Lecture 30: Clients for Assignment 3 Visit

Key Takeaways

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So, so I think both pretty well and um you know we we've been talking these past couple of uh oh actually >> yeah we hope um we've been talking the past couple of weeks about you know serious games games games games games games games games games games gamesgames games games games games gamesgames games games games for education game as an art form as a means of expression and we're going to be continuing some of those uh discussions later on um but the whole idea is sort of give you um to sort of prep you for the situation where uh you're going to make a game for a client and for this last assignment you're actually going going to be making a game on a based on a problem that these guys are going to be talking about actually. >> Sure. My name is Jim Cartran. I'm a clinical psychologist. uh work at Beth was at Beth Djan just started at Brighamin Women's Hospital um in one of the Harvard mafia hospitals and um my area is using interactive media for um for uh both uh clinical training but especially for treatment of clinical problems. So building computer programs to help treat uh clinical disorders in psychology. >> Okay, it's my understand I'm a psychiatrist at UMass. I trained in the same uh uh place like used to work as uh and my focus is primarily clinical. I'm I'm an attending psychiatrist in a variety of setting settings inatient outpatient and uh uh what I brought up to Jim and then Philip was a practical question that I'm going to try to uh present uh which is helping psychiatry residents deal with angry, agitated and potentially disordered patients as I'm going to say later. uh this is a uh significant and largely uh unknown issues. Certainly uh the research is uh picking up and people try to understand uh the extent of the problem and uh um but I see more I'll say it for for the presentation. So u thank you for having me here. So um when they contacted me um that there was the initial interest in trying to make some sort of digital uh uh piece of software to to be able to help the the training residents um in in learning how to deal with violence or violence in in in in u in mental in mental institutions um and um and immediately the first thing I thought well before we jump right into digital let's try doing something in analog first let's try um uh prototyping something first but it also occurred to that um in the real world of game design, there's actually a lot more jobs in game design outside of the game industry and inside the game industry. Uh there are a lot of companies out there that are basically looking for solutions, some of which may be games and uh you might end up working uh in in in some of those um in some of those capacities. A lot of folks in advertising for instance who are involved in games. a lot of folks who are interested in uh improving teaching methods or improving uh simulations, you know, working on um trying to think of an example uh public awareness uh and uh uh people who are also interest who who are now working in website design and you know v various online services who are trying to think about how to make their experiences a little bit more gamelike. There are really really good ways of doing them and there are really really bad ways of doing them. And for the most part, what we're hoping is that if you end up getting one of those jobs, you're you're going to be able to bring some of your personal insight as having actually done game design as opposed to just copying what games have done and and and just assuming well it kind of looks like a game therefore it is game. uh you guys that now. So, so, so this is this is kind of get your feet wet in in terms of designing something uh the designing for somebody else's needs. Um the the important things to keep in mind is, you know, who's who's going to be playing your game or who's who who's this game intended for and in what context are they going to be playing your game and what are the particular problems that you're trying to address? what's what what's the part of of the system that you're trying to to simulate uh and what kinds of things do what what what kinds of insights do you hope people are going to be able to get out of that the problem they're going to talk about is huge is that um if you notice I uploaded actually like four readings to the class web only one of them required but all of them are useful I'm going to be uploading more these are all reference material for your team to use um however you you wish because the problem is so huge and vast You don't have to solve the whole problem. You pick one thing that you are excited about, that you're interested about, and that you think that you might have a good strategy. And then do the the usual brainstorm. We're going to be going through brainstorming and team selection pretty much this this week. Um, and uh and try to identify some small part that might be, you know, addressable with a card game, world game or I'll talk a little bit about uh role playing games uh in a couple of weeks. So um with that being said, I'm going to hand it over to you guys. >> Great. So who's first? >> Uh Caesar will take the lead on this. >> Okay. So we'll try to take turns to uh talk about uh about violence and psychiatry in particular. So uh as Philip pointed out, violence is a is a large is a large issue. uh what I'm going to try to focus on is uh as I mentioned earlier uh the relevance in in dealing with uh psychiatric patients especially psychiatric patients on an inatient unit uh which is what uh you know what they actually request or the question for me uh came from um and uh obviously uh violence can be looked at in in a variety of uh of ways and uh uh I think in in one of the handouts that uh that I sent to Philillip, violence and mental illness. They talk about uh the biological the psychological theories, the the social uh uh dimension of uh of violence and how it can be understood. If you look at the human development and no matter what theory you uh you consider either trai traditional drive-based theory like pride or or Ericson stages uh each seems to define a certain um developmental goal and and often achieving or achieving in a faulty way that goal uh can create uh um the potential for aggression and sometimes violent um a little child or or an adult whose uh dependent oral needs are frustrated may try to take over and and get those uh u u you know those met in a way or another. So what I use as if you want the metaphor for uh for uh uh the origins of violence is the communication uh breakdown. at some level uh something doesn't happen right between you know the person who gets angry and uh those around him or her. Uh so in a more in the most generic way basically communication as Lasso said is about who says what to whom and what channel and with what effect. Uh the breakdown can occur at many levels and again this is the the generic reform. I hope uh I'll I'll make it clear what I mean and especially uh what can be done at a practical level when you're let's say the resident on call uh at night and the staff calls you up says so and so is getting out of control she's she's raising her voice threatening pounding walls wanting to get out refusing medications how do you approach such a person and again the intervention can happen at different levels and actually one uh one goal of uh of the training uh or or potentially the game uh that you might consider is what to do. How do you establish when to engage fully uh by yourself with outside help when the intervention is minimal and you just bring uh pens with you, restrain the patient, use pharmarmacology. So, it's a continuum of interventions. I'm going to just focus on what to do when you can actually engage the patient. Um again continuing the the metaphor uh is what people have what Walter Fish has described as as this type of uh uh narrative uh rationality as opposed to the uh um to the traditional rational paradigm that defines people as uh as thinking beings that have actually uh to make make decisions and and uh um and base their actions on evidential reasoning for aggression people. We analyze the situation and come up with the best possible outcome. Walter Fischer talks about uh uh the fact that we are all storytellers that we try to to interact to understand others based on a narrative that we have about ourselves and about others. My my assumption and again this is just the introductory metaphor if you want that at some point uh violence can be caused by by a disruption uh in in this narrative. Things don't make sense anymore. We feel u misunderstood. We uh we feel the victim of an injustice. And th those principles apply to uh to somebody who's who's struggling with a mental illness where things are, you know, have a much narrower window of opportunity than than the for people who are able to flexibly adapt to the demands of of reality. Um, so we all know who this is and uh uh the reason I I put it up and I have to admit I haven't looked into the copyright uh part of this uh I know there are uh longer and longer copyright rules for using cartoons so you'll have to forgive me. Uh my point is that this is an angry person. Uh and uh as a as someone who's communicating, I think we get uh quickly and and and clearly the fact that his emotional range may be intense, but it's fairly narrow. Uh doesn't cover white light broad spectrum and and the communication is fairly simple. He's in distress. He's he's imposing his point of view. He needs space. He uh he uh could uh become uh very aggressive and assaulted. I think that uh the language is very simplistic. How would we approach the Hulk and and trying to calm him down and change his color? Well, again, that's the end of my health. Um briefly and and please feel free to interrupt, jump in uh I can make this presentation as long as short as as as you want me to. There are many slides but don't I'm not going to go through every single line. I'm just using this as a as if you want as a stimulus for uh for the conversation especially from from your perspective and from from your needs. As I said I'm a clinical uh provider. I'm a psychiatrist. I deal with patients uh all the time many of whom uh are angry or potentially angry or potentially assaulted. And and I may do things some you know after so many years instinctively but sometimes I have to think through okay this is the situation. How do I do to to maximize uh the benefit for for the patient I'm treating and to keep myself safe? I've been assaulted just once in in 15 years. And it was like in the movies. Um a VA patient, former Green Beret, who got upset to the system and picked up a very heavy armchair and you know lifted above his head and I we we uh established eye contact and I think he wondered what should I do with this puny little little doctor? Should I squash him or not? And uh and in the end, I guess it was a last, you know, split-second moment, he decided to throw it, you know, to my side. A large section of the wall came down. So I looking I I was wondering, you know, I could have been that wall coming down. He ran out. It took him, you know, a while to to be, you know, be able to catch up with him and two cruisers full of police officers to subdue him. So I guess no communication there. Uh he was just subdued. what's the magnitude of of the problem? Uh I think it's substantial and actually more than 10 years ago there were some isolated reports of of how significant uh uh uh the problem was in terms of uh trainees and especially psychiatry trainees being uh uh the target of of verbal and physical violence. Um uh on this first page I I talk about medical students. Uh in one study you know numbers are relatively small uh but again uh the study is uh uh 14 years old. Um a survey of psychiatry residents showed that assault or threats of violence uh are clearly one of the most difficult uh events in their training. And some were wondering retrospectively this is the uh uh the right field for them. Actually some students may wonder reading this literature whether psychiatry is the right field for for them to go into. Uh and as you as you see uh uh the fourth um in the fourth article almost twothirds of psycho residents were assaulted at least once during their uh their training. And obviously like with any kind of dangerous situation, the risk of post-traumatic symptoms can be substantial either an acute stress uh response or longerlasting long longerlasting issues. The idea of uh improving their training and their ability uh to deal with the situation uh has multiple benefits. Those who know what to do are are almost never assaulted. Not only that, if they happen to be exposed, the likelihood of developing post-traumatic symptoms, you know, goes down significantly. So, uh I don't think I need to to demonstrate uh that point any further. Uh the assault rate in a in a more detailed a relatively more recent study, 10 years old, pretty old. Uh you see, uh that overall the number of assault rate was 30 to 40%. uh men tended to be slightly more frequently assaulted than than women. Uh >> can you define what what assault means exactly? >> Uh what qualifies as an assault? >> Assault um basically means kind of laying hands on on the person and uh uh the assault resulting in an injury uh of of any kind. Skin, you know, being kind of uh broken through or or some kind. just just holding the per the the clinician wouldn't be an assault. >> Well, it would be an assault because uh that such a kind of grabbing action could actually result in a in an injury. Um and uh um I think it would be uh probably very limiting to talk only about physical injuries especially since the psychological consequences are often uh the longerlasting and much more significant. I think what the surveys uh have shown also is that how unprepared uh trainees in the mental health and outside the mental health field are. Actually often this is reduced to a few lectures especially during orientation and then they are thrown into the uh you know lion cage and they learn on the job u and uh many of these findings are retrospective many trainees felt that well I didn't say anything because I thought I was supposed to just toughen up and bite the bullet and move on or this is part of the job I chose this it's my fault or maybe I did something wrong. Maybe I was the one who uh made it so that the assault happened. So, a lot of reasons that were just again not looked into. Um fear of being scrutinized. How come that I'm the one who want assaulted among 10 10 trainees? Uh how how I'm going to explain this? I was so frightened that I cannot even remember clearly what happened to me. So there are a variety of reasons why people who are in training and again I'm focusing on and again with a ve on on a very small segment uh specific group of of trainees in a in medical and psychic training but I could easily think of of other situations of people who are kind of exposed to the potential for violence and and where you know such training could be helpful uh until now and for the most part the data that I was able to collect that most people you know looking at this have been able to collect is fairly limited Um there are certain you know limited number of programs methodologically the research is is quite faulty. You can just talk uh about you know how uh you know how limited the generalizability of the findings are uh and often people talk about what happened in the past. So clearly the recall bias is a major limiting factor in understanding um what what happened. Also as uh Jim asked me so how do you define assault? One of the biggest problems with with most research in this field is that uh defining assault aggression is done in very ways. Uh it's hard to compare different uh uh different studies. Uh so this is a compilation of uh of what people in you know different areas have have thought about in terms of improving their psychiatric training. And as you see most often uh in the last few years, the idea of using simulation uh to uh expose the trainees to a uh to a protected environment that has really defined boundaries and consequences and basically uh that can be repeated almost in identical fashion in order to gain proficiency. Uh you know is is coming up more and more. Uh what uh many training programs uh are doing is to use standardized patients that are uh that use actors um and that of course will behave in a in a uh uh kind of programmed fashion. They may get up to you and make fists, but hopefully they'll not get so much into the role and end up punching you. So >> I think this is the real challenge is that there's there's different levels of of learning. You can learn kind of a list of facts, things to do if your patient starts to get agitated and threatening. And you know, you can learn that and take a test on it and forget it the next day, especially if it doesn't come up for you right away. Um, and then there's there's the question of internalizing it so you actually have a not just a kind of a working knowledge of really understand what you should do in different kinds of circumstances. And that's where the um the idea of role playing with live role plays for the trainees for the residents and mental health providers can really be helpful so that they've had some se semblance of this kind of um training. Um but it's the the tricky thing with these role plays is it's not easy to ensure that everybody receives you know high quality access to you know well-trained actor you here in you know Harvard Medical School they probably do probably but you know there's a lot of places and if you expand beyond psychiatry to every mental health center in the country every case worker who's going out to visit a patient at their home or social worker you know they're definitely not getting this kind of training and so you know the ones really I think you said before are really well trained are the nurses actually because they they they get a different kind of training that's really pretty effective it sounds like but the mental health care providers often have no training and then they're the ones who are kind of in a closed room with the person who can become really violent especially at their home or in inatient unit. >> Yeah Jim was making reference to that psychiatrist at MGH who last year was stabbed by a patient in the outpatient clinic in a rather >> you don't hear about this last year. >> Can you just describe the situation? Well, it was late in the evening when most things like this have this potential of happening and this was a new evaluation for uh this psychiatrist in the life of the clinic at MGH and basically he he was angry from the beginning and was able to staff repeatedly. Uh an offg guard, you know, person just happened to walk by. >> Was that police officer? Uh yeah, he was one of the security uh uh people for that particular clinic and he came apparently had a gun. I don't know how often offduty security people carry their guns with him but he opened fire and killed the the patient. So he was charged I think >> yeah eventually was cleared but for using excessive force. >> What happened to the psychiatrist? Well, psychiatrist was admitted and uh to a hospital and required, you know, extensive surgeries and I think um she was stabbed in the chest and in the neck and it was a fairly gruesome. She survived and I think she's back at work. But this is an extreme case and uh I'm afraid that uh many of the things that we talk about and principles that we may come up with may not necessarily be uh uh so helpful other than thinking back at a level intervention. It's quite conceivable that for somebody who charges at you, you won't be able to talk him down. You won't be able to use any of the uh nice deescalation principles that I'm going to talk about in a few minutes. But figuring out what to do, I think it remains important. >> Um so I have a question. You mentioned that nurses have sort of like a different training system for this and and it seems to be effective. Like what what what is that training? like what is different about what nurses get taught in the >> Well, um there are some in most states there are uh regulations that um try to implement some level of training for designed specifically for patients who get out of control and that's not in only psychiatry. uh emergency room uh teams have probably the most one of the most kind of the highest rate of of assaulted patients across uh across diagnostic boundaries. Often psychiatric patients especially patients using substance abuse will will uh will get out of control emergency room. So if you want to become emergency physician or you if you work in the field an EMT or another capacity you'll have to deal with these situations. what what makes the nurses uh somewhat better trained is that uh um they often are the frontline uh uh staff dealing with out of control patients and I think that's probably pretty probably sad because physicians should be equally you know and trainees and physicians in training should be equally well well trained but uh but on the nursing front uh there has been some progress in Massachusetts the department of mental health uh has some method of retraining there's a lot of red tape there. But there are a lot of um helpful helpful aspects uh including aspects related to self-defense and I wish I I could have presented a recording of of a of a training session for staff. Uh it's when I went through it I I thought it would be something like a very spectacular kind of kung fu how you do it. But in fact uh the emphasis is how to keep yourself safe and believe it or not how to keep the person safe. the person that you're kind of blocking the way punches uh the person that might be trying to kind of strangle you or or keep you in a stronghold or or scratch you or you know rip your your hair again even when you try to intervene or you're trying you're trying to protect yourself and keep the other other person safe. So no punching, kicking, no kind of spectacular kind of stunts in that respect. But again that also I feel could be you know an interesting topic for for simulation. How do you kind of interact with uh especially since again I'm I'm a total kind of outsider in the field but I um having kids you know they they were asking me the other day about Microsoft's connects uh connect um and I thought that was really interesting because the level of interaction with uh kind of computerenerated uh interfaces is very is very interesting and certainly would be a that to be attacked by by somebody from the TV person. >> It sounds like nurses get better training because the states require them to have better training. >> Yes. >> Okay. That's correct. >> All right. >> That that's in part of it. And I've been trying at at UMass to to suggest that not only the staff physicians get exposed to the training but even the um psychiatry trainees and other trainees especially in an emergency medicine. they they should all really, you know, know about it. >> I suspect some of this has to do with with the benefits of being in a union, which the union can demand that the nurses receive this better training where the physicians are not in the union. >> Uh, and it's also about numbers. I mean, on the on any unit, you know, the you have uh six, seven nurses per one physician uh and the nurses are they're in shifts around the clock. So the lackl of being exposed to a uh to an out of control you know much higher usually on on these units people intervene as a team uh and there's a team leader that tries to you know applies many of the principles I I hope to talk about uh and then if there is need for seclusionary strength then that has to be done in an automated fashion and and things are clearly much much clearer as I said on the nursing front maybe because they're doing it all the time because there are some ty relations maybe because they're unionized and you know at least half of the literature uh really comes from from the nursing direction. So uh so that's a that's a tangent just want to write on the on the connect uh uh uh comment that you were making. I mean we will be talking a little bit more about live action games. So, um, that's kind of how you prototype how you prototype something that's going to be a motion gesture computer game. You don't obviously actually having to write code to do that. That sort of body recognition is kind of annoying uh and and expensive, but it's but you can test out a lot of ideas uh just by having two people play physical game. Of course, safety becomes the biggest concern for players as well. It's kind of interesting because in this particular case, you're trying to teach someone how to prevent damage to both parties at the same time, which is an interesting it actually kind of helps you with the design of of of a live action. Now, that's only one problem. That's not the you go into more details about the kinds of things that you can do to prevent it escalating into actual combat. Combat is one of those things that >> and the idea is basically to do you know your best to not end up at that particular extreme of of a direct kind of combat which is not uh uh you know so ideally you don't have to go there and as I said in 15 years I've been assaulted once I'm sure I was lucky uh people see think that my eyebrows are intimidating so don't uh you know tend to to get very you know, friendly and and and and again, I'm going to, you know, sell a few, you know, tell you about a few pearls and a few tricks that I I personally use. It may not be, you know, they may not be helpful for for everybody over time. You develop your own style. The idea is to to uh be able to make an assessment and try to take preventative steps. And I think that that's the secret. And this is what I hope, you know, better training, maybe the use of simulation and and kind of gaming could be could be helpful. Okay. So, uh now I'm going to just uh you know I'm going to jump into uh uh talking about prevention and uh uh I not prevention but identifying how you assess and how you think about the potential for violence and uh and these are some some known uh um risk factors for aggression. Obviously the history of violence uh is is the top um how recent how frequently uh you know those people become uh assaulted what's the pattern of escalation what are the associated symptoms what happens when before somebody gets uh becomes assaulted. Why is this important? because you can you can do and at all you should do quickly before you know engaging with the patient uh an assessment at that level and it will help you uh figure out how deep to get involved how likely you are to gasolate the patient versus saying oh I don't need this I need help let's go in as a team you know so uh so that that makes it important uh people often talk about violent threats and fantasies young people uh tend to be more assaulted and there's no surprise also older people who have uh uh dementia uh and get uh more disinhibited and more likely to become reactive. Uh I always like to tell the story of a patient with dementia. I was moonlighting and he swung at me as I was passing and then I went to talk to him. So what happened? Well, I don't know. He just passed by me and I was upset and he was the closest. So I thought I would try to talk. Uh so um there was no way for me to to predict that it wasn't a serious thing. It wasn't the predatory type of of uh of assaultiveness where somebody plants you know you know doesn't like you goes after you colleague of mine was attacked by a patient patient watched when people were not around went into the doctor's room locked the door and started contacting. So that's a totally different animal. Uh so the distinction between impulsive, affective when you want or uh you know type of aggression and the predatory you know is essential to um in some uh subcultures violence is is uh is not allowed certainly much more much more frequent. Um people uh of a lower socioeconomic status uh may may be more likely to become uh assaulted. Patients of a limited cognitive ability especially when institutionalized may be more likely to to become assaulted and then it's a uh many many diagnosis uh increase the likelihood of assault. Uh the top are psychotic disorders like schizophrenia. Uh mood disorders like bipolar uh I told you about what uh we call cognitive disorders especially dementia and confusional states. um patients that have had traumatic brain injuries or that have have you know have epilepsy may be more likely a real problem with Iraq veterans coming back or rack or Afghanistan veterans when they have had an IED explode under their vehicle and they've had a brain injury and now they have a lot of just admission about violence and they can just go off sometimes very unexpectedly. The frontal lobe exerts an inhibitory uh influence on our ability to uh to function and that allows us to plan to think ahead to sequence events. Often when uh the exe this is the executive function of of our frontal lobe when he's impaired either you know in a trauma or after surgery you know or uh being in a in an accident or becoming demented that ability to uh to operate in that fashion maybe violence is a is a possible uh side effect. Substance abuse I think are are the top of the list. Uh because of the disinhibition both during the intoxication phase and during the withdrawal phase people tends to become very agitated and assaulted. There are certain personality disorders. Uh so uh when uh when we think as about a personality disorder we have this enduring maladaptive patterns of of relating to you know to the to you and to others and to the world. You know the obsessive compulsive personality disorder likes to have things organized, planned, nothing. Even going on vacation is an exhausting task. Nothing has to happen randomly. Uh grandio personalities really need this kind of feeding coming from from all directions. Uh they they need to be in the limelight. they they use people not as good people but as people that kind of uh provide sustenance their own self-esteem. two uh two type of uh personality disorders uh are particularly likely to uh promote violence. Uh the antisocial uh and you may have heard the term borderline personality disorder which is basically uh at core has uh significant instability in emotions in interpersonal relationships and identity and uh basically their lives are are a mess. often they feel abandoned, they feel put down, they uh they may get briefly paranoid and often uh they make they become assaulted. So again I'm throwing a lot of uh a lot of terms and definitions at you. I don't want to you know make this u lecture about psychiatry but these are conditions that I think u are helpful uh to think about. Yeah. >> People with delusional disorders like schizophrenia get violent. Is it usually because they're frustrated about something or is it because they suddenly have some sort of delusion about their their clinician that involves uh great question, >> you know, requiring them to to take some sort of action that is violent? >> I think both. I think even people that have a psychotic disorder have the right to, you know, feel the victim of an injustice or feel frustrated or u many of the reasons that I I I talked about could could happen. But in particular uh I think the other point is equally important that they may act on a on a delusional delusional conviction or their psychosis may also have uh may may have hallucinations and uh command auditor hallucinations uh are known to often be the forers of the violent attack. You talk about me and say things you know or the voice tells me I'm going to go after you. uh you do it and the person feels uh uh uh hopeless to uh uh to resist that. I discharge the patient who's doing great. Next day he comes back, went home. The boys told him that he needs to uh hurt his mother otherwise he will get disembowled. So he started punching her and then chased her with a with a knife. She had to hide in you know behind you know in in the neighbor's house until the police arrived. Uh there is an interesting threat control override pair that that people have looked at violence u have described as uh being sometimes the proximal uh cause for violence. People feel directly threatened uh and they also uh have this overpowering you know urge that they need to act on that cannot resist. It's a controversial concept. But I'm not for sure why I would give it give this particular association a a higher status than than other convictions about the neighbors, you know, watching me and uh and or planning to kill me or putting together a variety of clues that my friends are really trying to to to get rid of me and then I need to protect myself. But but you're absolutely right. What's interesting, even though patients with chronic psychotic disorders may have their reasons to um to become assaulted in the overall bigger scheme of things, when you look at actual uh violent assaults committed in in society, they're responsible for a tiny one. So, it's it's an interesting way of looking at numbers. Yes, they could uh become violent, but the reality is that the their numbers, you know, in terms of the actual violent acts very small. But anyway, this may just be a kind of statistical uh trick. >> You're talking about the number of cases of violent episodes where compared to the general population. >> Exactly. Okay. So, >> exactly. That's that's exactly the point I'm trying to make. And then there are uh various acute findings when you examine the patient on on what what we call the mental status examination. Obviously, hostility, suspiciousness, agitation are all associated with uh with violence. In terms of uh uh one one I want just to focus one minute on on the so-called aggressive attributional style. Um how do we uh uh respond to stress in when we have the per perception of uh uh of threat? Um this is the uh um threat override uh delusion that I mentioned but I think that's that's probably relevant and command explanations what happens in conditions of uncertainty and many of the patients or people may have to think in a distorted fashion. I was talking at the beginning about uh um the uh communication breakdown. You have the layer of the mental illness that that shrinks your options. You have a particular situation to deal with uh that makes you even more likely to become uh uh uh to become assaulted. And and this constellation of cognitive distortions may make you more likely for you to uh to become assaulted. neglecting the base information which kind of assigns a high weight to to certain events that otherwise uh you know are you know are low frequency uh attending uh only to facts that would confirm your assumptions I think. Go ahead. >> Oh okay. So if uh the psychiatrist's office calls to reschedule appointment the person assumes that this is because the psychiatrist doesn't like him. >> Exactly. this guy, this this person doesn't want to treat me. They don't like me. They don't want me to be their patient because they rescheduled me. >> Ignoring facts that could disisconfirm your hypothesis. Um, I just talked to the psychiatrist who who was nice to me, but still the fact that that he called and canceled is the overriding, you know, explanation that he doesn't like me. or focusing on on common events just because you remember them, which is an interesting way of explaining the fact that you remember them kind of brings them up in the in the rank. Uh, and other disisconfirming evidence is totally kind of ignored. It's like the assumption that the train on the other platform always always seems to arrive first because those are the ones you remember or kind of the garden ride with grass is always uh and I talked about uh about medication and street drugs some are more likely to be associated alcohol just by the sheer volume and especially because withdrawal is so violent uh you know it's it's a significant issue the intoxication phase your level of coordination you know your perception of facts. You know, it's it's just uh they're so off that you're more likely to to lose control. Uh anti-depressants um have an interesting impact because in people that have an underlying tendency to swing in their moods may actually augment those things. You may have heard of of the of the news of anti-depressants promoting violence and suicide in adolescence. Uh and while statistitians are still scratching their heads to figure out the exact numbers uh the truth is that mood is very unstable in in adolescence uh and uh often initial depression may turn out to be something else. You give somebody an interdepressant call him or her for followup in six or eight months in meanwhile lots of things happen. And I think in those cases when actually uh those young adolescents committed suicide, it was not so much about anti-depressant causing it. Probably the depressants made the symptoms worse. It was very poor followup and and poor diagnostic. But anyway, this is getting too too technical. Uh I included this in the last minute. This is an interesting summary of of a nationwide uh study uh focusing on violence violence risk assessment. Um let me um just say two minutes about useful measures in assessing dynamic violence. Um people have looked at violence uh in two ways. They have put together all those factors that I that I presented initially and uh uh they have looked at retrospectively that those would become violent and they compiled um the history clinical risk assessment scale. The problem is that when you're dealing with somebody those scales even though they may give you a good image of what happens in the long run uh they may not help you deal with the immediate situation. So clinical scales have have been used in IL you know one developed in Norway uh the other one the dynamic appraisal developed in Australia. This these are the items for the HCR20 uh and it's almost like a repetition of what I said earlier in terms of risk factors. This is the historical risk factors and these are validated skills that have been used for for more than 15 years. The clinical scale uh is the the dynamic part of the HCR. Uh and then the risk management scale is trying to project in the future what do you have to do in order to uh ensure safety what could go wrong and and >> so so the value of these scales is kind of sizing up the likelihood of this person becoming violent um in the absence of other information. Now the best predictor is probably what they're actually doing behaviorally in front of you. you know, they're reaching for for something heavy, you know, that's, you know, I take that into, you know, weigh that heavily. But, um, but in the absence of anything else, you know, that the people who meet a certain, I guess you could say, certain profile are more likely to be violent and as a psychiatric patient than others. >> This is a dynamic scale that looks at what happens in front of you. As you pointed out, u, you're considering confusion, irritability, how boisterous and how verbally threatening the person is. uh the most recent one is the dynamic appraisal of the situational aggression that has seven factors that seems to be the best uh one assessment or uh prediction of violence over the over the next 24 hours. Uh and uh this is an interesting psychopathy uh kind of index. Psychopathy uh is uh has an interesting history. I think the the the current uh version that we will talk about is the antisocial personality. Uh but basically refers to people with uh with minimal capacity for empathy uh whose kind of moral dimension is fairly fairly primitive who engage in stealing, cheating, violence and don't have a lot of kind of uh moral drawbacks to do it. Uh it seems to be associated with violence not surprisingly. And this is actually a factor analysis that you know identifies those two uh those two dimensions. Um now just at the end I want to talk about uh uh the deescalation principles uh that I actually I'm trying to incorporate in standardized patients u because the these should be uh fairly easy to to uh at least present and then maybe hopefully to to teach the residents how to use uh in terms of dealing with educated patients. So, and actually many of many of them are are are used by by staff u how to how to start the interaction with a um with a violent patient, how to position yourself within kind of arms length uh uh probably at 45 degrees u for two reasons. uh one to uh um if in case you're attacked to offer a much smaller surface uh of the impact and also to allow you a way to escape if you have to. Um not obviously to block the exit or stand over if the person is kind of kneeling down or or in the bed. Never turn your back. Uh what to do with your hands? Never make fists or kind of keep your arms crossed or behind you or in your pockets uh to kind of appear as uh um as non-threatening as possible. How to regulate the the eye contact? If it's too intense, it can become bothersome. If it if it lacks completely, then people could uh conclude that you're not really interested or involved. Um >> the thing that that's um important to keep in mind with a um psychiatric patient is well, a couple things. One is that mental health uh patients are much more likely to be the victims of violence than actually to commit violence. And this is, you know, that's really the outlier, the unusual case where the psychiatric patient becomes violent. But obviously, it's an important situation. It does happen frequently enough to be a real concern for the the providers for their well-being. Um but then um the I think I've lost lost my train of thought here and basically there's there's different levels of what you have to understand how to do. One, how to protect yourself and then two, how to protect the patient. It's almost like if your child who's 11 years old comes at you swinging, it's really different than if you're getting bugged on the subway in terms of what you're going to do. Now, the person who's sitting in your office might be a lot bigger than your 11-year-old, but you kind of get the idea. You're not you're not trying to punish them. You're not trying to uh you know inflict any more harm on them than is absolutely needed in order to stop the situation and for you know you to get out or let them out. >> Yes. And and that's important and that's somewhat counterintuitive because when uh I think an interesting aspect I'm just thinking or trying to think in terms of potential simulation uh and and targets for for a training uh paradigm. I think an important aspect is to uh uh for the person who's going through the training to understand himself or herself. How what's the reaction when you're threatened and how to uh to continue to think on your feet and and take decisions that are not based on a kind of flight or fight or tendon befriend you know attitude. Uh this is not about dealing with with a common situation. This is uh when you have to maintain your ability to uh to remain therapeutic and helpful and to minimize harm to yourself but certainly harm to to the other person. And the truth of the matter is that many people in this situations react the way they have that they have always done. I mean, I I I gave Jim the example of a social worker I work with who every time when she's confronted by a patient. She gets angry and and she gets defensive and and tells things, you know, to her that I find are are hurtful and are just kind of, you know, adding gas to the fire. I need to intervene between the two of them. It's almost like uh, you know, I'm there the umpire. I say, "Okay, time out. Stop. We need to do something else." And I I I try to explain to her, she just doesn't uh doesn't get it or you know can't theoretically figure it out but uh you know doesn't uh doesn't do a good job at it. When we are angry or frightened our behavior, our the way we talk, the way we track changes and that can those things can uh be major triggers for for the other person. So >> yeah, if you're if you're s stay really calm and the other person's escalating, that's a real dampening force on that other person from escalating even more. And it's really really hard to do that. Stay professional and recognizing that this this aggression is a really a medical symptom just like if there were bleeding on the floor that you know the difference obviously is that it could actually hurt you the provider. But you know you need to to recognize as a medical symptom that needs to be dealt with as opposed to taking it really personally or or you know getting violent act. >> Yes. Uh how do you hear? How do you uh uh obviously being calm, centered, self- assured is always helpful. It's it's the message that that you're you're you're conveying. often uh if you respond you know to anger by being fearful or anger yourself you know obviously this will just kind of escalate uh or if you're fidgety and you know pacing and gesturing yourself and and wondering so what do I do now I think uh the other person will clearly pick up that that feeling uh touching uh most often than not is not a good idea even though I mean instinctively we would like to kind of calm calm the other person down or wonder what it is. This is how we learn to show kind of empathy and that we care, we want to help. Well, it may not may not be a may not be a good idea. So, uh and then this could be a topic in itself. Um active listening would be uh the most uh u if you want the buzzword in terms of the verbal deescalation uh principle. often when I uh when I'm called and many of my colleagues are called to deal with such a situation I introduce myself I uh I'm telling the person no matter how agitated he is why I'm here uh and I'm trying to understand uh I may not respond or react to you know the person's curses or threatening behavior of course I try to maintain a safe distance and I continue my assessment I can I deal with this or I need help or I I need to stop and and and find another way. Uh and I give that person feedback about uh what I see, how he or she makes me feel. I feel, you know, you're threatening. I feel uncomfortable. I think we need to stop. Do you want to talk? What are the issues uh that that you're dealing with? And um I also explain uh and set limits on on what is acceptable and not acceptable. often that combination works. Um I listed phacotherapy and seclusion is trained because they're part of the process and I think uh I would like u people you know who are trained you know uh for this to understand that those things are available. Um, any questions so far? >> I I've just got a couple of comments on the position of the table. So, >> yeah, we can do that. And also, I wanted to suggest see what you think about this. If someone would like to play the role of a patient, I can meet with you briefly and just kind of prepare you to do that. If anybody's interested in taking on the role of the aggressive you'd like to do. Okay. So, why don't you and I step up for just a couple minutes and then you're talking. >> So, that's going to be a bit of a role play demonstration. >> No, that's okay. So, uh, so I mean there's a couple of things that that that that have been brought up that already immediately seem to be possible places where you guys can think of what what you're going to do your project on. Um that's that's uh that's identifying factors of course that I mean there's a whole bunch of different schemes that you that that that and different u metrics that that people have been using uh all the way from from known personality types to you know to social economic factors and and personal history. you can make some some some kind of kernel of war game, you know, I can imagine some some sort of like can you figure out enough information before it's too late, that sort of kind of thing. Um, the dynamic assessment of violence seems to be more of a time pressure kind of thing because it's like you almost have to like figure it out on the spot, right? But the factors are very different. But I thought it's like identifying um activists. The the deescalation um the active listening thing is kind of interesting because it almost seems like you could make it a word game or a face to face kind of party game kind of thing out of that of the can you remember what you're supposed to do with you know in conversation with each other without missing any of the any of the points and and that might be something that they could do. So that that would be like a live action game but not necessarily a physical game. It would be like you know like more like a party game you can imagine working. >> I mean one one way I uh I this is by the way I didn't want to go there to make this too long but this these are some parts of a standardized uh patient that I'm putting together. that I'm going to try actually to uh to talk to the simulation department at the mass to you know train an actor and this would be kind of the goals for uh you know the training modes um and I'm really particularly interested in how people respond when they're exposed to an angry situation or even to an angry face. What do