“Are you sure?” He hadn’t slept well last night. “Of course, I’m sure. You know the secret and they want you dead. Don’t you see? It’s a plot to kill you. You must get them first.” “My knowing the hidden secret of Peterbus has been such a burden. No one believes me.” “Wrong. They all believe you, which is why they want you dead. The secret gives you power over them. Get them first. It’s kill or be killed.” With that Henry lurched forward onto the back of the nurse and began assaulting her. The voices were right. The nurse was in on the plot to kill him. He had to strike first.
This episode of assault was precipitated in a patient with paranoid schizophrenia where voices in his head (auditory hallucinations) were telling him to harm others. Research (1, 2) has demonstrated patient assaults on staff on both psychiatric and medical wards to be a worldwide occupation health hazard. Health-care providers are not the only victims of this form of workplace violence. Police, emergency medical services, paramedics, teachers, and others are victims of assault by suspects, patients, students, customers, domestic batterers, and disgruntled employees. This victimization is true for both genders, all races, all creeds, and all socioeconomic classes. Level of education and length of experience do not preclude being victimized. This violence results in the obvious costs of possible death, disability, medical expense, sick leave utilization, industrial accident claims, legal costs, lost productivity, and poor morale. It also results in the not so obvious cost of psychological distress, including the severe stress of psychological trauma.
There are many helpful strategies to reduce the risk of this violence (3). Skills used (singly or in combination) in self-defense, scene surveillance, awareness of the early warning signs of loss of control, nonverbal communication skills, verbal communication and de-escalation strategies, use of restraints, and alternatives to restraint can enhance workplace safety. However, they will not prevent all workplace assaults from erupting. When violence occurs, most individuals and organizations know how to implement the necessary medical and legal tasks to restore some semblance of normality to the staff victim(s) and the worksite. Unfortunately, many organizations either do not address or do not address adequately the not so obvious issue of the employee victim’s psychological distress, anxiety, fear, and even terror.
The purpose of this essay is to review both the issue of the employee victim’s psychological trauma and to present a detailed discussion of a psychological counseling program for victims of violence to address that psychological trauma. Known as the Assaulted Staff Action Program (ASAP), ASAP is the most widely researched crisis intervention program in the published literature for assisting with the psychological aftermath of trauma and has been efficaciously assisting employee victims of assault for twenty-two continuous years of service (2).
Sound physical and mental health are based on adequate functioning in the three domains of reasonable mastery, caring attachments to others, and a meaningful purpose in life. Reasonable mastery includes the skills to shape the environment to meet our needs. Caring attachments to others are the supportive interpersonal relationships to others that we have at home, at work, and in the community. A meaningful purpose in life refers to what is important to us in life. It is the reason that we want to get up in the morning and invest our energy in the world about us. With these domains in place, we enjoy life and are able to weather its inevitable ups and downs. When these domains are in disarray, our sense of well-being and interest in life is considerably lessened. Anxiety, depression, and physical illness may follow. Psychological trauma may seriously disrupt the domains of good health with resultant psychological and physical distress.
Psychological trauma is the body’s psychological and physical response to a sudden, usually unexpected, life-threatening event over which the person has no control, no matter how hard the individual tries. Traumatic events may include actual or threatened death, serious injury, or the threat to the physical integrity of the individual or others. Common examples include natural and man-made disasters, homicides, rapes, robberies, assaults, terrorist events, hostage-taking, severe verbal abuse, and the like. These events need to result in an intense state of fear that would distress any reasonable person. One may become a victim of violence in one or more of three ways: by direct acts, by witnessing traumatic events to others, and/or by being told by victims what has happened to them.
Psychological trauma may disrupt any or all of the domains of good health. By the definition of trauma, victims loose reasonable mastery as they have no control over what is happening to them. Caring attachments are also likely to be disrupted. The victims withdraw from others as the world and its people seem unsafe. At the same time, the nonvictims realize just how tenuous their links are to life and become understandably distressed. They withdraw from the victims and they blame the victims for the misfortune that has befallen them. Such victim-blaming provides the illusion that the nonvictims would not be so foolish as the victims were and, thus, the nonvictims would not be victimized. Lastly, a victim’s meaningful purpose in life is shattered by the traumatic event. The world does not appear safe, orderly and predictable and it does not appear worthy of investing energy in it.
In addition to the disruptions of these three domains, psychological trauma, like any medical condition, has symptoms that manifest traumatic distress. As with the domains of good health, the symptoms of psychological trauma are also three in nature: physical, intrusive, and avoidant symptoms. The physical symptoms are in part the result of an adrenalin rush at the time of the crisis and may include an exaggerated startle response, hypervigilance, sleep disturbances, trouble with concentration, and mood irritability. Intrusive symptoms refer to memories of the event. These may include nightmares, thoughts, daydreams, and symbolic reminders. Intrusive symptoms are the brain’s way of trying to heal itself by reviewing what has happened so that the individual is better able to cope, should it ever happen again. However, the memories are so unpleasant to many victims that they find strategies to put these intrusive memories out of conscious awareness and recovery is delayed. Avoidant symptoms are behaviors that result in withdrawal from the site of the traumatic event. However, over time if the traumatic incident is left untreated, victims withdraw more and more from all forms of daily life activities.
There are stages in aftermath of a traumatic incident that unfold over time. In each stage, if the victim does not receive adequate treatment, one or more of the disrupted domains of good health and/or one or more of the three categories of symptoms will be present. The first stage is the acute phase in which the traumatic event happens and the victim’s functioning is negatively impacted. In these initial days, the victim attempts to restore mastery, attachment, and meaning and to calm down and reduce the physiological distress. The victim may withdraw. The acute phase may last for thirty days. By medical convention, on the thirty-first day, if the victim is still experiencing disruptions in the domains and/or the presence of symptoms, the victim has developed posttraumatic stress disorder (PTSD). If left untreated, the disruptive domains of good health and the symptoms of trauma will last until death. As the avoidance symptoms continue to generalize, the victim’s quality of life will be greatly reduced until that death. Effective treatment is needed to avoid these bleak outcomes.
The Assaulted Staff Action Program (ASAP)
Assaulted Staff Action Program (ASAP), (2, 3) is a voluntary system-wide, peer-help crisis-intervention program to address the psychological aftermath of acute traumatic violence. It is voluntary in that no employee victim is required to use ASAP. It is system-wide in that the ASAP-team facilitator responds to every incident of violence, even when ASAP services are declined. This visible presence at each incident provides a strong reminder of administration and union support and appears to play a crucial role in subsequent declines in violence, as we shall see later on. ASAP is a peer-help program in that the ASAP counselors are themselves members of the work force at risk for the same types of violent occurrences. The peer-help approach also minimizes potential role conflicts, such as a supervisor providing ASAP services to a supervisee. Finally, ASAP is a crisis-counseling approach based on intervention principles first devised during World War II in Great Britain for Blitz/air-raids victims, and since expanded in psychiatry and psychology in subsequent years (2). Although ASAP was originally developed for staff who were victims of patient assaults in health care settings, the ASAP model is flexible and can be adapted for any setting where violence is a frequent visitor.
ASAP Structure: The prototypical ASAP team structure includes ASAP first responders. These staff are oncall by beeper; go to the site of the incident; offer services; and then provide the counseling, if ASAP services are accepted. ASAP teams next include ASAP supervisors. The supervisors provide consultation to first responders in complicated cases; provide back-up, if more than one incident occurs at a time; and co-lead the ASAP group interventions noted below. Lastly, each ASAP team has a team leader(s). The leader is responsible for the quality management of all services provided by ASAP, oversees the day-to-day functioning of the team, sees that on-going in-service training is provided to ASAP team members, co-leads ASAP group interventions, and provides counseling to the team members if they become victims themselves. Team size varies depending on the number of employees, the number of potential sites where violence could erupt, and the number of such incidents in a given year.
ASAP Functions: ASAP offers five basic services: individual crisis counseling, group counseling, a staff-victims support group, staff victims family crisis counseling, and referrals for continuing care to therapists trained in crisis counseling as indicated. Individual crisis counseling is provided to employees who have been victims singly. (See below for specific individual interventions.) The ASAP-designed group crisis counseling is provided in situations wherein multiple employees are victims of the same violent episode. Frequently, there is a group intervention for the managers involved alone; a second group for both managers and staff; and a third group intervention for managers, staff, and patients. The staff-victims support group provides additional support to employees for whom the original intervention was not fully effective. Those needing the staff-support group are usually employees who have a past history of victimization. Employee-victim family counseling is to assist in situations where spouses, significant others, family members, and children may be frightened by what has befallen the employee victim. Single-parent children may fear being left as orphans. Finally, in cases of victimization not related to work but whose intrusive memories have been stirred by the present work-site incident are referred to therapists who are known to be trained in treating psychological trauma. All ASAP services are free of charge. If an employee victim chooses to see a private therapist, the employee victim’s insurance covers this non-ASAP treatment.
Confidentiality/Informed Consent: All ASAP interventions are confidential. Management and unions agree in advance to forgo ASAP information. The utilization of ASAP services never becomes part of one’s facility medical record or one’s employee-performance review section. Management agrees to hold other meetings to obtain any needed information about the violent, traumatic incident. Informed consent is obtained by informing all employees by letter or email of the presence of the ASAP team, that participation is completely voluntary, confidential, and that data will be kept anonymously and in the aggregate for quality management purposes. Employees have the right to accept ASAP services but request that no informational data be kept.
Basic ASAP Intervention: When a traumatic incident occurs in the facility, the ASAP first responder on call is summoned (by beeper) to the site of the incident. When the responder arrives onsite, the responder assesses for safety and any needed medical attention. These issues are always addressed first. Next, the responder gathers the facts about what has happened and then offers ASAP services to the employee victim. If the employee accepts ASAP, the first responder reviews the facts with the employee who may not know all of the precipitants. Next, the first responder monitors any symptoms of psychological trauma, and then restores reasonable mastery, develops links to the victim’s caring attachments, and restores a meaningful sense of purpose in the employee’s work life. With permission the same first responder contacts the employee victims three and ten days later to see if additional ASAP services are needed. Group interventions, the staff victims’ support group, and employee victim family outreach are also focused on restoring mastery, attachment, and meaning. (See  for more detailed discussion of the ASAP program and its interventions.)
ASAP Findings: As noted earlier, ASAP is the most widely researched crisis intervention program in the medical and scientific literature. In its twenty-two years of continuous service there have been forty ASAP teams in seven states, with 1,700 trained ASAP team members, who have responded to over 4,500 patient assault incidents. ASAP teams have volunteered over one and one-half million hours of service to their facilities.
ASAP has provided needed support to employee victims in restoring mastery, attachment, and meaning and in resolving the symptoms of trauma and of posttraumatic stress disorder (1, 2, 5). ASAP has also been associated with declines in violence facility-wide after the fielding of an ASAP team. This finding has been replicated seven times and may be due to ASAP responding physically to each violent incident. This continuous ASAP presence is a nonverbal message of support from management and unions. When staff feels supported, they calm down. When staff calm down, patients calm down and less violence occurs.
ASAP has been chosen as an innovative best practice by the federal governments of the United States and Canada.
When violence occurs, psychological distress follows. Employee victims need assistance with this not-so-obvious outcome of violence. An in-house ASAP program can be at the ready to provide such services.
(1) Flannery R. B. Jr. The Assaulted Staff Action Program: Coping with the Psychological Aftermath of Violence. New York: American Mental Health Foundation, 2012.
(2) Flannery, R. B., Jr., LeVitre, V., Rego, S., and Walker, A. P. “Characteristics of staff victims of psychiatric patient assaults: Twenty-year analysis of the Assaulted Staff Action Program (ASAP).” Psychiatric Quarterly, 2011, 82, 85-93.
(3) Flannery R. B. Jr. The Violent Person: Professional Risk Management Strategies for Safety and Care. New York: American Mental Health Foundation, 2009.
(4) Flannery R. B. Jr. Posttraumatic Stress Disorder (PTSD): The Victim’s Guide to Healing and Recovery. Second Edition. New York: American Mental Health Foundation, 2012.
(5) Flannery, R. B., Jr., Farley, E. M., Rego, S., and Walker, A. P. “Characteristics of staff victims of psychiatric patient assaults: Fifteen-year analysis of the Assaulted Staff Action Program (ASAP).” Psychiatric Quarterly, 2006, 78, 25-37.
Raymond B. Flannery, Jr., Ph.D. FAPM, is an internationally recognized scholar and lecturer on the topics of violence, victimization, and stress-management. Dr. Flannery is available for lectures and workshops for all sizes of groups and may be reached through The American Mental Health Foundation: 212-737-9027 orEmail Evander.