Protect yourself against patient assault
When to stop being therapeutic and get out of harm’s way.
- people had a sense that something was dangerous, but they ignored or dampened it
- people were passive when tension was mounting and didn’t abort an assault situation.
Anger is easy to recognize. Raised voice, inappropriate staring, clenched fists, agitation, and verbal threats are common before a violent episode. This seems self-evident, yet it’s surprising—even when these signs are obvious—that clinicians often took no de-escalation measures to ward off violence. A verbal threat is a red flag to prepare for violence.
Dr. Krahn: So, your senses are tingling. What do you do?
Dr. Battaglia: If the patient is threatening you and is in a negative affective arousal state that does not allow verbal redirection, you need to get away. Before you make your move, however, announce your behavior so that the patient will not interpret it as an attack (“Bob, I am standing up now because I need to leave the room”).
Schizophrenia symptoms associated with violent behavior
Schizophrenia patients with combined low negative and high positive PANSS scores were at highest risk to cause bodily injury or harm someone with a weapon in the past 6 months.
Dr. Krahn: Can that be a difficult call?
Dr. Battaglia: I think you learn when to shift gears. You undergo a number of incidents where you question yourself, and you go to an experienced colleague and say, “I was in a session with this patient. Here’s what I did. Do you think I was exposing myself unnecessarily?” Go over the incident in detail with someone who is supportive and understanding but also has a critical eye.
Dr. Krahn: Any suggestions as to how the room or other staff can be positioned to keep the risk as low as possible? Do you recommend alarms inside offices?
Dr. Battaglia: I think it’s smart to have an alarm system. And you need to think about the physical layout of the room ahead of time. You and the patient may need to have equal access to the door. If the patient is high-risk, you might want to arrange seating at a 90-degree angle rather than face-to-face to limit sustained confrontational eye contact. You might want to place your chair greater than an arm swing or leg kick away. You need to decide whether it’s safe to be alone, and whether to have the door open or to have security posted.
Dr. Krahn: What kind of training should staff be given?
Dr. Battaglia: Every office should have policies and protocols for handling behavioral emergencies. Who calls 911? What are each person’s responsibilities? Also, staff should be confident but not confrontational. That, in itself, may dissuade a patient from acting out.
Everyone should be taught de-escalation techniques. Body language can send threatening signals or they can signal a person that you’re not a threat and you’re going to work with them.
Dr. Krahn: Can you give an example where training might have helped?
Dr. Battaglia: I recently reviewed an incident where a nurse and a psychologist had a delusional, paranoid patient in their office and he wanted to leave. He was relapsed and clearly agitated; he was psychotic; he needed to be hospitalized. He wanted to escape, and they barred the door because they wanted to get him in the hospital.
The patient punched the nurse. If you bar someone’s escape, you’re very likely to get hurt. Let the patient go and call the police, who are trained to bring people in.
Dr. Krahn: What about building security? I know of a situation where a patient was found waiting for a psychiatrist in the parking garage. If there are threats, should an escort system be in place?
Dr. Battaglia: Security needs to work with the staff to come up with a plan.
Dr. Krahn: If someone in your office is assaulted, how do you handle the aftermath?
Dr. Battaglia: The person who is assaulted needs to get help. Crisis debriefing has been debated in trauma treatment, but there’s no debate about the benefit of “psychological first aid.” It provides an opportunity for the person to talk in confidence with another professional about what’s happened and how it may be affecting him or her.
Dr. Krahn: Can you continue to treat someone who has assaulted you?
Dr. Battaglia: That decision has to be made on a case-by-case basis. The main question is whether you feel safe enough to be therapeutic with the person in the future. Outside of a controlled setting, I don’t think you can effectively treat a patient you fear.
