1. Scott Woodside, LL.B, MD, FRCPC Centre for Addiction & Mental Health

2.  Outline  Factors considered in determining whether to admit or discontinue a Form 1 ▪ Risk for violence against self or others ▪ Lack of competence to care for oneself

3.  Multi-faceted construct  Nature: what kind of violence  Severity: how serious  Frequency: how often  Imminence: how soon  Likelihood: probability of violence occurring

4.  Statistical measures best for estimating long- term risk of violence but impractical in ER  Have to rely on clinical indicators of risk in deciding whether to certify or not  Clinicians actually reasonably good at identifying risk of violence over short-term (hours to days)

5.  Expressed intent to harm  Presence of a victim  Frequent/open threats  Concrete plan  Access to instruments of violence  Previous history of violence/loss of control  Chronic anger/hostility  Callous/lack of compassion  Views self as victim  Anti-authority  Childhood abuse/deprivation  Early loss of parent  Conduct Hx  Reckless driving

6.  Historical Factors (Fixed/Static):  Previous violence (frequency/severity)  Young age (under 20)  Relationship instability (unstable/conflicted intimate R/S)  Employment problems (unstable pattern)  Substance use problems (serious impairment)  Major mental illness  Psychopathy (PCL-R or PCL- SV score)  Early maladjustment (serious conduct problems or victimization)  Personality disorder (any non- psychopathic disorder)  Prior supervision failure

7.  Clinical Factors (dynamic/current):  Lack of insight (Dx or need for Tx)  Negative attitudes (procriminal/antisocial/ pessimistic/anti-authority)  Active sx of MMI (disturbance of thought, affect, perception)  Impulsivity (Behavioural, cognitive, affective)  Unresponsive to treatment (resistant or refractory)  Especially important re: imminence

8.  Risk Management Factors (dynamic/future):  Plans lack feasibility (no plans, unsuitable, unrealistic)  Exposure to destabilizers (weapons, substances, victims)  Lack of personal support (personal, emotional)  Noncompliance with remediation (cannot, will not comply with Tx)  Stress (serious psychosocial stressors, fragile)