Violence in Psychiatry: Stop Pretending It’s Just “Part of the Job”

COMMENTARY

Every psychiatrist has heard the debate: What is harder outpatient or inpatient work? Outpatient psychiatry demands relentless monitoring, subtle adjustments, and long-term responsibility. Inpatient psychiatry deals with individuals at their sickest where acuity and unpredictability define the work.

But let’s be clear: the hardest part of inpatient psychiatry is not the paperwork, the census, or the high-stakes decisions. It is the violence that has been quietly normalized in our field, violence we are told to accept as “part of the job.”

The Scope of the Problem

According to the US Bureau of Labor Statistics, workers in health care and social assistance are 5 times more likely to suffer a workplace violence injury than workers overall. In 2018, the incidence rate for nonfatal intentional injuries in psychiatric and substance use facilities was 124.9 per 10,000 full-time workers more than 60 times higherthan the all-worker rate of 2.1.¹

A 2024 integrative review of psychiatric hospitals concluded that violence toward staff is “persistent, underreported, and inadequately addressed at the system level.”² The message is clear: violence in psychiatry is not rare, it is epidemic.

The Lie We Tell Ourselves

Hospital administrators and policymakers are quick to remind clinicians: You signed up for this work. That statement is meant to justify what is, in truth, systemic negligence. “It’s just psychiatry,” they shrug, while another nurse leaves with a broken jaw, another tech with a concussion, another physician blindsided by a sucker punch.

We would not tell a pilot that a crash is “just turbulence.” We would not tell a firefighter that a collapsed building is “just part of the job.” Yet in psychiatry, when clinicians sustain physical and emotional trauma, they are expected to shrug it off and return to duty.

My Reality on The Ground

I have been attacked 3 times on the unit:

• A patient charged from a room and tried to kick me in the stomach. There was no opportunity for “talking them down.”
• Another sprinted from room to room, striking staff indiscriminately. I intercepted him, took punches to the head, and held him until medication could be administered.
• A third blindsided me, leaving no chance to prepare.

What happened after these assaults? Almost nothing. Patients typically face no legal consequences. Staff are expected to continue providing care for the same individual who assaulted them. There is initial sympathy, maybe even a short debrief, but systemic changes? Rare.

As for me, I relied on my self-defense training and my colleagues’ support. But emotionally, the scars linger. You do not simply “move on” from being assaulted at work. You learn to compartmentalize, to keep showing up. And over time, you grow dangerously desensitized.

The Systemic Failures

The failures are layered:

• Legal: Unlike airline employees, who are federally protected against assault, health care workers have no equivalent law. Some states have increased penalties, but enforcement is patchy and inconsistent.
• Policy: OSHA guidelines exist but lack teeth. Oversight is weak, and reporting systems are cumbersome and often discouraged by management.
• Culture: In medicine’s “patient-as-consumer” era, hospitals hesitate to hold aggressive patients accountable, prioritizing satisfaction scores over staff safety.

A persistent problem is underreporting. Staff often believe reporting is pointless, fear retaliation, or see violence as “just the way it is.” This culture of silence perpetuates risk.

What Can Be Done

There are glimpses of innovation. Some psychiatric units are piloting violence reduction programs integrating environmental design (safer layouts, clear sight lines), real-time de-escalation teams, and wearable panic buttons.³ Others have adopted patient-centered de-escalation protocols that incorporate both staff and patient perspectives.⁴ These programs show measurable reductions in assaults.⁵ But scaling these interventions requires leadership willing to invest in staff safety not just in metrics that make annual reports look good.

Practical Tips for Clinicians

While systemic reform is essential, frontline staff can take concrete steps:

• Complete violence-prevention training: Know de-escalation strategies, emergency codes, and restraint protocols.
• Stay situationally aware: Raised voices, pacing, clenched fists; do not ignore early warning signs.
• Position strategically: Always keep a clear exit path and avoid being cornered.
• Use tools and tech: Wear panic buttons if available; advocate for them if not.
• Prioritize recovery: Report every incident. Seek medical care, counseling, and time off when needed. Trauma unaddressed only compounds over time.

I also teach my students one rule: never get too comfortable on the unit. Complacency breeds vulnerability.

The Bottom Line

Psychiatry is about empathy, but empathy does not mean becoming a punching bag. We can honor the dignity of our patients while also demanding dignity for ourselves.

Violence in psychiatry is not “part of the job.” It is the result of systemic neglect, cultural complacency, and leadership failure. Until we acknowledge and confront this truth, we will keep losing staff not just to burnout, but to fear. And when clinicians lose, patients lose too.

Dr Rossi is an inpatient and consultation liaison psychiatrist who also performs electroconvulsive therapy services at AtlantiCare Regional Medical Center in Pomona, New Jersey. He currently serves on the board of the New Jersey Psychiatric Association, where he has worked on advocacy projects, including enhancing access to collaborative care in the state.

References

1. Workplace violence in healthcare, 2018. US Bureau of Labor Statistics. Accessed January 16, 2026. https://www.bls.gov/iif/factsheets/workplace-violence-healthcare-2018.htm 

2. Amara SS, R Hansen B. Reducing violence by patients against healthcare workers at inpatient psychiatric hospitals: an integrative review. Issues Ment Health Nurs. 2024;45(11):1185-1193.

3. Kernaghan K, Hurst K. Reducing violence and aggression: a quality improvement project for safety on an acute mental health ward. BMJ Open Qual. 2023;12(4):e002448.

4. Svensson J. Patient safety strategies in psychiatry and how they construct the notion of preventable harm: a scoping review. J Patient Saf. 2022;18(3):245-252.

5. Price O, Armitage CJ, Bee P, et al. De-escalating aggression in acute inpatient mental health settings: a behaviour change theory-informed, secondary qualitative analysis of staff and patient perspectives. BMC Psychiatry. 2024;24(1):548.