Use restraints as needed. When patients with a history of violence are brought to the hospital in high arousal states, I let them remain in restraint with security present during the initial interview. If the patient cannot have a back-and-forth conversation with me, I keep the security force present until I believe my verbal interactions have a substantial effect.
Patients must be responsive to talking interventions before restraint, security, or other environmental safety measures are removed. Some patients do not reach this point until after tranquilizing medications are given.
Step 5: Tthe clinical encounter
When discussing how to assess the likelihood of patient violence during a clinical encounter, a psychiatric colleague once commented, “Risk factors make you worry more; nothing makes you worry less.”
In other words, keep your guard up. Let clinical judgment take precedence over statistics when you are evaluating any patient. Statistics represent frequencies or averages; they may or may not apply to any one individual.
Techniques for assessing and treating violent patients are beyond the scope of this article, but at the very least:
- obtain training in safety/treatment protocols for violent patients
- ensure that your hospital/clinic has procedures in place to improve safety and to handle violent situations.
Visible, high numbers of confident-appearing—but not confrontational—staff or security may dissuade the patient from acting out. Then, most often, force will not be needed. If force is needed to control a violent patient, make sure the staff’s response is strong and overwhelming.
For every violent act requiring staff intervention, automatically schedule a debriefing session for those involved to assess the incident and allow them to express their feelings.
Related resources
- American Association for Emergency Psychiatry. www.emergencypsychiatry.org
- Volavka J. The neurobiology of violence: an update. J Neuropsychiatry Clin Neurosci 1999;11:307-14.
- McNiel DE, Eisner JP, Binder RL. The relationship between command hallucinations and violence. Psychiatric Services 2000;51:1288-92.