Violence in clinical psychiatry – the view from Oslo

In late October, I travelled to Oslo to attend the 11th European Congress on Violence in Clinical Psychiatry. This biennial conference is not just relevant to psychiatry, but to medicine generally, given the risks often incurred by practitioners in settings such as emergency departments and general practice. When I say Oslo, I really mean Lillestrøm, which is to Oslo perhaps what Bray is to Dublin. As such, there wasn’t much sightseeing to be enjoyed on my brief Norway trip, unless you count Olso-Gardermoen Airport which, to be fair, was architecturally impressive. What little spare time I had was spent reading the latest Jo Nesbø novel. Unlike my conference, it was set in Oslo. 

The 2017 conference was staged in Dublin, but there was limited Irish input this time round. The exception was a symposium talk delivered by Dr Amir Niazi, consultant psychiatrist, and Eugene Meehan, director of nursing, both from the Louth-Meath Mental Health Service. They spoke about combining an aggression-and-violence risk assessment with a structured-and-tiered care pathway. Other delegates hailed from around the world, mostly from Norway, the Netherlands, the UK, Germany and Switzerland, but also from more distant locations such as Canada, Australia and South America. Truly international, therefore.

The seven keynote speeches were impressive. On day one, Prof Kevin Douglas of Simon Fraser University, Canada spoke about risk assessment tools for violence and their applicability in real-world settings. He referred to the HCR-20, remarking that while it is effective in predicting violence, inter-rater reliability can be poor in some of its variables. He was less confident about the Psychopathy Checklist (PCL-R), and cited some legal challenges in Canada and the US regarding its validity in ethnic minorities, for example. He also highlighted substantial disagreement on the reliability of the PCL-R in real-world settings such as adversarial court proceedings. He concluded with the assertion that structured professional judgement often works best when assessing risk. 

He was followed by Prof Linda Gröning of Norway, who spoke about legal concepts, distinctions and definitions in relation to mental disorder and violent crime. The gear was then shifted slightly as Dr Wilma Boevink, a social scientist involved in the Dutch User Research Centre and a self-proclaimed ‘expert by experience’, gave a moving and personal account of her own mental illness and its treatment. Dr Peter de Looff, also from the Netherlands, then spoke about the use of biosensors (specifically skin conductance and heart rate monitors) to predict aggression in patients and burnout in the nurses who care for them.

On day two, Prof Stål Bjørkly of Oslo University Hospital regaled the audience with his views on milieu therapy to manage violence and aggression, whereupon Prof Gerben Meynen of Vrije University, Amsterdam gave a compelling talk about the philosophical theories underpinning the concepts of legal insanity and free will. In particular, he referred to the McNaughton rule. But perhaps the most compelling keynote speech of all was the last, delivered on day three just before the conference closed. With the narrative voice of a storyteller, Dr Pål Grøndahl of Oslo University Hospital described his experiences interacting with the mainstream media in the immediate aftermath of Anders Breivik’s atrocity of July 22, 2011, in which 77 Norwegians died.

In a sense, the conference was as reassuring as it was interesting. In Ireland, we have the Mental Health Commission and legislation that protects patients. Other countries aspire to human rights standards that we take for granted. I look forward to the next chapter – Rotterdam, 2021.