By Lisa J. Warren MAPS
Monash University School of Psychology, Psychiatry and Psychological Medicine

Mental health clinicians are more likely to be threatened with violence than many other professional groups. Surveys of mental health clinicians from all disciplines, including psychology, consistently find that more than half will be threatened with violence by one or more clients, on one or more occasions during their careers (e.g., Faulkner, Grimm, McFarland, & Bloom, 1990). Male clinicians report being threatened more often than female clinicians, while the opposite appears to be true for threats of sexual assault. Debate exists on the effect of clinician experience on the incidence of threats of violence, with some studies finding greater incidence among less experienced clinicians and others reporting threats to clinicians of varying levels of seniority.

Clinician reactions to threats of violence

Not surprisingly, clinicians' responses to threats vary. Commonly reported responses include a heightened vigilance for personal safety, a newfound pensiveness with clients, and a resolve to choose clients more carefully. PTSD-like symptoms, feelings of fear, and a sense of demoralisation have also been reported.

Some clinicians tend to minimise or ignore threats of violence from their clients. This is more common when clinicians view threats as an unpleasant but acceptable way for their clients to communicate, and assume it is a form of expression that carries a low risk of escalation to physical violence.

Very rarely clinicians are inclined to call police. In one study, police were contacted by 3.79 per cent of the clinicians who were threatened by their clients (Bernstein, 1981). This low rate might indicate clinician dissatisfaction with the police and legal system's response, a reaction that has been reported in other studies. Police reporting is always advisable when the threat occurs in the context of the client stalking the clinician (Pathe, Mullen, & Purcell, 2002).

Responding to threats of violence

A useful question to pose when attempting to assess the threatener is: how seriously should I take this threat by this threatener? Answering that question can unfortunately be a challenging task, as data on the association between threats and violence are scarce. Any client with a known history of violence should be assumed to be at a higher risk of future violence. Risk of violence assessments are now based on several decades of research and are invaluable in assessing the threatener's general risks of behaving violently.

A notable but dated study on the association between threats and violence by psychiatric patients found that within five years, 3.9 per cent will kill after threatening to kill (MacDonald, 1968). Importantly, the same study also found that threateners posed a greater risk to themselves, as 5.2 per cent had committed suicide within the same period.

Threats by clients labouring under heavily invested delusional preoccupations should elicit particular concern (Mullen, 1997). This risk can be heightened when the basis of the delusion is morbid jealousy and the delusional spouse has previously resorted to violence in an attempt to address their suspicions.

While repeated threats can decrease clinician anxiety and earn the label of being 'just behavioural', this can be a mistake in clinical practice. Similar to threats of suicide, threats of violence indicate the need for specific assessment and a review of treatment. Such an assessment is best conducted by a clinician who is not targeted in the threats.

All responses to threats of violence need to include exhaustive documentation that outlines the pathway of clinical decisions and the client's responses to those decisions. Clinicians should always be encouraged to report threats of violence to management as this promotes a timely response and combats the problem of under-reporting.

Clinicians may also witness threats that their clients issue against third parties. In these situations, knowledge of professional protocols and relevant domestic and international case law are important. Two international court cases remain the definitive case law for clinicians' responsibilities to third parties: Tarasoff vs Regents of the University of California, and the Supreme Court of Canada case of Smith vs Jones. While Australian clinicians are not legally bound by a duty to warn, moral and ethical obligations still exist. Marilyn McMahon's article on dangerousness and the duty to protect is an excellent discussion of the applicability of these duties in Australia (McMahon, 1992).

The author can be contacted on lisa.warren@med.monash.edu.au

References

Bernstein, H. A. (1981). Survey of threats and assaults directed towards psychotherapists. American Journal of Psychotherapy, 35, 542-549.

Faulkner, L. R., Grimm, N. R., McFarland, B. H., & Bloom, J. D. (1990). Threats and assaults against psychiatrists. Bulletin of the American Academy of Psychiatry and the Law, 18, 37-46.

MacDonald, J. M. (1968). Homicidal threats. Springfield, Illinois: C.C. Thomas.

McMahon, M. (1992). Dangerousness, confidentiality and the duty to protect. Australian Psychologist, 27, 12-16.

Mullen, P. E. (1997). Assessing risk of interpersonal violence in the mentally ill. Advances in Psychiatric Treatment, 3, 166-173.

Pathe, M., Mullen, P. E., & Purcell, R. (2002). Patients who stalk doctors: Their motives and management. Medical Journal of Australia, 176, 335-338.