Practitioner safety: more training needed

Approximately three years after getting licensed, C. Avila Wright, Ph.D., worked in an inpatient setting where she was assaulted by a patient. With limited training in non-violent crisis intervention, she was unnerved by the incident but fortunate to have the backup of a crisis team.

For the most part, however, safety programs for practitioners remain scarce.

Wright is director, Research and Special Projects, Practice Research and Policy, at the American Psychological Association’s Practice Directorate

Thirty-year veteran in the field Philip Kleespies, Ph.D., who works at the Veteran’s Administration Hospital in Jamaica Plain, Mass., also personally experienced issues with patients threatening him in the emergency room and inpatient units.

“I was not seriously assaulted, but some patients spit in my face and I have been charged,” he said.

These events launched a career-long study of and advocacy for increased safety training for psychologists.

In many cases, assaults happen to early career psychologists. According to a 1990 survey, conducted by James D. Guy, Ph.D., 35 to 40 percent of clinicians across all mental health disciplines have been physically assaulted by a patient with 80 percent of assaults occurring in the first eight to 10 years of practice.

Even though the data is more than 25 years old, Kleespies agrees. “We don’t really know why. We wonder is it because they are newer to the field or have less experience? Are they more eager to please patients? They may set fewer limits. There are a number of possible hypotheses, but none have been closely studied,” he noted.

He added that, in general, not much research has been conducted in this area and no survey focused specifically on psychologists has been done.

In 2005, a study conducted at the University of Rochester Medical Center showed results consistent with Guy’s survey regarding setting.

Kleespies said, “The setting in which you practice makes a difference.” Clinicians who work with more severely disordered patients in an inpatient setting are at greater risk than those in private practice. “You don’t necessarily see schizophrenic or manic patients in private practice.”

In spite of the potential for significant consequences, courses on practitioner safety are rare in Kleespies’ experience. “Not many graduate programs provide a course on patient suicide and patient violence,” he said. “Psychologists get experience in the field on internships or practicum. It’s a real lack that people are not educated about patient violence and patient suicide. While psychiatrists may get more training, all mental health disciplines are not terrific at addressing this issue.”

Kleespies believes in introducing students to potential risk gradually. For example, he has trained postdoctoral fellows and interns and first provides a lecture series about safety followed by training in an emergency room or urgent care setting.

“I have them observe me first interviewing and managing a case or two. Then we switch. They do the interview and I sit in. They become more independent. They get a safe, graduated experience to work with cases where there’s risk.”

Kleespies also suggested attending workshops on evaluating and managing potentially violent patients as well as sitting in on grand rounds. “They present problematic cases. It’s a terrific learning experience. You become competent by gradually increasing the experience of doing and learning to recognize situations that may be approaching risk more quickly,” he said.

In most cases, hospitals that treat patients with mental health issues have protocols in place to protect clinicians. At the VA Hospital where Kleespies works, a crisis team is available when an emergency occurs.

“The clinician dials the operator and says he is having a psychological emergency. The operator calls a code green to the team and they respond,” he says. “That’s typical in an inpatient setting where you see more impaired patients. They also have more resources available [in an inpatient setting]. In private practice, you don’t have as many resources.”

While a member of the Division of Clinical Psychologists at the American Psychological Association, Kleespies created a pamphlet containing safety tips for the private practitioner.

“For instance, get items that could be used as a weapon, such as a paperweight or letter opener” off your desk, he said. “Arrange your seating so you have access to an exit and have ways to communicate with others, like a panic button or emergency signal. Also, let other people know if you are seeing a high-risk patient. Don’t get isolated and don’t schedule edgy patients later in the day.”

Psychologists also need to be alert to signs of tension in the patient, such as pacing or clenching fists, according to Kleespies, but he emphasized that those with mental illness are not responsible for a great deal of the violence nation-wide.

“Actually, estimates are that only about three to five percent of the violence in the U.S. is attributable to those with mental illness, and that’s including the mass shootings, some of which have been perpetrated by those with a mental illness. Patients with mental illness are far more likely to kill themselves than to kill others,” he said.

Many clinicians have escaped any type of violent situation. Michael A. Goldberg, Ph.D., director of professional affairs and past-president of the Massachusetts Psychological Association said, “Throughout my career, I have never known any psychologist to experience violence or injury.”

He agreed, though, that training in this area is inadequate. “Likewise, I am unaware of any systematic efforts by any state psychological associations to address this low frequency but high consequence reality. I think it is fair to say that public sector psychologists working in state hospitals experience violence more than private practice clinicians.”

According to Wright, even though a psychologist may not know of anyone who has been assaulted or has never personally been assaulted, it doesn’t mean such events don’t happen.

She noted that if the most recent data comes from years’ old surveys, it suggests a gap exists in the research. The profession needs a better understanding of workplace violence for psychologists and other mental health practitioners, and studies and surveys can help provide that information, she pointed out.

“If we don’t know the numbers, we can’t figure out how to address it,” Wright said.