The data we have suggest that we are not very good at predicting which of our patients may represent a significant violence risk, he said. What's more, identified risk factors are so prevalent in this population that it becomes very difficult to make predictive judgments that distinguish among patients. Consequently, he said, psychiatrists and other mental health professionals would be "well advised to act as if any of our patients could conceivably be violent and to try to have in place procedures that are as protective as they can be in those circumstances."

Many psychiatrists, for example, are solo practitioners who are often alone in their offices without a secretary or nurse, and they often see patients in the evenings, on weekends, or on holidays when they may be alone in their buildings. "That, of course, was the unfortunate situation that Dr Wayne Fenton was in when he was murdered. [Fenton was found unconscious and bleeding in his Maryland office in 2006. He had been severely beaten and died at the scene.] This is not to blame the victims in these cases, but to point out that there is something flawed with the model that we have been using. Correcting that model means paying reasonable, but not excessive, attention to safety concerns. . . . If a patient gets out of control in your office and becomes threatening, what exactly are you going to do? Do you have a panic button you can push that will alert people perhaps in the next office down the hall? If that is impractical where you are practicing, perhaps you shouldn't be practicing there and should be in a setting where it is easier to provide security."

Additional guidelines offered by Appelbaum include ensuring that you have a means of egress from the office if a patient gets out of control and removing from your office heavy objects that could be thrown or used as weapons. Violence risk assessment Jeffrey Swanson, PhD, professor of psychiatry and behavioral sciences at Duke University, contended in February's Psychiatric Services that clinicians could improve their prediction of violence if they routinely used structured risk assessment instruments—but they don't, possibly because of time constraints and lack of reimbursement.6

A medical sociologist who has studied violence and mental disorders since the 1980s, Swanson stated that only a small minority of patients need formal risk assessment, because the base rate of violence among persons with mental illness is very low. The landmark NIMH Epidemiologic Catchment Area study found that 2% of persons without a mental disorder had perpetrated violence in the previous year, compared with 11% to 13% of persons with severe mental illness.7 The Clinical Antipsychotic Trials of Intervention Effectiveness study of 1410 patients with schizophrenia residing in the community found that 19.1% had committed violent acts within the previous 6 months, while 3.5% had engaged in serious violent behavior involving weapon use or injury to others.8 Screening all psychiatric patients would be excessive and stigmatizing, Swanson said, but situations exist in which psychiatrists and others may want to do a structured risk assessment, such as when patients have a history of violent behavior or are making threats to harm others and when there is a history of or current manifestation of psychopathology plus substance abuse.

More accurate and efficient violence prediction tools are needed, particularly for use in nonforensic patient populations, Swanson said. The most widely used of the actuarial risk assessment instruments is the Violence Risk Appraisal Guide, designed for use in forensic settings. However, some questions exist regarding this instrument's applicability to nonforensic populations, he noted. Another instrument is the Historical, Clinical, and Risk Management 20-item checklist. It includes historical variables (eg, age at first violent incident and previous violence), clinical items (eg, major mental illness, impulsivity, and lack of insight), and risk management variables (eg, lack of personal support and nonadherence with remediation efforts). The clinician uses this assessment of risk factors and his or her clinical judgment to classify the patient as presenting high, medium, or low risk for violence. "It is very important to not only gather the information but also document how the decision was made," he said, so as to protect patients and for liability reasons.

Getting help after an incident

In the days following the murder of Dr Faughey, the New York State Psychological Association made available its Disaster/Crisis Response Network for family, friends, and colleagues of the psychologist. "Psychiatrists, psychologists—we are all human," said Richard Wexler, PhD, the association's president. "We have techniques that can be helpful for others, but these techniques aren't helpful if we don't apply them for ourselves."

Reid had similar advice: "Clinicians, especially psychotherapists, who are severely assaulted generally have a number of often confusing reactions, including guilt about their behavior, guilt about their professional adequacy, guilt about what happens to the patient, anger (both visceral and countertransferential), professional difficulties (short- or long-term), challenges with injuries or disabilities, ambivalence about immediate postassault behavior, [and] ambivalence about later postassault behavior (including law enforcement or legal involvement). . . . Recognizing and dealing with them almost always goes much better with competent professional help."
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