Characteristics of patients in restraint: six year analysis of the Assaulted Staff Action Program (ASAP).

Emergency service providers, including mental health care providers, are often called upon to impose restraint procedures. These procedures may result in physical injury and psychological distress and provide a unique opportunity for emergency mental health personnel to be of assistance. Reviews of the literature on restrained patients have suggested that clinical variables studied need to be added to demographic factors in order to better clarify those at high risk for restraint procedures. This study compared restrained and non-restrained subjects on basic demographic variables and the clinical variables of histories of violence toward others, personal victimization and substance use disorder. The clinical variables did not enhance the prediction of the use of restraints. The implications for reducing the use of restraints, for needed emergency mental health services and future research directions are explored.

Placement challenges: implications for long-term care of dementia sufferers.

Caregivers and long-term care staff seek appropriate placements for dementia sufferers, but there is little empirical research to guide such decision-making. However, recent national trends in mental health care have emphasized the placement of persons with serious mental illness in privatized, community-based residences. This body of empirical research has indicated that persons with psychosis, substance use disorder, assaultive behavior, and medication noncompliance have shorter tenure in these residential settings. These findings are also important for other, more traditional health care settings, as the patients discharged from community residences may require assistance on occasion from such other settings. This study continues the inquiry into the characteristics of patients with serious mental illness, who have shorter tenure in community residences. Dangerous behaviors, treatment-resistant psychosis, medical illnesses, and social-interpersonal skill deficiencies were common causes for discharge in this study. Since there remains a paucity of published empirical studies on the issue for patients with Alzheimer's disease and other dementias, we present the implications of, and guidelines for, addressing these issues in dementia sufferers in long-term care settings.

The employee victim of violence: recognizing the impact of untreated psychological trauma.

The impact of psychological trauma in the workplace often goes unaddressed. The untreated aftermath of these critical incidents may manifest itself in various states of anxiety, depression, substance use disorders, and even subsequent violence by the victims. This paper reviews common presentations of untreated traumatic events and provides suggestions for outreach to untreated employee victims as well as basic prevention strategies to reduce the risk of additional episodes of violence and enhance safety in health care facilities, including long-term care (LTC) and special-care units (SCU) for dementia patients.

Characteristics of staff victims of patient assault: ten year analysis of the Assaulted Staff Action Program (ASAP).

Patient assaults on staff have been a continuing risk for inpatient and community-based psychiatric healthcare providers. This study presents a ten-year analysis of the characteristics of staff victims of patient assaults in one public mental health system of care, a period which included the transition to managed care initiatives within this system. Assault data was gathered within the context of the Assaulted Staff Action Program (ASAP), a voluntary, system-wide, peer-help, crisis intervention program that is designed to assist employees with the psychological sequelae of these patient events. In general, the findings were consistent with previously reported inpatient and community studies. Less experienced, less formally trained employees remain at high risk. The impact of managed care initiatives was found in community residences where younger female staff were most at risk. The implications of the findings and possible risk management strategies are discussed.

Characteristics of assaultive psychiatric inpatients: updated review of findings, 1995-2000.

The present paper reviewed the studies of the characteristics of assaultive psychiatric inpatients from 1994 to the present. These studies partially confirmed earlier findings that assaultive patients are older persons with a diagnosis of active psychosis or other neurological abnormality and histories of violence toward others and substance-use disorder. However, the recent studies also document the profile of a second group of assaultive patients: younger females with personality disorders and histories of violence toward others, substance-use disorder, and personal victimization. Since there is a paucity of published empirical research on Alzheimer's and dementia patients for this topic, the implications from the present findings for long-term care and clinical intervention are examined.

The Assaulted Staff Action Program (ASAP): ten year empirical support for critical incident stress management (CISM).

Critical Incident Stress Management (CISM) refers to an integrated comprehensive, multicomponent, crisis intervention approach for addressing the psychological aftermath of critical incidents. It includes pre-incident training, acute crisis intervention, and post-incident responses. The Assaulted Staff Action Program (ASAP) is a voluntary, system-wide, peer-help, crisis intervention program for staff victims of patient assaults. ASAP is a CISM approach, and this paper evaluated fourteen empirical studies of ASAP to assess the empirical justification for ASAP and CISM approaches, which demonstrated a 25%-62% reduction in staff assaults.

Nonviolent psychiatric inpatients and subsequent assaults on community patients and staff.

Health care staff on psychiatric inpatient units are at high risk for work-related assaults by patients. Recent studies have begun to document similar patient assaults toward staff in community-based residences. Earlier community studies did not control for the level of patient assault prior to community discharge, and it remains unknown whether the community residence assaults were a function of community placement or a reflection of ongoing control issues by the recently discharged patients. This preliminary inquiry retrospectively tracked the nature and frequency of assaults by patients newly discharged to community residences from a state hospital setting where there had been no assaults by these patients for a two-and-one half-year period. While base rates remain to be determined, the findings in this study suggest the assaultive patients to be younger males with diagnoses of schizophrenia and histories of violence toward others, substance abuse, and violence toward self. Nine patients committed the majority of the assaults. There was a significant decline in the frequency of assaults nine months post-discharge. The implications are discussed.

Characteristics of four types of patient assaults: six year analysis of the Assaulted Staff Action Program (ASAP).

Although psychiatric patient assaults may include physical and sexual assaults, nonverbal intimidation, and verbal threats, most studies of assaultive psychiatric patients to date have grouped all assaults together in one category. This study explored differences in patient assailant variables and staff victim variables in each of the four categories of patient assault during a six-year period. These differential analyses of assault types yielded at least three important findings: the presence of significant numbers of females as both assailants and victims in several categories of assaults, the importance of psychological fright in staff victims, and the serious psychological disruptions found in staff victims of physical, sexual, and verbal assaults. The findings are discussed and the implications for health care safety and emergency mental health are noted.

Violence against women and the assaulted staff action program.

Women have been subjected to high rates of victimization at home, in the community, and at work. An earlier study found female inpatient staff to be at risk for same-gender patient assaults in psychiatric hospitals and female community residential staff to be at increased risk for assaults from male patients in residences. This study sought to revisit the original 2-year findings during a subsequent 6-year period. Inpatient and community assault data were gathered within the context of the Assaulted Staff Action Program (ASAP), a post-incident crisis response approach. Female inpatient staff were again found to be at increased risk in both inpatient and community settings. However, in this second study, female community residential staff were found to be at increased risk for assault from both male and female patients. The findings and their implications are discussed.

Characteristics of patient and staff victims of assaults in community residences by previously nonviolent psychiatric inpatients.

There currently exists a large body of empirical research examining patient assaults in inpatient psychiatric facilities. These studies have focused primarily on staff and have found younger, male mental health workers with lower levels of formal education and experience as well as nurses involved in restraint procedures to be most at risk. However, despite the increased utilization of community-based services, little attention has been directed toward patient assaults on patients and staff in community settings, particularly residential services. This study began to respond to this need by examining patient assaults toward other patients and staff in community residences during the first twelve months post-discharge for a group of newly discharged patients who were not violent as inpatients. This study found female patients and staff to be at greater risk for assault than male patients. Lack of experience by staff was also a risk factor. The clinical, administrative, and research implications of these findings are discussed.

The Assaulted Staff Action Program (ASAP) and declines in rates of assault: mixed replicated findings.

The Assaulted Staff Action Program (ASAP) is a crisis intervention program that has been associated with providing both needed support for employee victims of patient assault and declines in rates of assaults in traditional state hospital and community mental health settings. This study examined the possible role of ASAP and declines in rates of assault in three community-based services impacted by privatization and managed care approaches: community residences, an acute care rural community mental health center, and an urban intermediate/extended care facility. ASAP was associated with a statistically significant decline in the rate of assault in the intermediate/extended care facility. The community residence program was not a true test because of structural issues associated with managed care. The community mental health center appeared to be a true failed replication. The extended care facility's decline in the rate of assault was interrupted by the aftermath of one serious clinical incident during one month and then continued to decline. The implications are discussed.

Characteristics of substance-abusing persons with schizophrenia: the paradox of the dually diagnosed.

Previous studies have noted the paradox of the dually-diagnosed (serious mental illness and substance abuse) in which the dually-diagnosed are judged to be both behaviorally more disorganized and simultaneously more socially competent. This study sought to further assess this paradox with a large sample size and a comprehensive assessment approach. In this study, the dually-diagnosed (N = 233) differed significantly from the non-dually-diagnosed (N = 262) in the symptom paradox. The dually-diagnosed were judged both more behaviorally disorganized and socially intact. The comprehensive assessment approach yielded empirical data in support of three possible hypotheses to explain the paradox. The implications of the findings and the three possible hypotheses are discussed.

Linking substance abuse and serious mental illness service delivery systems: initiating a statewide collaborative.

In the past, persons with serious mental illness and substance abuse often found themselves in parallel systems of care that inadequately addressed their needs. Recent advances have seen the development of an integrated approach to care for these disorders in both the public and private sectors. While some state departments of mental health have developed integrated systems of care for public sector patients, no department appears to have developed such a system for both public and private clients, and there appears to be no published journal report of a model to induce cooperation by all stakeholders. This article outlines a two-step approach by the Massachusetts Department of Mental Health to foster stakeholder cooperation in designing an integrated system of care for both public and private clients with co-occurring disorders.

Assaults on staff by psychiatric patients in community residences.

The study examined assaultive behavior directed toward staff of community-based residential facilities by patients who had been discharged to these facilities from Massachusetts state psychiatric hospitals in the early 1990s. Observed rates of assault declined by 61 percent over a six-and-a-half-year period. Early in the study period, male patients were more likely than female patients to be assaultive, but men and women had similar rates of assaultiveness later in the study period, after they had been in residential placements for several years. The most common diagnosis among assaultive patients was schizophrenia.

Past violence and substance use disorder and subsequent violence towards others: six year analysis of the Assaulted Staff Action Program (ASAP).

Recent research has begun to document evidence of associations between past violence toward others, untreated personal victimization, and substance use disorder and later acts of violence toward others. This appears true for many types of individuals, including psychiatric patients who have been victims of violence. This six-year retrospective study sought to evaluate these possible associations in assaultive psychiatric patients. Data were gathered in the context of the Assaulted Staff Action Program (ASAP), a crisis intervention program for staff victims of patient assault. Both histories of violence (violence toward others and/or personal victimization) and substance use disorder in assaultive psychiatric patients were individually and jointly examined and found to be associated with subsequent assaults by these patients. Increased levels of both past violence toward others, personal victimization, and substance use disorder were associated with the largest increased frequency of subsequent assault. The implications and possible links to emergency mental health services are discussed [International Journal of Emergency Mental Health, 2(4), 241-247].

The assaulted staff action program (ASAP) and declines in assaults: a meta-analysis.

Crisis intervention procedures have been demonstrated to be of assistance in addressing the aftermath of psychological trauma. The Assaulted Staff Action Program (ASAP) is a Critical Incident Stress Management (CISM) approach that has been associated with providing needed support to employee victims of patient assaults and sharp reductions in the frequency of assaults in facilities where ASAP has been properly fielded. The purpose of this study was to conduct a meta-analysis of the effectiveness of ASAP in reducing frequency of assault. Results yielded a highly statistically significant Cohen's d of 3.1 and fail safe number of 202. The implications for risk management are discussed.

Preventing youth violence: a CISM pre-incident approach.

Violence in the United States is a national public health epidemic, and increasingly, much of this violence is committed by the country's young people. Critical Incident Stress Management (CISM) approaches emphasize a comprehensive continuum of services from pre-incident training through acute care to post-intervention services. This paper outlines a pre-incident approach to preventing youth violence for parents, teachers, and counselors. The approach includes the identification of a continuum of warning signs and five guidelines to address the underlying needs manifested in the warning signs. The implications are discussed.

Coping with psychological aftermath of school violence: the teacher and the assaulted staff action program.

Violence in the United States has become a national public health epidemic. Increasingly, much of this violence has been committed by our young people. School settings have not been exempt from these aggressive acts, and principals, teachers, and support staff have been victims of murder, physical and sexual assaults, verbal threats, and the destruction of personal property. This present paper outlines a cost-effective, empirically-based, crisis intervention approach that was designed for health care providers, and that has immediate application to providers of school psychological services. Known as the Assaulted Staff Action Program (ASAP), ASAP has provided needed support to these employee victims of violence and has been associated with sharp reductions in facility violence. Since ASAP interventions are appropriate for all victims of violence, the implications of an ASAP approach for school faculty and staff victims are examined. The roles of school counselors in designing, fielding, and maintaining an ASAP program are presented.