Impact News

Responding to Violence, Suicide, Psychosis and Trauma

Difficult, Disturbing & Dangerous Behaviour Workshop in Nottingham

Nottingham HLG are putting on an open access workshop delivered by Dr Iain Bourne on 28th November 2012. For further information and booking details visit:

http://www.hlg.org.uk/training/quarterly-training-schedule

If you are interested in this as an in-house course please visit www.dangerousbehaviour.com. The book that supports this course is due out in March 2013 and details can be found at www.facingdanger.com

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Difficult, Disturbing & Dangerous Behaviour

This dramatic course delivered by Dr Iain Bourne is being made available by Sitra:

20th September 2012 in London

26th September in Leeds

 

Filed under: Impact Training, Other Mental Health, Violence, , , , , , , ,

NHS Trust Guilty Following Fatal Stabbing of Care Worker

Care staff are having to work with increasingly challenging service users, often inappropriately placed, without adequate training or supervision. Another tragic death …
Central Bedfordshire Council

20 July: Sentencing of former Dunstable care home owner and county NHS Trust
A county NHS Trust and the owner of a former Dunstable care home have been sentenced after being found guilty of safety failings following the fatal stabbing of a care worker at a private residential care home in Dunstable.

Kathleen Bainbridge, 58, from Luton was killed at Abacus House, on Princes Street, on 24 August 2007 by resident Stephen Flatt, then aged 55, who attacked her with a knife from a kitchen. Fellow care worker Barbara Hill, from Dunstable, was also attacked when she went to help her colleague.

A joint investigation by the Health and Safety Executive (HSE) and Central Bedfordshire Council found that Abacus House was not the correct care facility for Mr Flatt, who had been placed there by the Hertfordshire Partnership NHS Foundation Trust.

A trial at Luton Crown Court heard he had been diagnosed with bipolar disorder and that Abacus House staff had no expertise or training for dealing with people with this disorder, or for managing violent or aggressive behaviour.

Hertfordshire Partnership NHS Foundation Trust was yesterday (19 July) fined £150,000 and ordered to pay costs of £326,346 for breaching Section 3(1) of the Health and Safety at Work etc. Act 1974 for its failings in relation to the fatal incident after being prosecuted by HSE.

The council brought proceedings at the same time against the owner of Abacus House, Chelvanayagam Menna, who was fined £75,000 and ordered to pay costs of £338,996 after being found guilty of breaching Sections 2(1) and 3(1) of the same Act.

After the sentencing HSE Inspector Karl Howes said: “This was a tragic incident that left a family without a wife, mother and grandmother. No-one expects to go to work and never return home.

“Care homes have a duty not only to protect the safety of their residents but their staff as well. The NHS Trust failed to adequately assess the risks that were posed to staff and other residents from placing Mr Flatt in Abacus House.

“I hope this will make all NHS Trusts and care facilities carefully consider the procedures that they have in place during patient placement.”

Councillor Budge Wells, Deputy Executive Member for Sustainable Communities, Services at Central Bedfordshire Council said: “The legal process has been long and difficult, particularly for Mrs Bainbridge’s family but also for her former colleagues – especially Mrs Hill.

“Of course the trial of Stephen Flatt had to take initial priority and once this was concluded the police instigated a further investigation of the Trust and care home owner. However the Council and HSE cooperated closely on their investigation from the outset and were in a position to progress with proceedings as soon as the police cleared the way.

“All concerned in the case hope that the right lessons are learned from this tragedy and that nothing of a similar nature occurs in future.”

Filed under: Impact Training, Other Mental Health, psychosis, trauma, Violence, , , , , , ,

Open Courses “Difficult, Disturbing & Dangerous Behaviour”

SITRA is now offering individual places on the DDDB course around the country. Details below:
SITRA- DDDB

Difficult, disturbing and dangerous behaviour

3 February 2012, Newcastle

9 March 2012, Bristol

15 March 2012, Southampton

27 March 2012, London

19 April 2012, Birmingham

18 July 2012, Southampton

20 September 2012, London

26 September 2012, Leeds

Anyone working in settings where people may behave in a difficult, disturbing or dangerous way. This is an intensive, practice-based course, which can be emotionally demanding as incidents are acted out by the trainer in front of the group. This provides a springboard for you to experience and examine some of your own reactions to difficult, disturbing, and/or dangerous behaviour.

At the end of the course, you should:

Feel more confident to deal with aggressors in crisis
Have a greater awareness of how their own feelings and reactions may help or hinder the resolution of a crisis
Be more able to identify indicators of violent behaviour, and take appropriate preventative measures
Have identified strategies for responding effectively to uncontained behaviour.
Price: Members £89/Non-members £129

Trainer: Dr Iain Bourne

Book now

Filed under: Impact Training, Violence, , , , , , , ,

Dundee & Edinburgh: Difficult, Disturbing and Dangerous Behaviour

If you you are looking for a DDDB course in Scotland, Blue Skye Consultancy are offering places in Dundee on 30th April and Edinburgh on 1st May. Details and Booking forms can be found at:

http://blueskyeconsultancy.co.uk/dddbcourse.htm

Filed under: Impact Training, Violence, , , , , , , ,

Open Difficult, Disturbing and Dangerous Behaviour Course in Brighton

If you are interested in attending a one-day DDDB course in Brighton ob 28th April 2009 please contact

http://www.rocc.org.uk/training/course?id=215

Filed under: Impact Training, Violence, , , , ,

Open Difficult, Disturbing & Dangeroous Behaviour Course in Southampton

If you are interested in attending a DDDB one-day course on 23rd Aprl in Southampton please contact ROCC at:

http://www.rocc.org.uk/training/course?id=213

Filed under: Impact Training, Violence, , , , ,

Dangerous Behaviour Courses in Scotland

Two one-day open access courses are being organised on “Difficult, Disturbing and Dangerous Behaviour” in Scotland during the Spring. These are being organised by Vance Finnon of Blue Skye Consultancy for :

  • 30th May in Dundee
  • 1st April in Edinburgh

If you are interested please go to:

http://blueskyeconsultancy.co.uk/dddbcourse.htm –  for further information

http://fs11.formsite.com/KBFinnon/form244062311/index.html – to book a place

Filed under: Impact Training, Uncategorized, Violence, , , ,

The Dangerous Behaviour Masterclass 5 – Reading: Violence and Dissociation

Another reading, this time an excellent review of the literature on Violence and Dissociation by Andrew Moskowitz. In the following Masterclasses we will begin to explore how violence, dissociation and and understanding of brain function can come together to highlight effective de-escalation (and ineffective) strategies. Unusually, the full text, originally published in Trauma, Violence & Abuse (a review journal)/ January 2004, is available online at:

http://www.hawaii.edu/hivandaids/Dissociation_and_Violence__A_Review_of_the_Literature.pdfHappy reading!

Iain Bourne

 impact@dangerousbehaviour.com

www.dangerousbehaviour.com

Filed under: Violence, , , , , , ,

The Dangerous Behaviour Masterclass 4 – Reading: The Biology of Violence

For this Masterclass, instead of continuing with my own discourse, I’d like you to read the following article taken from Neuropsychiatry Reviews, Vol .8, N0. 5, May 2007. Later on, I will expand upon how understanding the interplay between brain function and violence can highlight effective strategies for responding to imminent violence.

Does Biology Play a Role in Domestic Violence?

TUCSON—Between 20% and 30% of all men and women in the US will be victims of domestic violence in their lifetime. Domestic violence accounts for 20% of all emergency department visits, 50% of police calls, and about 30% of murdered women. While considerable research into understanding the perpetrator’s mindset has focused on learned behaviors and psychosocial issues, comparatively little effort has been devoted to exploring possible biological causes of the problem, according to David George, MD.

“Most people look at domestic violence from a psychodynamic/psychosocial perspective,” said Dr. George, Section Chief of Clinical and Translational Studies at the National Institute on Alcohol Abuse and Alcoholism in Bethesda, Maryland. “These people believe that perpetrators feel inadequate and try to control other people by their behaviors or that they grew up in homes where they were exposed to violence, and, therefore, they’ve learned these patterns. I was particularly interested in the fact that there has been so little emphasis given to any biological understanding of what might be taking place.” Dr. George made his presentation at the 18th Annual Meeting of the American Neuropsychiatric Association.

The first step in determining whether biological abnormalities may lead to acts of domestic violence is to closely examine who the perpetrators are, according to Dr. George. The incidence of domestic violence is approximately equal in men and women, and about 70% of perpetrators abuse alcohol, he noted. Based on interviews with several hundred people who have committed acts of domestic violence, as well as their spouses and significant others, Dr. George has observed several recurring patterns. One of these patterns is that perpetrators are likely to have been in multiple fights during their childhood. “They are going to push their teachers,” noted Dr. George. “They fight with their siblings and with the kids down the street. As they grow older, most of them tend to limit their violence to the home and direct it toward their spouse or significant other.”

Perpetrators also have little insight into why they become violent, and most acts of domestic violence are impulsive, said Dr. George. “There are those with a predatory side, but I do not see it often. Alcohol plays an important role in domestic violence. Alcohol is a two-edged sword. Perpetrators are going to use alcohol to calm down, but often the alcohol contributes to the likelihood of violence.”

Typical behavioral symptoms in perpetrators include racing thoughts, supersensitivity to environmental stimuli, and mood swings that range from shutdown to flight, fight, and stalking. “I had one person tell me, ‘If you ever got in my mind, you would probably lock me up. You would think I was crazy.’ This is something that is going on inside of them,” said Dr. George. “Little things are going to set them off—spilled milk at the dinner table, dirty dishes that aren’t taken care of in the sink, the dinner that’s late. The most interesting thing was that they feel afraid at the time of the aggression. That was very difficult for me to comprehend, because so often we are working with large and aggressive perpetrators whose victims are smaller in stature. Fear just doesn’t look like it should be a significant factor.”

ANXIETY, PERSONALITY DISORDERS, AND SUBSTANCE ABUSE

Dr. George has conducted a number of studies regarding domestic violence. One trial included perpetrators of domestic violence with alcohol dependence, nonviolent alcoholics, and healthy controls. The researchers found that violent alcoholics had a higher incidence of major depression, panic attacks, social phobia, obsessive-compulsive disorder, generalized anxiety, and certain personality disorders than did nonviolent alcoholics.

In a double-blind, placebo-controlled trial involving the administration of sodium lactate to participants, Dr. George and colleagues found that behavioral symptoms such as speech, breathing, facial grimacing, and motor activity in the arms and legs were much more accentuated in the perpetrators, as was their sense of fear, panic, and rage, compared with nonviolent controls. “These results were instrumental in changing my thinking about perpetrators of domestic violence,” commented Dr. George. “It moved me from seeing them as offensive individuals to seeing them as defensive individuals. This was extremely important to me, because it directed my attention to the neuropathways that have been shown in animals to mediate defensive aggression.”

PSYCHOPATHOLOGY AND FEAR RESPONSE

Dr. George devised a basic model for understanding the psychopathology of perpetrators of domestic violence. “Perpetrators frequently misinterpret environmental stimuli, which gives rise to a perceived sense of threat,” he explained. “Sensory stimuli enter the thalamus, and from there are processed by both the cortex and the amygdala. The processing of the sensory stimuli in the amygdala is extremely fast and serves as an early warning system. The processing of the sensory stimuli in the cortex is going to be much slower and much more detailed than in the amygdala…. The cortex and the amygdala talk to each other. In certain situations, these sensory stimuli give rise to defensive behavior, autonomic arousal, and hypoalgesia…. If you talk to these people and ask them what it is like when they are hitting someone, they will tell you, ‘It feels like my hands and arms are like feathers. I have no feeling in my hands. I don’t feel as though I’m doing anything.’”

In formulating a theory for the etiology of domestic violence, Dr. George reasoned that threats trigger a conditioned fear response in perpetrators that is out of proportion to the stimulus, which may result in fear-induced aggression. “This misinterpretation arises from the abnormality in structures and pathways that mediate fear-induced aggression,” he said.

In a study using PET (18FDG) imaging to examine the neural structures and pathways involved in fear conditioning and fear-induced aggression, Dr. George’s group found that mean CMRglc in the right hypothalamus was significantly lower in perpetrators with alcohol dependence, compared with nonviolent alcoholics and healthy controls. “At rest, when you compare the activities in the left amygdala with various cortical and subcortical structures like the thalamus and cingulate, you see a strong correlation in the nonviolent alcoholics between these structures and the amygdala, whereas in the perpetrators, you had decreased correlations,” said Dr. George. “We are interpreting this to mean that the ability of the cortex to modulate the amygdala in these people is reduced. Similarly, we compared perpetrators with healthy controls. We found the same kind of finding here, decreased correlations [with the left and right amygdala]. And the nonviolent alcoholics had an increased correlation between the left thalamus and left posterior orbitofrontal cortex.”

Such findings may indicate different motivations to drink alcohol for nonviolent alcoholics and alcoholic perpetrators. “Basically, we arrived at two different possibilities,” Dr. George said. “The increased correlation found in nonviolent alcoholics maybe makes them more susceptible to environmental cues that trigger drinking. Whereas, I think alcoholic perpetrators are more prone, at least in the initial stages of the disease, to drink in order to decrease anxiety.”

In another study, Dr. George and colleagues performed lumbar puncture in the left lateral decubitus position in alcoholic perpetrators of domestic violence, nonalcoholic perpetrators, and healthy controls. The researchers found that the nonalcoholic violent group had lower 5-HIAA [5-hydroxyindoleacetic acid] concentrations than did the other two groups, which was “not particularly surprising, given the huge literature that’s out there saying that 5-HIAA is involved with impulsive types of aggression,” noted Dr. George. “It is unclear as to why the alcoholics didn’t have it. We then looked at testosterone, and there we found that [alcoholic perpetrators] did have higher levels of testosterone. So we have at least two neurotransmitter systems that theoretically could be involved, that could be modulating the way they process sensory information. We are looking at a number of other transmitter systems at this time.”

CAN DOMESTIC VIOLENCE BE TREATED?

Dr. George’s current research is focusing on fMRI, genotyping, and potential treatments. To date, he emphasized, “Treatments for domestic violence are often ineffective.” In one ongoing trial, he has been comparing fluoxetine with placebo regarding their effect on measures of aggression, anxiety, and depression in those who commit acts of domestic violence. “What is really interesting is when you look at what serotonin does, it modulates sensory information,” noted Dr. George.

Dr. George believes that it is possible to piece together some of these findings to understand domestic violence on the basis of a biological pathway. “This is such a primitive pathway,” he commented. “Defensive aggression is present throughout the whole animal kingdom and promotes survival. With reduced cortical connection to the amygdala, perpetrators process sensory information very quickly. Based on fMRI studies, this processing of sensory information by the amygdala is out of the conscious awareness. I think that’s why therapy has been so ineffective in these individuals. They are responding so quickly to sensory information that they don’t even have time to think about it.”

Ultimately, Dr. George believes that further studies linking conditioned fear and fear avoidance with behaviors and psychiatric diagnoses will help change the way researchers and clinicians perceive and treat perpetrators of domestic violence.           

—Colby Stong

Suggested Reading
Fils-Aime ML, Eckardt MJ, George DT, et al. Early-onset alcoholics have lower cerebrospinal fluid 5-hydroxyindoleacetic acid levels than late-onset alcoholics. Arch Gen Psychiatry. 1996;53:211-216.
George DT, Phillips MJ, Doty L, et al. A model linking biology, behavior and psychiatric diagnoses in perpetrators of domestic violence. Med Hypotheses. 2006;67:345-353.
George DT, Umhau JC, Phillips MJ, et al. Serotonin, testosterone and alcohol in the etiology of domestic violence. Psychiatry Res. 2001;104:27-37.
Umhau JC, Petrulis SG, Diaz R, Rawlings R, George DT. Blood glucose is correlated with cerebrospinal fluid neurotransmitter metabolites. Neuroendocrinology. 2003;78:339-343.

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