The Assaulted Staff Action Program (ASAP) Turns 35
by Dr. Raymond B. Flannery Jr. on
The Assaulted Staff Action Program (ASAP) (1) is a voluntary, peer-help, system-wide crisis intervention program to address the psychological impact of psychiatric patient assaults on healthcare staff. ASAP is voluntary in that the employee victims are free to decline ASAP services; peer-help in that fellow agency staff is taught to provide the ASAP services; and system-wide in that ASAP teams respond to all episodes of assault, even if services are subsequently declined. ASAP is the only data-based program of its kind in the published literature. On March 31, 2025, ASAP completed its 35th year of continuous service. See earlier blogs in this series of April 12, 2012, and March 18, 2021, for discussions of ASAP in its earlier years. While ASAP had grown over the years, its basic services have remained unchanged: individual crisis intervention, group (e.g., a ward) crisis interventions, staff support for assaulted employees, family victim outreach, and referral to outside therapists trained in treating psychological trauma and posttraumatic stress disorder (PTSD). In addition, ASAP has provided reviews of the published literature on the characteristics of both patient assailants and staff victims. As with ASAP, there have also been earlier blogs in this series on patient assailants (January 16, 2015, January 30, 2018, and May 6, 2024), as well as staff victims (January 9, 2015, January 16, 2015, February 5, 2018, and July 21, 2024).
As with much of healthcare, ASAP was seriously impacted by the COVID–19 pandemic. All ASAP services were provided at a distance of six feet, and all ASAP responders wore masks. Since ASAP trainings require hands-on exercises, the training of new teams was put on hold. However, two new ASAP training directors were trained and brought on board as new ASAP directors. COVID–19 took the lives of healthcare providers in institutions with ASAP teams. ASAP did not lose any providers itself through death. ASAP team members were pressed into coverage of other facility services in addition to ASAP. This resulted in mandated overtime, limited time off, curtailed vacation days, and stress and burnout with the net result of increases in early retirements, providers leaving the field, and a growing national shortage of new hires.
This blog presents a state-of-the-art review of ASAP and the characteristics of patient assailants and staff victims at the end of 35 years. A much more detailed review of this data may be found in Crisis, Stress, and Human Resilience: An International Journal (2).
Patient Assailants. There have been 144 research papers that have assessed the characteristics of patient assailants over time, across cultures and countries, for a period of 46 years. Perhaps the most surprising finding is the consistency of the patient assailant characteristics. Assailants were most often males diagnosed with both schizophrenia and substance use disorder with past histories of violence and personal victimization. Simliarly, the precipitants to these assaults were also fairly uniform (3) and included acute psychosis, younger age, impulsivity, and being denied services.
While there have been advances in medicines, rehabilitative services, and various clinical advances, no basic treatment paradigm has emerged.
Staff Victims. As with the patient characteristics, the staff-victim data, gathered over 29 years in 96 data-based research papers, demonstrated the same uniformity of results. The staff victim at higher risk was a younger, less experienced, female nurse, especially in restraint and seclusion incidents. As in the culture at large, female staff were at greater risk for violence than male staff. As with the patient assailants, no general way to address patient violence has emerged. There is the beginning of an approach that would include a zero-tolerance-of-violence position paper, rapid behavioral response teams, and trauma-informed care restraint and seclusion procedures (1). The victim literature also indicates repeated requests for additional trainings in dealing with patient violence, and post-incident support.
ASAP. The Assaulted Staff Action Program (ASAP) can be one of the these requested post-incident supports. When an assault incident occurs, ASAP is summoned to the site, offers ASAP confidential services, and provides them if the employee victim requests. To date, there have been 45 teams in nine states. ASAP has trained 2,500 employees to provide ASAP services for their peers. ASAP Teams have volunteered 2,450 free hours of 24/7 coverage and treated 12,956 employee victims. ASAP had been associated with providing needed post-incident support, reduced medical and legal expense, less utilization of sick leave and industrial-accident claims, enhanced productivity and morale, and reductions in assaults facility-wide in some facilities. ASAP teams pay for themselves.
Since ASAP is manualized (1), facilities can start ASAP teams on their own, or for a modest fee; hire the ASAP team leaders to provide an onsite, day-long training for the team with subsequent free consultation for a year; and have the free opportunity to attend monthly team leaders’ conferences online. ASAP is a sound response to an ongoing and serious issue.
References
1. Flannery, R. B. Jr. The Assaulted Staff Action Program (ASAP): Coping with the Psychological Aftermath of Violence. Riverdale, NY: American Mental Health Fdn 2012.
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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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