Q&A: When Patients Attack Shrinks

On Tuesday night, a man wielding a meat cleaver and other knives killed 56-year old psychologist Kathryn Faughey and seriously wounded her 70-year-ld colleague in their Manhattan office, leaving behind a bizarre collection of clues in the building's basement, including adult diapers, women's clothing, rope, duct tape and additional knives. Though police say they are not currently focusing on the theory that the killer was a patient of the victim, the act brings to mind a disturbing set of questions about the risks taken on by those who spend their days treating mentally ill patients.

The concerns are real. Fifteen years ago, the MacArthur Violence Risk Assessment Study concluded that 30 percent of the psychiatric patients tracked had committed at least one act of violence after being discharged, ranging from relatively minor attacks like biting and hitting—which constituted about half of the incidents—to rape and murder, in rare cases. In 2001, Gary Arthur and Joel Brende, professors emeritus at Georgia State University and Mercer University School of Medicine, respectively, found striking evidence of workplace safety concerns for mental healthcare providers: Of the 1,131 therapists who responded to his survey, 14 had been shot at, 6 knifed, 209 shoved, and 87 hit by objects thrown at them by patients.

NEWSWEEK's Katie Paul talked about the risks facing mental health professionals with Dr. Spencer Eth, a forensic psychiatrist who directs the Behavioral Health Services at St. Vincent's Medical Center in Manhattan and teaches as a professor of psychiatry at New York Medical College. Excerpts:

NEWSWEEK: How common is violence against mental health professionals? And to what extent is this a known occupational hazard?
Spencer Eth:
Assaultive behavior is not uncommon. Thankfully, murder is quite rare. In the course of a career, more than half of therapists sustain some kind of injury, but minor injuries are much more common. There are significant differences in the type of practice: psychotherapists versus psychiatrists, those who work in office settings versus those who work in in-patient units in emergency rooms. It also depends a lot on the kind of practice one has, so the incidence of violence differs considerably. If one has a more traditional psychotherapy practice, working with employed people who are generally high-functioning with neurotic-type anxiety or depression, that is a relatively safe situation. If you're talking about a therapist or psychiatrist who works with criminals, or alcohol or drug abusers, or people who are psychotic, with a history of aggression, then that work can be quite dangerous.

Have you experienced incidents of violence in your own practice?
I'm hospital-based, so we have a very different kind of patient population. We have staff and security guards around, as all hospitals do, so it is a safer setting for extreme violence, but more common setting for assault. In fact, ERs and psychiatric units are associated with a substantial degree of staff injury, but very rarely lethal.

So it's more likely that incidents occurring in small practices will result in extreme violence?
Yes, because one could be quite alone in a setting where there are no metal detectors or security guards.

Is that seen as a profound problem or just an occupational hazard? Should more precautions be taken?
There's no question that working in an ER or psychiatric in-patient unit is a dangerous line of work. People who work there are aware and take precaution to minimize risk. Treating psychiatric patients carries with it some degree of irreducible risk. Psychiatric illness can be managed, but there are exacerbations and relapses of psychotic patients, patients who have poor judgment or impulse control problems, maybe substance abuse—this is why they come for treatment, and we can help them, but our treatments aren't entirely successful and therefore these patients often continue to pose risks. But it's important to note that patients tend to be victimized far more than they are perpetrators. Many are victims, and the work we do is important. So we try to assess the risk threat, address those risk factors that are treatable, and intervene where and when we can. In doing so, we try to increase the level of safety for ourselves, but also for families and communities.

What kinds of precautions do many mental healthcare professionals take?
Panic buttons are standard. Clinicians often do pre-screening. Trying to know what kind of help may be available. I don't think clinicians have weapons of their own for protection; that, to me, is very unusual. More than that, it's very tough to do. But the majority of situations pose risk of harm but not of substantial harm. For instance, it could come in an elderly patient in early dementia who has temper tantrums and suspiciousness, so it's not always the patient you think you should be concerned about. One of the areas associated with the highest risk of injury is our child unit. The child may look small, but is there because of aggression problems and can bite, kick and scratch, and the staff can get hurt.

Often, therapists may feel threatened but not physically attacked. There is a psychological danger for therapists in situations where they feel threatened, manipulated, where they have been followed when they leave the office, when patients find out where they live and send them things. So what we see in this terrible event in New York is the tip of the iceberg. The random killing catches the media attention, but in the day-to-day work, so much more goes on that imposes burnout for people who do this work for years.

Is there any industry standard for having weapons? Is that looked down upon or is it seen as an acceptable precautionary method?
I know of very few therapists who would have a weapon. There's always a danger that the weapon could be turned against you. In psychiatric units, we insist that police officers do not bring weapons into the unit because it's too dangerous, even though they're police officers trained to use them. A view shared by most clinicians is that they're not helpful.

What about metal detectors? Is that something that should be taken into consideration more when choosing an office space?
Unfortunately, more often than not, the main concern is cost. But location is important, especially since therapists tend to work late—and this incident occurred at night. A lot of psychiatrists won't open the door unless they know the person who is there. It's particularly a problem for those who practice in home offices. The notorious case of Wayne Fenton [an expert on schizophrenia who was beaten to death by a patient in 2006], when he was killed, occurred in his home office. It's a balancing act because of cost consideration and convenience, but it's worrisome for the therapist and family members.

How have you handled any incidents you've faced?
All of us who have worked in this profession have handled patients who are angry and threatening. That's fairly common. If you work in a hospital setting, there isn't a day that goes by that there isn't a call for assistance because a patient has lost control. In outpatient settings, it's much more unusual. But when treating unstable patients or substance abuse patients, there are emergencies and 911 has to be called.

This is a particularly vicious crime, getting lots of coverage as result. Is that changing the outlook in the psychiatric community about managing risk?
It colors people's perspectives. Right now, we're going into the national match where senior medical students are matched with training programs, and this news is not good for the field of psychiatry. Now, the majority of med students are women, who understandably feel more vulnerable. So this is not good for recruitment to our field. It does have an effect. We in psychiatry also worry about the contagion effect. Whenever there's a well-publicized event, it makes such an act more conceivable. So this is a more dangerous time, and a more anxious time, because the risk of recurrence is higher now.

vThere is no easy fix to the problem. It comes with the territory. But knowledge is very helpful, and it's stressed in medical and psychiatric education—how to do a violent risk assessment, and determine what interventions are helpful in trying to reduce the risk. This is wakeup call to people who haven't paid sufficient attention to that.