Psychiatric Patient Assaults and Psychological Trauma
by Dr. Raymond B. Flannery Jr. on
Psychiatric patient assaults on healthcare providers are an ongoing risk in all types of psychiatric settings, including private practice (1). A recent 46-year review of studies of assaultive psychiatric patients indicates that younger, male patients with diagnoses of both schizophrenia and substance use disorder presented the greatest risk (2). The research community has understandably focused on understanding the various possible neuropsychological pathways that might yield important causative factors.
However, generally overlooked in these studies of assaultive psychiatric patients is the possible role of untreated psychological trauma and posttraumatic stress disorder (PTSD) (3). It is well documented that violence begets violence (4,5,6), yet in most studies of assaultive psychiatric patients, the presence of a trauma history is rarely assessed.
An extensive published literature documents that psychiatric patients are both victims of many types of violence (7,8,9,10) as well as themselves subsequently becoming assailants and victimizers (11,12,13,14). Often, these assaults on others are perpetrated on family members, the original family caretakers.
It seems reasonable to assume that some of these psychiatric patients may in fact be victims of untreated previous violence with PTSD whose triggers for violence are activated due to some activities or interactions on the ward.
This review’s references present an additional opportunity to enhance mastery and safety of staff in the face of the ongoing risk of patients’ assaults. The cited references suggest the importance of taking a routine history of traumatic incidents upon admission. Although some patients may at first refuse, they may be more forthcoming as they become familiar with caregiving staff over time. This self-awareness may be further complicated as some patients may not know about psychological trauma and may not realize that when they were uncomfortably touched without permission may constitute a traumatic incident. They need to be educated about trauma, its symptoms, and the role of triggers in subsequent daily life.
Since the research has shown that psychiatric patients often first assault immediate family members, it may be helpful to utilize the Adverse Child Events Questionnaire (ACE) (15) as part of the assessment to educate the patient to family life experiences that may have proved traumatic. The ACE was developed by the Centers for Disease Control and Prevention and Kaiser Permanente Health Plan in the 1990s as a way of documenting faulty family coping strategies that if left unaddressed would result in various types of early illness onset. There are 10 questions that assess family mental illness, family substance abuse, family physical abuse, and abandonment. Helping the patient complete the 10 questions or asking about each area during the initial assessment will contribute to the patient’s understanding of potentially traumatic events. Since patients’ first assaults are often perpetrated on family caregivers, it would be reasonable to ask the patient if there were family conflicts over personal hygiene, meals, parental/sibling interactions, discipline, and the like: issues that may create triggers on the ward during similar activities. When an assault occurs, staff meets with the patient as the situation calms and tries focusing on what the trigger(s) may have been. Modifying the situation or altering the ward response may help to defuse any subsequent assaultive incidents.
As with any patient-diagnosed condition, if the patient has psychological trauma, or untreated PTSD, addressing this condition should be a significant part of overall treatment. Since many victims of violence self-medicate their symptoms (3), this trauma-treatment initiative may also improve the patient’s substance use disorder. Enhancing control and preventing assaultive incidents enhances staff and patient safety and improves ward morale.
References
1. Flannery, R. B. Jr. The Assaulted Staff Action Program (ASAP): Coping with the Aftermath of Violence. Riverdale, NY: American Mental Health Fdn., 2012.
3. Flannery, R. B. Jr. Posttraumatic Stress Disorder: The Victim’s Guide to Healing and Recovery. Second Edition. Riverdale, NY: American Mental Health Fdn., 2012.
6. Van der Kolk, B. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York: Penguin, 2015.
12. Latalona, K., Kamaradova, D., Pasko, J. “Violent Victimization of Adults with Severe Mental Illness: A Systematic Review.” Neuropsychiatric Disorder Treatments, 2014, 10:1925-39.
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Dr. Raymond B. Flannery Jr., Ph.D., FACLP, is an internationally recognized scholar and lecturer on the topics of violence, victimization, and stress management. Dr. Flannery is available for lectures and workshops, all types of groups, and may be reached at The American Mental Health Foundation: elomke[at]americanmentalhealthfoundation.org.
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