Violent patients are more than just occupational hazards

It became crystal clear that I was going to work in a risky environment when the state medical director of prisons gave me a few instructions before I started to work at a men's medium-security prison. I was told that knocking the phone off the hook would send the guards running. And, it did, when I accidentally knocked the phone off the hook shortly after I started. This was much better than having to locate a button to press on the phone to alert security.

I was also told: do not wear a tie; do not shake hands; and keep your chair between the patient and the door.

I easily followed the first rule about the necktie, so as not to give an inmate an easy way to choke or pull me. I didn't like wearing a tie anyway. No problem either with the chair placement. And, I was assured that it was common to leave the door open if I felt like it.

But not shaking hands? I understood the rationale. Even though I had always felt strong and fit enough to take care of myself in a fight, these men often had extensive experience with fighting and with more practice, could grab my hand and put me in a hammer-lock hold. So I decided on a compromise.

When I felt emotionally connected to my patient, especially if we seemed to make some progress, I offered my hand. When I felt no empathic connection, my sense of risk rose up as goosebumps, and I did not shake hands. All ended well. Perhaps such a humanistic approach avoided some violence, though that may just be wishful and naive thinking.

Strangely enough, I felt more at risk in my public clinic than in the prison. There were no guards in the clinic. No security cameras. If an act of aggression happened, it seemed up to the staff to control it. Moreover, some of the clinic patients ended up in prison.

I suppose, like me, that many of you don't follow all the security precautions they you perhaps should. Consider what happened just recently at the Mercy Fitzgerald Hospital clinic south of Philadelphia: A psychiatrist’s patient suddenly pulled out a gun, killing his caseworker and grazing Dr. Lee Silverman twice. Perhaps to the surprise of so many of us in the field, Dr. Silverman had a gun in his desk and fired at the patient several times, thereby saving his own life and those of others nearby.

This must be an administrative nightmare turned into reality.

The hospital policy, according to a Mercy Health System spokesperson, bars anyone except on-duty law enforcement officials from carrying weapons. This patient had previously complained about the rule. Apparently, Dr. Silverman didn't follow the rule or was allowed an exception.

Challenging the rules

Although psychiatric patients rarely try to kill their caregivers, it does happen. Each time, there is a scramble of discussion, new literature, and new policies. However, we don't know the outcome of these policies and procedures. We don't know why professionals don't follow all the rules. Like me, did Dr. Silverman think that something was wrong with the rules at his hospital? Who was consulted in drafting the rules? Dr. Silverman? The patients?

It may be reassuring that violence in our settings is rare. Perhaps we are similar to the airline industry, which strives toward the ideal of zero crashes, for example. Yet, there have been three airline crashes in recent weeks to shatter the sense of safety.

As rare as violence is in psychiatric patients in society, the risk can be higher in treatment settings. We should not be blasé. One higher-risk scenario is in treatment of those with schizophrenia who are psychotic, paranoid and refusing medication. Perhaps the risk is even higher in a solo private practice when other staff are not around to help.

If you look at the Israeli airline El Al, it has used hidden profiling of passengers as the prime tool to avoid risk. Do we need to do more of that before we accept patients into our clinics and practices? The patient in the recent gunfire exchange had three prior commitments and four gun arrests. Wouldn't that be enough of a warning for utmost precaution?

At the same time, do we also need to get input from patients on safety from their unique perspective, which would also reinforce their empowerment and potential for recovery. Certainly, staff ideas need careful consideration by administration.

Our hearts must go out to all involved in this hospital tragedy, including the ripple effects of the trauma on others nearby, physically or emotionally. We also need to anticipate the shame that may accompany the aftermath: the shame of being hurt by those we are trying to help. Reputations can be tarnished inappropriately.

We can't—and shouldn't—settle for this just being an occupational hazard. Sharing approaches can help us learn what we have missed. What are your approaches to prevent violence in your workplace?