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Tips for avoiding potentially dangerous patients



– Clinicians who treat patients with emotional and psychiatric problems must put risk management interventions in place for their safety, Jeffrey N. Younggren, PhD, said at the annual convention of the American Psychological Association.

“Many times, people lose sight of the nature of their therapeutic relationship,” said Dr. Younggren, professor of psychology at the University of Missouri in Columbia. To stay safe, clinicians must overreact, he said, just as they do with suicide risk assessments.

Dr. Younggren critiqued an American Psychological Association article on safety and offered his own recommendations. Among them:

  • Think about evacuation strategies. “Don’t get between that individual and the door,” said Dr. Younggren, a clinical and forensic psychologist.
  • Refuse to see patients who are inebriated or intoxicated. If such a patient shows up for an appointment in one of these conditions and refuses to leave, call the police.
  • Remove yourself from physical danger. “I’m a very good ‘fall on the ground’ person,” said Dr. Younggren, who said he has been attacked by patients three times in his career. “That’s a risk management strategy.”
  • Terminate patients appropriately in the absence of threats. However, “if someone threatens you, write them a letter, and you’re done,” he said.

Dr. Younggren suggested that other recommendations in the article were unrealistic, such as, don’t work alone at night, install security cameras, and learn self-defense techniques. “What does [learn self-defense techniques] mean,” he asked. “My best one is to fall down.”

Mismanagement of the therapeutic alliance can careen out of control, as it did in the case of Ensworth vs. Mullvain.

In that case, decided in 1990, Heather Ensworth, PhD, a psychologist who practiced in California, treated a patient named Cynthia Mullvain for just short of 2 years and then terminated the treatment. But Ms. Mullvain did not accept the termination and persuaded Dr. Ensworth to see her again “to resolve the termination issues to help [Mullvain] disengage from [Ensworth].”

After several harassing incidents, Dr. Ensworth terminated contact with Ms. Mullvain a second time. At this point, Dr. Ensworth sought and was granted a restraining order against the patient. Despite the restraining order, Ms. Mullvain’s harassing behavior continued. Among other things, she stalked Dr. Ensworth, sent her threatening letters, and started doing community service work at a library located about 150 feet away from Dr. Ensworth’s home, according to Dr. Ensworth’s petition seeking a second restraining order. Ultimately, the court ruled that Ms. Mullvain had “willfully engaged in a course of conduct that seriously alarmed, annoyed, or harassed Ensworth, and that Ensworth actually suffered substantial emotional distress.”

Ernest J. Bordini, PhD said that, beyond private offices, nurses and aides are at greatest risk when it comes to workplace violence. According to a report by the Occupational Health and Safety Administration (OSHA), in 2013, psychiatric aides had the highest rate among health care workers of violent injuries that led to days away from work: 590 per 10,000 full-time employees, compared with 55 such injuries per 10,000 for nursing assistants. The report said the highest risk areas were emergency departments, geriatrics, and behavioral health.

Dr. Ernest Bordini, executive director of Clinical Psychology Associates of North Central Florida in Gainesville

Dr. Ernest Bordini

Psychiatric patients are more likely to be the victims of violence than perpetrators, but Dr. Bordini, a neuropsychologist with expertise in forensic assessment, said in an interview that he wanted to add a point.

“It is important to dismiss the notion that all psychiatric patients do not have elevated risks of assault,” he said. “Those who present with psychoses or bipolar disorder can have elevated risk, especially if they develop delusional thoughts or obsessions about the therapist or another individual. Paranoid individuals already feel threatened, and hence can strike out in anticipation.”

He said he and his colleagues are not advocating that all clinicians train in self defense or arm themselves. However, it is essential to be proactive. Falling down can work for some, Dr. Bordini said, but “experience teaches us that playing possum does not always cease an attack. I recommend de-escalation, escape, and/or self-defense plans that one has practiced, feels comfortable with, and feels confident that they can execute under stress.”

At the meeting, he said some patients are able to sense fear from the clinician. “If you’re skittish, [this will] put you at higher risk,” said Dr. Bordini, executive director of Clinical Psychology Associates of North Central Florida in Gainesville. “That sense of intuition is something you should tend to,” he said, citing The Gift of Fear (New York: Dell, 1999) by Gavin de Becker as an example of a book that explores recognizing and reacting to subtle signs of danger. “If you’re not comfortable seeing a patient, listen to that.”

Neither Dr. Younggren nor Dr. Bordini had financial disclosures.

To access OSHA’s guidelines for workplace violence in health care settings, visit The American Medical Association’s latest policy on workplace violence can be found at

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