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Risk Management

Working with violent and potentially violent individuals can be a stressful and anxious experience. A sense of helplessness, fear for personal safety, and concern about being held liable for the consequences of destructive behavior can inhibit the development of an effective therapeutic relationship. Fortunately, there are some practical steps one can take in dealing with such individuals.

1. Deal candidly with patients regarding issues of confidentiality. Despite the obvious significance of confidentiality to the effective operation of the psychiatrist-patient relationship, there are times when a psychiatrist is obligated to disclose confidential information. The patient should be made aware of these limits. Some practitioners may be concerned that such candidness might contribute to a defensive posture on the part of the patient, especially adolescents. Dr. Henry Gault, spokesperson for the American Academy of Child and Adolescent Psychiatry, disagrees: "From a therapeutic point of view it gives the youth a very powerful message. It’s saying ‘I’m on the side of health and safety and protecting you.’"

2. Be alert for signs of potential violence. When interviewing or treating patients, perform appropriate assessments. Inquire about past anti-social or violent acts, access to weapons, violence in the home, homicidal ideation, etc. "The best risk management is to have a high level of suspicion for children who talk about violence and who write about violence either in poetry or diaries or express it to other peers and adults," says Dr. Ellen Fischbein, a psychiatrist in Waterbury, Connecticut. In addition, says Dr. Gault, "[Those] who do not typically deal with children or adolescents may have a tendency to say that this is just adolescent talk when they are seeing an 11 or 12 year old. Those of us who deal with kids all the time know that you have to take what they say seriously regardless of their age. Young kids do commit suicide, and, as we’ve seen, young kids commit homicide."

3. Engage in careful decision-making. As with any patient, assure that decision-making about treatment, hospitalization, discharge, passes, etc., is thorough and appropriate. Make attempts to obtain past records so that you will have full information. Document all attempts to obtain records. Also document a patient’s refusal to consent to the release of other records or to the contacting of prior/other treaters. If a patient refuses to allow you access to information, you should seriously consider whether or not you can work therapeutically with the patient. Where significant doubt exists about treatment decisions, consult with a colleague.

4. Be willing to commit if necessary. Many psychiatrists view civil commitment as a procedure to be used only in the most extreme cases, if at all. The failure to commit a patient who subsequently becomes violent may lead to the psychiatrist being held liable for injuries caused by the patient. Know the standards and procedures for civil commitment in your state. Document that you have considered the option of civil commitment and the clinical basis for rejecting or proceeding with that option. As with any treatment decisions, consult with a colleague if necessary.

5. Give warnings when appropriate. As discussed previously, most states require psychiatrist to warn identifiable potential victims when a realistic threat has been made. Know the standards and procedures related to the duty to warn in your state. If necessary, consult an attorney knowledgeable in this subject.

6. Make sure that post-discharge treatment plans are being followed. Many times, hospitals and psychiatrists who treat hospitalized patients view their responsibility for a patient as ending when the patient is discharged. When dealing with a potentially violent individual, such an attitude is legally perilous. In particular, the discharge summary should fully address the issues of potential violence. Furthermore, the discharging hospital or psychiatrist should set up a mechanism whereby the outpatient facility or doctor notifies the hospital and psychiatrist if the patient does not follow through with the recommended outpatient treatment. If plans are not being followed the hospital and psychiatrist should assess what options are indicated: Is it possible to re-hospitalize the patient? Are warnings now indicated? Should the family be contacted? If there are no other options, should the police be notified?

The follow-up psychiatrist also bears responsibility for seeing that discharge plans are followed. If you know that a recently discharged individual is scheduled to see you, keep track of whether or not the individual is complying. Document your attempts to get the individual to comply with the treatment plan. If a patient is not keeping appointments or taking prescribed medication, assess what options are indicated and take action based upon your evaluation of the patient’s potential for violence.

7. Stress responsibility to patients and their families. Where appropriate, get family members involved so that they understand their obligations to deal with potential violence. The necessity of treatment, medications, a stable environment, etc., should be stressed. Especially when working with minors, it is important to be aware of what other entities are involved, for example schools, courts, and government agencies. It may be appropriate to involve them in the treatment planning. They may also be useful sources of information about the patient, both historical and on-going information.

The appropriate people should be advised about what to do if the patient begins to escalate or destabilize. For example, sometimes teachers, classmates, a social worker, parents, or others who know or work with an individual who acts out violently, will claim that there were signs of the impending violence. However, they often do not know how serious the signs are or what steps to take when they are aware of them. Be as clear as possible about when you should be contacted and when other interventions should be used. Also, establish alternative plans for who may be contacted when you are not available.

8. Assure that documentation is accurate and complete. Record keeping has become an increasingly burdensome and often mechanical endeavor. Nonetheless, when dealing with a patient who presents signs of potential violence, careful and thoughtful record keeping is essential. Document all assessments, evaluations, and actions taken (and why) and those rejected (and why). Document instructions and information given to the patient and the family. Also note whether or not they agree with the treatment decisions, as well as non-compliance with treatment recommendations.

9. Be mindful of the safety of the yourself and staff. Risking personal safety is a fact of working with violent and potentially violent patients, especially in an outpatient setting. There are, however, ways in which to reduce the risks. For example, see patients only during business hours; decide when it is appropriate to see patients in your office as opposed to in the local hospital Emergency Department; have procedures in place to deal with violent outbursts; and, discuss your concerns and ideas with your officemates. As Dr. Marilyn Benoit, a Washington, D.C. psychiatrist explains, "If a parent calls and describes a child who has already hit a couple of adults in the house who are supposed to be authority figures and the child is on the phone cursing me out, I don’t want to see that kid in my office. That is not good risk management."

Document the steps you take to address safety concerns. If such documentation is inappropriate for patient records, consider incorporating the documentation into your office policies and procedures.

10. Reduce your risk of liability when providing education and consultation about violent behavior. Many schools are hiring psychiatrists to participate in workshops to educate teachers and childcare workers about how to identify the signs of potential violence in their students. Psychiatrists are also being asked to teach students and teachers conflict resolution techniques in an attempt to prevent violent situations from erupting. A psychiatrist in an educational and consultative role should make it clear that he or she is discussing the topic in general and is not giving advice that is relevant to a particular student or individual.

Some schools are now requiring a letter from a psychiatrist before a student who has made violent threats or engaged in violent behavior may return to campus. If you are asked to write such a letter, it should be done only after a comprehensive evaluation of the student and his or her situation. Be cautious not to predict or guarantee the future actions of a student because such prediction is unreliable and you may be held responsible for the consequences of such predictions.

11. Stay informed about professional developments in the prevention and treatment of violent behavior. The problem of violent behavior is receiving increased attention from healthcare professionals and researchers as well as from the media. New interventions for the prevention and treatment of violent behavior in both children and adults are being proposed, researched and recommended. The accepted legal standard of care will be influenced by the development of these new treatments and interventions. Psychiatrists are responsible for keeping up with the advancing standard of care.

Conclusion

Psychiatrists are not responsible for perfectly predicting patient behavior when working with violent and potentially violent patients, but psychiatrists are responsible for meeting the accepted legal standard of care. In other words, the best risk management strategy is good clinical judgment. Despite the above advice, it is still necessary to realize that the exercise of good clinical judgment must remain paramount. Dealing with potentially violent patients is a very difficult clinical responsibility. There is no doubt that, no matter how skilled and careful patients are, some violence by present and former patients will occur. Where it appears that risk management precautions are an impediment to effective therapeutic management, the psychiatrist must weight the pros and cons and then choose what he or she believes to be the best course of action.

Sources:

Committee on Psychopathology of the Group for the Advancement of Psychiatry, "Taking Issue: Confronting Violence." Psychiatric Services. Vol. 49, No. 7., (July 1998).

Kaplan, Arline. "Violence Prevention Seeks to Save American Children." Psychiatric Times. Vol. XV, No. 8, (August 1998).

Legal and Risk Management Issue in the Practice of Psychiatry. Psychiatrists’ Purchasing Group, (1994).

Mitka, Mike. "Medical Groups Say Physicians Can Help Keep Kids From Killing." JAMA, Vol. 279, No. 23, (July 17, 1998).

The previous article appeared in Psychiatric News, October 2, 1998.