Assault BY
on
ROY
M.
the
Therapist
WHITMAN.
M.D..
BEATRICE
B.
ARMAO.
The (lilt/tars
comiducted a questionnaire surt’ev among psv(’hotherapists in p.sv(’hiatr’, psv(’hology amid social stork to determnimie host’ mizami’ pati(’nts posed a threat to others or to th(’ therapist zizd host’ m;ian’ actualh’ (lss(Il4lted the therapist. The’fumid that 9.27e 01(111 patients seemi h’ /01 therapists in one ‘ear presented a threat to others, 1 .9 posed (1 physical threat to the therapist. (mild .639’ actuall’ assaulted tile therapist. The authors conclude that attacks on a therapist are ,
infrequent
hilt
(IliflOst
inevitable
and
suggest
the
wit/i
(lssaultil’e
M.S.W..
AND
ORAN
B.
DENT.
PH.D.
cussion had a cathartic value for them. Our interest was further augmented by the fact that incoming trainees were encountering threatening patients. The pooled clinical experience of therapists and trainees suggested that impulsive. violent patients were being seen more frequently in mental health facilities than cver before. It seemed to us that the Viet Nam experience. for example. had left many of our veteran patients with residual rage that was poorly controlled. The literature on assaultive patients that we sunveyed ( I 2) tended to emphasize countertransference on the part of therapists and to deemphasize realistic fear reactions. Lion and Pasternak ( I ) commented that therapists have some anxiety about treating a violent patient,’ but the main emphasis of their paper was that the physician distorts and exaggerates the patient’s dangerousness by means of projection. Macdonald (2) studied how seriously the therapist or other evaluator should take homicidal threats toward others; we are asking how seriously a therapist should take threats toward himself. Should he be afraid or not? What does the therapist feel when he is threatened with assault? How does he cope with the patient and his own feelings? ,
des’elopmnent
o,ftec/iniques
patielits
therapists
that
,for aiz
(aping
use in crisis
situ(ltions.
‘ ‘
‘
WE
FIRST
BECAME
INTERESTED
in
the
subject
of
as-
saultive patients when one ofus (B.B.A.) reported duning a supervisory consulting session that she had been threatened by a potentially violent patient. The literature offered little information concerning thenapists’ fears of assaultive patients; neither did our associates. It appeared that the subject was often ignored during training and that it did not arise very often in consultation. Our discussion of the situation raised several questions: How many other therapists are similarly threatened? How do they handle both the patient’s and their own feelings? Do level of training and experience make a difference in the clinical approach to these problems? We were surprised at the variations in our colleagues’ responses to questions about assault. A number of them said that they had never been frightened or assaulted by a patient, but more recalled incidents that had happened recently or some years past. The willingness of some therapists to relate in detail dramatic incidents in which they had been involved was impressive. Therapists then came to us with more experiences not recalled at first inquiry. Recall and subsequent dis-
Revised American Dr.
version of a paper read Psychiatric Association.
Whitman
Psychiatric
is Professor
Social
Work.
at the 128th annual Anaheim. Calif..
of Psychiatry.
and
Dr. Dent
Ms.
Armao
is Adjunct
meeting May
of the
5-9.
1975.
is Instructor
Associate
in
Profes-
We sent a questionnaire’ to 184 mental health workin the three professions ofpsychiatry. psychology. and social work in the Cincinnati. Ohio, area. The respondents could remain anonymous if they wished. The questionnaire requested information on the discipline of the therapist. number of years in practice. and number of patients seen during the calendar year 1972. Questions were then directed toward the number of patients seen during the year who the therapist felt posed physical threats to others. the number who the therapist felt posed threats to himself, and the number who actually assaulted him. We then requested a narrative description of the most frightening experience the therapist had had with an assaultive patient in 1972. If he had had none that year. we asked for an account of an experience from any time during his professional career. We asked for the strategies that the therapist used to deal with the situation described, the therapist’s reactions, and the final outcome of the event. ers
sor of Psychology. University the Veterans Administration Ohio. Address reprint requests
Cincinnati Ohio
426
College
of
of Cincinnati College of Medicine and Mental Hygiene Clinic. Cincinnati. to Dr. Whitman at the University of Medicine. 231 Bethesda Ave.. Cincinnati.
METHOD
45267.
Amn
J Psychiatry
133:4.
April
/976
‘Copies thors.
of the
questionnaire
are
available
on
request
from
the
au-
WHITMAN.
One month after the same questionnaire them to fill out the so.
our
initial mailing, we circulated again to the same group. urging form if they had not already done
ARMAO.
FIGURE 1 Percents of Patients Who Posed Threat Who Assaulted Therapist
to Others
AND
DINT
or to Therapist
or
11 10
RESU
9
1.TS C,,
Seventy-eight ofthe 184 therapists (429) responde#{231}i to the first mailing. The second mailing increased the total number of responses to 101 (55%). Of the 96 psychiatnists contacted. 53 (55%) responded: 27 of43 psychologists (63%) responded: and 21 of44 social workens (48%) responded.2 Thus 52% ofthe sample of 101 therapists were psychiatrists (the ratio of residents: staff was 17:36), 27Y were psychologists. and 2l were social workers. These percentages approximate the relative numbers of active psychotherapists in the Cincinnati area for the three disciplines. Twelve ofthe respondents were from the University ofCincinnati Counseling Center. 14 from the Northern Kentucky Comprehensive Care Center. and 75 from various settings (including 17 in private practice) affiliated with the University of Cincinnati Department of Psychiatry. Ofthe 101 respondents. SOworked primanily in outpatient settings and 21 in inpatient settings. The psychiatrists were more experienced as a group and saw more patients than either psychologists or social workers. The range ofexperience for psychiatrists was 1-40 years. with a median of5 years’ experience: psychologists reported 1-22 years’ experience. with a median of4: and social workers had l-2Oyears’ experience. also with a median of4. All three disciplines reported a full range for number of patients seen. Psychiatrists. however. reported a median of8l-l0() patients seen, while both psychologists and social workers reported a median of4l-60 patients. Our findings reflect a population in which the psychiatrists were older and saw more patients than psychologists or social workers. A surprising number of therapists reported that they had seen more than 100 patients during the year (24 psychiatrists. 3 psychologists. and 4 social workers). In estimating the total numbers of patients seen. the 1-20 category was counted as 10 patients. 2 1-40 as 30, and so forth. As shown in figure 1. ofthe 3,810 patients seen by the 53 psychiatrists during 1972, 416 ( 10.9%) were perceived as presenting some assaultive threat to other people in their environment. 91 (24%) posed some physical threat to the therapist. and 33 (.87c/) actually assaulted the therapist. The 27 psychologists reported that they had seen 1 .740 patients and that 85 (4,9%) presented some threat to others. 18 (1.0%) posed some threat to the therapist. and 2 (.1 1%) assaulted the therapist. Twenty-one of the social workers reported that
2One of the responses from a social worker was incomplete: this respondent reported data on I(S) patients and answered only the questions on how many ofthese patients posed some threat to others and whether he had ever been assaulted by a patient in the past.
z uJ
1 Psychiatrists
S
]
7
Psychologists Social workers I All respondents
0 L. C
z uJ C-) OC
6 5 4
0
3 2
I
r-i THREAT
THREAT
TO
OTHERS
TO
ASSAULT
THERAPIST
FIGURE 2 Percents of Therapists Who Reported ening Patients in 1972
ON
THERAPIST
Having Seen One or More Threat-
1
Psychiatrists Psychologists
1 Social
workers I All respondents
they had seen 1.170 patients and that I 14 (9Th) presented some threat to others. Twenty of the social workers reported that 17 of 1.000 patients (l.6c4) posed some threat to the therapist and that 7 of I .070 patients (.65%) actually assaulted the therapist. Of the total of 6.720 patients. 615 (9.2%) presented some assaultive threat to others. I 26 ( I .9% ) posed a physical threat to the therapist. and 42 (.63Y) actually engaged in assaultive behavior toward the therapist. A major finding of this study thus emerged a a ratiopatients who presented threats to others: those presenting threats to the therapist: those who assaulted (15:3:1). As shown in figure 2. 79% of the total group of 101 therapists
(77%
of 53 psychiatrists. Ammi J Psychiatry
81% 133:4.
April
of 27 psychol1976
427
ASSAULT
ON
THERAPIST
ogists. and 8 1% of 2 1 social workers) reported at least one incident in which a patient was perceived as presenting some threat to others. Forty-three percent of 100 therapists (53% of 53 psychiatrists. 33% of 27 psychologists. and 35% of 20 social workers) reported at least one incident in which the therapist felt personally threatened. Twenty-four percent of 100 therapists (34% of 53 psychiatrists, 7% of 27 psychologists, and 20% of 20 social workers) reported that they were actually assaulted during the year by one on more patients.3 No psychologist reported more than one assault for the year. but 8 ( I 5%) of 52 psychiatrists and I (5%) of 20 social workers reported two or more. Although the percent of patients who actually attacked therapists is low (less than 1%). the likelihood that a therapist who sees a large number of patients will be assaulted is strong. A series ofchi-square tests were performed to investigate relationships within the data.4 No differences were found between staff and students for personal threats and for actual assaults. Staff psychologists and psychiatrists reported a significantly smaller percent of patients who presented threats to others than student psychologists and psychiatrists (p
on
ROY
M.
the
Therapist
WHITMAN.
M.D..
BEATRICE
B.
ARMAO.
The (lilt/tars
comiducted a questionnaire surt’ev among psv(’hotherapists in p.sv(’hiatr’, psv(’hology amid social stork to determnimie host’ mizami’ pati(’nts posed a threat to others or to th(’ therapist zizd host’ m;ian’ actualh’ (lss(Il4lted the therapist. The’fumid that 9.27e 01(111 patients seemi h’ /01 therapists in one ‘ear presented a threat to others, 1 .9 posed (1 physical threat to the therapist. (mild .639’ actuall’ assaulted tile therapist. The authors conclude that attacks on a therapist are ,
infrequent
hilt
(IliflOst
inevitable
and
suggest
the
wit/i
(lssaultil’e
M.S.W..
AND
ORAN
B.
DENT.
PH.D.
cussion had a cathartic value for them. Our interest was further augmented by the fact that incoming trainees were encountering threatening patients. The pooled clinical experience of therapists and trainees suggested that impulsive. violent patients were being seen more frequently in mental health facilities than cver before. It seemed to us that the Viet Nam experience. for example. had left many of our veteran patients with residual rage that was poorly controlled. The literature on assaultive patients that we sunveyed ( I 2) tended to emphasize countertransference on the part of therapists and to deemphasize realistic fear reactions. Lion and Pasternak ( I ) commented that therapists have some anxiety about treating a violent patient,’ but the main emphasis of their paper was that the physician distorts and exaggerates the patient’s dangerousness by means of projection. Macdonald (2) studied how seriously the therapist or other evaluator should take homicidal threats toward others; we are asking how seriously a therapist should take threats toward himself. Should he be afraid or not? What does the therapist feel when he is threatened with assault? How does he cope with the patient and his own feelings? ,
des’elopmnent
o,ftec/iniques
patielits
therapists
that
,for aiz
(aping
use in crisis
situ(ltions.
‘ ‘
‘
WE
FIRST
BECAME
INTERESTED
in
the
subject
of
as-
saultive patients when one ofus (B.B.A.) reported duning a supervisory consulting session that she had been threatened by a potentially violent patient. The literature offered little information concerning thenapists’ fears of assaultive patients; neither did our associates. It appeared that the subject was often ignored during training and that it did not arise very often in consultation. Our discussion of the situation raised several questions: How many other therapists are similarly threatened? How do they handle both the patient’s and their own feelings? Do level of training and experience make a difference in the clinical approach to these problems? We were surprised at the variations in our colleagues’ responses to questions about assault. A number of them said that they had never been frightened or assaulted by a patient, but more recalled incidents that had happened recently or some years past. The willingness of some therapists to relate in detail dramatic incidents in which they had been involved was impressive. Therapists then came to us with more experiences not recalled at first inquiry. Recall and subsequent dis-
Revised American Dr.
version of a paper read Psychiatric Association.
Whitman
Psychiatric
is Professor
Social
Work.
at the 128th annual Anaheim. Calif..
of Psychiatry.
and
Dr. Dent
Ms.
Armao
is Adjunct
meeting May
of the
5-9.
1975.
is Instructor
Associate
in
Profes-
We sent a questionnaire’ to 184 mental health workin the three professions ofpsychiatry. psychology. and social work in the Cincinnati. Ohio, area. The respondents could remain anonymous if they wished. The questionnaire requested information on the discipline of the therapist. number of years in practice. and number of patients seen during the calendar year 1972. Questions were then directed toward the number of patients seen during the year who the therapist felt posed physical threats to others. the number who the therapist felt posed threats to himself, and the number who actually assaulted him. We then requested a narrative description of the most frightening experience the therapist had had with an assaultive patient in 1972. If he had had none that year. we asked for an account of an experience from any time during his professional career. We asked for the strategies that the therapist used to deal with the situation described, the therapist’s reactions, and the final outcome of the event. ers
sor of Psychology. University the Veterans Administration Ohio. Address reprint requests
Cincinnati Ohio
426
College
of
of Cincinnati College of Medicine and Mental Hygiene Clinic. Cincinnati. to Dr. Whitman at the University of Medicine. 231 Bethesda Ave.. Cincinnati.
METHOD
45267.
Amn
J Psychiatry
133:4.
April
/976
‘Copies thors.
of the
questionnaire
are
available
on
request
from
the
au-
WHITMAN.
One month after the same questionnaire them to fill out the so.
our
initial mailing, we circulated again to the same group. urging form if they had not already done
ARMAO.
FIGURE 1 Percents of Patients Who Posed Threat Who Assaulted Therapist
to Others
AND
DINT
or to Therapist
or
11 10
RESU
9
1.TS C,,
Seventy-eight ofthe 184 therapists (429) responde#{231}i to the first mailing. The second mailing increased the total number of responses to 101 (55%). Of the 96 psychiatnists contacted. 53 (55%) responded: 27 of43 psychologists (63%) responded: and 21 of44 social workens (48%) responded.2 Thus 52% ofthe sample of 101 therapists were psychiatrists (the ratio of residents: staff was 17:36), 27Y were psychologists. and 2l were social workers. These percentages approximate the relative numbers of active psychotherapists in the Cincinnati area for the three disciplines. Twelve ofthe respondents were from the University ofCincinnati Counseling Center. 14 from the Northern Kentucky Comprehensive Care Center. and 75 from various settings (including 17 in private practice) affiliated with the University of Cincinnati Department of Psychiatry. Ofthe 101 respondents. SOworked primanily in outpatient settings and 21 in inpatient settings. The psychiatrists were more experienced as a group and saw more patients than either psychologists or social workers. The range ofexperience for psychiatrists was 1-40 years. with a median of5 years’ experience: psychologists reported 1-22 years’ experience. with a median of4: and social workers had l-2Oyears’ experience. also with a median of4. All three disciplines reported a full range for number of patients seen. Psychiatrists. however. reported a median of8l-l0() patients seen, while both psychologists and social workers reported a median of4l-60 patients. Our findings reflect a population in which the psychiatrists were older and saw more patients than psychologists or social workers. A surprising number of therapists reported that they had seen more than 100 patients during the year (24 psychiatrists. 3 psychologists. and 4 social workers). In estimating the total numbers of patients seen. the 1-20 category was counted as 10 patients. 2 1-40 as 30, and so forth. As shown in figure 1. ofthe 3,810 patients seen by the 53 psychiatrists during 1972, 416 ( 10.9%) were perceived as presenting some assaultive threat to other people in their environment. 91 (24%) posed some physical threat to the therapist. and 33 (.87c/) actually assaulted the therapist. The 27 psychologists reported that they had seen 1 .740 patients and that 85 (4,9%) presented some threat to others. 18 (1.0%) posed some threat to the therapist. and 2 (.1 1%) assaulted the therapist. Twenty-one of the social workers reported that
2One of the responses from a social worker was incomplete: this respondent reported data on I(S) patients and answered only the questions on how many ofthese patients posed some threat to others and whether he had ever been assaulted by a patient in the past.
z uJ
1 Psychiatrists
S
]
7
Psychologists Social workers I All respondents
0 L. C
z uJ C-) OC
6 5 4
0
3 2
I
r-i THREAT
THREAT
TO
OTHERS
TO
ASSAULT
THERAPIST
FIGURE 2 Percents of Therapists Who Reported ening Patients in 1972
ON
THERAPIST
Having Seen One or More Threat-
1
Psychiatrists Psychologists
1 Social
workers I All respondents
they had seen 1.170 patients and that I 14 (9Th) presented some threat to others. Twenty of the social workers reported that 17 of 1.000 patients (l.6c4) posed some threat to the therapist and that 7 of I .070 patients (.65%) actually assaulted the therapist. Of the total of 6.720 patients. 615 (9.2%) presented some assaultive threat to others. I 26 ( I .9% ) posed a physical threat to the therapist. and 42 (.63Y) actually engaged in assaultive behavior toward the therapist. A major finding of this study thus emerged a a ratiopatients who presented threats to others: those presenting threats to the therapist: those who assaulted (15:3:1). As shown in figure 2. 79% of the total group of 101 therapists
(77%
of 53 psychiatrists. Ammi J Psychiatry
81% 133:4.
April
of 27 psychol1976
427
ASSAULT
ON
THERAPIST
ogists. and 8 1% of 2 1 social workers) reported at least one incident in which a patient was perceived as presenting some threat to others. Forty-three percent of 100 therapists (53% of 53 psychiatrists. 33% of 27 psychologists. and 35% of 20 social workers) reported at least one incident in which the therapist felt personally threatened. Twenty-four percent of 100 therapists (34% of 53 psychiatrists, 7% of 27 psychologists, and 20% of 20 social workers) reported that they were actually assaulted during the year by one on more patients.3 No psychologist reported more than one assault for the year. but 8 ( I 5%) of 52 psychiatrists and I (5%) of 20 social workers reported two or more. Although the percent of patients who actually attacked therapists is low (less than 1%). the likelihood that a therapist who sees a large number of patients will be assaulted is strong. A series ofchi-square tests were performed to investigate relationships within the data.4 No differences were found between staff and students for personal threats and for actual assaults. Staff psychologists and psychiatrists reported a significantly smaller percent of patients who presented threats to others than student psychologists and psychiatrists (p
