The brutal murder of New York psychologist Kathryn Faughey and attempted murder of psychiatrist Kent Shinbach this past February has provoked warnings to psychiatrists about personal safety and overreliance on clinical judgment. David Tarloff, a person with schizophrenia, was indicted for the attacks. According to press reports, Tarloff blamed Shinbach for having him institutionalized in 1991. While he was wait-ing to see Shinbach, Tarloff allegedly entered Faughey's nearby office and slashed her to death with a meat cleaver and knives. Shinbach heard her screams, tried to rescue her, and was assaulted and robbed.
"Fatal attacks on clinicians such as psychiatrists and psychologists are rare," said forensic psychiatrist William H. Reid, MD, MPH, clinical professor of psychiatry at the University of Texas Health Science Center, San Antonio. "On the other hand, most mental health professionals deal with hundreds of patients, at least, every year and many thousands over a career."
Attacks, Reid added, occur in a variety of settings and contexts, including hospitals, offices, clinicians' homes, and public places. During their training, up to 65% of psychiatry residents are physically assaulted by patients.1 In a 2003 survey of employees of the University of Rochester Medical Center's inpatient and outpatient services, 40% of responding physicians, 3% of psychologists, and 57% of registered nurses said patients had assaulted them.2 In outpatient settings, a survey found that 32 of 92 psychiatrists (35%) reported serious assaults by patients (knife or gun used) and 59 respondents (64%) reported less serious assaults.3
The June 2008 issue of Psychiatric Services contains several articles on mental illness and violence. Choe and colleagues4 reviewed 31 US research studies published since 1990 and found that 2% to 13% of outpatients had perpetrated violence in the past 6 months to 3 years and up to 23% of inpatients had perpetrated violence during their hospitalization.
In a discussion of the MacArthur Violence Risk Assessment Study, Torrey and colleagues5 pointed out that among 951 psychiatric patients who were followed for an average of 41 weeks after discharge from hospital inpatient units, 262 (27.5%) committed at least 1 act of violence, and 3 (0.3%) of the discharged patients committed homicides.
Risk factors for violence are many, and most have been known for decades, said Paul Appelbaum, MD, professor of psychiatry and director of the Division of Psychiatry, Law, and Ethics at Columbia University. Variables that have the strongest relationship to violence, he said, include past violence; history of ar- rests; psychopathy or other indications of antisocial personality; substance use, especially alcohol abuse; younger age; male sex; unemployment; so- cial instability; and recent losses in relationships.
"All of these predictors are well known, but even taken together, they don't enable any psychiatrist in any particular case to say that this person whom I don't know very well is not likely to be violent with me, so I don't have to worry about my safety," he told Psychiatric Times.
The recent sad events in the Manhattan East side offices of Shinbach and Faughey "demonstrate how even the most upscale practices in the nicest, most exclusive neighborhoods are not immune from violence," Appelbaum said. Reid recommended that clinicians take reasonable precautions regardless of the demographics of their patients and pay attention to individual warning and risk factors, not just statistics. Safety advice When asked what psychiatrists could do to protect themselves, both Reid and Appelbaum suggested some guidelines.
"Remember that psychiatrists and other mental health professionals are not particularly good at predicting' who will assault in the immediate future, when it will occur, or what form it will take (though we are fairly good at assessing risk and the need for caution)," Reid said. "Do not think that your psychiatric or psychological training gives you a particular advantage in recognizing and dealing with danger from patients, unless your training had particular focus on that topic (and it is rarely taught in training programs)."
"Do not allow yourself to be placed in a very vulnerable position with patients, particularly those who are psychotic, have histories of violence, are intoxicated, are delirious or demented, or are unstable or with whom you are unfamiliar," he added. "Many assaults happen when an unsuspecting clinician tries to examine an unfamiliar, intoxicated, and/or psychotic patient in a closed room, in a room far from other people (such as well away from a nursing station or waiting area), in an emergency room, and/or in an empty or sparsely staffed after-hours clinic."
Reid also warned against seeing patients at home and against divulg-ing personal information to patients, which a few clinicians may do to develop the physician-patient alliance or to make the patient feel comfortable. A surprising number of stalking events and injuries, he added, are prompted by patients' delusional or other potentially violent thinking after a clinician has mentioned a pregnant wife or shared a "part of himself/herself to help the patient identify.'"
Going it alone can sometimes be a dangerous idea, according to Reid. "Do not accommodate a patient's request for absolute privacy unless you are reasonably sure it is safe to do so, and do not hesitate to demand a chaperone if there is any indication, even a subtle or subjective one, that the setting is unsafe," he said.
Many clinicians have been injured because they thought that they could deal with an uncomfortable or dangerous situation without help from security staff or without consulting about the patient with a more experienced colleague. Do not try to "talk down" an agitated patient without adequate physical safety precautions, Reid warned, adding that psychiatrists and psychologists make poor negotiators with agitated, threatening, or intoxicated people. He also cautioned men not to rely on their size and strength, "since even big, strong, young males can be severely injured or killed by psychotic or intoxicated patients, by patients who attack suddenly or from hiding, or by patients who wield weapons." Appelbaum called for a revision in the way psychiatrists and others think about patient violence. Just as those in general medicine take universal precautions to protect themselves from infectious agents, so too, psychiatrists must take universal precautions.
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