Is this patient dangerous?
5 steps to help clinicians prepare for violent behavior and improve safety.
In the outpatient practice, terminate the interview or evaluation session if a patient in a negative affective arousal state does not allow verbal redirection. Before you make any movement to exit, however, announce, “I am leaving the room now.”
Trust your intuition. I do not enter a closed, private space with a patient unless I feel safe. If I feel afraid, I take that as a valuable warning that further safety measures are necessary.
Use restraints as needed. When patients with a history of violence are brought to the hospital in high arousal states, I let them remain in restraint with security present during the initial interview. If the patient cannot have a back-and-forth conversation with me, I keep the security force present until I believe my verbal interactions have a substantial effect.
Patients must be responsive to talking interventions before restraint, security, or other environmental safety measures are removed. Some patients do not reach this point until after tranquilizing medications are given.
Step 5: The Clinical Encounter
When discussing how to assess the likelihood of patient violence during a clinical encounter, a psychiatric colleague once commented, “Risk factors make you worry more; nothing makes you worry less.”
In other words, keep your guard up. Let clinical judgment take precedence over statistics when you are evaluating any patient. Statistics represent frequencies or averages; they may or may not apply to any one individual.
Techniques for assessing and treating violent patients are beyond the scope of this article, but at the very least:
- obtain training in safety/treatment protocols for violent patients
- ensure that your hospital/clinic has procedures in place to improve safety and to handle violent situations.
For every violent act that requires staff intervention, automatically schedule a debriefing session for those involved to assess the incident and allow them to express their feelings.
Related resources
- American Association for Emergency Psychiatry. www.emergencypsychiatry.org.
- Volavka J. The neurobiology of violence: an update. J Neuropsychiatry Clin Neurosci 1999;11:307-14.
- McNiel DE, Eisner JP, Binder RL. The relationship between command hallucinations and violence. Psychiatr Serv 2000;51: 1288-92.
