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Prediction of Violence: Safer Management Using a Team Approach
By Katie Przychodzen, National Commission on Correctional Health Care
Published: 05/21/2018

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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.

De-Escalation Techniques

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 threat is made in person
  • The threat is specific
  • A close relationship exists between the one making the threat and the potential victim
  • The threat is introduced late in the exchange
In the case that violence seems imminent, there are several proven techniques for de-escalation, he said. For one, it is important to minimize distractions such as background noise and people speaking over one another. Next, introduce yourself to the violent individual and state simply that you are there to listen. Speaking slowly and calmly, and attempt to adapt the conversation to their vocabulary level. If possible, try to extract a concession from the individual. Finally, and most importantly, allow as much time to pass without incident as possible, said Dr. Federbush. Over time, the individual will expend adrenaline and fatigue will start to set in. In other words, the more time that passes without injury, the more likely a nonlethal outcome to the crisis.

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:
  • The inmate’s mental health history from the time of incarceration until the UOF event
  • Factors leading up to the UOF event
  • Custody administration feedback on the event
  • Recommendations including training opportunities and policy changes
The team approach proved to be much more effective than the system that was previously in place before the interventions. From 2014-2015, UOF events across all populations dropped 24%, and those involving mentally ill inmates dropped 33%. Comparing 2013 to 2017, these interventions resulted in continued successes, including a 63% reduction in UOF across the board, a 64% reduction in suicide attempts and an 81% reduction in injuries to staff.

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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