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Violent patients are more than just occupational hazards

July 28, 2014
by H. Steven Moffic, MD
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It became crystal clear that I was going to work in a risky environment when the state medical director of prisons gave me a few instructions before I started to work at a men's medium-security prison. I was told that knocking the phone off the hook would send the guards running. And, it did, when I accidentally knocked the phone off the hook shortly after I started. This was much better than having to locate a button to press on the phone to alert security.

I was also told: do not wear a tie; do not shake hands; and keep your chair between the patient and the door.

I easily followed the first rule about the necktie, so as not to give an inmate an easy way to choke or pull me. I didn't like wearing a tie anyway. No problem either with the chair placement. And, I was assured that it was common to leave the door open if I felt like it.

But not shaking hands? I understood the rationale. Even though I had always felt strong and fit enough to take care of myself in a fight, these men often had extensive experience with fighting and with more practice, could grab my hand and put me in a hammer-lock hold. So I decided on a compromise.

When I felt emotionally connected to my patient, especially if we seemed to make some progress, I offered my hand. When I felt no empathic connection, my sense of risk rose up as goosebumps, and I did not shake hands. All ended well. Perhaps such a humanistic approach avoided some violence, though that may just be wishful and naive thinking.

Strangely enough, I felt more at risk in my public clinic than in the prison. There were no guards in the clinic. No security cameras. If an act of aggression happened, it seemed up to the staff to control it. Moreover, some of the clinic patients ended up in prison.

I suppose, like me, that many of you don't follow all the security precautions they you perhaps should. Consider what happened just recently at the Mercy Fitzgerald Hospital clinic south of Philadelphia: A psychiatrist’s patient suddenly pulled out a gun, killing his caseworker and grazing Dr. Lee Silverman twice. Perhaps to the surprise of so many of us in the field, Dr. Silverman had a gun in his desk and fired at the patient several times, thereby saving his own life and those of others nearby.

This must be an administrative nightmare turned into reality.

The hospital policy, according to a Mercy Health System spokesperson, bars anyone except on-duty law enforcement officials from carrying weapons. This patient had previously complained about the rule. Apparently, Dr. Silverman didn't follow the rule or was allowed an exception.

Challenging the rules

Although psychiatric patients rarely try to kill their caregivers, it does happen. Each time, there is a scramble of discussion, new literature, and new policies. However, we don't know the outcome of these policies and procedures. We don't know why professionals don't follow all the rules. Like me, did Dr. Silverman think that something was wrong with the rules at his hospital? Who was consulted in drafting the rules? Dr. Silverman? The patients?

It may be reassuring that violence in our settings is rare. Perhaps we are similar to the airline industry, which strives toward the ideal of zero crashes, for example. Yet, there have been three airline crashes in recent weeks to shatter the sense of safety.




Herb Bateman writes this response:

"I sure agree with the proactive steps you mentioned, i.e., looking at the patient's history of violence or even potential violence so extra precautions can be taken. I am not sure how practical it would be to have weapon scanners. For sure an expense but worth it to save one life. Placing a sign on the door saying no weapons allowed will not deter someone in a psychotic episode.

Until we figure out better public policies enabling professionals/law enforcement to be more proactive, we need to take more of a Homeland Security approach. Our public policy formation seems to rely on tragedies before we figure out solutions. How many mental health tragedies is it going to take?

Our immigration laws are not the only thing broken. Maybe we need to look back to the 1970s and evaluate the public mental health policies that might have decreased the mass shootings by someone suffering from a mental illness".

My psychiatrist colleague George Dawson conveyed that on the same day mine was post, that he posted a complementary blog on his blog site called "Real Psychiatry: Why Would a Psychiatrist Carry a Gun?" It is available at

Dr. Moffic


H. Steven Moffic

H. Steven Moffic

H. Steven Moffic, M.D. retired from the clinical practice of psychiatry and his tenured...

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