Protect yourself against patient assault

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When to stop being therapeutic and get out of harm’s way.



Wayne Fenton, MD, an associate director of the National Institute of Mental Health (NIMH), was murdered September 3—allegedly by a patient—in his Bethesda, MD, office. The case has led other mental health professionals to wonder how susceptible they are to assault and whether they are doing all they can to protect themselves.

To explore these safety issues, Current Psychiatry Deputy Editor Lois E. Krahn, MD, talked with John Battaglia, MD, medical director of the Program of Assertive Community Treatment (PACT) in Madison, WI.

Dr. Battaglia’s work takes him into the community to treat patients with severe chronic mental illnesses. The Madison PACT program uses an intensive, team-based approach for patients who have been inadequately treated in usual mental health services. Patients with complicated psychiatric, social, and legal problems are seen in their homes, at work, or on the streets in an assertive and comprehensive style of case management.

Dr. Krahn: Dr. Fenton’s death was a tremendous loss to the psychiatric community.

Dr. Battaglia: We were all shaken; my first reaction was horror and sadness.

Dr. Krahn: Dr. Fenton was a very experienced psychiatrist (Box 1). His murder makes us think about our own vulnerability and wonder if such an assault could happen to us.

Dr. Battaglia: Yes, it’s very common for psychiatrists or mental health providers to be assaulted (Box 2).

Box 1

Wayne S. Fenton, MD: Advocate for the mentally ill

Dr. Fenton devoted his life to schizophrenia, through his compassion for those afflicted and his research that aided untold numbers of the mentally ill and their caregivers.

So it was especially sad that Dr. Fenton died while reaching out to a patient in need. On September 3, the NIMH associate director answered an urgent call to help a distressed, psychotic young man. A short time later, Dr. Fenton was found beaten to death at his Bethesda, MD, office.

Dr. Fenton was just 53 when he died, but his accomplishments were great. He joined NIMH in 1999, helping the organization find new treatments to enable schizophrenia patients to function in society. In this role, he galvanized colleagues nationwide to tackle the complex issue of difficult-to-treat schizophrenia. Before joining NIMH, Dr. Fenton was director and CEO of the Chestnut Lodge Hospital in Rockville, MD, where he did pivotal long-term studies of therapies for schizophrenia. From 2000 to 2005, he was deputy editor-in-chief of the journal Schizophrenia Bulletin. He served on numerous boards and in advocacy roles and won numerous awards.

In addition to these responsibilities, Dr. Fenton made time for his patients. And he gave his life, as he had lived it, trying to help. His obituary in the Washington Post included this quotation from Dr. Fenton, whom the newspaper interviewed in 2002:

All one has to do is walk through a downtown area to appreciate that the availability of adequate treatment for patients with schizophrenia and other mental illnesses is a serious problem for the country. We wouldn’t let our 80-year-old mother with Alzheimer’s live on a grate. Why is it all right for a 30-year-old daughter with schizophrenia?

In one study, more than 50% of psychiatrists and 75% of mental health nurses reported experiencing an act or threat of violence within the past year.1

Dr. Krahn: Have you been assaulted by a patient?

Dr. Battaglia: Yes I have, and I think we need to define assault. A 15-year analysis of assaults on staff in a Massachusetts mental health system divided the acts into four types: physical, sexual, nonverbal threats/intimidation, and verbal assault.2 And you might think physical assault would be worse than verbal assaults. But a threat from a patient—especially one aimed toward your family—can leave you feeling vulnerable, stressed, and hypervigilant. Every sound at night makes you wonder if that person is coming after your family.

Dr. Krahn: What kinds of patients are associated with violence and assault?

Dr. Battaglia: The DSM-IV-TR diagnosis that comes up most often is schizophrenia, but it’s debatable whether diagnosis alone increases the risk of violence.

A study in Sweden published this year found a definite correlation between severe mental illness and violent crime. The authors concluded that about 5% of violent crimes in that country were committed by persons with severe mental illness.3

Also this year, a study of data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) found an increased risk of violence in schizophrenia patients with positive psychotic symptoms but a decreased risk in those with predominantly negative symptoms such as social withdrawal. Those with a combination of above-median positive and below-median negative symptoms were at highest risk for serious violence (Box 3).


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