Various forms of violence by patients against psychiatry
residents—from inappropriate touching and verbal abuse to outright
physical assault—are not rare in training programs.
Moreover, such incidents can be traumatizing, causing some young
psychiatrists to consider leaving the specialty.
Those were tentative conclusions of a nationwide survey of psychiatry
residents regarding incidents of violence in the workplace presented at last
month's meeting of the American Association of Directors of Psychiatric
Residency Training (AADPRT) in Tucson, Ariz.
Marshall Forstein, M.D., who conducted the survey, said the results point
to a problem that may be "flying under the radar" of program
directors. Of particular concern is a finding showing that many residents do
not report incidents to program directors or to security, and the fact that
some respondents said they had been so severely affected by a violent incident
that it caused them to reconsider their choice of specialty.
Forstein is director of adult psychiatry residency training at Cambridge
Hospital in Cambridge, Mass, and is an APA-nominated member of the Residency
Review Committee for Psychiatry of the Accreditation Council for Graduate
Forstein cautioned that the response rate to the survey (approximately 13
percent) was low, and not all respondents answered all questions. Still, the
results are worthy of attention, he said.
"The amount of violence reported in the survey across the spectrum of
severity is significant and really indicates a problem we as program directors
need to think about," Forstein told Psychiatric News."
The rate of reporting [of violent incidents by residents to
authorities] is less than I would have expected and suggests we need to be
thinking about how to get the message across to residents that we want to know
The survey results were presented at the AADPRT meeting in the session"
The Psychiatric Resident Experience of Violence in the Workplace:
Training Issues and Clinical Supervision." Training directors and
faculty at the session, many of whom came with their own vignettes of
workplace violence, agreed that the problem is significant and said it points
to a number of challenges for psychiatric education: how to create systems to
prevent violent incidents or to rapidly de-escalate them when they do happen;
and how to create an atmosphere in which residents can feel supported and
nurtured in the aftermath of a violent incident.
Some participants—echoing resident comments reflected in the
survey—said that while many violent episodes occur in the context of
treating patients having a psychotic episode, the problem is also compounded
by the increasing numbers of antisocial and/or drug-abusing individuals who
may be sent to psychiatric inpatient centers.
The survey was sent to all psychiatry residency training programs in the
United States. Of some 4,700 residents and fellows at programs to which the
surveys were mailed, 570 responded: 349 women and 221 men.
Residents were asked to report the occurrence of the following incidents:
harassing phone calls, threatening phone calls, face-to-face verbal assaults,
threatening e-mails or letters, physical assaults, directed sexual comments,
inappropriate touching, and sexual assaults. (Respondents could indicate more
than one incident.)
The response rate was roughly equivalent across the four years of
residency, ranging from 22 percent to 23.4 percent for all four residency
years. Response rates from fellows in PGY-5, -6, and -7 were smaller, all
under 10 percent.
Respondents covered all geographic regions of the country and all major
The tally came to 327 face-to-face verbal assaults, 187 directed sexual
comments, 113 incidents of physical assault, 106 harassing phone calls, and
three sexual assaults. There were only a few threatening phone calls, e-mails
or letters, and incidents of inappropriate touching.
The survey also asked respondents to indicate in which of the following
settings the incident had occurred: psychiatric emergency department, medical
emergency department, psychiatric inpatient ward, medical inpatient ward,
partial hospitalization program, community outreach program (such as PACT team
setting), or outpatient setting.
The three reported sexual assaults occurred in three settings: a
psychiatric emergency department, medical emergency department, and
psychiatric inpatient unit.
The highest percentage of physical assaults (63.7 percent) occurred in the
psychiatric inpatient unit, while the highest percentage of face-to-face
verbal assaults occurred in the psychiatric emergency department.
Threatening phone calls, e-mails, or letters were most common in outpatient
settings. Community outreach settings recorded the smallest number of
incidents, with one harassing phone call and incident of inappropriate
Residents were also queried about whether and to whom they reported an
incident and the response by the program or institution to the incident. Of
357 residents who responded to this question, most said they reported an
incident to their immediate attending physician (68.1 percent), to another
resident (51.0 percent), and/or to other staff at the site (50.7 percent).
Only 14.9 percent of the 357 respondents reported an incident to the
program director, and only 33.9 percent reported the incident to security.
When asked how supported they felt by their program or institution, 208
residents said they felt "very supported," while 123 felt"
somewhat supported," and 37 felt "not very
Finally, among residents responding to a question about whether a violent
incident had caused them to consider leaving psychiatry, 18 residents
"That worries me," Forstein told participants at the AADPRT
meeting. "I don't want to think we are possibly losing even one
promising psychiatrist because of events like this."
He emphasized that the survey has a number of limitations and that the
results point to any number of unanswered questions.
The survey appears to be the first of its kind: an initial literature
search revealed that past research on psychiatric workplace violence is scarce
and is largely confined to the experience of nursing and milieu staff.
"What we know is that the literature is scarce, violence is
underreported, and this is not a small problem," Forstein said.▪