Guidance for Working With a Patient Who Elicits Fear in the Psychiatrist

Abstract

While it is clear that most societal violence is not due to mental illness, there is conflicting evidence regarding whether mental illness itself increases violence risk. 1 Nonetheless, variables associated with mental illness, particularly substance abuse, have been shown to be predictors of violence. 1 As such, psychiatrists do treat individuals at risk of violence and are at times themselves at risk. The rate of nonfatal violent crime against mental health professionals is more than 5 times that for all occupations. 2 While underreporting of assaults seems prevalent, more than one-third of psychiatrists report having been physically assaulted at least once, and psychiatrists in training seem particularly vulnerable. 2 This article provides guidance to psychiatrists and other mental health clinicians regarding working with a patient who evokes anxiety and fear in the clinician regarding their own physical safety or the safety of others. This may involve overt aggression or violent behavior, explicit or implicit threats of violence, or stalking behaviors. The encounter with a patient who elicits fear can be immediate, such as an extremely agitated patient in an inpatient unit, or fear can emerge over time, such as when a psychiatrist is treating an individual as an outpatient who they fear could harm them despite the absence of evidence of imminent risk. This guidance provided in this article applies to both types of encounters.While psychiatrists experience anxiety and fear when treating patients with suicidal ideation, the quality of the anxiety and fear is different and more personally disturbing when clinicians fear for their own safety or that of their loved ones. Clinicians may also feel anger at the patient or feel helpless to effectively intervene. Defenses such as denial, reaction formation, or withdrawal may interfere with the clinician's recognition and management of risk. A clinician's emotional reactions and clinical judgment can be distorted when interacting with a patient whom they fear.The approach to working with a patient who elicits fear begins with conducting a violence risk assessment, assessing both static (eg, violence history, psychopathy, head trauma, male sex) and modifiable dynamic risk factors (eg, substance use, impulsivity, access to a weapon, psychosis, treatment nonadherence) initially and over time, ideally using a structured assessment tool that incorporates professional judgment. 3 Structured assessment tools help to guide the systematic assessment of risk factors but to date have only low to moderate positive predictive value, limiting their clinical utility in identifying those at increased risk. 4 The modest success associated with such tools presumably contributes to the anxiety and fear that clinicians may experience.Identification of interpersonal risk factors "associated with the relationship between the clinician and the patient, particularly when the relationship is… emotionally intense… or has particular psychological meaning to the patient" 5 may be particularly rele...