Violence Against Mental Health Professionals: Fenton Death Highlights Concerns

Once his colleagues began to recover from the shock, the death of Dr Wayne S. Fenton triggered a discussion in the professional and lay press about the risks of violence to mental health professionals posed by mentally ill patients.Fenton was found unconscious and bleeding in his office in Bethesda, Md, on Sunday, September 3, 2006. He had been beaten severely around the head and died at the scene.

A 19-year-old man, Vitali A. Davydov-his name was published following his arrest-was found nearby with blood on his hands and clothing. Fenton had met with Davydov for the first time the day before, on a referral from a colleague. On Sunday morning, Davydov's father asked Fenton to meet with his son again because the young man was refusing to take his medications.

According to news accounts, the charging document presented in court says that Davydov "elected to make a statement of admission to the crime" after being informed of his rights. Davydov was indicted for the killing on October 26. The charging document also says that Davydov was being treated for schizophrenia and bipolar disorder.

Fenton was director of the Division of Adult Translational Research and associate director for clinical affairs at the National Institute of Mental Health. According to a statement from NIMH, he "authored textbook chapters and more than 50 scientific papers on [the] diagnosis, treatment, outcome, and service delivery for schizophrenia. He also served as Deputy Editor of Schizophrenia Bulletin and served as a consultant to the Department of Justice, Civil Rights Division. He was active in the National Alliance for the Mentally Ill, serving on the Scientific Council of this advocacy organization."

In addition, he was NIMH's liaison to the American Psychiatric Association (APA) and the World Psychiatric Association and was involved in the development of the agenda for the forthcoming DSM-V. Fenton also maintained a private practice in Bethesda and had a reputation for working with extremely difficult patients.

Two days after Fenton's death, the Washington Post headlined a story, "Devotion to Most Severe Cases Raises Risk of Personal Danger." The article began, "Wayne Fenton knew better than most about the risk of treating people with severe mental illness," which drew an immediate response from Liz Spikol, managing editor of the Philadelphia Weekly, who writes a blog about mental illness.

"This is entirely predictable spin, but it's misleading. The fact is, the vast majority of violent crimes are NOT committed by a person with mental illness," she wrote, citing a passage in an August 2005 commentary by Leon Eisenberg, MD, published in Archives of General Psychiatry: "In the public mind, violence is associated with mental illness. Yes, there is a strong association, but . . . persons who are seriously mentally ill are far more likely to be the victims of violence than its initiators."The Post article, quoting Fuller Torrey, MD, said that "each year, people with serious mental illness commit about 750 murders, or five percent of the homicides, in the United States."

But the risks of treating the mentally ill are measurably greater than the risks facing other physicians or the American workforce as a whole. Times Online, a Web site combining reports from The Times and Sunday Times of London, reported that "the rate of [being a victim of] non-fatal, job-related violent crime is put at 12.6 per 1000 workers across all occupations in a survey by the US Department of Justice. Among doctors, the rate is 16.2 per 1000. For psychiatrists and mental health professionals, the rate is 68.2 per 1000."

Commenting on the Fenton case, the writer added, "Dr Fenton, 53, clearly had not foreseen that he was at serious risk. And if he couldn't predict it, who can?"

Paul Jay Fink, MD, past president of the APA and a consultant on youth violence and youth murder working with the city of Philadelphia, echoed the same thought in an interview with Psychiatric Times. "Can we actually determine who's going to be violent? We know that patients with untreated schizophrenia have more of a tendency toward violence, especially if they have been using alcohol. We know there are parameters to determine the possible level of dangerousness. Can we ever be 100% accurate? The answer is no."

Fink believes that a psychiatrist, especially one working with unstable patients, has an obligation to learn something about referrals if he or she can.

"When you have somebody who is dangerous and you don't know them and they don't know you, you need to be careful," he said. "Any little insult can fire up a paranoid patient, and that's a danger. The first thing a psychiatrist should learn is that he should get some information when he does the consultation, so he can get some sense of the presence of danger. You can get a message on your answering machine with no information and end up walking into a patient's gun, so to speak.

"Patients are impulsive," Fink added. "They can react negatively to a remark that you didn't think was terrible."

Inexperience-not a factor in the Fenton case-often leads physicians into difficulty, especially in dealing with mentally ill patients. Fink recalled an example from his own past.

"The uninitiated sometimes make big mistakes and say things they shouldn't say. I did once, 50 years ago, when I was a resident: I was in the residents' area and heard a noise in the day room. I went in and saw a patient of mine screaming and acting very psychotic. He was surrounded by 30 or 40 staff and other patients who were making things worse.

"I walked into the circle, took the patient by the hand, walked him across a lawn and up 2 flights of stairs. I got him into the locked men's ward, and I said 'I'm going to have to take away your ground privileges.' He picked up a water fountain-pulled out the pipes-and threw it through the nurses' station window. I thought, 'That was stupid. It could have been me.'"

Fink's personal experience reflects the findings of researchers of violence against physicians. David Fink, MD, surveyed psychiatric residents at several institutions in Pennsylvania and found that 41% said they had been assaulted and 48% had been threatened during their training. In an essay included in the APA's clinical practice publication Patient Violence and the Clinician, he noted that "Available studies confirm that a substantial percentage, approximately 40 percent, of psychiatric residents will be assaulted at least once during the course of a 4-year residence. . . . Violence against residents cannot be considered as an occasional and acceptable risk of training."¹

Citing an earlier study, David Fink quoted S. I. Hallack as pointing out a possible reason for the increased risks during residencies: "Psychiatric training programs traditionally place their least experienced doctors in the most difficult treatment situations."

The effort to predict which patients may present a threat is still in its infancy. A study reported in BMC Psychiatry by Abderhalden and colleagues² noted that the BrØset Violence Checklist has been effective when used with patients in the hospital:"The [checklist] assesses the presence of six observable patient behaviors namely whether the patient is confused, irritable, boisterous, verbally threatening, physically threatening, and attacking objects. The reported discriminatory ability is good with a correct prediction rate around 85%."

Paul Jay Fink suggested that practitioners dealing with unstable or unknown patients might improve their safety by redesigning their offices. "Place your chair closest to the door so you don't paint yourself into a corner. . . . There are times when you may . . . have to leave the door of the office open so that you have vocal access to somebody who will hear you. But that's when you know a patient is threatening.

"Most offices are not organized in the way I'm talking about," he added. "I don't have a single schizophrenia patient in my practice. I'm an analyst; I see patients on the couch. If I had Fenton's practice, which was almost all schizophrenia, I might have a panic button. If I thought a patient was extremely dangerous, I might ask a family member or a colleague to sit in with me. But you can't do that frequently. You've got to know the customer."

References:

References1. Eichelman BS, Hartwig AC, eds. Patient Violence and the Clinician. Washington, DC: American Psychiatric Press; 1995.
2. Abderhalden C, Needham I, Dassen T, et al. Predicting inpatient violence using an extended version of the Brøset-Violence-Checklist: instrument development and clinical application. BMC Psychiatry. 2006;6:17.