William R. Dubin, MD

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.

 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 colleagues

 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. Tardiff

 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.

 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.

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.

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.

 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.

 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.

 However, prolonged or intense direct eye contact can be perceived as menacing by the patient.

 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.

 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 colleagues

 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.

 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.

When interviewing an acutely disturbed patient, it is frequently necessary to structure the interview by asking straightforward questions using easily understood words and short and clear sentences.

 If the patient begins to ramble, the interviewer should indicate that he understands what the patient is saying while helping him pick up the trend of his thinking. When patients have disordered perceptions, it is important not to attempt to correct the misperceptions but to clarify how the patient experiences them. Avoid the temptation to use logic to convince the patient that he is wrong: such an approach can make the patient more defensive.

A treatment alliance should be built by establishing emotional contact with the patient to help identify his feelings. A psychotic patient’s feelings are not unique, and the interviewer can usually identify with them and empathize. A patient’s need to protect his sense of integrity and self-control may initially make him reluctant to engage in the interview. If a patient is resistant to the idea of talking, it is useful to elicit his feelings about the situation and try to understand his discomfort and concern about what may happen to him. Sometimes, it may be better to drop a particular subject and come back to it later when the patient is more at ease. When psychotic patients do not respond to questioning, the interviewer should use whatever data are available to make contact with the patient. This may include the patient’s words, expressions, appearance, or behavior, as well as the physician’s feelings.

Of all patients, the most difficult to evaluate is the hostile, paranoid patient.

 If a patient is frightening, the physician should not ignore his own fear. The patient quickly senses the physician’s discomfort and may become frightened, which can lead to a violent episode. At times, however, the physician may have to acknowledge his fears to the patient, “The way you are looking at me is scary, like you are on the verge of striking out. I won’t be able to give you my full attention if I am afraid.” If the physician remains professionally confident and does not avert his eyes, the patient is reassured. The patient’s anxiety can be further ameliorated if the interview is conducted with the door open. If the patient engenders a level of anxiety in the clinician to the extent that it interferes with the evaluation, ask another clinician to interview the patient or interview the patient with a staff member present.

It is important to be extremely tactful with paranoid patients because they are easily humiliated and made to feel guilty about their actions and thoughts. Never become involved in how the patient’s beliefs are distorted: if you try to determine what is real and what is not, the patient may perceive you as a prosecutor and become more argumentative and defensive. Frequently, paranoid patients who are angry begin with a tirade of accusations about being mistreated. You may have to interrupt these outbursts and ask, “How can I help you?”

With the hostile, paranoid patient, keep a professional distance by avoiding jokes or parental-style reassurance and not becoming too friendly. Occasionally, highly paranoid patients can make the interviewer feel defensive and foolish by twisting the meaning of the interviewer’s words, making it impossible to sustain any direction in the interview. Under these circumstances, alter the course of the interview and explore the patient’s behavior with him. If meaningful contact cannot be made, terminate the interview and reassure the patient of your concern for his safety.

Prevention of violence and aggression in the outpatient setting

Psychiatrists who are in private practice are well advised to screen all prospective new patients via the telephone for at least 15 to 20 minutes, in part to assess risk for violence. The evaluation should then elicit information about intent to harm self or others, possession of or access to a weapon, recent violence, formulation of a definitive plan of violence, alcohol and illicit drug use, adherence to aftercare and medication management, and any associated psychiatric or medical conditions.

 Other components of a risk assessment include present illness, past psychiatric history, military history, legal history, and a mental status examination.

Patients with a history of violence or paranoia or who have borderline personality disorders with little impulse control should not be interviewed initially in a private office.

 If possible, these patients should be interviewed in a more secure setting, such as an outpatient department, a crisis service, or an emergency department. If this is not possible, it may be necessary to request the presence of a family member(s) at the first interview. Appointments for new patients can be scheduled for the middle of the day when numerous staff members are present (as opposed to early morning or late evening). Sessions may be scheduled so that other staff are nearby and immediately available during the appointment.

The evaluation and treatment of a potentially violent patient can be anxiety-provoking and stressful. Management strategies often focus primarily on pharmacotherapy. Medication, however, should always be considered an adjunct to treatment and not the primary intervention-even when medication must be used. The foundation for any aggression management strategy is to be aware of the risk factors for violence and to recognize that the clinician’s relationship with the patient remains key to the clinical outcome. How the clinician manages the patient’s affect and addresses the patient’s psychological needs will determine the patient’s ultimate response. Psychotherapeutic interventions are demanding and require more time. However, implementing strategies that minimize humiliation and helplessness will al-most always lead to a safer and more successful outcome.

 Bureau of Justice Statistics Special Report, NCJ 190076. Washington, DC: US Dept of Justice; 2001.


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William R. Dubin, MD

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Safety in the Evaluation of Potentially Violent Patients