to model answers to threats or problems that involve violence (Franklin, Menaker & Kercher, 2011), rather than non-violent alternatives. Additionally, family of origin violence can lead to a sense of detachment which can involve the attachment difficulties noted in the Psychological Factors above; finally, a family that suppresses emotional expression may prevent men from ventilating their stress until it is expressed in a maladaptive way (e.g. through violence.)

Economic instability or poverty is a static or dynamic risk factor for violence (McAra, & McVie, 2016) because of the known causal relationship between poverty and violence; additionally, for those who are at risk of or have recently lost their jobs, intense anger can cause violent acts and so should be kept in mind. (Catalano, Novaco, & McConnell, 1997)

Weapons history/skill/interest is a static variable and approach behaviour is a dynamic behaviour. The first set refers to a potentially violent individual’s history with weapons, especially firearms. Do they own any guns, have they received professional training (e.g. police, military, private instruction)? Owning guns does not make a person more violent on their own, but they do provide a violent individual with easier tools with which to carry out their violence.

“Approach behaviour” (Meloy, 2000; p.57) is the term used to describe what someone does when they cannot possess guns (for instance, because of a felony conviction or financial reasons). This could include reading about guns, owning gun accessories and being around people who own guns. Approach behaviour is  a person’s ability to “approach” the off-limits items psychologically. The more approach behaviour is noted, the higher the violence risk is.

Victim pool is important in assessing violence risk because violence does not occur in a vacuum. This is especially important in predatory violence (such as sex offenders or serial killers) but may also be important for gang members or others who only become violent in specific, limited situations. Meloy (1996) discusses this in particular in violent stalkers but it applies equally to all violent crimes.

Drugs and alcohol (especially psychostimulants like cocaine) increase violence risk by reducing one’s inhibition and increasing impulsiveness. (Haggård-Grann, Hallqvist, Långström, & Möller, 2006) Additionally, stimulants like cocaine, methamphetamine and others can cause “stimulant psychosis” (Curran, Byrappa & Mcbride, 2004), a condition that can cause paranoia and homicidal thoughts.

The last element in assessing social factors of violence risk is popular culture. (De Venanzi, 2012) This is a controversial element but like suicide contagion, mass media glorifying elements of homicide can increase the risk of violence in vulnerable individuals. It’s important to pay close attention to court cases, movies or other elements that the person being assessed may identify with.

Assessing Biological Factors of Violence Risk

Biological factors are elements not related to a person’s mental health or social environment, but rather their neurological. They include a history of central nervous system (CNS) trauma (Rao et. al., 2009), signs and symptoms of CNS problems (such as headaches, dizziness, memory difficulties, and many others), objective CNS measures and the presence of a mental health diagnosis. (Rueve & Welton, 2008)

With the exception of some CNS measures which may be administered by clinicians, these items are most easily determined by a neuropsychologist or neurologist who can perform the required brain scans and administer and interpret the tests for CNS function. Major mental disorders may be diagnosed by social workers in some jurisdictions, or may be required to be diagnosed by a psychologist or psychiatrist in others.

Violence Risk Assessment Tools

Below are some tools that I’ve got articles for on my blog.

Other Resources

References

Bureau of Justice Statistics. (2011) “Homicide Trends in the United States, 1980-2008” Retrieved on October 28, 2016 from https://www.bjs.gov/content/pub/pdf/htus8008.pdf

Berg, L. (2014) “Comparing Predatory Versus Affective Violence and Examining Early Life Stress as a Risk Factor” Writing Excellence Award Winners. Paper 37. Retrieved on October 28, 2016 from http://soundideas.pugetsound.edu/writing_awards/37

Brown, J. & Singh, J.P. (2014) Forensic Risk Assessment: A Beginner’s Guide. Archives of Forensic Psychology. 1(1). 49-59. Retrieved on October 28, 2016 from http://www.archivesofforensicpsychology.com/web/wp-content/uploads/2015/01/Brown-and-Singh1.pdf

Brook, M., & Kosson, D. S. (2013). Impaired cognitive empathy in criminal psychopathy: Evidence from a laboratory measure of empathic accuracy. Journal Of Abnormal Psychology, 122(1), 156-166. doi:10.1037/a0030261

Catalano, R., Novaco, R., & McConnell, W. (1997). A model of the net effect of job loss on violence. Journal Of Personality And Social Psychology, 72(6), 1440-1447. doi:10.1037/0022-3514.72.6.1440

Curran, C., Byrappa, N. & Mcbride, A. (2004) Stimulant psychosis: systematic review. British Journal of Psychiatry. 

De Venanzi, A. (2012). School shootings in the USA: Popular culture as risk, teen marginality, and violence against peers. Crime, Media, Culture, 8(3), 261-278. doi:10.1177/1741659012443233

Falzer, P. R. (2013). Valuing Structured Professional Judgment: Predictive Validity, Decision-making, and the Clinical-Actuarial Conflict. Behavioral Sciences & The Law, 31(1), 40-54. doi:10.1002/bsl.2043

Franklin, C. A., Menaker, T.A. & Kercher, G.A. (2011) The Effects of Family-of-Origin Violence on Intimate Partner Violence. Crime Victims’ Institute. Retrieved on October 28, 2016 from http://dev.cjcenter.org/_files/cvi/7935%20Family%20of%20Origin%20Violence.pdf

Freeman, G. (2012) The relationship between lower intelligence, crime and custodial outcomes: a brief literary review of a vulnerable group. Journal of Society, Health & Vulnerability. Volume 3. Retrieved on October 28, 2016 from http://www.societyhealthvulnerability.net/index.php/shv/article/view/14834/22691

Hare, R. D. (2003). Manual for the Revised Psychopathy Checklist (2nd ed.). Toronto, ON, Canada: Multi-Health Systems

Haggård-Grann, U., Hallqvist, J., Långström, N., & Möller, J. (2006). The role of alcohol and drugs in triggering criminal violence: a case-crossover study. Addiction, 101(1), 100-108.

Harris, G. T., & Rice, M. E. (2007). Adjusting Actuarial Violence Risk Assessments Based on Aging or the Passage of Time. Criminal Justice & Behavior, 34(3), 297. doi:10.1177/0093854806293486

Helfgott, J.B. (2008) Criminal Behavior: Theories, Typologies and Criminal Justice. Thousand Oaks, CA: SAGE Publications.

McAra, L., & McVie, S. (2016). Understanding youth violence: The mediating effects of gender, poverty and vulnerability. Journal Of Criminal Justice, 45. 71-77. doi:10.1016/j.jcrimjus.2016.02.011

Meloy, J.R. (1996) Stalking (Obsessional Following): A Review of Some Preliminary Studies. Aggression and Violent Behavior. 1(2). 147-162. http://drreidmeloy.com/wp-content/uploads/2015/12/1996_StalkingObsessi.pdf

Meloy, J. R. (2000). Violence risk and threat assessment. San Diego, CA: Specialized Training Services.

Murray, J., & Thomson, M. E. (2010). Clinical judgement in violence risk assessment. Europe’s Journal Of Psychology, 127-149.

Public Safety Canada. (2010) “Giving Meaning to Risk Factors.” Research Summary. 15(6) Retrieved on October 28, 2016 from https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/mnng-fctrs/mnng-fctrs-eng.pdf

Rueve, M.E & Welton, R.S. (2008) Violence and Mental Illness. Psychiatry.

Sorrentino, R., Friedman, S. H., & Hall, R. (2016). Gender Considerations in Violence. Psychiatric Clinics Of North America, doi:10.1016/j.psc.2016.07.002

Yang, S. (2008) Dangerously Paranoid? Overview and Strategies for a Psychiatric Evaluation of a Highly Prevalent Syndrome. Psychiatric Times.
Rao, V., Rosenberg, P., Bertrand, M., Salehinia, S., Spiro, J., Vaishnavi, S., Rastogi, P., Noll, K., Schretlen, D.J., Brandt, J., Cornwell, E., Makley, M. & Miles, Q.S. (2009) Aggression After Traumatic Brain Injury: Prevalence and Correlates. The Journal of Neuropsychiatry and Clinical Neurosciences. 21(4):420-429
Cite this article as: MacDonald, D.K., (2016), "Biopsychosocial Model of Violence Risk Assessment," retrieved on November 17, 2017 from http://dustinkmacdonald.com/biopsychosocial-model-violence-risk-assessment/.
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