Lessons in Mitigating Violence

Violence Toward Staff in Health Care Settings: Workplace violence in the medical occupations represents 10.2% of all workplace-violence incidents. In addition, violence toward staff tends to be underreported. Rape, assault, and murder of health care staff are reportable sentinel events (see Reference 1 here). In January 2015, OSHA revised its Guidelines for Preventing Workplace Violence, noting that “Health care and social service workers face an increased risk of work-related assaults resulting primarily from violent behavior of their patients, clients, and/or residents”(see Reference 2 here). The risk of violence in clinical settings can best be managed by correct diagnosis and psychopharmacologic treatment of the underlying disorder. This article gives an overview of motivation for assaults by chronically aggressive inpatients and steps to de-escalate.

Practical Tips for Managing the Agitated Patient: Avoiding Violence in the Clinical Setting: Imagine this: 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. How could this have happened? What could he do to keep himself and his team safe? Events like this are experienced by scores of health professionals. What could you do to keep yourself and your team safe from another code white?

STAGES OF VIOLENCE: 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. Early recognition of agitation is crucial to preventing or avoiding escalating behavior problems. The Table outlines the stages of violence and the levels of intervention required. Noticing early warning signs such as pacing and frustrated affect can avoid danger and allows an opportunity to help patients feel safe and stay in control. View a mobile-friendly version of Table 1.

SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST: Although uncommon, violence is a frightening aspect of psychiatric practice. Because violent events are hard to predict, clinicians must institute universal precautions that emphasize prevention and avoid stigmatizing vulnerable populations. View a mobile-friendly version of the Monarch notes.

UNIVERSAL SAFETY PRECAUTIONS: Before and during an assessment, review the referral and any available clinical records to assess the level of risk. Whenever possible, observe the patient before the assessment and interview patients in a larger space when there are clinical concerns or multiple risk factors for violence. Recognize that many patients have had personal experiences of abuse or violent victimization. Maintaining a trauma-informed perspective and awareness of this disturbing reality can help patients feel dignified and respected in a time of personal crisis. Trauma-informed services acknowledge the prevalence and impact of trauma, and prioritize patient safety, choice, and control. (see Reference 6 here). The goal of universal precautions is to keep patients and providers safe. The Table highlights recommendations for process and structural prevention methods. View a mobile-friendly version of Table 2.

VERBAL DE-ESCALATION: When violence is imminent, clinicians can use verbal strategies to de-escalate patients in distress. Verbal de-escalation involves validating a patient’s experience, establishing a collaborative relationship, and finding solutions to ensure the patient’s needs are met. Clinicians should set firm boundaries and limits but offer choices and optimism. Modulating one’s tone of voice and using a reassuring, respectful, and nonjudgmental approach can help a patient maintain an internal locus of control. Common mistakes in verbal de-escalation include arguing or taking the emotional state personally. Instructing a patient to “calm down” or falsely threatening to call security or police is generally unhelpful and can increase the acuity of the situation. The Table highlights some practical statements that can be used in verbal de-escalation. View a mobile-friendly version of Table 3.

Strategies to Reduce and Prevent Restraint and Seclusion in Pediatric Populations: There are compelling reasons for judicious use of restraint and seclusion, as well as alternative approaches to mitigate the negative impact on children and adolescents of traumatization and re-traumatization. Trauma-informed care is conceptualized as mental health treatment grounded in a thorough understanding of biological, psychological, and social effects of trauma on children and adolescents and recognition that coercive interventions cause traumatization and re-traumatization and are to be avoided. Primary prevention principles such as Six Core Strategies have been helpful in both hospital and residential treatment facilities (see Reference 12 here).

SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST: Although described as safety interventions, restraint and seclusion are known to affect children and staff adversely: physical injuries, psychological trauma, and deaths have been reported. A knowledge base of the core strategies used to reduce and prevent restraints and seclusions among pediatric populations in psychiatric settings is extremely important in providing trauma-informed care. View a mobile-friendly version of the Monarch notes.

The Role of Psychiatrists in Countering Violent Extremism: Most research on violent extremism-defined here as the threat of real or perceived violence against civilians-has been conducted in relation to conflict zones and in the fields of political science and international relations to examine violence against social, political, and economic variables. There is no predictive tool that is likely to have validity for rare outcomes such as terrorist attacks and the evidence for mental health is also mixed. However, because terrorism poses sufficient danger to public safety, psychiatrists would benefit from an awareness of general issues with the data we have, especially because initiatives to counter violent extremism are increasingly calling on mental health professionals to participate. Indeed, the initiatives touch upon subjects of abiding interest in psychiatry such as the delineation of normal versus abnormal thoughts, emotions, and behaviors and violence risk assessments.

SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST: Individuals in terrorism networks and organizations are unlikely to answer transparently or participate. Such challenges highlight the difficulties in investigating the relationship between mental illness and terrorism even in the best studies, yet this is exactly what mental health professionals are asked to undertake. General psychiatrists should be aware that no specific mental disorder has been reliably implicated in radicalizing individuals toward violent extremism. View a mobile-friendly version of the Monarch notes.

Depressive Symptoms Associated With Aggression: Violence is not usually considered to be related to depression, yet findings suggest an association between violent behavior and depression or depressive symptoms in many different disorders. When we assess the risk of violence in people with depressive symptoms, we must consider the specific disorder in which these symptoms exist. Depressive symptoms may occur in MDD, bipolar disorder, or schizophrenia. They may also occur in dementia, PTSD, or personality disorder. The assessment and treatment of the underlying disorder is important. We must also consider that this association between aggression and depressive symptoms is further modified by various demographic and historical factors. Assessment of a depressed patient’s potential for violence takes into consideration many risk factors, including a history of violence, substance abuse, childhood trauma, and impulsivity. Once these factors are combined, the risk of violence is considerably more elevated.

SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST: When depressive symptoms are present, poor impulse control renders violence more likely. Therefore, when patients present with depressive symptoms, it is important not only to assess them for suicidal ideation and suicidal potential, but to evaluate the risk of violence directed at others. This association between violence and depression allows us to understand some important facts about the effect of emotional dysregulation on behavior. View a mobile-friendly version of the Monarch notes.