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