As evidenced by the Feb. 12 murder of psychologist Kathryn Faughey, PhD (see "A life well lived"), psychologists must be vigilant about keeping themselves--and their staffs--safe.
In fact, psychologists and therapists who have studied the issue say that the profession needs to better recognize and acknowledge the risks, train practitioners in creating more secure environments and prepare students for possible threats before they begin interacting with clients.
That caution is necessary because there is a moderate elevation in risk of violence in people dealing with some mental and emotional disorders, says Phillip Kleespies, PhD, a clinical psychologist at a VA hospital in Boston, who chaired a 2000 Div. 12 (Society of Clinical Psychology, Section on Clinical Emergencies) task force on education and training in behavioral emergencies.
"But it's not off the charts or anything, so we could get too defensive, and inappropriately so, but that having been said, I don't think psychologists think enough about the safety measures that they might have in place, in case things do go awry," Kleespies says. According to the task force report, between 35 percent and 40 percent of psychologists in clinical practice are at risk of being assaulted by a patient at some time during their clinical careers.
Most of these assaults do not result in serious injury, but they are emotionally disturbing.
Other studies suggest that assaults happen more frequently in predoctoral training years, and in psychologists' early careers. In a chapter in a textbook edited by Kleespies, "Emergencies in Mental Health Practice: Evaluation and Management" (The Guilford Press, 1998), authors James D. Guy, PhD, and Joan Laidig Brady, PhD, suggest that newer therapists may be less alert to cues of violence, may set fewer limits and allow aggressive behavior to escalate, and may be more likely to work in inpatient settings with more severely impaired patients.
And, the report concludes, psychologists don't get nearly enough training in how to evaluate potentially violent patients and defuse potentially violent encounters, Kleespies says.
"I think there's a fair amount of denial," says Kleespies, who during his own career has experienced a number of threats and an attempted assault.
At a minimum, say psychologists who study safety issues, practitioners need to consider these important safety factors when working with clients: their office layout, their initial visit procedures and their ability to handle a patient who's become angry or agitated.
An eye for safety
Tips given by a number of psychologists for maintaining a safer office include:
Lock the door. Patients should always need an appointment to get into the main waiting area and be "buzzed" in. A larger practice might also consider a video monitoring system, says Robert Reiner, PhD, a New York clinical psychologist with a staff of two dozen psychologists, psychiatrists and clinical social workers. Every common area in the office is in view of security cameras, with a bank of monitors in view of the receptionist, Reiner says.
Screen potential clients. Conduct an initial assessment to determine every patient's potential for violence, advises forensic psychologist Reid Meloy, PhD. He believes psychologists need to "return to their roots" and use more psychological tests such as the MMPI-2 during the initial client sessions. Meloy also suggests that psychologists should consider using forensic violence risk instruments and also do additional clinical testing.
"I think psychologists overestimate their ability to understand a patient just through their clinical interviews," says Meloy, who authored a textbook about the topic in "Violence Risk and Threat Assessment: A Practical Guide for Mental Health and Criminal Justice Professionals" (Specialized Training Services, 2000).
Develop an officewide evacuation drill. Work out a plan and practice it with your staff and fellow practitioners in case a patient does become violent. The goal should be to remove everyone to safety and calling for help.
Install a "panic" room. Have a secure space inside your practice where staff can retreat and telephone for help.
Give patients a locker. Ask patients to store their belongings inside a locker in the waiting area and give them the key. That way, a patient who might be carrying some kind of weapon in their personal belongings, unknown to the staff, will have it locked up during the session.
While interacting with clients, be sure to:
Give yourself an out. Keep yourself closer to the door, so you can quickly exit if needed.
Be able to call for help. Some offices equip therapists with "panic buttons" that alert other colleagues and staff to a dangerous situation. If there's a serious risk of violence, keep your door open slightly, so that your colleagues will hear if something bad starts to happen.
Allow your colleagues to interrupt. Give your colleagues permission to "pop in" on a session where a patient might be edging toward violence. That's important because if an assault hasn't occurred and a patient is getting "revved up," the presence of another person sometimes helps calm things down, says Gary Schoener, a licensed psychologist who runs the Walk-In Counseling Center, a free clinic in Minneapolis.
Remove potential weapons. Don't have anything that could be turned into a weapon, such as a letter opener or heavy paperweight, within a client's easy reach. Install chairs that are too heavy to be picked up and thrown.
Avoid working alone at night. If you can, don't see patients when everyone else is gone. And always, when you're working with a patient with a potential for violence, make sure someone else is around.
Just as important for psychologists are tips for de-escalating a hostile situation and defending yourself in an attack. Psychologists might want to consider:
Making an excuse. If a client won't calm down and is becoming violent, get out of the room by saying you need to use the bathroom or that you forgot to give a staff member a message.
Learn self-defense techniques. If trying to calm down a client doesn't work, you can't retreat to safety and an assault begins, use basic self-defense techniques to prevent physical harm to yourself, says Walter Bera, PhD, a clinical psychologist who's also a third-degree black belt and teaches self-defense workshops to therapists, including those who work at his Minneapolis practice. Besides learning to step aside from a lunging assailant, Bera says he teaches therapists to break free from an assailant's grasp.
Education and training
Psychologists in small, private practices face additional potential hazards because they often don't have a support staff or fellow practitioners working in the same office.
That's why it's key to become familiar with the risks and how to handle potentially violent patients in predoctoral training. Unfortunately, students are rarely trained in dealing with violent situations.
Laura Gately, PhD, who surveyed more than 200 doctoral students, found that students said their training in the management of potentially violent clients was less than adequate. In fact, they rated training in the phases of a violent episode, intervention strategies and defense techniques as "virtually none" and "poor" (Professional Psychology: Research and Practice, Vol. 36, No. 6).
"When it came right down to it, if [a client] came across the desk at you, what were you supposed to do? During the time of this study, there just wasn't much guidance available," Gately says.
All the more reason, say experts, for psychologists to seek out training for themselves--and always be aware of the risks.
"We don't see ourselves as potential targets, but we are," Bera says.