Risk management from Black-box to Brain-box by means of The Early Recognition Method Frans Fluttert Phd B. Van Meijel PhD Prof. dr. M. Grypdonck Prof dr. H. Nijman Prof dr. S. Bjørkly
FPC Dr. S. Van Mesdag Forensic Psychiatric Hospital The Netherlands
Centre for forensic psychiatry, Oslo Molde University College, Molde Norway
Aim of this presentation
Early Recognition Method [ERM]
Development of the FESAI [Forensic Early Signs of Aggression Inventory]
Detached Concern of nurses to patients
Frans Fluttert Copyright 2012
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256 Patients 190 Nurses
FPC Dr. S. Van Mesdag Norway Buskerud Lier Ulleval University Oslo Blakstad COMMUNITY SERVICES
A’dam
PRISON SERVICES General Psychiatry Netherlands Belgium Ghent University Germany Lippstadt Paderborn Oldenburg Dortmund Essen FPC Dr. S. van Mesdag
November 2009
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Inpatient aggression Key variable: Causes: Staff-Patient Multi Factor models Interaction (Mason 2009, Martin 2006, Meehan (Binnema 2006, 2004, Duxbury Hiday 2005, 2005, Whittington Kettles 2006)) 1996,)
Factors related to violence
(Hiday, 1997, 2005)
Antisocial personality disorder
Social desorganisati on / poverty
Substance abuse dependency
Stressfull Tense
events
situations
Victimization
Violence Violence
Violence Neurobiological
Suspicion
pathology
mistrust
‘Threat/control override -
Severe mental illness Disorder
Bizarre symptoms
symptomen’
Bartels 2005, Fluttert et al. 2008
Identity
Representation
Core beliefs
F
Event
Life rules
Thoughts
I L
Result:
T E R
Feelings
Skills
Behaviour
Result
The ERM concept Symptoms and / or Stress
Crisis Phase of increasing Disturbing behavior
baseline
early
crisisintervention
intervention (stressor) Coping + early intervention Early Recognition
Time
Method
Early signs: pattern?! Changes in the Perceptions, thoughts and objective behaviour occuring in the first phase preceding violence. (Fluttert et al. 2008)
Signature risk signs, Idiosyncratic based (Fluttert et al. 2008, Webster et al. 2004)
Inside versus outside behaviours (Fluttert et al. 2008, 2011, 2012)
Early Recognition Method Van Meijel , Fluttert 2008
Phases ERM Protocol 1: Introduction 2: Listing early warning signs 3: Monitoring 4: Actionplan
Copyright Fluttert 2012
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Listing Early warning signs Patient
Sociaal netwerk
Main Early Warning Signs 1. 2. 3. 4. 5.
Nursing staff Additionally E-W Signs 1. 2. 3.
Copyright Fluttert 2011
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Early Sign (5): Changing eating pattern
Early Sign (4): … Anger… Datum Early SignDatum (3) Withdrawal from contact… Niveau 3: ernstig ……………………………………………..
Niveau 3: ernstig Datum voel woede bij Early Sign (2): Increasing Ik physical complaints ……………………………………………..
licht in mijn ogen Ik voel woede bij
Niveau 3: ernstig …………………………………………….. EarlyDatum Sign (1): Fear forlicht light… in mijn…………………………………………….. ogen …………………………………………….. ……………………………………………..
Ik voel woede bij …………………………………………….. Niveau 2: matig aanwezig ernstig Date Niveau 3: licht in mijn ogen …………………………………………….. …………………………………………….. Niveau 2: Ik matig aanwezig …………………………………………….. trek me terug en plak
…………………………………………….. Ik voel woede bij …………………………………………….. de ramen dicht om daglicht Ik trek me terug en plak licht in mijn ogen te vermijden Niveau I feel anger when light 2: matig aanwezig …………………………………………….. de ramen dicht om daglicht …………………………………………….. is shining in my…………………………………………….. eyes. …………………………………………….. te vermijdenNiveau 1: normaal / stabiel Ik trek me terug en plak Ik vermijd zonlicht maar Niveau de 2:ramen matig aanwezig dicht om daglicht Niveau 1: normaal / stabiel Level 2: moderate Kan overige licht wel …………………………………………….. te vermijden Ik vermijd zonlicht maar I withdraw and prefer to Verdragen. ………….. Ik trek me terug en plak
Level 3: severe
x
x x
. Kan overige/licht wel darkende my room ramen dicht om1: daglicht Niveau normaal stabiel …………………………………………….. Verdragen.………….. te vermijden Ik vermijd zonlicht maar ……………………………………………..
. Level 1: normal / stable Kan overige licht wel …………………………………………….. Niveau 1: normaal / stabiel
I avoid sunlightVerdragen. however ………….. …………………………………………….. Ik vermijd zonlicht maar . me. it doesn’t trouble …………………………………………….. Kan overige licht wel .
x
…………………………………………….. Verdragen.………….. . …………………………………………….. ……………………………………………..
A C T I O N P L A N
Design ERM-study (+ ‘one way case-cross over’ design) N= 189. 30 months STUDYGROUP 1
(Fluttert et al. 2010) STUDYGROUP 2
STUDYGROUP 3
Research T1
Start INTERVENTION
SOASR
CARE AS USUAL
CARE AS USUAL
Research T2
MAINTAIN INTERVENTION
Start INTERVENTION
CARE AS USUAL
Research T3
MAINTAIN INTERVENTION
MAINTAIN INTERVENTION
Start INTERVENTION
Research T4
MAINTAIN INTERVENTION
MAINTAIN INTERVENTION
MAINTAIN INTERVENTION
T5 FPC Dr. S. van Mesdag
November 2009
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Related factors in ERM Early Recognition Method
Detached Concern
Decrease of incidents
Nurses to patients
Nature of Early Warning Signs
Forensisch Psychiatrisch Centrum Dr. S. van Mesdag
April 2009
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ERM results
(Fluttert et al. 2010)
Frequency of incidents 0,2 0,15 0,1 0,05 0 All
Schizofrenie TAU
ASPD
Subst Abuse
Sexual offence
ERM
Severity of incidents (SOAS-R) 2,5 2 1,5 1 0,5 0 All
schizophr TAU
Frans Fluttert Copyright 2009
ASPD
Substance Abuse
Sexual offence
ERM
Juni 2009
13
Group and Individually focus Variables related to restrain
Individual related factors:
(Knutzen et al. 2011)
Patient’s behaviours / perceptions?! 1. 2. 3. 4.
Diagnostic Group (psychotic disorder) Lenght of stay (>16) Early warning signs Number of admissions (In)voluntary referral.
(controlled for age, gender, ethnicity, residentally status)
FESAI – Design I (Fluttert et al. 2011) Forensic Early Signs of Aggression Inventory
INPUT
Analyses PROCESS 240 early detection plans 3768 Early signs descriptions Phase 1
Hospital I (M. v. Leeuwen 2006, Fluttert et al. 2011) (n=130 early detection Compiling early warning plans) signs Hospital II (n=37 early detection plans)
Phase 2 FESAI: Inventory drafting and face validity testing 15 categories Forensic professionals (n=3) 44 early warning signs
Figure 1: design
Phase 3 Assessing inter-rater agreement
RESULTS Survey of all early warning signs (n=3768)
44 items within 15 main categories
The FESAI
[FESAI] (Leeuwen v. 2008, Fluttert et al. 2011, 2012)
Forensic Early Signs of Aggression Inventory SOCIAL ISOLATION, DECREASED SOCIAL CONTACT - MORE SUPERFICIAL CONTACT, DECREASED INTERACTION - AVOIDANCE OF EYE CONTACT - ISOLATION, WITHDRAWAL - WALKS AWAY FROM CONVERSATION OR OTHER ACTIVITIES
FESAI categories 1 . Change of daily activities 2 . Social isolation, decreased social contact COGNITIVE CHANGES 3 . Declining self-management DIFFICULTIES THINKING, RECALLING, CONCENTRATING 4 . Physical changes ASSOCIATIVE OR CHAOTIC THINKING 5 . Changed substance needs (alcohol, drugs, medication) 6 . Cognitive changes 7 . Dejection and anxiety TENSION, AGITATION, ANGER LESS OPEN TO ADVICE FROM OTHERS 8 . Tension, agitation, anger EXPERIENCING STRESS 9 . Antisocial behaviour INCREASED DEMONSTRATION OF ANGER, FRUSTRATION /TENSION 1 0. Disinhibition and impulsivity RESPOND IN A VERBALLY/PHYSICALLY AGGRESSIVE MANNER 1 1. More (extreme) sexual fantasies,SUPPRESSION needs, behaviour OF EMOTIONS 1 2. Criminal behaviour 1 3. Irrational ideas, perceptions 1 4. Very specific changes of behaviour. VERY SPECIFIC CHANGES OF BEHAVIOUR IDIOSYNCRATIC BEHAVIOUR CHANGE OF EATING / DRINKING HABITS SPEAKS IN A DIFFERENT MANNER.
PATTERNS
Category
Early warning signs The change described in the individual item below can be perceived by the pa9ent or observed by others. a) Change in day-‐night rhythm Change in daily ac9vi9es b) Decreased ac4vity c) Increasing boredom d) Difficul4es complying with agreements, daily structure a) Increasingly superficial contact Social isola9on, b) Avoidance of eye contact decreased social contact c) Increasing isola4on, withdrawal d) Walks away from conversa4on or other ac4vi4es a) Declining self-‐care and/or care for surroundings Change of selfmanagement b) Decreased problem solving skills c) Increasing financial problems Physical changes a) Increasing physical complaints Changed substance needs a) Decreasing medica4on compliance (alcohol, drugs, medica9on) b) Increasing substance abuse ( alcohol and/or drugs) Cogni9ve changes a) Increasing difficul4es in thinking, recalling, concentra4ng b) Increasing associa4ve disturbances or chao4c thinking a) Increasing worries Dejec9on and anxiety b) Increasing loneliness c) Increasing low self-‐esteem d) Increasing feelings of sadness and/or desperateness e) Increasing feelings of,being hurt, offended and/or rejected f) Increasing behaviours of self-‐harm or considering it g) Increasing anxiety h) Increased nightmares a) Less open to other’s ideas, thoughts or ways of behaving Tension, agita9on, anger b) Increased experience of stress c) Increased anger, frustra4ons and/or tensions. d) Increasingly responding in a verbally/physically aggressive manner e) Increased suppression of emo4ons a) Increasingly breaking other’s boundaries, humilia4ng and/or An9social behaviour cynicism/sarcasm b) Increased failure to take responsibility c) Increasingly being unreliable or lying. d) Increased spliKng behaviour, seKng people up against each other e) Provoking conflict(s), coercive, demanding Disinhibi9on and impulsivity a) Increasingly chao4c, restless and/or impulsive More (extreme) sexual a) Increasingly having extreme sexual fantasies, needs and/or
Score yes/no a) b) c) d) a) b) c) d) a) b) c) a) a) b) a) b) a) b) c) d) e) f) g) h) a) b) c) d) e) a) b) c) d) e) a) a)
Early Sign (5): Changing eating pattern
Early Sign (4): … Anger… Datum Early SignDatum (3) Withdrawal from contact… Niveau 3: ernstig ……………………………………………..
Niveau 3: ernstig Datum voel woede bij Early Sign (2): Increasing Ik physical complaints ……………………………………………..
licht in mijn ogen Ik voel woede bij
Niveau 3: ernstig …………………………………………….. Early Sign (1): Fear forlicht light… in mijn…………………………………………….. ogen Datum …………………………………………….. ……………………………………………..
Ik voel woede bij
…………………………………………….. Niveau 2: matig aanwezig licht in mijn ogen ernstig Date Niveau 3: …………………………………………….. …………………………………………….. Niveau 2: Ik matig aanwezig …………………………………………….. trek me terug en plak
…………………………………………….. Ik voel woede bij …………………………………………….. de ramen dicht om daglicht Ik trek me terug en plak licht in mijn ogen te vermijden Niveau I feel anger when light 2: matig aanwezig …………………………………………….. de ramen dicht om daglicht …………………………………………….. is shining in my …………………………………………….. eyes. …………………………………………….. te vermijdenNiveau 1: normaal / stabiel Ik trek me terug en plak Ik vermijd zonlicht maar Niveau de 2:ramen matigdicht aanwezig om daglicht Level 2: moderate Niveau 1: normaal / stabiel Kan overige licht wel …………………………………………….. te vermijden I withdraw and prefer to Ik vermijd zonlicht maar Verdragen. ………….. Ik trek me terug en plak
Level 3: severe
. Kan overige/licht wel darken de myramen roomNiveau dicht om1: daglicht normaal stabiel
……………………………………………..
Verdragen.………….. te vermijden Ik vermijd zonlicht maar ……………………………………………..
. Level 1: normal / stable Kan overige …………………………………………….. licht wel Niveau 1: normaal / stabiel
I avoid sunlight Verdragen. however ………….. …………………………………………….. Ik vermijd zonlicht maar it doesn’t trouble me. .
.
Kan overige licht wel …………………………………………….. …………………………………………….. Verdragen. ………….. . …………………………………………….. ……………………………………………..
FESAI Results 1st
5 rank order all patients N=177
FESAI Item level 1. 2. 3. 4.
6.
Diagnoses SchizoASPD phrenia N=47 N=69 Rank Rank
(Fluttert et al. 2012)
O f f e n c e ManSevere Sexual Slaughter Violence Offence N=40 N=83 N=32 Rank Rank Rank
PCL-R PCL-R PCL-R <26 >25 N=90 N=38 rank Rank
Increased anger, frustration and/or tension Increased isolation, withdrawal Increasing superficial contact Increasingly responding in a verbally/physically aggressive manner
1
1
1.5
3
1
3
2.5
2
5
4
2
2
1
4.5
1
4
1.5
1
4
2
2.5
5
2
3
4
4
5
4.5
Difficulties complying with agreements, day structure
4
4
6
5
6
4
6
The rank-order correlation (Spearman Rho) ‘Schizophrenia’ and ‘ASPD’ Subgroup ‘offence’ this varied between Subgroups regarding ‘PCL-R’
: r=.614, p<.001, r=.747, p<.001 and r=.856, p<.001, : r=.768, p<.001.
FESAI Results 1.
FESAI items
BVC items
DASA items
(Rank order)
(matched)
(matched)
Anger, frustration and/or tension
2, 3. 4.
Isolation, withdrawal Superficial contact Responding in a verbally/ physically aggressive manner
5.
Difficulties complying with agreements, day structure Overstepping other’ the boundaries, humiliation and/ or cynicism/sarcasm
6.
(Fluttert et al 2012)
Change in day-night rhythm Less open to other’ ideas, thoughts or manners 9. Chaotic, restless and/or impulsive 10. Substance use, involvement with alcohol and/or drugs
§
§ § §
§
Irritated
Physically threatening Verbally threatening Attacks of objects
Boisterous
7. 8.
§
Easily angered when requested are denied Irritability
§ •
Verbal threats Impulsivity
§
Unwillingness to follow directions Negative attitudes
§
§
§ §
Confused
Sensitive to perceived provocations
Detached Concern (Betgem 2000, Schaufelli 2005 Fluttert et al. 2010 )
PCQ = Patient Contact Questionairre
(Betgem 2000)
Range of the PCQ
9
Detachment
-
180
Concern
Score Detached-Concern
?? Professional Distance ?? Cynism
(Leitinger 2009)
Burn-out (Maslach 2000)
Design Detached Concern Paired analysis n=60 GROUP 1
GROUP 2
GROUP 3
All
PCQ
T1
ERM MAINTAIN INTERVENTION
T2
(Fluttert et al. 2010)
SOAS -R
CARE AS USUAL
CARE AS USUAL
ERM
CARE AS USUAL
MAINTAIN INTERVENTION
MAINTAIN INTERVENTION
MAINTAIN INTERVENTION
MAINTAIN INTERVENTION
ERM MAINTAIN INTERVENTION
PCQ
Forensisch Psychiatrisch Centrum Dr. S. van Mesdag
April 2009
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Results
(Fluttert et al. 2010)
Gender
120 118 116
TAU
114 112 110
Male
Female
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ERM
Results
(Fluttert et al. 2010)
Experience and detached concern
125 120
122
120
125
115
120
110
115
105
124 115
113
115
118
117
114
111
TAU 2003 Vroegsign2005
110
100 105 1-2yrs
exp
2-5yrs exp
1-2 jr Mesdag 2-5 jr Mesdag
TAU NL
>5yrs exp
>5 jr Mesdag
ERM NL
>10yrs exp
TAU DE
TAU 2-5yrs - >5 yrs [U=796.5, z=-1.336, p<.05, r=.25].
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Discussion Context of two hospitals in The Netherlands
Increased insight in inside and outside behaviours
Focus on individual idiografic warning signs FESAI Dialogue, decrease of coercion / seclusions (Fluttert et al 2008, 2010)
Key variable: Staff-Patient Interaction
Thanks for your attention
[email protected]
