Threats and assaults made by patients toward residents are a challenging aspect of training experiences for some residents. The estimated prevalence of assaults by patients against psychiatry residents ranges from 36% to 64% (1–6). Limitations to the data include, however, studies of limited geographical areas (2, 3) or single programs only (4, 5), a focus on physical assaults only (4, 5), variable definitions of terms (1–5), and a lack of currency of data (1–6). Only one study has looked specifically at psychological sequelae with a validated questionnaire (6).
In light of these limitations, and given a recent call for more data (7), we surveyed psychiatry residents from several different training programs across the United States in order to determine the current prevalence of threats and assaults by patients and their psychological consequences for the residents. Also, we sought to establish the rate of reporting of these events and examine barriers to reporting. Finally, the study asked participants to comment on the adequacy of program responses and the availability of safety resources.
We distributed an anonymous survey to 13 psychiatry programs across the United States between March and June of 2008. We surveyed programs that had representatives in the American Psychiatric Leadership Fellowship, which provided support to this project; hence, the selection of primarily academic training programs. The number of residents ranged from 14 to 65 across programs, and all programs were in an urban setting. The residents were asked to fill out a web-based survey on a voluntary basis, using SurveyMonkey.com. Completion of the survey was indicative of consent. This research received approval from the ethics review committees of the participating programs. The survey was both quantitative and descriptive in nature, in order to ascertain the experiences of the residents and understand the psychological impacts. Survey questions were based on a previous study questionnaire evaluating residents' safety (6), and included Yes/No, multiple-choice, open-ended, and Likert-type questions. This survey is available to readers on request. Demographic information was collected for each resident. Given the variability of definitions of assault in the literature, the definitions used were taken from a previous study (6, 7). In particular, verbal threats were defined as menacing words directed at the resident by a patient, in an aggressive and/or threatening manner; physical intimidation was defined as menacing behavior, threats with a weapon, throwing objects, or damaging property; and physical assault was defined as direct physical contact directed at the resident by a patient in an aggressive and/or threatening manner—such as pushing, hitting, kicking, spitting, etc. Residents were also asked whether they had been harassed with unwanted comments or advances, sexually harassed with inappropriate touching, or if a patient had ever stalked, monitored, or followed them. Finally, residents were asked to describe any psychological sequelae, using the Impact of Events Scale, which is used to rate the frequency of symptoms for the most distressing incident over the previous 7 days (9). Residents were also asked to describe the institution's response to the incident and to provide suggestions on how this response could have been improved, if at all.
In total, the survey was distributed to 519 residents, and 204 responded: a response rate of 39%. Thirty-nine percent (80/204) of respondents were men, and 61% (124/204) women. Twenty-five percent of respondents (51/204) were first-year residents; 24% were second-year (50/204); 23% were third-year (47/204), 16% were fourth-year (33/204), and 10% were fifth-year (20/204). Thirty percent identified themselves as a member of a visibly identifiable ethnic minority.
As many as 86% (175/204) of the residents had been threatened, and the majority of residents (71%; 145/204) had been physically intimidated. Another 25% (51/205) were physically assaulted. Also, 58% (118/205) received unwanted advances; 11.5% (23/205) were sexually harassed with inappropriate touching; and 7.5% (15/205) were stalked, followed, or monitored. The 1-year prevalence of physical intimidation was 49% and of physical assault was 11%; 4% were assaulted twice, and 1.5% were assaulted three-or-more times. Women were significantly more likely to experience unwanted advances than men (65.8%; 77/124 versus 48.6%; 36/80; χ2 =5.5; p=0.02). No other significant differences for each category by gender were identified.
The most common location of incidents was the inpatient unit (45%), followed by the emergency department (39%), the outpatient department (11%), and on hospital grounds (3%). A lack of readily available safety resources (alarms, security, other staff, cellular phone) was described at 6% of the locations where an incident occurred.
The psychological consequences were rated as mild (56%), moderate (22%), or severe (4.5%) by the residents. Responders were asked what residual effects the incident had had on them (Figure 1); 46% reported that they were taking greater precautions; 20% reported increased vigilance; 10% reported avoidance of certain patient types; 9% reported increased anxiety; and 2% reported a change in their career interest after the incident.
FIGURE 1.Residual Effect of Threats and Assaults
Thirty-six percent of respondents felt residency programs provided adequate training in the area of safety, and 46% felt that the facilities for assessing patients were safe. Almost one-third (32%) made requests to the hospital or department to improve safety, and 26% of those felt the response was adequate; 34.7% of residents were aware of a reporting policy for assaults and threats, and 39% did not report an incident when it occurred. After an incident, 54% of residents reported to their supervisor; 39% did not report the incident at all; 18% reported to security; 11% reported to a hospital coordinator; 10% reported to the police; 9% reported an incident of threat or assault to their training director; and 7% reported it to another physician. Residents who did not report an incident were asked why they chose not to do so; 63% reported that they did not consider the incident severe enough; 34% thought it was an inherent part of the profession; 34% excused the patient because of his or her illness; 20% thought that reporting would be futile; 5% blamed themselves for the incident; and 5% reported that they lacked support from the administration. Most residents (94%) felt that policies on discussion or psychological support after an assault would be helpful.
The following comments from responders to our survey describe incidents associated with severe distress and their psychological consequences:
“The patient pulled out a serrated jack-knife in my office.”
“He stated, ‘I wanted you to feel what PTSD was like.’”
“Punched in the head five times … while pinned against a table by a female patient.”
“I was pushed against a wall and urinated on.”
“Patient grabbed my tie…tried to choke me.”
“I was dragged by the hair to the ground…I continue to have back and neck pain, along with hypervigilance, flashbacks, and hyperarousal.”
“The idea of starting out my career in such circumstances is very distressing. I ended up taking a leave of absence in the aftermath.”
“I realized how traumatic an assault could be to some people and was very disappointed that there was not a formal process to allow residents to deal with these specific situations.”
We found that the majority of responding residents had been threatened, physically intimidated, or subjected to unwanted advances at some point during their training, and one in four had been physically assaulted. Yet only 36% of respondents reported that their program provided adequate training, and fewer than half felt that their facilities for patient assessment were safe. Almost one-third had requested safety improvements, although the majority of responses to those requests were described as less-than-adequate. Program directors, faculty, and administrators should be cognizant of the risk faced by psychiatry residents within their own programs of being threatened or assaulted and should be aware of the safety of the facilities.
It is our opinion that mandatory reporting requirements of threats or assaults and education about those requirements should be implemented, in order to allow for the provision of supportive interventions for all victimized residents. Almost 40% of the residents who experienced a threat or an assault did not report the incident, and only 9% of residents reported such an event to their training directors. Although many responders replied that the event was not severe enough or was an inherent part of the profession, it appeared that feeling blamed or not-supported, was a significant barrier to reporting.
The view that patients are excused for violent behavior because of a mental illness is not necessarily justifiable and warrants close examination in individual cases (8). We should also appreciate that threats alone can lead to distressing and long-standing psychological consequences (6). It would be interesting to pool data from individual programs about how they have responded to threats or assaults by patients in order to assist the development of policy at local and national levels and to inform on supportive interventions. The vast majority of responding residents supported this goal of policy-development.
Our findings should be understood in terms of the low response rate of around 40%, although this does fall within the range of studies on this topic. This study focused primarily on 13 selected academic psychiatry training programs, and did not include community-based residency programs. This suggests the possibility of a study selection-bias and the idea that the data might therefore not be generalizable to all programs. Contrary to previous studies (2–6), however, multiple programs were surveyed. It is also possible that there was a subject-selection bias, in that residents who had experienced assault were more likely to respond to the survey. Furthermore, we did not learn how remote the traumas were in relation to their psychological consequences, nor did we learn whether residents had sought personal treatment. Despite these limitations, our findings add to the existing literature by further underscoring the importance of developing formal responses to both enhance the safety of psychiatry trainees and to support those who are victimized.
The authors thank APA Leadership Fellows 2006–2009 for their help with distributing this survey. Disclosure: The APA Leadership Fellowship has received unrestricted educational funds from Glaxo Smith Kline.
We also acknowledge Dr. Leah Dickstein for her guidance and mentorship.