Can an innovative program reduce violence and self-harm on inpatient psychiatric units?
We are testing a program designed to prevent violence by changing institutional risk factors like authoritarian staff-patient relationships.
Introduction and development
In state hospitals, staff treat people with mental illness who are detained against their will and restricted in their activities. Here, violence is a common and persistent problem with profound costs—including personal harm, difficulties retaining a talented workforce, and a compromised therapeutic environment. Creating a safe environment is the top goal of the California Department of State Hospitals (DSH), the largest inpatient system in the world.
Over the past seven years, we have been partnering with DSH and the Department of State Hospitals Napa (DSH-Napa) to implement and evaluate a pioneering, population-based approach to violence prevention. Hospitals typically focus on high-risk patients as the source of the problem. Our innovative approach recognizes that situational and institutional risk factors also evoke violence—including authoritarian staff-patient relationships, limited staff training and competencies, and problems with the built environment.
Institutional risk factors matter
Our new approach grew out of an intensive study at DSH-Napa. There, we partnered with staff and patients to comprehensively assess 26 treatment units’ institutional risk factors for violence. Results indicated that these factors strongly predicted differences in units’ future rates of violence (r=.42). This suggests that a population-based approach that targets unit-level risk factors will add value to current patient-focused programs. Common risk factors included authoritarian staff-patient relationships, limited staff training and competencies, and problems with the built environment.
Operationalizing & evaluating the approach
Based on these results, we worked with national and local experts to develop the Trauma-Informed Verbal De-escalation Training (TID). This light-touch training targets the common institutional risk factors we identified to help staff prevent and/or de-escalate “hot situations.” The training is delivered by experienced and well-respected local practitioners and tailored to DSH.
To date, local experts have trained 142 staff across seven units. Preliminary results indicate that TID training is associated with decreased work stress (d=.25) and increased staff confidence in their ability to de-escalate violent situations (CCPAI scores, d= -.43). A comparison of a well-matched control unit and treatment unit over a one-year period indicates a greater increase in base rates of violence on the control unit than the treatment unit, after the target unit’s training date. Although preliminary, these results suggest that training promotes violence prevention.
Current status
Today, we are expanding TID training to higher-risk units at DSH-Napa and testing its impact on units’ rates of violence, self-harm, use of seclusion and restraints, and staff absenteeism. If the strategy continues to prove successful, it may be implemented in other DSH institutions as a targeted intervention for moderate-to-high risk units.
