These are notes transcribed by April Cyr from two free seminar courses listed on the Veteran's Affairs catalog. One is titled Post-Traumatic Stress Disorder (PTSD) 101: Assessing and Reducing Violence Risk in Veterans with PTSD. The other is Legalized Cannabis and PTSD Treatment by

Melanie Hill, PhD.
The first presentation focuses on identifying Violence Risk and Protective Factors in Veterans with PTSD.
“Although PTSD in Veterans is associated with a higher risk of violence, the vast majority of Veterans with PTSD report no violence or problems with aggression. Concurrent factors and specific PTSD symptoms must be considered.”
For a patient who claims they smoke cannabis multiple times a day to ‘take the edge off,’ it’s important to screen propensity towards violence. A subset of 33% of veterans report engaging in violence or aggression towards others in a one-year period. This may be as minor as pushing and shoving. Roughly one third of that 33% (12% of total) reported incidents of severe or lethal violence in that time. We as Clinicians can engage in a systematic and evidence-informed process of reviewing risk and protective factors in a client, to ensure they or he or she are supported best. It is completely necessary for us to do our best to detect risk factors for violence in our clients as clinicians. There is no single risk factor alone that is enough to predict violence, however, several risk factors of increased violence that exist are:
    • Younger age
    • Past of violent behavior
    • Child abuse/maltreatment
    • Combat Exposure
    • Substance Abuse
    • Post Traumatic Stress Disorder
    • Financial Instability
    • Male gender
Something this presentation does go into is looking at Protective Factors and making a Safety Plan. This looks at life details such as stable living arrangements, employment, financial management, chaplain connection, social support, and self-care.We identify how to manage and lower risk of violence in veteran and military populations, and better understand the role of PTSD and violence, as well as evidence-based risk factors for violence in veteran and military populations. Identifying the circumstances person is at highest risk, and how to lower that risk by increasing protective factors. This is how you address addiction in this community.

Predictive Factors

It's not an exact Science predicting individual behavior, or propensity to violence. However, we have learned a lot about which evidence-based approaches are most valid and accurate. We also have a grasp on what are called Protective Factors, or factors that lower the overall risk. A trained Clinician guessing, or making educated guesses based on intuition, is a little bit more accurate than flipping a coin. When we are looking at probability like this, we are using a metric called AUC or Area Under the Curve. Here is a breakdown of several methods of predicting individual propensity towards violence, measured with AUC:
Method AUC
Flipping a Coin .5
Clinical Decision Making .66
History of Violence .71
Psychopathy Checklist .75
Violence Risk Appraisal Guide .76
HCR-20 .8
MacArthur Risk Assessment Study .82
Perfect Accuracy 1.0

Protective Factors

    • When veterans are working, severe violence reported half as much (9% vs 17%)
    • When basic needs are met, risk of violence is decreased (7.3% vs 15.7%)
    • When veterans are able to take care of themselves, risk is decreased (9.4% vs 23%)
    • When faced with homelessness in past year, risk is increased (37% vs 9.5%)
    • High reported resilience, self-determination, spiritual faith, and social support all had lower risks of violence.
We are looking at risk factors of violence, not to incriminate or stigmatise, but to understand more holistically what the clients needs are. It's recommended against using a single tactic listed above, but to use two or three in tandem with each other. A very simple Violence Prediction Assessment that is free and takes a minute or two to complete is called VIO-SCAN or the Violence Screening and Assessment of Needs which looks at, in binary detail (yes or no) if the person is: Financially Stable, has Combat Experience, Misuse of Alcohol, History of Violence or Arrests, and Probable PTSD plus Anger. In my assessment I am going to use both the VIO-SCAN, and the Cannabis Abuse Screening Test (CAST).

Post-Traumatic Stress Disorder (PTSD) 101: Assessing and Reducing Violence Risk in Veterans with PTSD (By Veterans Health Administration - Employee Education System). (2019, September 19). [Video]. VHA TRAIN: U.S. Department of Veterans Affairs. https://www.train.org/vha/course/1088734/details

Clinical Takeaways on Cannabis and PTSD

PTSD predicts greater difficulty quitting cannabis. Traumatized people are more vulnerable to addiction. "22% of cannabis users meet the criteria for addiction disorder", altered brain development, poor educational outcomes, bronchitis and psychosis.

CUDIT-R: Problematic cannabis use screener. https://wellness.caltech.edu/documents/18162/CUDIT.pdf

There is insufficient evidence to recommend cannabis for PTSD Treatment. Some veterans with PTSD may experience worsening symptoms and/or difficulty stopping chronic use.

Long term effects of cannabis use in Veterans with PTSD remain unclear. Clinical trials of specific cannabinoids have tested different products than what is commercially available. Clinicians should monitor veterans cannabis use and discuss possible risks versus benefits of using cannabis to manage ptsd symptoms.

Legalized Cannabis and PTSD Treatment. Melanie Hill. Phd. VA.gov | Veterans Affairs. (n.d.). https://www.ptsd.va.gov/professional/continuing_ed/legalized_cannabis_and_tx.asp