The very nature of a therapeutic relationship lends itself to a close, emotional bond between therapist and patient. But, what happens when that bond leads to a release of negative emotions or a physically violent reaction from a patient? According to an article published by the American Psychological Association, the risk of confrontations with patients during therapy is more common than is often thought.
“Estimates vary,” said author Elizabeth Winkelman, JD, Ph.D, director of professional affairs for the California Psychological Association, “but as of 2012, studies suggested that almost half of psychotherapists will at some time experience at least one incident of physical attack, verbal abuse or other harassment by a client.”
Not all of these confrontations, of course, lead to injury.
“In a 1990 study,” said Philip Kleespies, Ph.D, a clinical psychologist at a VA hospital in Boston who wrote a book on the topic, “Handbook of Behavioral Emergencies and Crises,” (Oxford University Press, 2017), “only about 10% of the assaults were serious where people had some injury.”
Still, even though most confrontations do not result in injury, it is assumed that most psychologists would prefer to avoid situations where they felt physically or verbally threatened. According to Kleespies, problems often arise because a therapist in a small practice is not prepared to handle issues of violence. Whereas, in larger settings, such as hospitals or long-term care facilities, there are procedures regarding aggressive behavior.
One problem with being prepared in advance, Kleespies pointed out, is the lack of training in risk management in psychology programs.
“The 1990 study found that there was very little training of psychologists for assessing and managing potential violence,” said Kleespies, “Another more recent study in 2005 surveyed graduate students and found that the majority did not feel prepared to manage patient violence.”
In his practice, Kleespies has found several tools to be useful in identifying potential violence in patients.
“There are some decision support tools that are a bit more advanced in assessing risk of violence,” he explained. “They are not psychological tests, but these decision support tools combine actuarial factors and clinical judgment. Actuarial methods outperform clinical judgment, but actuarial methods also have problems. What is unique about the decision support tools is that they combine actuarial methods with clinical judgment, and that seems to make for better prediction.”
Even with testing and using good clinical judgment, what one psychologist calls your “third ear,” a therapist can still find herself in a difficult situation.
“In some cases there are patients with no known history of violence who can have an emotional release within the confines of the office that can lead to a disintegration before your eyes,” said John Daignault, Psy.D, a Massachusetts-based forensic psychologist.
“It is not that common for a therapist to be injured in terms of a physical assualt,” Daignault added, “but having said that, if you are the .01% who gets the brunt of it, statistical factors don’t really matter.”
Tips on Avoiding Violence
1. When arranging an office, be sure that the therapist cannot be locked inside with a client and that he/she has access to the door at all times.
2. With potentially violent or abusive patients, schedule appointments during daytime office hours when others can be present.
3. If possible, ask another therapist to be present in therapy sessions or to pop in during a session if a client is potentially violent. The addition of another person often helps to deter outbursts.
4. Consider installing a “panic button” set to notify office staff of a situation or even to contact a local police department directly.
5. Require patients be “buzzed in” to the waiting room by keeping outside door locked.
6. Provide lockers for patients to store personal items, such as purses or bags and jackets to reduce ability to introduce weapons to the inner office.
7. Exit a room if a situation is getting too confrontational.