Violence Against Mental Health Professionals: A Reader Responds

The problem of violence directed against mental health professionals by patients is a serious one. Finding the basic causes of such actions and establishing preventive measures is of utmost urgency. In this regard, studying profiles of patients who have acted in this manner is critical, as is developing profiles and guidelines that would alert clinicians to such dangers.

I am, however, seriously concerned and highly critical of the one-sided thinking and approach to this problem. The focus is almost entirely on the patient, while major ways in which therapists contribute to their own endangerment are given little or no attention.

In "Violence Against Mental Health Professionals: Fenton Death Highlights Concerns," by Richard A. Sherer (Psychiatric Times, January 2007, page 1), Dr Paul Jay Fink acknowledged that a therapist might say or do something that provokes a patient to become violent. Even so, there is no sense conveyed in the article that all these acts are interactionally based and that both parties are always contributors. In addition, the critical role that therapists play in violating ground rules and boundaries, which in my vast experience is the major contributing factor on their part, is almost entirely neglected. This is a very dangerous oversight.

It is painful for us to review cases of this kind and to highlight likely contributing factors from our deceased colleagues, but failure to do so endangers currently practicing therapists.

In brief, years of clinical research from the adaptive viewpoint have shown that there is in fact an archetypal set of ground rules that is ideal for psychotherapy. This archetype is universally sought and appreciated by the deep, unconscious system of the emotion-processing mind of both patient and therapist&mdashthat is, the ideal frame is confirmed and validated through encoded imagery, even as its effects are of enormous and real consequence behaviorally. Securing the framework of therapy in this manner keeps the patient safe and well and actually acts as a constraint on his or her urge to act violently. Patients interpret departures from these basic rules for any reason as actions that are both assaultive and adversarial by therapists. This can open the door to violent responses by patients.

It is, of course, often necessary to depart from the ideal frame&mdashI know this very well from doing therapy under managed-care conditions&mdashbut the point is that therapists should know the risks involved and try as much as possible to adhere to the ideal frame under limitations imposed by a given set of circumstances. Again, I want to point out that therapists' handling of the ground rules of therapy has unconsciously mediated, but real and highly consequential, effects.

Every case that I have studied directly or read about regarding a patient's violence against a therapist has involved major frame violations by the therapist, which were, by and large, ignored and not factored into the tragic event. After Dr Fenton was killed, I sent an e-mail to an online psychotherapy group with these thoughts in mind and was refuted immediately. There is strong resistance among psychotherapists against recognizing the power of the frame to both heal and harm.

Tragedies of this kind should, but seldom do, motivate therapists to reconsider the frame-related realm of behavior and experience. They might even think it advantageous to learn how to decode their patients' narrative imagery in response to securing the frame and to departures from ideal ground rules. They will then discover that their patients' responses to ground rule-related events are indeed archetypal and universal and learn that there are consistent tendencies within the emotion-processing mind that they should take into account while working with all patients.