Clinicians are faced with significant risk as targets of patient violence. According to the Department of Justice’s Crime Victimization Survey for 1993-1999, the annual rate of nonfatal violent crime (rape and sexual assault, robbery, aggravated and simple assault) for psychiatrists was 68.2 per 1000 persons. This rate compares with 21.9 for nurses, 16.2 for all other physicians, and 12.6 for all occupations.1 Therefore, it is important for psychiatrists to understand the principles of managing aggression.
The focus of this article is on nonpharmacological strategies for ensuring clinician safety. We will address risk assessment for aggression and violence, psychotherapeutic interventions, and prevention strategies. Physicians who do not embrace these assessment and management approaches are at increased risk for being the victims of violence. (See Rocca and colleagues2 and Pereira and colleagues3 for excellent reviews of medication management for potentially violent patients.)
Risk assessment of violence and aggression
Anticipation of potential aggression is the most effective strategy for enhancing clinician safety. Aggression rarely occurs suddenly and unexpectedly. Generally, there is a prodromal stage involving increasing tension and anxiety; escalating verbal abuse; and increasing motor activity, often characterized by pacing behavior. Tardiff4 has suggested certain clinical, psychological, and historical variables that increase a patient’s potential for violence. These variables include a history of repetitive violence, agitation, anger, disorganized behavior, and poor compliance during the interview. Other factors include a detailed or planned threat of violence and an available means for inflicting injury, such as ownership of a weapon. The presence of a neurological illness with psychosis, borderline or antisocial personality disorder, and alcohol or illicit drug use increases a patient’s potential for violence. In addition, a history of childhood physical or sexual abuse may predict violence.4 Other factors associated with violence include command auditory hallucinations, paranoid delusions, suspicion, poor impulse control, poor insight, poor adherence or nonadherence to treatment, and low IQ score.2
While there is no specific combination or number of risk factors that can predict violence, their presence alerts the clinician that the patient poses a risk of violence. The clinician who is aware of these risk factors has the opportunity to develop treatment strategies to minimize the potential for aggression.
Psychotherapeutic management of agitated, potentially violent patients
The core clinical strategy for managing aggression includes understanding the dynamics of violence and implementing interpersonal strategies that emphasize verbal intervention techniques.5 Aggression occurs when a patient feels helpless, trapped, or humiliated. Therefore, it is important for the clinician to reduce the patient’s anxiety and fear by maintaining a humane and respectful approach. A patient who is treated with honesty and respect is likely to believe that he or she will be helped.
Affect management is central to any effective aggression management technique.5 Patients who are aroused need to vent and talk about their mental health history; the clinician should not overly intrude into the interview while the patient is talking.6 Management involves recognizing the patient’s affect, validating it when appropriate, and encouraging the patient to talk about his feelings. Addressing the affect serves several purposes:
• It teaches the patient to reduce his tension by verbalizing his feelings; he learns that he does not have to hit someone or destroy furniture to feel better.
• It gives the patient the opportunity to vent, which can often defuse escalating agitation and avert a violent confrontation.
Emotionally distraught patients require the clinician’s active response. Direct eye contact and body language that signals attentiveness and connectedness will reduce the patient’s need to explode or assault someone to get his point across.6 However, prolonged or intense direct eye contact can be perceived as menacing by the patient.7
Eichelman6 has described interventions that are effective in aggression management. The use of active listening techniques, such as paraphrasing the patient, helps convey that the clinician understands what the patient is experiencing. It is important to be honest and precise when responding to patients. Dishonesty may set the clinician up for either retribution or a tenuous therapeutic relationship.
•Aggression rarely occurs suddenly and unexpectedly. Generally, there is a prodromal stage of increasing tension and anxiety, escalating verbal abuse, and increasing motor activity usually characterized by pacing behavior.
•Aggression occurs when a patient feels helpless, trapped, or humiliated. Therefore, a humane and respectful approach on the clinician’s part can help reduce the patient’s anxiety and fear.
•Emotionally distraught patients require the clinician’s active response. Direct eye contact and body language that signals attentiveness and connectedness to the patient will reduce the possibility that the patient will need to explode or assault someone to get his or her point across.
•Of all patients, the most difficult to evaluate is the hostile, paranoid patient. If a patient is frightening, the physician should not ignore his or her own fear. The patient quickly senses the physician’s discomfort and may become frightened, which can lead to a violent episode.
Eichelman further recommends that the clinician keep a proper physical distance from the patient in all situations. The rule of thumb is to keep 2 quick steps or at least an arm’s distance from patients who are on the offensive. A personal space can be visualized as an oval zone extending 4 to 6 feet all around.7 If the patient is standing, the clinician should stand. If the patient is sitting, the clinician should also sit down and avoid standing over the patient during the interview. If the patient is pacing, the clinician can model for the patient by walking with the patient but at a much slower pace. Berg and colleagues7 recommend that the clinician assume a posture that makes him or her appear small and thus less threatening. Some patients may not respond, or may only partially respond, to verbal interventions and will require psychotropic medication.
Ideally, the interview of an agitated or potentially violent patient should take place in a quiet, comfortable setting with both the patient and the clinician seated.5 Access to an exit door should be unimpeded for both the clinician and the patient. The physician should always introduce himself and address the patient as Mr or Ms to restore the patient’s sense of dignity. The interview should begin with nonspecific, less intrusive questions. Only after the patient begins to show some comfort with the interviewer should the physician start questioning him about the specific details of the present illness. Questions should be open-ended, and the physician should be flexible in his approach to the interview.
1. Duhart DT. Violence in the Workplace, 1993-1999. Bureau of Justice Statistics Special Report, NCJ 190076. Washington, DC: US Dept of Justice; 2001.
2. Rocca P, Villari V, Bogetto F. Managing the aggressive patient in the psychiatry emergency. Prog Neuropsychopharmacol Biol Psychiatry. 2006;30:586-598.
3. Pereira S, Fleischhacker W, Allen M. Management of behavioural emergencies. J Psychiatr Intensive Care. 2007;2:71-83.
4. Tardiff K. Clinical risk assessment of violence. In: Simon RI, Tardiff K, eds. Textbook of Violence Assessment and Management. Washington, DC: American Psychiatric Publishing, Inc; 2008:3-16.
5. Dubin WR, Ning A. Violence toward mental health professionals. In: Simon RI, Tardiff K, eds. Textbook of Violence Assessment and Management. Washington, DC: American Psychiatric Publishing, Inc; 2008:461-481.
6. Eichelman BS. Strategies for clinician safety. In: Eichelman BS, Hartwig AC, eds. Patient Violence and the Clinician. Washington, DC: American Psychiatric Press, Inc; 1995:139-154.
7. Berg AZ, Bell CC, Tupin J. Clinician safety: assessing and managing violent patients. New Dir Ment Health Serv. 2000;86:9-29. doi:10.1002/yd.23320008604.
8. Petit JR. Management of the acutely violent patient. Psychiatr Clin North Am. 2005;28:701-711.
9. Buckley PF, Noffsinger SG, Smith DA, et al. Treatment of the psychotic patient who is violent. Psychiatr Clin North Am. 2003;26:231-272.