Assaultive and Destructive Behaviour in a Treatment Setting: Guidelines for the Psychiatrist

Philip R Beck, MD, FRCPC, Renée Roy, MD, CRCPC

This position paper was developed in collaboration with the Canadian Psychiatric Association's Professional Standards and Practice Council and was approved by the Canadian Psychiatric Association's Board of Directors on October 4, 1996.

Introduction

Psychiatric patients, whether hospitalized or ambulatory, have responsibilities as well as rights. As patients, they are expected to participate actively in the treatment process and to respect the rights and needs of others. As citizens, they must abide by the law and may be required to answer for their conduct in court should they commit a crime. Reports in the psychiatric literature describe the reactions of clinicians who have been victims of violence or assault by their patients, suggest techniques for predicting and limiting the risk of violence, and address the issue of prosecution as one of the possible responses. They indicate that acts of violence against the person (for example, assault, death threats, sexual assault) or against property (for example, arson, theft, mischief) are not uncommon in psychiatric settings and require special knowledge, skills, and interventions for their management.

Although treatment settings vary widely in terms of their resources or organization, and although health professionals may have different levels of experience and ways of working, nearly all will have to deal with dangerous situations from time to time. No rules or guidelines can apply equally well in all cases, but certain basic principles should be known and understood by all those exposed to violence or potential violence.

This paper attempts to address some of the issues involved in the management of assaultive and destructive behaviour. It not only acknowledges the importance of clinicians' containing and controlling the expression of violence in the treatment setting but also stresses the need for the proper training of staff in identifying and limiting potential risk factors. It reinforces the need for all patients, as well as members of the treatment team, to be aware of their roles and responsibilities in the treatment process and of the consequences of unacceptable behaviours when they occur.

Some Basic Considerations

Violent incidents may take place in emergency rooms, on psychiatric wards, in outpatient clinics or private offices, during home visits, or in community clinics; they may vary from relatively minor verbal expressions of hostile intent to serious, life-threatening attacks with resulting injury or death. Patients with a wide variety of psychopathologies may behave violently, with or without provocation and with or without warning. Whatever the circumstances, the result is a situation characterized by alarm, a high level of emotion and, quite often, a sense of confusion and ambivalence about how to proceed.

A number of psychiatric patients are difficult to treat because they do not comply with treatment, miss appointments, fail to take their medications, or are unable to form an adequate working alliance with their therapists. Some behave in ways that jeopardize the health or safety of others. Their illnesses or their character structures result in high levels of aggression and poor impulse control. Unfortunately, despite our best intentions and plans, crises cannot always be foreseen or prevented because human behaviour is often unpredictable. Even in the best-organized setting and even with highly skilled treatment teams, violent incidents will occur and must be managed.

When patients' behaviours threaten the physical integrity of others around them, it can be difficult for the treating clinician to maintain a sense of fairness and objectivity. Strong countertransference feelings tend to complicate the management of already stressful and anxiety-provoking situations. Denial, identification with the aggressor, fear, anger, and feelings of helplessness or guilt all may be prominent features. In circumstances such as these, there may be a risk of overestimating or underestimating the potential danger or the urgency of the crisis. The treatment team members may find themselves ambivalent or divided in deciding upon an appropriate course of action.

Staff may feel that stricter limit setting, the use of restraints or seclusion, the withdrawal of privileges, or the involvement of the legal system could be harmful or untherapeutic for the patient. Because of their own personal experiences with violence or because of their concern that limit setting might provoke further acting out, the responses of different team members in high-risk situations may vary considerably. Some staff members may become excessively alarmed and fearful while others may tend to play down or deny danger even when immediate action is called for.

When the victim's relationship to the patient-aggressor is that of caregiver, management decisions become particularly difficult. The clinician may fear direct retaliation by the patient, may fear being seen by peers as being incompetent or unfair, or may experience inner conflict and guilt for having given up the traditional nonjudgemental attitude toward the patient.

The victim of a violent act may be a member of the treatment team, but this is not always the case. Clinicians uninvolved in the patient's treatment, nonclinical staff members, other patients, family members, visitors, or friends may find themselves victims of violence. These situations are equally serious from a personal or legal point of view and may evoke strong countertransference reactions even from the treatment team.

Quite apart from the initial responses designed to reestablish control and safety for staff and patients, there are important issues to be dealt with once the immediate crisis has been resolved.

Management following Episodes of Violence

Regardless of the details, certain issues must be addressed following an episode of assaultive or violent behaviour. After the immediate crisis has been contained and the safety of patients and staff assured, clinical issues must be addressed and a treatment plan put into place. What needs to be done at that point?

The Patient

In every case of violence or assault, a careful reassessment of the patient's mental status should be carried out. All aspects of the patient's mental functioning should be assessed, including the possibility of further violent behaviour. From a clinical point of view, the team should review the patient's treatment plan regarding security measures, pharmacotherapy, psychotherapy, and behavioural approaches, seeking a second opinion when doubt exists. It is extremely important that the treatment team develops a meticulous plan for continuing care, taking special precautions to prevent a recurrence of the violent behaviour. The patient has the right to receive the care and protection required by his or her condition, but staff and other patients also have the right to feel safe and secure. All involved should have an opportunity to work through their feelings and reactions surrounding the violent episode.

In order to reduce potential untoward responses and reactions, clinicians can establish a framework within which the patient-aggressor and the situation may be evaluated as rapidly and objectively as possible. Clearly, every incident must be assessed on its own merits, but the analysis should at least include variables such as a previous history of violence, precipitants, the severity of the incident, the degree of stress or provocation, the consequences of the incident on the victim, previous treatment attempts, the psychiatric diagnosis, and the motivation for the violent behaviour, as well as the risks and benefits of laying charges for the patient, the victim, and the clinical team.

Management decisions should never be based solely on one or 2 factors. For example, considerations of diagnosis are pertinent but do not always provide a clear guide as to how to proceed. Whether a patient is psychotic or is suffering from a personality disorder may be relevant, but the significance of the diagnosis in determining what limits to set or what actions to take may not always be obvious. For example, some patients, although suffering from psychotic disorders, can be helped greatly when the legal system is called upon to reinforce compliance with treatment. By contrast, some patients with personality disorders are best helped by avoiding involvement with the courts.

The Clinical Team and Setting

Since treatment settings differ widely in their structure and organization, it is not possible to develop management guidelines that have universal application. Depending on the context, certain patients who have been violent should be transferred to another unit; others might remain but with conditions. The patient's interactions with the victim, however, should nearly always be limited or curtailed. If the victim was the primary caregiver, his or her role usually should be transferred without delay to another clinician. Here again, there may be exceptions to the rule; each situation must be judged on its merits.

In therapeutic settings, it is useful to provide sessions for other patients to ventilate, to ask questions, to hear again what constitutes acceptable behaviour on the unit and what does not, and to be reassured of their safety and welfare. Individuals particularly disturbed by expressions of violence should be given additional time and attention until they feel more settled. Suggestions regarding the prevention of violence in the future should be elicited and taken into consideration.

Staff must also be given proper attention. The role of caregiver is demanding and complex. The personal needs of team members are usually subordinated to the needs of the patient, and many staff members are reluctant to seek help and support, even after having been involved in severely stressful situations.

Victims of Violent Behaviour

Victims of aggression often require special help and attention. Continuing support and assistance to them is not only appropriate but essential. Clinicians who contemplate pressing charges against patients must be able to assess the pros and cons of taking legal action, must know how to initiate legal procedures, and must be aware of what must be done once the judicial system has become involved.

Prevention

Prevention is always preferable to cure. Although one cannot predict violent behaviour in a reliable or systematic way, it is possible to assess risk through the evaluation of a patient's history and background and with an appreciation of clinical and situational factors known to be associated with the increased likelihood of aggressive behaviour. In any treatment setting, the institution and its clinical staff should be properly organized to provide a secure environment in which violent or potentially violent behaviour is unlikely to occur or can be rapidly detected and controlled if it does occur. Staff should be proficient in the use of physical and pharmacological restraints and should be trained to manage anger, interpersonal conflict, and stress. They should be familiar with each patient's condition, background, previous history of violence or substance abuse, and other factors that might be predictive of violence. They should be expert in the use of the clinical team as a treatment tool and as a vital resource in the management of difficult or dangerous situations. They should also know their own weaknesses and limitations and feel comfortable in seeking assistance and support well before crises develop.

Depending upon the circumstances, advance precautions should be taken to ensure the safety of both patients and staff. In the emergency room or outpatient department, interviews with potentially violent individuals should be held in rooms that are stripped of dangerous materials, that permit easy exit, and that are large enough to allow the presence of other staff members. When interviews must be conducted by a single staff member, other staff should be advised in advance of the possibility of problems so that they are ready to assist immediately if required. Similarly, home visits should be planned with considerations of safety clearly in mind.

Staff should always be aware of the types of behaviour that will not be tolerated, should set clear and explicit limits for patients at the beginning of their treatment, and should ensure fair and consistent enforcement of limits by all members of the treatment team. In hospital settings, support staff, including members of the security and communications departments, fire marshals, and others involved with safety, should be properly trained in the prevention and management of violent situations. Everyone should be familiar with the institution's policies for the management of unacceptable behaviours and should be aware of all current policies, procedures, and protocols provided by the institution's administration. Specific guidelines should be established by the treatment team and the administration with respect to legal actions.

The Legal System

If legal action has been initiated, clinical staff should ensure that the victims are supported throughout the process. Victims will have to be present in court and through all stages of the legal process, which could take months. They may be subjected to a variety of pressures and reactions from the patient, the treatment team, police, and lawyers. Support to them includes showing genuine concern for their feelings and sensitivities and providing reassurance regarding their decision to press charges.

When an incident occurs in an institution, the administration must be informed immediately if legal action has been contemplated or taken. All members of the treatment team must also be notified of the decision to press charges. The most appropriate staff member or administrator (not the victim) should inform the patient that a complaint has been filed and that the police will be coming to investigate. Recognizing that the patient has a right to counsel, staff should facilitate contacts with a lawyer when requested.

Efforts should be made to cooperate with law enforcement personnel, making them aware of the importance of attributing the proper degree of responsibility to psychiatric patients for their actions and helping them to understand the relationship between mental illness and behaviour. All concerned individuals (patient, victim, members of the treatment team, hospital authorities) should be informed of developments at each stage of the process. It should be ascertained that the patient fully understands the legal action undertaken. As in any criminal case, fitness to stand trial should be evaluated by the court during the proceedings.

Following a legal action, clinical staff should ensure that everyone involved has been informed of the outcome of the proceedings and is cooperating with those provisions of the judgement affecting the treatment program.

Follow-up

Whether or not there have been legal proceedings, clinical staff should ensure that treatment continues in the most appropriate context possible. Here again, a second opinion from a previously uninvolved clinician may be required. When appropriate, this consultation may be done through clinical discussion and without necessarily interviewing the patient. If the patient remains in the original treatment setting, staff must continue to review the treatment plan regularly, consulting early when problems, doubts, or anxieties arise.

Care should be taken to ensure adequate and timely discussion with the aggressive patient, other patients, and members of the treatment team of the effect, both immediate and delayed, of the disturbed behaviour on the treatment setting. Even after a violent episode has been resolved, involved parties may need reassurance that a secure, nonpunitive, therapeutic environment has been restored and is being maintained.

Difficulties arising during or as a result of the violent episode or as an effect of any legal proceedings should be discussed and evaluated by staff during follow-up so that similar problems might be avoided in the future. Administration should also review its policies and procedures regarding the management of offences committed by psychiatric patients, insisting on the involvement of clinicians in the subsequent development or revision of all policies that have a direct effect on patient care.

Conclusion

Crises, although unpleasant and stressful, often provide useful learning experiences if they are handled properly. Although no 2 situations involving assaultive behaviour or violence are identical, certain general principles for managing them apply in nearly all cases. The Canadian Psychiatric Association recommends that the guidelines suggested in this paper be followed when violence occurs in a treatment setting. Particular attention should be paid to protecting the patient's rights when legal action is considered clinically and ethically appropriate. Preventive measures, including the adequate training of staff in the assessment of risk and in the management of potentially dangerous situations, should be given high priority in all treatment settings that provide care to seriously disturbed patients.

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