Recently, I came across a news story about a woman in a public psychiatric hospital who had been attacked and seriously injured by another patient. While I’ve seen stories like this before, this story was particularly shocking, because it contained a YouTube clip of the attack taken from a surveillance video. The video showed the woman calmly sitting in an outdoor smoking area near a male patient who also sat smoking calmly for several minutes. The two didn’t appear to interact or speak, and there was no clear precipitant for the attack. The male patient suddenly stood up and punched her in the face repeatedly. The woman was hospitalized with serious facial injuries but fortunately lived.
The video immediately brought back a memory of another attack. I was sitting in my prison clinic when a prisoner was carried into the dispensary, a victim of a gang fight in the recreation yard. He was brought in on a stretcher carried by five black-uniformed correctional officers. He was moaning, and there was blood running between his fingers as he held his hands over his face. Later, I found out that six other inmates had been sent out to the emergency room with stab wounds. Again, this assault victim was lucky to survive.
Police officers and firefighters know that their work is inherently dangerous and that there is a risk of serious injury or death. Other vocations like construction workers, roofers, and electrical linesman are at risk for accidental injuries. Forensic psychiatry is a little different. Although forensic patients can be potentially dangerous, or have a proven history of violence, we work in facilities where security procedures and custody staff can almost always mitigate that risk. When people learn I work in a prison and ask if I feel afraid to work there, I can honestly answer in the negative.
Public psychiatric hospitals face a bigger challenge when it comes to staff safety issues. There must be a balance between the right of forensic patients to be free from restraint and the employees’ right to a safe work environment. Over the last 10 years, various professional organizations and the Joint Commission have worked to reduce the use of seclusion and restraint in psychiatric facilities. Some hospitals have recently experienced an increase in patient-on-staff assaults, and labor unions have alleged that this is caused by the decreased use of restraints. Patient-on-staff assaults have drawn the attention of the Occupational Safety and Health Administration, which has fined hospitals in Maine, New York, and Massachusetts for failing to protect staff.
As the YouTube clip demonstrated, patient violence can be sudden and unanticipated. Safety regulations are no substitute for good verbal de-escalation skills, rapid and reliable security staff, and personal awareness of safety policies. Inpatient treatment teams must know their patients well enough to recognize early signs of impending aggression and to help the patient identify and use strategies to manage anger appropriately. Involuntary medication, seclusion and physical restraints are only the endpoint of a safety management plan. If these elements are in place, forensic mental health professionals will be able to look at news reports like the one I found without thinking, “That could have been me.”
<[QM]>—Annette Hanson, M.D.
Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.