|Prediction of Violence: Safer Management Using a Team Approach|
|By Katie Przychodzen, National Commission on Correctional Health Care|
At NCCHC’s 2018 Spring Conference on Correctional Health Care, Joel Federbush, MD, and Allison Genberg, LCSW, CCHP, presented their talk on predictors of violence and using collaborative efforts to reduce use of force against inmates with mental illness. Dr. Federbush’s discussion of factors associated with violence provided the theoretical backdrop for Genberg’s case study of use of force at the Passaic County Jail in Paterson, New Jersey.
Violence and Mental Health
Dr. Federbush opened with an overview of demographics and an alarming homicide statistic: A white male has a 1 in 131 chance of being a murder victim in his lifetime, while a black male’s chance of the same is 1 in 21. Research shows that sex, social class, substance use, education level, employment and residential stability, and neighborhood poverty impact rates of violence across populations. Importantly, when mental health is added to the equation, the aforementioned demographics do not always hold up as solid predictors of violence.
For example, he said that males generally exhibit higher rates of violence than females, yet among people with mental disorders, males and females tend to show similar base rates of violent behavior. Additionally, while males with intellectual disabilities are 5 times more likely to commit a violent offense, females with intellectual disabilities are 25 times more likely to do so.
“Common errors in predicting violence,” according to Dr. Federbush, “include overestimating violence among minorities and underestimating violence among women with mental illness.”
The latter misconception is especially troubling considering the impact of mental illness on rates of violent behavior. Factors scientifically shown to be associated with violence, he explained, include diagnosable conditions such as depression and mania, as well as more common personality traits like impulsivity, egocentricity and recklessness. Dr. Federbush also talked about childhood factors that correlate with violence later in life. Among these, several are directly related to mental health, including abuse by a parent, ADHD, fire setting and cruelty to animals.
After examining the factors that contribute to violent behavior, the discussion moved into what to do when confronted with violence. Dr. Federbush explained that certain behaviors tend to foreshadow aggression, including clenching of the fists or jaw, expanding the chest, staring, standing with feet apart, pacing and exhibiting general impatience. He said that, while all threats should be taken seriously, the likelihood that a threat will be carried out increases if:
The Case of the Passaic County Jail
The presentation then transitioned into an in-depth look at use of force against mentally ill inmates at the Passaic County Jail, where Genberg is the health services administrator. “In the early 2000s, the 900-bed facility housed approximately 2,000 inmates, and the conditions concerned both inmates and advocates,” said Genberg. Eventually, the ACLU found out about the poor conditions and brought a class action lawsuit against Passaic County in 2008.
In 2011, after years of negotiations, the county and the ACLU entered into a memorandum of understanding. This MOU outlined the changes that both parties had agreed upon to improve conditions in the jail. Once these changes were implemented, she explained, monitoring began to move toward compliance in the areas of mental health, medical services and physical conditions in and around the facility.
The monitors were especially concerned about the disproportionally high rates of force being used on mentally ill inmates. “On average,” Genberg said, “the number of mental health patients involved in use of force events was approximately 50%, even though the mental health roster was only 10-15% of the jail’s population.” To remedy this, in 2014 jail staff devised a three-phase plan that included data collection, data analysis and interventions.
A Multidisciplinary Team Approach
It was clear early on, Genberg explained, that a more collaborative approach was necessary in order to reduce use of force against the mentally ill population. Interestingly, while custody staff had been tracking these UOF incidents, mental health staff had not. In light of this, a multidisciplinary team was created to review all UOF incidents involving mentally ill inmates. This team included custody administration, mental health staff and medical administration. During the review hearings, the team discussed:
Genberg noted that, in addition to implementing the multidisciplinary team meetings, two other interventions played an important role in significantly reducing UOF – namely, aggressive and appropriate psychiatric treatment and de-escalation training for custody staff.
Katie Przychodzen, MA, is marketing and communications manager for NCCHC.
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