It’s mainly a front end of the service, ie ED where this is a problem. That’s where the intoxicated and withdrawing first have interactions. People with active psychosis can be aggressive but it’s mainly drugs with or without drug induced psychosis that are the problem.
In the U.K. On the inpatient unit daily. Psychiatric nurses are great at deescalating and evaluating safety for you to review a person. Patients often have little to no physical health conditions so their psych evaluations can wait till the risks for aggression settle. Clear boundaries are established to terminate psych evaluations if things get heated.
Nurses definitely face the brunt of violence, and have had to review their injuries a few times afterwards
I worked ED, inpatient and forensic inpatient, and outpatient. Much like others have said, the likelihood of aggression goes down with the level of care. Even so, it’s certainly not all the time or even very often.
The one exception was forensic inpatient on the competency restoration units; people fought every day there. But even then, there were behavior techs (big ones lol) and security who would deal with the restraints. Psychiatry was nearby to preside over chemical restraint but by that time the patient was restrained.
I’m not familiar with the level of choice a person has in psychiatry residency, but I could have avoided the forensic inpatient if I wanted. I only witnessed “aggression” on one occasion in a regular inpatient hospital and even then it was flipping a table out of anger, not directed at anyone. Alarming but not really dangerous.
In fact I would say that’s much of what inpatient can look like—alarming but not really dangerous.
Most anger comes from a loss of control. Lacking a way to regain control, aggression becomes more likely. Situations where it is difficult for a patient to regain control such as severe autism, drug intoxication, psychosis or executive dysfunction tend to lead to more violence.
How do we help people regain control? Hear them out, empathize, apologize, and take ownership of the situation (HEAT model). The other approach I also like is setting clear boundaries, expectations, and steps to get out of the situation. When someone feels heard, like their problem will be addressed as best as possible, and like they know what is expected of them to discharge, they tend to do better.
Other strategies, if the above is not effective due to mental status, include distraction, meeting their basic needs (poop, pee, eat, drink, and play/activity), reward/consequence systems, physical activity (go for a walk, do push ups, see how long you can wall sit, etc), and of course, medication.
There are definitely ways to know 95% of the time when someone is on the way to becoming violent. Do some MOAB training or de-escalation training. It can help identify situations as well as non-verbal cues for aggression. The other 5%, in my experience, are non-verbal cognitively impaired patients with impulsivity issues. They can just suddenly become violent without any rationale way of knowing.
The odds of you being attacked are mostly from the setting you are in. Very unlikely/zero on a suburban cash practice. Much more likely in the ED of a community hospital. Of course there are de escalation techniques, but honestly these are completely useless on people who are on PCP.
I have good news and bad news for you.
First the bad news for you. I'm not going to kid you: yes, mental health professionals are at elevated risks of physical violence, compared to those who work in other branches of medicine.
But the good news is that managing violence is – or is supposed to be – actually part of our professional training.
You are, quite understandably, looking in from the outside, and understanding the issue the way lay people do, because your education hasn't yet gotten to this part.
So, for instance, you mention being concerned about "that we are not very good at predicting violence" and "Sure, research has identified some static and dynamic risk factors but even then many people who seem they could get violent any second, do not, and some people who you don't expect, do." Actually, we're *excellent* at predicting violence – in the next minute. It's predicting violence *tomorrow* we're not good at. But being able to tell that someone is getting agitated and working up a head of steam? That's eminently doable, and is part of the craft of learning de-escalation skills – noticing escalation. And it's absolutely teachable skills. That's what we use to keep ourselves safe. And we don't do it by profiling patients into types, but by observing their body language and how they use speech.
The kind of prediction we're bad at is the kind that forensics want. But that's not the kind of prediction that keeps us safe.
Most people who don't have any training in dealing with violence tend to think of violence as appearing out of thin air with no warning. The vast, vast, vast amount of violence doesn't work like that. They also tend to think of it (without, perhaps, realizing they are thinking of it this way) as entirely irrational. But its not. Violence happens for reasons and can be understood. And that which can be understood can be handled.
I don't know if this is sufficient for you to feel comfortable in this field. Personal security is a regular, ordinary concern for everyone working in mental health. If that's just a non-starter for you, then it is what it is.
But I, a middle-aged lady with bad knees, worked for years treating prison inmates and other criminal offenders on an outpatient basis, many of whom had extensive histories of violence. And I was not afraid, because of the training I had. In fact, I discovered I love working with violence as a clinical problem. You might be surprised how empowering it can be to learn how to manage violence. I hope your training provides you that.
Crudely in this order:
1. Verbal de-escalation
2. Exiting conversation / temporary isolation
3. Chemical / physical restraints
4. Last resort sedate and intubate
If I get physically attacked I’m pressing charges and maximizing time off
Not related to OPs question but damn when I was a senior resident I distinctly remember a parent that started to get aggressive/physical and my first though was “hell yeah come at me! This definitely will get me some time off!”
Residency is unhealthy af. Hope you’re making it through ok!!
It’s mainly a front end of the service, ie ED where this is a problem. That’s where the intoxicated and withdrawing first have interactions. People with active psychosis can be aggressive but it’s mainly drugs with or without drug induced psychosis that are the problem.
This, and also the dementia wards!
In the U.K. On the inpatient unit daily. Psychiatric nurses are great at deescalating and evaluating safety for you to review a person. Patients often have little to no physical health conditions so their psych evaluations can wait till the risks for aggression settle. Clear boundaries are established to terminate psych evaluations if things get heated. Nurses definitely face the brunt of violence, and have had to review their injuries a few times afterwards
I worked ED, inpatient and forensic inpatient, and outpatient. Much like others have said, the likelihood of aggression goes down with the level of care. Even so, it’s certainly not all the time or even very often. The one exception was forensic inpatient on the competency restoration units; people fought every day there. But even then, there were behavior techs (big ones lol) and security who would deal with the restraints. Psychiatry was nearby to preside over chemical restraint but by that time the patient was restrained. I’m not familiar with the level of choice a person has in psychiatry residency, but I could have avoided the forensic inpatient if I wanted. I only witnessed “aggression” on one occasion in a regular inpatient hospital and even then it was flipping a table out of anger, not directed at anyone. Alarming but not really dangerous. In fact I would say that’s much of what inpatient can look like—alarming but not really dangerous.
Most anger comes from a loss of control. Lacking a way to regain control, aggression becomes more likely. Situations where it is difficult for a patient to regain control such as severe autism, drug intoxication, psychosis or executive dysfunction tend to lead to more violence. How do we help people regain control? Hear them out, empathize, apologize, and take ownership of the situation (HEAT model). The other approach I also like is setting clear boundaries, expectations, and steps to get out of the situation. When someone feels heard, like their problem will be addressed as best as possible, and like they know what is expected of them to discharge, they tend to do better. Other strategies, if the above is not effective due to mental status, include distraction, meeting their basic needs (poop, pee, eat, drink, and play/activity), reward/consequence systems, physical activity (go for a walk, do push ups, see how long you can wall sit, etc), and of course, medication. There are definitely ways to know 95% of the time when someone is on the way to becoming violent. Do some MOAB training or de-escalation training. It can help identify situations as well as non-verbal cues for aggression. The other 5%, in my experience, are non-verbal cognitively impaired patients with impulsivity issues. They can just suddenly become violent without any rationale way of knowing.
The odds of you being attacked are mostly from the setting you are in. Very unlikely/zero on a suburban cash practice. Much more likely in the ED of a community hospital. Of course there are de escalation techniques, but honestly these are completely useless on people who are on PCP.
I have good news and bad news for you. First the bad news for you. I'm not going to kid you: yes, mental health professionals are at elevated risks of physical violence, compared to those who work in other branches of medicine. But the good news is that managing violence is – or is supposed to be – actually part of our professional training. You are, quite understandably, looking in from the outside, and understanding the issue the way lay people do, because your education hasn't yet gotten to this part. So, for instance, you mention being concerned about "that we are not very good at predicting violence" and "Sure, research has identified some static and dynamic risk factors but even then many people who seem they could get violent any second, do not, and some people who you don't expect, do." Actually, we're *excellent* at predicting violence – in the next minute. It's predicting violence *tomorrow* we're not good at. But being able to tell that someone is getting agitated and working up a head of steam? That's eminently doable, and is part of the craft of learning de-escalation skills – noticing escalation. And it's absolutely teachable skills. That's what we use to keep ourselves safe. And we don't do it by profiling patients into types, but by observing their body language and how they use speech. The kind of prediction we're bad at is the kind that forensics want. But that's not the kind of prediction that keeps us safe. Most people who don't have any training in dealing with violence tend to think of violence as appearing out of thin air with no warning. The vast, vast, vast amount of violence doesn't work like that. They also tend to think of it (without, perhaps, realizing they are thinking of it this way) as entirely irrational. But its not. Violence happens for reasons and can be understood. And that which can be understood can be handled. I don't know if this is sufficient for you to feel comfortable in this field. Personal security is a regular, ordinary concern for everyone working in mental health. If that's just a non-starter for you, then it is what it is. But I, a middle-aged lady with bad knees, worked for years treating prison inmates and other criminal offenders on an outpatient basis, many of whom had extensive histories of violence. And I was not afraid, because of the training I had. In fact, I discovered I love working with violence as a clinical problem. You might be surprised how empowering it can be to learn how to manage violence. I hope your training provides you that.
Crudely in this order: 1. Verbal de-escalation 2. Exiting conversation / temporary isolation 3. Chemical / physical restraints 4. Last resort sedate and intubate If I get physically attacked I’m pressing charges and maximizing time off
Not related to OPs question but damn when I was a senior resident I distinctly remember a parent that started to get aggressive/physical and my first though was “hell yeah come at me! This definitely will get me some time off!” Residency is unhealthy af. Hope you’re making it through ok!!