Violence: balancing treatment efficacy with provider safety

Last October, shock waves rippled through the mental health community when a patient at the bipolar clinic at Massachusetts General Hospital (MGH) stabbed his psychiatrist. While such events – although rare – grab media attention, they serve as reminders to providers of the importance of awareness and preparation.

According to Steve Nisenbaum, Ph.D., J.D., past president of Division 18 (Psychologists in Public Service), Division 18’s public policy liaison to the American Psychological Association, and 30-year staff member at MGH, these violent episodes create a conflict between the efficacy of treatment and the safety of the provider. “This is a key concern,” he says, “especially when practicing in areas or agencies where there is an increased likelihood of violence or when operating solo.”

Andrea Celenza, Ph.D., psychoanalyst with a private practice in Lexington, Mass. and assistant clinical professor at Harvard Medical School, generally treats highly functioning clients and hadn’t seriously considered the possibility of a physical confrontation until one client expressed his fantasy of killing her during the course of therapy. Celenza reports that the client’s intake and past history indicated no predisposition toward violence. However, as treatment awakened unconscious fantasies related to unresolved childhood relationships, the client overcame his timidity and latent feelings of humiliation surfaced; he then began to direct his frustrations toward her. “The day he told me about the fantasy, I became frightened,” says Celenza. Thankfully, physical violence never occurred.

Nisenbaum notes that most psychologists have had a certain amount of training that makes them attentive to the climate in which they attempt to build a trusting alliance with a client. “They are generally prepared to deal with treatment-resistant patients,” he says. Certain actuarial tools, specifically the Classification of Violence Risk (COVR) and the Violence Risk Appraisal Guide (VRAG), also enable providers to assess the possibility of danger. Unfortunately, the VRAG, the most widely used instrument, was developed out of the Canadian prison system, according to Nisenbaum. “Generalizability to psychiatric patients that don’t have co-occurring criminal justice issues is not clear,” he says. “Sometimes these tools are adapted without being clear how norms develop and how to transfer [them], especially to the outpatient setting, even to psychiatric inpatients.”

While solo practitioners may face occasional threats to personal safety, those who work on inpatient units run this risk daily. However, while inpatients may have a higher propensity toward violence – at times directed toward staff – Nisenbaum points out that most agencies have developed protocols and details systems to protect employees, including psychologists.

DMH and the state hospitals provide “fairly systematic training,” which all staff is required to undergo, notes Nisenbaum. The Danvers and Tewksbury State Hospitals use Non-Violence Self-Defense (NVSD) training, which orients a psychologist toward identifying a potential threat and intervening prophylactically, says Nisenbaum. However, he notes that predictability rates vary. “These are mostly very short-term predictions and for a very specific setting, based on information that is hard to calculate and evaluate in terms of applicability outside that setting,” he says. “To produce relativity and validity, you have to resort to an actuarial system, but you lose a lot in the process. The individual characteristics of patients are hard to incorporate and [the outcome] gives [the provider] less confidence.”

At Tewksbury Hospital, the DMH also collaborate with security experts to teach engagement and disengagement skills. “They are trying to change the level of cyclical violence on inpatient units,” says Nisenbaum. “The training pulls together all elements of nonviolent engagement of the patient: how to physically present, cultivate rapport and respond behaviorally.”

Nisenbaum points out that MGH developed MOAB (Management of Aggressive Behavior) training in conjunction with the campus police long before the October attack took place to increase clinical staff awareness. This program uses verbal, nonverbal and physical techniques to address several types of situations. Bonnie S. Michelman, head of security at MGH, says, “We have been using MOAB here for 17 or 18 years, nothing to do with the incident. It is a fabulous program on managing aggression and conflict.”

Studies indicate that the number of violent episodes against mental health workers is increasing. Researchers at the University of Rochester Medical Center – Psychiatry conducted a survey in which 43 percent of respondents reported being threatened and 25 percent had been assaulted.

In the United Kingdom and New Zealand, study findings reflect similar results. In the UK study, 51 percent of respondents reported an assault and 24 percent had been attacked by a patient in the previous year. The New Zealand study revealed 46 percent of respondents experienced verbal threats and 39 percent, physical intimidation. Sixteen percent suffered minor assaults requiring no medical intervention, 14 percent were harassed, 10 percent were sexually harassed and five percent were stalked.

All of the studies recommend personal safety training across disciplines to enhance team building, improve communication and prevent future events and post-event protocols to assess incidents.