JUN 12 - 14  

The Early Recognition Method: Bridging Risk Management from Secure to Rehabilitation Environments

Inpatient aggression is a main topic in forensic psychiatric care. The ‘Early Recognition Method’ [ERM] is a risk management strategy objective to support self-management of patients regarding relapse prevention of aggression. Staff and patient discuss and describe patient’s early warning signs of aggression.

The concept of early recognition within a forensic context emphasizes the description and exploration of the early signs of deteriorating behavior in situations associated with violent and aggressive patient behavior with the patients themselves. These early signs can be defined as the subjective perceptions, thoughts, and behaviors of the patient occurring prior to the incidence of violent behaviour. The patient's objective behavior is usually quite easy to grasp; that is, a shouting male patient clearly shows that he is angry. However, the source of the man's anger may be more difficult to grasp at times: Why is he shouting? Why is he so angry? What is going on in his mind? For the detection of early warning signs, considerable attention must be devoted to the recognition and exploration of the subjective factors underlying patient's aggression or the precursors to violence. Furthermore, the focus of early recognition training efforts is on the enhancement of patient's self-management skills and thereby their capacity to recognize the early stages of behavioral deterioration. The focus is on those early warning signs that are very personal based, which are referred to as ‘signature risk signs’, which resonates with patient’s, ’Individual Risk Theory’ as mentioned in the HCR-20V3. The early warning signs and the accordingly early interventions are described in the so-called Early Detection Plan [EDP].  

The Forensic Early Signs of Aggression Inventory [FESAI] was developed in order to assist nurses and patients in identifying the patient’s personalized early warning signs. Using the FESAI the nurse and patient together explore which items of the FESAI represent the patient’s early warning signs of aggression, after which nurse and patient elaborate on these early warning signs in the Early Detection Plan. Research suggests ERM can contribute to a significant decrease of inpatient violent incidents and a significant decrease of severity of inpatient incidents.


This is an interactive workshop. The Early Recognition Method will be outlined, and the application of the Early Detection Plan and the Forensic Early Warning Signs of Aggression Inventory will be demonstrated and trained, by using case descriptions and movie fragments. The content of ERM will be explained in respect of security and (‘Individual’s risk theory’) and protective measures (‘Grow theories’). By means of movie fragments, the audience will practice with the ERM protocol and rate early warning signs of aggression on the FESAI, and discuss these in subgroups. 

Learning Objectives:

  • How the concept of ERM is rooted in risk management theory and fits to the ‘state of the art’ of risk management and risk assessment strategies
  • How aggressive, violent or psychotic behaviours could be understood in the perspective of early warning signs as precursors of deteriorating behaviours
  • How ERM-risk management is applied (and studied) in several international settings, from secured clinical settings to ambulant and the transfer between these


Dr. Frans Fluttert Ass. Professor, PhD, MSc, RN (FPC Dr. S. van Mesdag NL, Molde University Hospital NO, Oslo University Hospital NO, Southern Denmark University DK) is senior researcher, lecturer and research supervisor. He is involved in many international research projects and is affiliated to many institutes in the forensic field. Over the years he did many risk management trainings, seminars and presentations across Europe. After he finished his PhD on the topic of ERM, he further developed the concept of ‘early recognition’ into a broad concept for academic studies and clinical applications.

Gunnar Eidhammer MSc. RN. (Oslo University Hospital NO, Vestre Viken Trust Mental Health NO) is a very experienced nurse and researcher with extensive knowledge of ‘state of the art’ of forensic mental health care & risk management. He is ‘the ERM-ambassador’ for Scandinavia: he contributes importantly to the application, developing and facilitating of ERM for research and clinical practice. He is very experienced in risk management trainings and seminars and published internationally.

Kirsten Johansen Katballe MSc. PhD candidate. (Southern Denmark University) is an experienced clinician and has worked internationally. She has a background in chiropractic care. She has done a pilot study on behavior change among people suffering. She is presently doing a Ph.D. project applying ERM in ambulant psychiatric care in Southern Denmark.


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