How to Stay Safe in Your Office

Obtain a thorough history, including history of violence or interaction with law enforcement, to help identify potentially violent patients and use a standardized risk assessment tool, such as the MacArthur Community Violence Interview used in NIMH's CATIE study.

Be aware that previous violence and/or substance abuse are the most significant predictors of future violence.

Share your assessment of patients' risk of violence with them. Ask patients to estimate their risk of violence and discuss the issue fully.

Foster impulse control through setting strong limits on patient behavior and offer acceptable alternatives to inappropriate behaviors.

In private offices in homes or office buildings, foster a more secure physical environment:

Never see patients who have a history of violence or paranoia or who are borderline with little impulse control in a home-office setting or in a private office suite when no support staff are immediately available. A more secure setting is indicated, such as a hospital ER or a community mental health clinic that has security staff.

When confronted with an imminent threat of violence, use clinical skills to de-escalate the situation.

If you are physically attacked by a patient who has no weapon and are unable to escape or summon support/security staff immediately, a good strategy is to “clinch” or employ the “bear hug.”

If attacked, you must actively defend yourself; under these circumstances, self-defense must take priority over Hippocrates' admonition to “first, do no harm.”