Violence: incidence and frequency of physical and psychological assaults affecting mental health providers in Georgia
IT HAS BEEN KNOWN FOR SOME TIME that mental health professionals are not immune from physical and psychological trauma and its potential sequelae (Jayaratne, Vinokur-Kaplan, Nagda, & Chess, 1996; Lion, Snyder, & Merrill, 1981; McFarlane & van der Kolk, 1996; Whittington & Wykes, 1989). Such trauma may include posttraumatic stress disorder (Caldwell, 1992), burnout (Patrick, 1981), vicarious victimization (Pearlman & Saakvitne, 1995), and compassion fatigue (Figley, 1995). The acts of violence and the results thereof constitute a serious problem for mental health professionals. One way to address the situation would be for professionals to become more familiar with the issues relating to workplace violence and to learn how to cope with them.
During the past decade, professionals have viewed violence as a real but poorly acknowledged occupational hazard in mental health facilities. Data collected over a 1-yr period revealed that 1.9% of psychiatric hospital staff in a California forensic state hospital--primarily male mental health technicians-- were injured by patients (Carmel & Hunter, 1989). However, a rise in the incidence of violence in the United States (Lanza, 1983) combined with an increase in the number of professionals in the mental health field have increased the likelihood of danger to mental health professionals. In fact, recent statistics gathered by the Bureau of Justice between 1992 and 1996 indicate that in the field of mental health there are 80 nonfatal workplace experiences of victimization per 1,000 workers nationally, per year. This rate of victimization experiences is higher only for police officers, security guards, taxi drivers, prison guards, and bartenders (Warchol, 1998). By comparison, the victimization rate among non pychiatric physicians is 15 incidents per 1,000 workers nationally, per year. This trend toward increasing victimization of mental health professionals is a topic that is worthy of closer examination.
Researchers who have investigated violence in mental health settings have focused primarily on six factors: the definitions of violence, the victims (i.e., nurses, psychiatrists, social workers, marriage and family therapists, and psychologists), the incidence of violent acts, the location of violent acts, the reliability of the reports, and the aftereffects.
Definitions of violence. The definitions of violence perpetrated on mental health professionals have been inconsistent (Whitman, Armao, & Dent, 1976), although Brizer, Convit, Krakowski, and Volavka (1987) developed a rating scale to quantify the nature and frequency of violent incidents. Violence has been defined in terms of categories such as (a) physical violence, verbal threats, and property violence (Schultz, 1987); (b) physical assault (Lion et al., 1981; Whittington & Wykes, 1994); (c) different forms of assault, such as aggressive physical contact with aggressive intent (Whittington, Shuttleworth, & Hill, 1996); (d) an "act or situation in which there is severe and intense exercise of force and power in a direct attack resulting in physical injury or loss of psychological integrity" (Van-Soest & Bryant, 1995, p. 549); (e) "any behavior that could physically damage a person or property" (Kelsall, Dolan, & Bailey, 1995, p. 151); and (f) "any physical contact by a patient that results in a staff member f eeling personally threatened" (Poster & Ryan, 1989, p. 315). Violence has also been defined as physical contact such as striking, kicking, pushing, or scratching (Krakowski, Czobor, & Chou, 1999; Lanza, 1988); sexual assault (Flannery, Hanson, Peak, & Flannery, 1994); verbal assault, such as curses, insults, and threats (Krakowski et al); and "physical injury defined as bruises, cuts, or some other external or internal injury, close calls, near misses defined as those incidents in which the worker was able to dodge or escape injury, and verbal threats" (Horejsi, Garthwait, & Rolando, 1994, p. 175).
The victims. No group of mental health professionals has been immune from violence. In fact, Whitman et al. (1976) concluded that every mental health professional would be assaulted by a patient at some time during the professional's career. There are few recent studies that provide the numbers or percentages of professionals who have been physically attacked. Bernstein (1981) reported that 14% of psychiatrists, psychologists, clinical social workers, marriage and family counselors, and child counselors in a San Diego county had been threatened or assaulted during the course of their careers. Psychiatrists have been frequent victims (Madden, Lion, & Penna, 1976; Whitman et al., 1976), and nursing personnel in psychiatric hospitals have been victimized to an alarming degree (Appelbaum & Appelbaum, 1991; Lanza, 1988; Whittington & Wykes, 1994). Psychologists have also experienced victimization (Guy, Brown, & Poelstra, 1990; Tryon, 1986), as have social workers (Ellwood & Rey, 1996; Horejsi et al., 1994; Newhill , 1995; Schultz, 1987).
Incidence of violent acts. A number of studies have reported the incidence of violence toward mental health professionals, but none has reported the frequency of threats by patients toward staff (Flannery, Hanson, & Peak, 1995). Twenty-six years ago, 43% of 53 psychiatrists who were surveyed reported that they had been victims of violence perpetrated by their patients during a single year (Whitman et al., 1976), and in another study, 42% of 115 psychiatrists reported that they had been attacked at some time during their lifetimes (Madden et al., 1976). Whitman et al. reported that only 1.9% of the patients who were being treated by psychiatrists, psychologists, and clinical social workers were perceived to be threatening, yet 0.63% of them had assaulted their therapists. It is interesting to note that in the study by Whitman and colleagues only 24% of the professionals who were surveyed reported that they had been attacked by at least one patient during the year. A national survey of 340 psychologists reveale d that 39.9% had been attacked and that 49% had been verbally threatened with a physical attack (Guy et al., 1990). Tryon (1986) surveyed psychologists in private practice and reported that during their careers 81% had experienced assaults, which included physical attacks, verbal abuse, and harassment.
Location of violent acts. Most research has been limited to hospital settings, where the victims of violence have been psychiatrists (Dubin & Lion, 1993; Madden et al., 1976; Ruben, Wolkon, & Yamamoto, 1980), social workers (Ellwood & Rey, 1996; Horejsi et al., 1994; Newhill, 1995; Schultz, 1987), and nursing personnel (Appelbaum &Appelbaum, 1991; Helmuth, 1994; Lanza, 1983, 1988; Lanza, Kayne, Hicks, & Milner, 1991). Most violence toward psychiatrists occurs in psychiatric emergency rooms and in inpatient units (Dubin & Lion), where the risk appears to be greater during meal times (Carmel & Hunter, 1989; Flannery, Hanson, & Penk, 1994). There has been very little investigation into violence against licensed psychotherapists or counselors in outpatient settings.
Reliability of reports. Levin, Hewitt, and Misner (1998) found that injury rates related to violence are based on data that are obtained from current reporting systems such as workers' compensation reports and hospital incident reports. The latter are assumed to be more accurate sources of data than relying on long-term memory. Researchers who study assault incidents have typically used reviews of nurse reports, patients' charts, and interviews with those who were present during the incidents as the sources for their data. But although the reports are perceived as being reliable, they often underrepresent the true prevalence of violence in the workplace (Bensley, Nelson, Kaufman, Silverstein, & Kalat, 1993; Hewitt & Levin, 1997; Lanza & Campbell, 1991; Lion et al., 1981; Liss & McCaskell, 1992). This underrepresentation was exemplified in an official report of violent acts in which the number of assaults reported by mental health staff was found to be almost five times lower than the actual assaults suffered by other hospital personnel (Lion et al.). Some mental health professionals in hospital settings did not report being assaulted because they were not encouraged by the administration to do so (Norris, 1990), they feared reprisals by the perpetrators later at their private residence (Nelson, 1983), they expected that they would be viewed negatively by colleagues and managers, or they didn't expect any positive outcome from reporting assaults (Littlechild, 1995; Protherough, 1987; Woody, 1996). The failure to acknowledge the seriousness of workplace assaults has also affected the accuracy of the data that are gathered. This fact has prompted some authors to emphasize that staff members should be properly educated about the risk and incidence of work-related assaults (Poyner & Warne, 1986).