It had been a long week, and there was only one new consult standing between now and the upcoming call-free weekend. Dr. Taylor didn’t usually see new consults on a Friday afternoon, but an urgent request from a colleague had piqued his interest, and having a resident around for the assessment made it all too easy. Handing over the faxed referral to the eager and capable learner, he got to work reviewing the day’s cases.
Twenty minutes later, Dr. Taylor heard a loud thump and a yell from down the hall. Springing to his feet, he dashed to the door to see the clinic administrative assistant rushing across the waiting room with a look of panic on her face. A scream echoed from the consult room, along with the rumble of furniture dragging across the tiled floor. Fear gripped his chest as he realized what was happening, and he shouted for someone to call a code white.
Thoughts raced through his mind: what should he do? How could this have happened? What could he do to keep himself and his team safe?
In medicine, safety is paramount. As a specialty, psychiatry seeks to help those experiencing extreme psychological distress and vulnerability. Although providers may be hopeful and well intentioned in their clinical encounters, violence against health care professionals is an unfortunate and disturbing reality. A survey of American psychiatry residents indicated that 25% had been physically assaulted by a patient at some point in their training. Rates of threats and physical intimidation reached 86% and 71%, respectively.1
Providers might anticipate violence in the emergency department or an inpatient setting, but violence can occur anywhere. Among outpatients with severe and persistent mental illness, 2% to 13% had perpetrated violence in the community in the past 6 months to 3 years.2 Although violent attacks in outpatient settings are less common, recently publicized violent episodes highlight the importance of office safety strategies to keep patients and providers safe.3
Understanding risk factors
An appreciation of how risk factors interact is key to understanding and predicting violent behavior in people with mental illness. Having a mood or psychotic disorder carries only a small increased risk of violence compared with the general population but when combined with a history of substance abuse, personal victimization, or exposure to violence in the surrounding environment, the likelihood of violence increases.4 Risk factors for violence include a history of violence or arrests, psychopathy or antisocial personality disorder, substance abuse, young age, male gender, unemployment, and relationship losses.5
Risk assessment tools vary from unstructured approaches based on intuition to validated actuarial tools weighed to an explicit algorithm. Clinicians who receive referrals in the outpatient setting may not have the information necessary to make an accurate prediction of risk using an actuarial tool. In addition, there are no tools that can routinely predict in-office violence, and a clinical gestalt may not suffice. Accordingly, universal precautions and preventive measures must be applied in all clinical settings.
When clinicians work without ready access to a security team or environmental safety features, it is important to employ a standard process and screening tools to appropriately triage and anticipate violence. Clinicians who work alone, or who see patients after hours and on weekends, are particularly vulnerable.
Kendra, the 2nd-year resident on her community psychiatry rotation with Dr. Taylor, was eager to wrap up the day’s work and drive back to the city for the weekend. Feeling comfortable with her newly developed assessment skills, she quickly reviewed the referral letter while calling the patient into the consult room. Twenty-three-year-old Mark had recently been discharged from the local hospital’s inpatient psychiatry unit, where he had been referred for follow-up and diagnostic clarification regarding a primary psychotic disorder or substance-induced psychosis. In the waiting area, Mark appeared nervous, rapidly tapping his feet and glancing around the empty room.
Dr. Lofchy is Director, Psychiatry Emergency Services, University Health Network, Department of Psychiatry; and Associate Professor, University of Toronto, Canada. Dr. Fage is a Third-Year Psychiatry Resident, University of Toronto.
The authors report no conflicts of interest concerning the subject matter of this article.
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