Commentary When Residents Are Victims ofViolence Seymour L Halleck, M.D. Many studies of the relationship of mental illness to violence focus on subsequent arrest rates of individuals already hospitalized with a diagnosed mental illness. The results are equivocal, but generally no dear relationship betweenmental illness and violence isdiscovered. These are the studies so often quoted by those who argue that a mentally ill person is no more likely to be violent than anyone eise (1). Practitioners of psychiatry, however, fear that these studies are misleading. First, those labeled mentally ill are unlikely to be subject to arrest if they become violent. Rather, their violence will be viewed as a manifestation of illness, and they will be treated outside the criminal justice system. Thus, the true incidence of violence by the mentally ill cannot be assessed by looking at arrest rates. Second, some of the studies of violence among the mentally ill fai! to consider substance abuse disorders as mental disorders. Psychiatric practitioners who treat these patients are weIl aware of their tendency to be violent while they are intoxicated (2). Finally, unpublished surveys and anecdotal evidence suggest that violent acts perpetrated by the mentally ill are not uncommon. Surveys of family members of chronic patients by the National Alliance for the Mentally mindicate that 60% of those surveyed have been physically assaulted by a mentally ill family member. Physicians who work in the "trenches" (emergency rooms, public institutions, and walk-in clinics) are also increasingly concerned about their personal safety. Psychiatrie residents are at especially high risk of being assaulted. The most dangerous site for psychiatrie residents appears to be the emergency room or walk-in clinic. Last year in my own program there were eight completed assaults (physical contact was actually made) on residents in the two emergency rooms through whieh the residents rotate. There were many more linear misses," in which a show of force or intervention by security officials prevented a completed assault. On a number of occasions patients were found to have weapons. Data about the frequency of patient violence toward psychiatrie personnel are not available, but the \l \1)I\ill [',(11[\11\\

Dr. Halleck is professor of psychiatry at the University of North Carolina in Chapei Hili. His address is C.B. 7160, Medical School Wing 0, University of North Carolina, Chapei Hili, North Carolina 27599-7160. Copyright @ 1989 Academic PsychÜltry. 11,

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problem is probably even more urgent in large urban centers. In some mental health centers in our larger dties assaults are so frequent that all personnel, induding psychiatrists, are required to undergo training in physical means of self-protection. The potential violence of mentally ill patients raises two basic questions for those of us who deal with the training of residents. First, what can we do to prevent physical attacks upon residents? Second, what can we do to help residents who have been victims ofattack? There are certain physical measures that can be taken in most hospitals to increase protection for hospital personnel. The key site where protection is needed is the emergency room or walk-in dinic. One basic need in this type of setting is the ready availability of security people and a warning system that alerts them quickly when violence is imminent. The physical structure of the interviewing room is also important. Many emergency rooms are not designed to provide the resident with sufficient protection. For example, doors open inward rather than outward; the interview room may be too remote from other people; the buzzer system may not function well; and there may not be an easy way for the physician to exit the room quickly. Some of these conditions are surprisingly difficult to remedy because of space requirements, fire ordinances, and perhaps, an insuffident concern by some administrators for the safety of personnel. Once the attention of the administrator is gained, however, these conditions, often can be remedied without great expense. The decision to use metal detectors in emergency rooms raises serious questions of balancing the dignity of patients with the safety of personnel. Unfortunately, as episodes of violence increase, we may see more and more institutions resort to the use of metal detectors, regardless of its impact on patient morale. Another major preventive measure is directly relevant to training. It is obviously I

desirable that each resident who works in the emergency room be highly skilled in dealing with potentially violent patients. Unfortunately, psychiatrie training programs traditionally place their least experienced doctors in the most difficult treatment situations. Educators and administrators are not the only ones responsible for this practice. The residents themselves often want to get into the action as quickly as possible, and most of them find that the ''baptism of fire" of emergency room work enhances their self-image and sense of competency. My own belief is that although "macho" on-the-job training fulfills certain psychological needs of the trainee, it provides inferior training and exposes the trainee to too great a risk of danger. Recent medical graduates in nonpsychiatric spedalties begin their first year of training with a reasonable degree of experience in managing physical aspeets of illness. Beginning psychiatrie residents, however, have leamed very little about managing psychiatrie patients. Until they have been tutored, precepted, and had the chance to watch others handle difficult situations many times over or unless a more advanced resident or attending is physically present, they should never be allowed to manage the most difficult patients in the most difficult situations in psychiatry. Of particular concern is the residents' involvement in making decisions about involuntary commitment in the emergency room. These decisions require a very high level of clinical and sodal judgment, and theyare made in a setting that carries a high risk of violence. One useful way of diminishing violence toward residents would be to limit their responsibility for emergency room call until they had at least one, and preferably two, years of psychiatrie training. Other educationally related measures can contribute to the process of prevention. Residents can be taught to anticipate and avoid creating situations or actions that the patient may perceive as a confrontation. We need to teach residents how to recognize \\

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factors that suggest imminent violenee and to develop techniques for muting violent responses. These kinds of skills are teaehable, although they are not systematieally taught in many programs. The second issue, helping the resident who is assaulted, can be dealt with in a relatively straightforward way. Here it is important to realize that like any group of individuals, residents will respond differently to a traumatie event. Some will be bothered by it only briefly. Others may respond by developing a troubling post-traumatie stress syndrome. Sinee there are few dear predictors of how a resident will respond to victimization, eertain general preventive measures seem to be indicated. It is important that a mechanism be established for the training director or someone closely involved in the edueational process to be notified of eaeh assault. Unless the resident insists upon not talking about the event, he or she should be urged to discuss it with a supervisor. The usual prindpIes of dealing with an individual involved in a traumatie event would be applieable here. In my experience, residents who have been assaulted are particularly likely to blame themselves for not having the skills or

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diligenee to have predicted and avoided the assault. Sueh self-blame is unrealistic and painful to the resident. It needs to be addressed with a rational, cognitive approach. An opportunity for the resident to ventilate feelings of shame, anger, rage, or helplessness should also be provided. Where indicated, eontinued psychotherapy should be available. It is also useful for the training director or other designated person to follow up to try to understand how the victimization event has impacted on the resident' s work with patients and to correct any adverse effects. Violenee by mentally ill patients is a daily concern of psychiatric residents. It is tempting to deny the problem, both to reassure ourselves and to avoid stigmatizing our patients. Yet, such denial is likely to increase risks to residents' safety and probably does nothing to diminish stigmatization. The efficacy of psychiatrie treatment is ultimately dependent on the skillfulness of the psychiatrie physidan. The exerdse ofskills requires that the physidan feel a eertain degree of eomfort. By focusing on the problem of protecting residents, we can increase their sense of eomfort and maximize their capadty to help patients.

References 1. Monahan J, 5teadman H: Crime and mental dOOrders: an epidemiological approach, in Review of Research in Crime and Justice. Edited by Morris N, Tonery M. Chicago, University of Chicago Press,

1982 2. Halleck 5: The mentally disordered offender. DHHS pub no ADM 86-1471. Rockville, Md, NationalInstitute of Mental Health, 1986

When residents are victims of violence.

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