Psychiatric Annals

Feature Article 

Homicides of Mental Health Workers by Patients: Review of Cases and Safety Recommendations

Michael B. Knable, DO

Abstract

A systematic search for accounts describing homicides of mental health workers between 1981 and 2014 was conducted. Demographic characteristics of the mental health workers and clinical characteristics of the perpetrators were collected. These data revealed that homicides occurred at a frequency of approximately 1 per year. Young women caseworkers who were unaccompanied during visits to residential treatment facilities were the most common victims. Men with a diagnosis of schizophrenia were the most common perpetrators. The most likely method of homicide was by gunshot (42.4%), but 57.6% of homicides were committed by less lethal, and possibly preventable, means. Perpetrators often had a prior history of violence, criminal charges, involuntary psychiatric hospitalization, or nonadherence to medications. After their legal trial, perpetrators were more likely to be imprisoned than hospitalized. Strategies to accurately identify risk and to train acute care staff in possible prevention measures are much needed. Some policy and training recommendations are offered in conclusion. [Psychiatr Ann. 2017;47(6):325–334.]

Abstract

A systematic search for accounts describing homicides of mental health workers between 1981 and 2014 was conducted. Demographic characteristics of the mental health workers and clinical characteristics of the perpetrators were collected. These data revealed that homicides occurred at a frequency of approximately 1 per year. Young women caseworkers who were unaccompanied during visits to residential treatment facilities were the most common victims. Men with a diagnosis of schizophrenia were the most common perpetrators. The most likely method of homicide was by gunshot (42.4%), but 57.6% of homicides were committed by less lethal, and possibly preventable, means. Perpetrators often had a prior history of violence, criminal charges, involuntary psychiatric hospitalization, or nonadherence to medications. After their legal trial, perpetrators were more likely to be imprisoned than hospitalized. Strategies to accurately identify risk and to train acute care staff in possible prevention measures are much needed. Some policy and training recommendations are offered in conclusion. [Psychiatr Ann. 2017;47(6):325–334.]

Within the last decade, two psychiatrists that were known to the author were killed by their patients. This article attempts to determine how frequently homicides of psychiatrists and other mental health workers can be expected to occur. Although the general literature on violence toward mental health workers remains relatively sparse, reports using a variety of methodologies indicate that acts of violence among those with untreated, persistent mental illness may be quite common. For example, studies using survey techniques report that 50% to 60% of mental health workers can expect to be threatened, 30% to 40% can expect to be assaulted, 40% can expect to receive some type of physical injury, and up to 5% can expect to experience serious physical harm.1–3

Retrospective studies using population-based strategies or registries also suggest that violence perpetrated by the persistently mentally ill is quite common. Using data from the Epidemiologic Catchment Area study, Swanson4 estimated the lifetime prevalence of violence to be 16.1% in patients with serious mental illness (schizophrenia, major depression, or bipolar disorder), 35% in patients with substance abuse or dependence, 43.6% in patients with both serious mental illness and substance abuse, and 7.3% in people with no major mental disorder. In the most recent data available from the US Department of Justice's National Crime Victimization Survey,5 the rate of workplace violence between 2005 and 2009 was reported to be 5.1 per 1,000 people overall, 10.1 per 1,000 for physicians, and 8.1 per 1,000 for nurses. For mental health workers, the rates were 20.5 per 1,000 overall, 17 per 1,000 for professional workers, and 37.6 per 1,000 for custodial workers.5 The rate of violence toward mental health workers was second only to the rate for law enforcement workers (47.7 per 1,000).5 In the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), 19.1% of 1,410 patients with schizophrenia had exhibited some type of violence over the prior 6 months, and 3.6 % had exhibited “serious violence.”6 Furthermore, violence declined from 16% to 9% in CATIE trial participants retained in the study who received 1 of 5 antipsychotic medications.7 Factors associated with a history of violence included childhood antisocial behavior, substance use, victimization, and economic deprivation. Negative symptoms were negatively correlated with a risk for violence. In a meta-analysis of 110 studies reporting on 45,533 people with psychiatric disorders, it was found that 18.5% had a history of violence.8 Violent patients were most likely to have had a diagnosis of schizophrenia, recent substance misuse, and nonadherence with psychological therapies or medications. Using a Swedish registry of 82,647 patients who were prescribed antipsychotics or mood stabilizers, Fazel et al.9 reported that 6.5% of men and 1.4% of women were convicted of violent crimes. Compared with periods when participants were not on medication, violent crime fell by 45% in patients receiving antipsychotics and by 24% in those receiving mood stabilizers.9

Prospective studies have also found elevated rates of violence among those with chronic mental illness. Newhill et al.10 observed 1,136 patients who had been admitted to 1 of 3 psychiatric hospitals for 1 year. Although the authors found that the rates of violent or aggressive acts were quite common, patients with borderline personality disorder were significantly more likely to commit violent acts even when intentional self-harm was excluded. Langeveld et al.11 observed 178 patients with a first episode of psychosis in Norway for 10 years. Twenty percent were reportedly apprehended or incarcerated compared with 1.6% of the general population. Fifteen percent reportedly perpetrated or engaged in threatening or physically violent behavior. Apprehension or incarceration decreased over time to the level found in general population except in those with illicit drug use.

Methods

For this article, I searched the medical literature (PubMed) and the Internet at large to find cases in which mental health workers in the United States had been killed by patients. I excluded cases that occurred in correctional settings that were not part of a psychiatric hospital or health care system, cases related to court-ordered child custody evaluations, cases occurring in child protective service agencies, and cases occurring in state social service agencies that were not specifically geared toward psychiatric treatment. All data were collected from public sources, including publications in journals, newspaper accounts, and court records (when available). Data regarding diagnosis and treatment history were not verified independently.

I attempted to note the age, sex, and occupational role for the mental health workers; the age, sex, and probable diagnosis of the perpetrators; the method of homicide; the setting of the homicide; a history of prior involuntary hospitalization for the perpetrators; a history of prior violence for the perpetrators; and a history of prior criminal convictions for the perpetrators. I also attempted to summarize the disposition of the perpetrators after the homicides (ie, to determine if they were killed at the site of the crime, committed suicide, were found guilty and sentenced to prison, or were committed to psychiatric hospitals).

Results

Table 1 contains demographic data on victims and perpetrators, and Table 2 summarizes information regarding the setting and method of homicide, and prior histories of involuntary treatment, medication nonadherence, violence, or criminal charges.


            Demographic Data on Victims and Perpetrators
            Demographic Data on Victims and Perpetrators

Table 1:

Demographic Data on Victims and Perpetrators


            Setting and Method of Homicide, Historical Predictors of Violence, and Status of Perpetrator
            Setting and Method of Homicide, Historical Predictors of Violence, and Status of Perpetrator

Table 2:

Setting and Method of Homicide, Historical Predictors of Violence, and Status of Perpetrator

The case of Stephanie Moulton38 illustrates many of the features that we describe in this report. Moulton was age 25 years, 5 feet and 1 inch tall, and weighed approximately 110 pounds when she was killed by Deshawn James Chappell in 2011. Moulton was the first in her family to graduate from college. She had earned an associate's degree in mental health and a bachelor's degree in social work. She was drawn to the mental health field partly because she had an uncle with schizophrenia. After graduation from college she began work with the North Suffolk Mental Health Association, a nonprofit organization that provides community-based contract services, including residential care, to the Massachusetts Department of Mental Health, for approximately 600 patients. This type of contractual arrangement has become increasingly common with the closure of state mental hospitals and outpatient programs. The North Suffolk Mental Health Association had previously been fined by the Occupational Safety and Health Administration for failing to provide adequate safeguards against workplace violence.38

The family of Chappell had noticed his increasingly bizarre behavior since 2003. During that year, he was arrested for the assault and robbery of a homeless man, during which he slashed the forehead of his victim and caused an eye injury that required surgery. After this incident, Chappell's psychosis appeared to worsen and he began using alcohol and marijuana on a regular basis. He was later hospitalized at Massachusetts General Hospital and was given a diagnosis of schizophrenia. His condition seemed to improve with antipsychotic medications, but he frequently failed to take prescribed medications after discharge from the hospital. He had at least four additional hospitalizations and several arrests for assaults. In 2006, he attacked his stepfather, fracturing the bones of his orbit. At that point, Chappell was committed to the Bridgewater State Hospital for 3 months and then released. The terms of Chappell's release are not known, but it is interesting to note that Massachusetts is 1 of only 5 states in the US that does not have an assisted outpatient treatment law, also known as civil outpatient commitment. In 2010, Chappell had an altercation with a group home resident and he was transferred to several other group homes before coming to reside at the home in Revere, MA managed by the North Suffolk Mental Health Association. In November 2010, Chappell began calling his mother complaining of paranoid thoughts and of intense auditory hallucinations. His mother believed that he had again stopped taking his medications. In January 2011, Moulton called Chappell's mother and confirmed that he had not been receiving antipsychotics and said she would try to get them started again. On January 20, 2011, Chappell and Moulton were alone inside the group home when he beat and stabber her, slit her neck, and then dumped her body in a church parking lot. It is not known what transpired between the two of them prior to the murder. The murder occurred 2 days before Governor Deval Patrick released his annual state budget, which proposed funding cuts for mental health services for the third straight year. Chappell was found guilty of first-degree murder on October 28, 2013, in the Suffolk Superior Court and was sentenced to life in prison. Moulton's family filed suit against the North Suffolk Mental Health Association for failing to protect her and later helped to establish the Stephanie Moulton Safety Symposium, which is now hosted annually by the Massachusetts Department of Mental Health.38

Of the 33 victims identified in this article, 20 (60.6%) were licensed professionals (psychiatrist, physician, psychologist, nurse, social worker) and 13 (39.4%) were technical or case workers. As a class, “case workers” were the most likely group to have been exposed to attack. Fifteen (45.4%) of the victims were men and 18 were women. The mean age of the victims overall was 41.6 years, but for women the mean age was 35.4 years and for men it was 49.1 years. Therefore, the most common subgroup to have been the victim of a homicide was composed of young women case workers with relatively little experience in the field. Victim characteristics are summarized in Table 3.


            Summary of Victim Characteristics (1981–2014)

Table 3:

Summary of Victim Characteristics (1981–2014)

Twenty-seven perpetrators were men (81.8%), four were women (12.1%) and for two the gender could not be determined (6.1%). The mean age of the perpetrators was 34.5 years, with a tendency for women to be older (44.3 years) than men (33.0 years). Seventeen perpetrators were thought to have had a diagnosis of schizophrenia and one was given a diagnosis of the closely related schizotypal personality disorder (54.5% taken together). Four perpetrators were thought to have a diagnosis of bipolar disorder (12.1%) and 1 (3%) was given a diagnosis of major depression. Public records did not yield a diagnosis for 10 (30.4%) perpetrators. The lack of diagnosis in public accounts was frequently due to concerns over confidentiality, especially in cases where the perpetrator did not have a criminal record, or in which the perpetrator was killed during the incident or committed suicide. The most common subgroup to have been a perpetrator of homicide was composed of young men diagnosed with schizophrenia.

Eleven homicides (33.3%) occurred during visits to residential facilities, six occurred in public clinics (18.2%), five occurred in private offices (15.2%), six occurred in private hospitals (18.2%), four occurred in public hospitals (12.1%), and one occurred while in transit with a patient 3%). Therefore, the most common setting for homicides of mental health care workers was during visits to patients in residential facilities. There was relatively little difference in the frequency of homicides that could be explained by public versus private hospital settings, or public versus private clinic settings.

The most common method for homicide was by gunshot (42.4%). Four victims (12.1%) were killed by beating, three (9.1%) by a combination of beating and stabbing, and one (3%) by a combination of beating and strangling. Ten victims (30.3%) were killed by stabbing or laceration with a sharp object. One victim was killed by strangling (3%). One could argue that it is difficult for an individual mental health care worker to defend themselves against gunshots without comprehensive institutional procedures for weapons screening or more restrictive legislation regarding gun possession. However, non-gunshot methods for homicide constituted the majority when grouped together (57.6%), and it may be argued that these are quite preventable if appropriate safety precautions and educational requirements for mental health workers were to be enforced.

Sixteen of the perpetrators (48.5%) had a prior history of criminal charges, six (18.2%) did not have such a history, and inadequate information was available for 11 (33.3%). Seventeen of the perpetrators (51.5%) had a prior history of violence, three (9.1%) did not have such a history, and inadequate information was available for 13 (39.4%). Thirteen of the perpetrators (39.4%) had a prior history of nonadherence to medications, and inadequate information was available for the remaining 20 (60.6%). Seventeen of the perpetrators (51.5%) had a prior history of involuntary hospitalization, two (6.1%) did not have such a history, and inadequate information was available for 14 (42.4%). Thus, a prior history of criminal charges, violence, nonadherence to medications, and involuntary hospitalization were quite common among perpetrators and should be seen as warning signs for potential violence. After the homicides, 15 perpetrators (45.5%) were found guilty of criminal charges and were imprisoned, eight (24.2%) were committed to psychiatric hospitals, four (12.1%) committed suicide, two (6.1%) were killed at the crime scene, and one (3%) was awaiting trial at the time of this writing. Legal status could not be determined for three (9.1%) perpetrators. Perpetrator characteristics and crime details are summarized in Table 4.


            Summary of Perpetrator and Crime Characteristics (1981–2014)

Table 4:

Summary of Perpetrator and Crime Characteristics (1981–2014)

Discussion

I was able to identify 33 cases since 1981 in which mental health workers were murdered by patients in the US; therefore, one might expect that such events can be expected approximately once per year. I cannot conclude that the list of cases is complete, especially because many documents and news reports related to homicides of mental health workers prior to the widespread use of the Internet in the 1990s may be more difficult to locate. I also excluded cases of homicide outside of psychiatric settings providing direct care to the perpetrators; I personally believe that many homicides committed in other social service agencies may also involve perpetrators with mental illnesses.

Homicides seem to have been committed against a wide range of professional roles within the mental health system. Indeed, the prolonged training necessary to become a psychiatrist or psychologist, and long experience as a practitioner, did not seem to protect particular victims from these tragic events. Nevertheless, the largest single group to have been victimized appeared to be young women case workers who had been sent, usually unaccompanied, to perform tasks within residential treatment settings. This would appear to be a practice that could be remedied quite easily with appropriate safety measures followed in these settings. Although residential facilities were a common site for the homicides we found, it is important to note that no particular clinical setting seemed to be immune from the risk for attack. It may be misguided for practitioners in private offices to feel safe without putting into place specific safeguards.

With regard to the perpetrators, this summary seems to be consistent with other reports concerning the risk of violence among the mentally ill, in that most perpetrators were men, had a diagnosis of schizophrenia, and frequently had prior histories of violence, arrest, involuntary hospitalization, or nonadherence to treatment recommendations.

Based on the data, I offer safety recommendations for practitioners. These are listed in Table 5. I also suggest policy considerations for administrators and government officials. These are listed in Table 6.


            Safety Recommendations for Mental Health Practitioners

Table 5:

Safety Recommendations for Mental Health Practitioners


            Policy Considerations for Administrators and Government Officials to Protect Mental Health Workers

Table 6:

Policy Considerations for Administrators and Government Officials to Protect Mental Health Workers

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Demographic Data on Victims and Perpetrators

Case Worker Occupation Year State Age (y) Sex Perpetrator Age (y) Sex Diagnosis
1 Ernest Pullman12 Psychiatrist 1981 CA 55 M N/A N/A N/A N/A
2 Alan Shields12 Psychiatrist 1981 MA 32 M James Palmer 27 M Schizophrenia
3 Deanne Coombs13 Psychologist 1981 MA 32 F James Palmer 27 M Schizophrenia
4 Juan Ocana14 Psychiatrist 1981 FL 48 M John McGoff 35 M N/A
5 Brian Buss15 Psychiatrist 1985 OR 37 M Kedron Ellis 39 M Bipolar disorder
6 Michael McCulloch16 Psychiatrist 1985 OR 41 M John Eaton 39 M Schizophrenia
7 Dr. O17 Psychiatrist 1986 FL 38 M Mr. F 32 M Schizophrenia
8 Norman Fournier18 Social worker 1987 WA 51 M N/A N/A N/A N/A
9 Linda Rosen19 Social worker 1988 PA 27 F Edith Anderson 32 F N/A
10 Robbyn Panitch20 Social worker 1989 CA 36 F David Smith 27 M Schizophrenia
11 Rebecca Binkowski21 Case worker 1993 MI 25 F David Stappenbeck 26 M Schizophrenia
12 Sharon Edwards22 Nurse 1995 MD 26 F Benjamin Garris 16 M N/A
13 Donna Millette-Fridge23 Social worker 1998 CT 36 F Adrian Isom 28 M Depression and substance abuse
14 Reuven Bar-Levav24 Psychiatrist 1999 MI 72 M Joseph Brooks 27 M Schizophrenia
15 Judy Scanlon25 Nurse 1999 NY 44 F Diane Wylie 46 F Schizophrenia
16 Laura Wilcox26 Case worker 2001 CA 19 F Scott Thorpe 41 M Schizophrenia
17 Nicole Castro27 Case worker 2002 MD 23 F John Lutz 64 M Schizophrenia
18 Erlinda Ursua28 Physician 2003 CA 60 F Rene Pavon 37 F Bipolar disorder
19 Teri Zenner29 Case worker 2004 KS 26 F Andrew Ellmaker 17 M Schizotypal personality
20 Wayne Fenton30 Psychiatrist 2006 MD 53 M Vitali Davydov 19 M Schizophrenia
21 Marty Smith31 Case worker 2006 WA 42 M Larry Clark 33 M Schizophrenia
22 Genine Holznagel-Leary32 Case worker 2007 AK 32 F Brian Galbraith 53 M Schizophrenia
23 Louis Martin33 Psychiatrist 2007 NE 78 M Eric Lewis 35 M Schizophrenia
24 Diruhi Mattian34 Social worker 2008 MA 53 F Thomas Belanger 18 M Bipolar disorder
25 Kathryn Faughey35 Psychologist 2008 NY 56 F David Tarloff 39 M Schizophrenia
26 Scott Fleming36 Case worker 2010 AR 40 M Samuel Lands 24 M Bipolar disorder
27 Donna Gross37 Technician 2010 CA 54 F Jesse Massey 37 M N/A
28 Stephanie Moulton38 Case worker 2011 MA 25 F Deshawn Chappell 27 M Schizophrenia
29 Mark Lawrence39 Psychiatrist 2011 VA 71 M Barbara Newman 62 F N/A
30 Jennifer Warren40 Case worker 2012 OR 38 F Brent Redd 30 M Schizophrenia
31 Stephanie Ross41 Case worker 2012 FL 25 F Lucious Smith 53 M N/A
32 Michael Schaab42 Case worker 2012 PA 25 M John Shick 30 M N/A
33 Theresa Hunt43 Case worker 2014 PA 53 M Richard Plotts 49 M N/A

Setting and Method of Homicide, Historical Predictors of Violence, and Status of Perpetrator

Case Perpetrator Setting Method Involuntary Hospitalizations Non-adherence Violence Criminal Charges Status of Perpetrator
1 N/A12 Hospital Gunshot N/A N/A N/A N/A N/A
2 James Palmer12 Office in clinic Gunshot N/A N/A N/A N/A Suicide
3 James Palmer13 Office in clinic Gunshot N/A N/A N/A N/A Suicide
4 John McGoff14 Office in clinic Gunshot Yes N/A N/A Yes Guilty of first degree murder and imprisoned
5 Kedron Ellis15 Private hospital Beating with object Yes N/A No No Guilty and insane and hospitalized
6 John Eaton16 Private office Gunshot Yes N/A Yes No Hospitalized with civil commitment without trial
7 Mr.F17 Public hospital Gunshot Yes N/A Yes No Not guilty by reason of insanity and hospitalized
8 N/A18 Home visit Gunshot N/A N/A N/A N/A N/A
9 Edith Anderson19 Private hospital Gunshot N/A Yes N/A N/A Guilty of third degree murder and imprisoned
10 David Smith20 Office in clinic Stabbing Yes Yes Yes Yes Guilty of first degree murder and imprisoned
11 David Stappenbeck21 Transporting patient Stabbing Yes N/A Yes Yes Guilty of first degree murder and imprisoned
12 Benjamin Garris22 Private hospital Stabbing N/A N/A N/A N/A Guilty of first degree murder and imprisoned
13 Adrian Isom23 Office in clinic Stabbing N/A N/A N/A N/A Killed at scene
14 Joseph Brooks24 Private office Gunshot N/A Yes N/A N/A Suicide
15 Diane Wylie25 Home visit Beating with object Yes N/A Yes Yes Guilty of first degree murder and imprisoned
16 Scott Thorpe26 Clinic Shooting N/A Yes N/A Yes Incompetent to stand trial and hospitalized
17 John Lutz27 Home visit Beating and stabbing Yes N/A N/A N/A Incompetent to stand trial and hospitalized
18 Rene Pavon28 Public hospital Beating and strangling Yes Yes Yes No N/A
19 Andrew Ellmaker29 Home visit Stabbing Yes N/A N/A N/A Guilty of first degree murder and imprisoned
20 Vitali Davydov30 Private office Beating No Yes No No Guilty but not criminally responsible and hospitalized
21 Larry Clark31 Home visit Beating and stabbing N/A N/A Yes Yes Guilty of first degree murder and imprisoned
22 Brian Galbraith32 Residential facility Stabbing N/A N/A Yes Yes Guilty of first degree murder and imprisoned
23 Eric Lewis33 Public hospital Beating Yes Yes Yes Yes Guilty of second degreemurder and imprisoned
24 Thomas Belanger34 Home visit Stabbing N/A N/A N/A Yes Guilty of manslaughter and imprisoned
25 David Tarloff35 Private office Meat cleaver Yes Yes Yes Yes Guilty of first degree murder and imprisoned
26 Samuel Lands36 Residential facility Gunshot Yes Yes Yes Yes Guilty of first degree murder and imprisoned
27 Jess Massey37 Public hospital Strangling Yes N/A Yes Yes Guilty of first degree murder and imprisoned
28 Deshawn Chappell38 Residential facility Beating and stabbing Yes Yes Yes Yes Guilty of first degree murder and imprisoned
29 Barbara Newman39 Private office Gunshot No N/A No No Suicide
30 Brent Redd40 Residential facility Stabbing Yes N/A Yes Yes Guilty and insane and hospitalized
31 Lucious Smith41 Home visit Stabbing N/A N/A Yes Yes Incompetent to stand trial and hospitalized
32 John Shick42 Private hospital Gunshot N/A N/A Yes Yes Killed at scene
33 Richard Plotts43 Private hospital Gunshot Yes N/A Yes Yes Awaiting trial

Summary of Victim Characteristics (1981–2014)

Criteria Number (%)

Professional Status
  Technical or case worker 13 (39.4%)
  Psychiatrist 10 (30.3%)
  Social worker 5 (15.1%)
  Psychologist 2 (6.1%)
  Nurse 2 (6.1%)
  Physician 1 (3%)

Female gender 18 (54.6%)

Mean age
  All victims 41.6 years
  Female victims 35.4 years
  Male victims 49.1 years

Summary of Perpetrator and Crime Characteristics (1981–2014)

Criteria Number (%)

Male gender 27 (81.8%)

Mean age (y)
  All perpetrators 34.5
  Male perpetrators 33
  Female perpetrators 44.3

Diagnosis
  Schizophrenia 1 (3%)
  Schizotypal personality 4 (12.1%)
  Bipolar disorder 1 (3%)
  Major depression 10 (30.4%)
  Unknown 17 (51.5%)

Location
  Residential facility 11 (33.3%)
  Public clinic 6 (18.2%)
  Private clinic 5 (15.2%)
  Public hospital 4 (12.1%)
  Private hospital 6 (18.2%)
  In transit 1 (3%)

Method
  Gunshot 14 (42.4%)
  Beating 4 (12.1%)
  Beating and stabbing 3 (9.1%)
  Beating and strangling 1 (3%)
  Stabbing 10 (30.3%)
  Strangling 1 (3%)

Prior History
  Criminal charge 16 (48.5%)
  Violence 17 (51.5%)
  Nonadherence 13 (39.4%)
  Involuntary hospitalization 17 (51.5%)

Status
  Imprisoned 15 (45.5%)
  Suicide 8 (24.2%)
  Killed 4 (12.1%)
  Awaiting trial 2 (6.1%)
  Unknown 1 (3%)
  Committed to hospital 3 (9.1%)

Safety Recommendations for Mental Health Practitioners

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Develop the capacity to assess the danger level of patients in a prescreening interview before the first appointment

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Take special care with evening or weekend appointments or in other situations in which additional office personnel is not present

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For patients that have a history of violent acts or poor impulse control, see the patient along with family members or with colleagues

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Have a security barrier between the waiting room and the consulting room so that patients cannot easily “barge in.” This might include electronic locks or video surveillance of the waiting room, which would allow practitioners to see who is waiting prior to admitting them to the office

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Sit behind a desk rather than in a more traditional “psychotherapeutic” environment. This barrier would allow some defense against assaults that do not involve firearms

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Have an escape route: do not let the patient sit between you and the only available exit from the office

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If feasible, have an emergency alert system; however, these are only effective when the consulting room is in an institutional setting with enough personnel present who are equipped to respond to the alert

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Home visits to patients with a history of violence or involuntary treatment should be made by teams (not by one person)

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For patients who become threatening, obtain consultation sooner rather than later. In isolated outpatient settings, consultation with other colleagues may be the only way to get further guidance and support. In institutional settings, threats should be reported to appropriate administrators immediately. These reports do not usually constitute a violation of privacy laws

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For direct threats of violence or threats that occur outside of an office or institutional setting, law enforcement agents should be informed

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One must evaluate the need for restraining orders, understanding that they sometimes provoke increased threats or violence. One must also determine if there is a sufficient level of danger to merit criminal charges or involuntary psychiatric detention

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Policy Considerations for Administrators and Government Officials to Protect Mental Health Workers

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Mental health workers should receive training in violence risk assessment as a core competence, and this training should be reviewed periodically

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In the United States, there are currently five states that do not have legislation allowing assisted outpatient treatment, or outpatient commitment. There is substantial evidence that AOT reduces violence in the community perpetrated by people with persistent mental illness44

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Even in states with adequate assisted outpatient treatment laws, there is frequently not an efficient method to implement the law or to enforce the court orders remanding the patient to treatment; this is an urgent problem that state governments must work to resolve

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Patients with prior history of criminal convictions, arrest, violence, and involuntary hospitalization should have these factors clearly noted in the medical record, and these factors should be given adequate weight when planning treatment

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Consideration should be given to the idea of having involuntary psychiatric treatment become a matter of public record, so that more adequate screening for gun possession and determination of the appropriate site for detention (psychiatric hospital versus prison) can be made more easily

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Authors

Michael B. Knable, DO, is the Executive Director, Sylvan C. Herman Foundation, and the Medical Director of Clearview Communities, LLC.

Address correspondence to Michael B. Knable, DO, DFAPA, Sylvan C. Herman Foundation, 611 West Patrick Street, Frederick, MD 21701; email: mknable@cvcmail.org.

Presented at the 169th Annual Meeting of the American Psychiatric Association; May 15, 2016; Atlanta, GA.

Disclosure: Michael B. Knable is a stock shareholder with MedAdvante, Inc.

10.3928/00485713-20170227-01

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