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Rosana Oliveira, PharmD, BCPS, BCPP
CPNP Program Committee Member

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Pharmacists do not typically receive training on how to triage violence risk despite the pervasive impact of violence. Psychiatric pharmacists in particular should have increased knowledge of the violence triage and risk assessment process, because there is an important and complex association between mental disorder and violence risk, although the vast majority of individuals who suffer from a major mental disorder do not engage in violence.1 As psychiatric pharmacist level of autonomy in practice continues to expand, so should their comfort with triaging violence risk.

Dr. Kelly Watt, Director and Threat Assessment Specialist at Protect International Risk and Safety Services Inc. in Vancouver, presented on the complex topic of violence risk assessment at the 2019 CPNP Annual Meeting.  First and foremost, a working definition of violence was presented as actual, attempted, or threatened physical harm of another person that is deliberate and nonconsenting.2 Because violence has far-reaching and serious physical, psychological, and economic consequences, Dr. Watt explained the importance and process of identifying warning signs of violence, which is a critical step of the violence risk triage process.3-6 Triaging violence risk is a fast-paced process wherein an individual determines whether there are reasonable grounds to believe there is a risk for violence. To determine this, one should consider whether a patient is currently or has recently exhibited primary warning signs of violence. If so, further assessment of violence risk is recommended. A comprehensive violence risk assessment, which is best completed by a forensic specialist, will usually include a structured professional tool and helps to identify critical risk factors and plausible scenarios of violence in addition to informing case management plans.

Even with consistent attention to mitigating violence risk, there will inevitably be situations that require our quick judgment and possibly intervention. Dr. Watt reviewed appropriate action steps to take in these situations depending on if a patient is vaguely threatening, clearly threatening, or is acting or attempting to act violently.7 The audience was reminded to be observant of a patients behaviors and nonverbal cues, and of techniques to include making an assertive request, such as asking a patient to please lower their voice. In closing, the development of detailed violence management plans and suggested strategies were presented, which includes victim safety planning such as enhancing security resources for identified targets of violence.

Take Home Points

  • Violent behavior with the intent of causing harm has consequences far beyond physical injuries
  • Psychiatric pharmacists should at a minimum be able to triage violence risk by identifying primary warning signs of violence and be able to respond to obvious risk appropriately
  • Violence risk assessment and management plans require integration of structured tools and repeated monitoring over time in order to mitigate violence risk

References

  1. Douglas, K. S., Guy, L. S., & Hart, S. D. (2009). Psychosis as a risk factor for violence to others: A meta-analysis. Psychological Bulletin, 135, 679-706.
  2. Douglas, K. S., Hart, S. D., Webster, C. D., & Belfrage, H. (2013). HCR-20V3: Assessing risk of violence –User guide. Burnaby, Canada: Mental Health, Law, and Policy Institute, Simon Fraser University.
  3. Flannery, R. B. (1996). Violence in the workplace, 1997-1995. A review of the literature. Aggression and Violent Behavior, 1, 57-68.
  4. Gerberich, S. G., Church, T. R., McGovern, P. M., Hansen, H. E., Nachreiner, N. M., & Geisser, M.S. (2004). An epidemiological study of the magnitude and consequences of work related violence: The Minnesota Nurses Study. Occupational and Environmental Medicine, 61, 495-503.
  5. Krug, E. G., Dahlberg, L. L., Mercy, J. A., Zwi, A. B., & Lozano, R. (Eds.). (2002). World report on violence and health. Geneva, Switzerland: World Health Organization.
  6. Brewin, C., Andrews, B., Rose, S., & Kirk, M. (1999). Acute stress disorder and post-traumatic stress disorder in victims of violence. American Journal of Psychiatry, 156, 360-366.
  7. Health Employers Association of BC (2010). Provincial Violence Prevention Curriculum. Retrieved 07/01/2017 from http://www.heabc.bc.ca/Page4270.aspx#.XHclGi2ZPAw.
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