Patient assaults on inpatient psychiatric units often arise out of a confluence of interpersonal dynamics and bureaucratic issues that may be avoided by improving communication among treatment-team staff and reviewing administrative protocols.

This was the message delivered by a panel of psychiatrists and mental health professionals at APA's Institute on Psychiatric Services in October in New Orleans.

"Violence is not only about the victim and the victimizer," noted Lindsey Rutledge, M.D., a PGY-4 psychiatry resident at Albert Einstein College of Medicine/Montefiore Medical Center. "Violence occurs when there is a breakdown of multiple systems" and often has many causes.

Such systems, Rutledge said, involve hospital administrators and members of the patient's therapeutic team, including supervising psychiatrists, residents, psychologists, social workers, and nurses.

When treatment-team members do not communicate with one another openly, feel as if their opinions are not valued, or perceive that inherent differences in professional status have a negative impact on the working environment, this can more easily lead to an environment that creates instability both for staff and patients, she noted.

She and fellow Albert Einstein resident, Ann Baron, M.D., illuminated how problems with treatment-team dynamics and other systemic issues at one psychiatric center in New York contributed to a patient assault in which they were involved.

Baron was beginning a six-month rotation at the facility as a PGY-2 resident, and her assigned patients was a woman with schizophrenia who was paranoid and extremely disorganized, she explained.

The patient was also emotionally distressed, which kept her from participating in group activities on the unit. The treatment team assigned to work with the patient had a new attending physician just out of residency, she noted, and certain members of the team needed to be on the unit and couldn't attend the meetings on a regular basis.

Team members were struggling with how to best care for the patient, Baron noted. "There was a degree of helplessness" among them, she said.

At one point, the patient's medications were changed and she had been assaulted by another patient, factors which may have led to her becoming less stable in the subsequent days.

The patient with schizophrenia became more loud, disruptive, and emotional. When Baron was asked to keep her out of a certain group, she brought the patient to her office, and the patient became further distressed.

The patient called home, because this had calmed her in the past, but this time, she became increasingly agitated and assaulted Baron.

After the assault, Baron said, "I experienced a whirlwind of emotions, including shame, helplessness, vulnerability, and anger."

Mostly, however, she felt self-blame. "I'd taken responsibility for this patient and for the assault as well," she said.

Baron's supervising psychiatrist and members of the hospital administration were supportive, she noted, yet other staff were not helpful. "Some people didn't want to hear about [the assault]."

One of the things that most bothered Baron about the handling of the assault is that there was no meeting among treatment-team members to discuss the incident or what went wrong. In addition, while supervisors and administrators checked in with her after the assault, after a while," the issue was dropped... people wanted to move on," she said." The message was that [the assault] was better to keep under wraps."

Rutledge, who was assaulted by the same patient a few minutes later, noted that one common reaction of staff who are directly or indirectly involved in patient assault is to scapegoat other members of the treatment team." Those on the treatment team will have a lot of strong feelings toward the patients and one another," she pointed out.

It is essential for team members to meet to process their emotions after the incident to avoid "retraumatizing anyone on the team," she said. Individual treatment-team members may have different views of what happened, she noted, and some of those views are bound to conflict with one another.

Discussing the event with their colleagues will help treatment-team members understand how the incident happened and how to prevent similar ones in the future, Rutledge said.

According to Dan Smuckler, M.D., who also presented at the session, on an interpersonal level the need to distance oneself from danger "may play out in some way at the systemic level"; with hospital administrators it may be evident in policies regarding violent incidents on inpatient units. These may include how quickly patients are transferred off a unit where an assault takes place, or where the patients are transferred.

Smuckler is an assistant professor of psychiatry and behavioral medicine at Albert Einstein College of Medicine.

He pointed out that there may also be problems with communications from one shift to another that prevent crucial information from being passed on about patients and their status.

Staff should be trained about handling possible assaults and other forms of conflict on the unit before these situations happen, he noted. ▪