Introduction

On October 5, 2014, The Atlantic featured an article entitled I Stalked my Psychiatrist. It was the first person account of a former patient who stalked her psychiatrist. The stalking consisted of surveillance and reviewing publicly accessible records of her psychiatrist. Her intentions appeared to be a longing for a connection lacking in other areas of her life (Maloney, 2014). Sometimes stalking has a much more intrusive, and dangerous motive. MH/SA (Mental Health/Substance Abuse) staff work with individuals whose grip on reality may be tenuous or distorted, or who cannot regulate their emotions and behaviors, as a result of mental illness or substance abuse.  Staff must sometimes transport patients in their own vehicles as part of their job, or make home visits, or may be left alone with multiple patients due to understaffing. All of these dynamics increase risk to staff, as well as other patients or bystanders (McPhaul, Lipscomb, & London, 2006).

Risks to Mental Health Staff

If you are a MH/SA staff, providing counseling, psychotherapy, case management, or medication to this population, there is a certain degree of risk involved. The risk is greater if you work with an offender population, and individuals with a history of violence. If proper precautions are taken, support and protection are provided from co-workers and the agency, proper training is received, and good judgment based on training and education are exercised, safety to staff, as well as patients and bystanders, is enhanced. It is akin to a career handling hazardous materials- with proper care, there should be no problems. Sloppiness, complacency, carelessness, poor safety procedures, and disrespectful handling will result in problems.

I have been an outpatient clinician for 14 years- in community mental health clinics, a substance abuse treatment clinic, and now private practice. Before that, I worked at a program for drunk drivers working toward regaining their driving privileges for four years, and prior to that, a supervised community residence for the severely and chronically mentally ill for five years. The population I have chosen to work with are addicted to drugs and/or alcohol, have committed acts of domestic violence, assault, or sexually based offenses, including those who have perpetrated on children. Nearly all of the people I see are mandated to receive an evaluation or treatment by the state Department of Corrections.  I also see victims of molestation and other violent crimes for PTSD ( Post-traumatic Stress Disorder).

Here are some of the high risk situations I have been privy to:

• One of my colleagues had her life and the lives of her children threatened, and has been yelled and sworn at by enraged patients. I was threatened with being pepper sprayed and stabbed by a patient. Both of these patients were allowed back in the clinic.

• I have been stalked by someone who could not grasp I did not want a relationship with her.

• Two other colleagues were punched in the face by the same patient on different occasions.

• A patient drove their car through the front door of a clinic, fortunately, after hours when no one was there.

• A patient smashed the windows of the reception area of a clinic out with a hammer. He returned twice to do this in the same hour.

• A patient brought a handgun into a clinic, and another had a gun in his car in our parking lot.

• A colleague was frequently required to transport a convicted sex offender in her own vehicle- she was a young, pretty woman, and the sex offender made inappropriate comments and suggestions to her. Her concerns were not taken seriously by her supervisor until she became adamant that she would not be alone with him or she would resign.

• Another young woman quickly left the field after being inappropriately placed alone with older male patients who were leering at her and crossing boundaries- including one of them following her home.

• A case manager was beaten unconscious with a baseball bat, and another was stabbed to death by a client. The agencies they worked for did not do enough to protect them from harm, and did not prepare them to protect themselves.

The potential for violence in the workplace, or in the community toward staff, seems to be a largely unspoken matter. All of the settings I have worked at have denied the possibility of violence, minimized it, or offered highly questionable solutions to safety, (if someone gets violent, just ask them to leave), or dubious trainings and policies to protect staff.  In some treatment settings, the response of administrators or management to threats or perpetrated violence toward staff is described as inconsistent or inadequate, (SEIU 1000 Research Department, 2011). In some treatment facilities, there are contradictory or unclear policies in place regarding violence from patients and appropriate response (McPhaul, Lipscomb, & London, 2006).  In some settings administrative response is downright senseless and unrealistic. Violence from patients is something that too many clinics and agencies pretend will never happen, actively discourage discussion about, or offer poorly considered solutions that provide the illusion of safety. The denial and complacency started early- I cannot recall either my undergraduate or graduate education even mentioning dealing with violence toward staff, or personal safety.  

This does not appear to be my unique experience, but rather it is pervasive throughout the field (Anderson & West, 2011; Munsey, 2008). MH/SA staff has a fourfold chance of being assaulted on the job compared to other workers. The actual figure is probably higher due to underreporting (Anderson & West, 2011; NOLA Media Group, 2014). According to a seven year compilation of the DOJ (Department of Justice) NCVC (National Crime Victimization Survey), the rate of assault is 5.5 times higher for MH/SA staff than the overall rate for other professions (Anderson & West, 2011).

Why the Lack of Safety?

Why is there such denial and complacency, and lack of action to keep staff safe? I believe the answer is threefold: 1) Anxiety about liability; 2) Collective guilt about patient abuse of the past; and 3) Complacency and lack of knowledge about the dynamics of violence.

1.  The mental health and substance abuse field, as least as I have seen it, is an anxiety driven endeavor. The primary anxiety is about liability. A concern I have heard expressed in one version or another is: What if staff restrains a patient and we are sued? Out budget is limited, we are a non-profit, we don’t have the money to pay an attorney or for a settlement.  While this is a concern, there are multiple others that are potentially costly, for administrators to consider:

• Fear of staff suing due to the agencies failure to provide a safe work environment.
• Other patients or members of the public being harmed due to lack of effective response.
• High employee turnover due to lack of safety, protection, and support.
• Poor morale in the workplace and all of the ripple effects this causes, such as lowered standards and productivity, and eventual burnout and disillusionment with the field.
• Lost productivity from injury or disability.
• Staff with PTSD returning to work fearful or defensive, or leaving the profession (Anderson & West, 2011).

2.  The facility’s public and professional reputation as place that does not care for its employees.There was a time in the history of mental health care that patients were verbally abused, and subjected to brutal treatment- they were beaten, restrained unnecessarily, overmedicated, treated inhumanly, and molested and raped behind the closed doors of an institution, with no voice, no creditability, and no witnesses. This was a shameful period in the history of mental health care, and in some places, it may still occur to one degree or another. There is a collective guilt about this in the profession, and we have swung the pendulum of the opposite extreme – never put your hands on a patient, even in self-defense. 

3.  I have encountered a complacency and naiveté among many staff that work with the mentally ill, or substance abusers. Most I have encountered do not have an awareness of the realities of violence, the dynamics of violence, and think it can’t happen. They do not have a frame of reference for critical evaluation when a policy is enacted, or training is offered which is intended to manage risk. Complacency can lead to a lack of awareness of threats. There is a big difference between being paranoid, and aware. The former is seeing threats were there are none. The latter is recognition of real threats.

Conclusion                                              

The topic of personal safety is a very broad and complex area- far beyond the scope of this paper. It encompasses many areas, and includes physical procedures such as traffic control and restricted access in the workplace, securing/concealing objects that could be used as weapons, awareness of one’s surroundings, and  means for communicating with police or emergency medical services, or high quality on-site security. Knowledge of the dynamics of violence, and verbal de-escalation skills are essential. Staff safety also includes realistic, effective, and clearly defined policies regarding appropriate response to violence, and administrative support to staff that are victims of violence, or who have responded to patient violence. This also includes procedures for when off duty in the community- having an unlisted phone with no reverse lookup, suppression of personal information in public records and internet-accessible databases, randomly changing routes of travel, and practicing situational awareness. In my opinion, staff have to take direct responsibility for their own safety, because administrators may or may not. Please see the addendum below for some material to introduce you to this topic.

References

Anderson, A., and West, S.G., (2011). Violence Against Mental Health Professionals: When the Treater Becomes the Victim. Innovations in Clinical  Neuroscience. 8(3): 34–39. PMCID: PMC3074201

Maloney, E. (2014). I stalked my Psychiatrist. The Atlantic. Retrieved October 5, 2014 from http://www.theatlantic.com/health/archive/2014/10/i-stalked-my-psychiatrist/380845/?single_page=true

McPhaul, K.M., Lipscomb, J., London, M. (2006).The Risk of Violence in Mental Health Work: A Report on Workplace Violence in Washington State Community Mental Health Services. Work and Health Research. Retrieved October 5, 2014 from http://www.seiu1199nw.org/files/2011/05/Risk-of-Violence.pdf

Munsey, C. (2008). Stay safe in practice. APA Monitor. Retrieved October 5, 2014 from http://www.apa.org/monitor/2008/04/client-violence.aspx Vol. 39, No. 4

NOLA Media Group. (2014).Are mental health workers sitting ducks? Philadelphia slaying raises the issue anew. The Times Picayune. Retrieved October 5, 2014 from http://www.nola.com/news/index.ssf/2014/08/how_safe_are_mental_health_pro.html

SEIU 1000 Research Department. (2011) Violence in California’s Mental Health Hospitals Workers Deserve Stronger Protection. SEIU 1000 Research Department. Retrieved October 5, 2014 from http://seiu1000.org/research/research_white%20paper_dmhviolence.pdf

Addendum: Suggested reading for MH/SA staff

Debecker, G. (1997). The Gift of Fear. NY.  Dell: Elliot,

Grossman, D. (2004). On sheep, wolves, and sheepdogs. On Combat. PPCT research. Available: http://mwkworks.com/onsheepwolvesandsheepdogs.html

Harris, S. (2011). The Truth about Violence: 3 Principles of Self-Defense. Sam Harris. Available: http://www.samharris.org/blog/item/the-truth-about-violence

Lane, L.A., and Wilder, K. (2010). The Little Black book of violence. Wolfeboro, NH:  YMAA Publication Center.

Macyoung, M, and Macyoung, D.G. (1998-2014) No Nonsense Self-Defense.  Available: http://www.nononsenseselfdefense.com/

Macyoung, M. (1992) Violence, Blunders and Fractured Jaws: Advanced Awareness Techniques and Street Etiquette. Paladin Press: Boulder, CO.

Miller, R. (2008). Meditations on Violence: A comparison of Martial Arts training and real world violence. YMAA Publication Center. Wolfeboro, NH.

William, E.N. (n.d.). Power and Control Tactics Employed by Prison Inmates—A Case Study. Federal Probation. Available: http://www.uscourts.gov/uscourts/federalcourts/pps/fedprob/2006-06/inmatetactics.html