August 6, 1999

When psychiatrist Reuven Bar-Levav, M.D., was fatally shot in his suburban Detroit office practice at point-blank range in June by a patient he had seen for about a dozen sessions last year, shock and disbelief echoed around the state.

Just two months earlier in Toledo, Ohio, Wakil Khan, M.D., was shot at point-blank range by a patient he had seen for only a month. Khan remains in a coma, according to his office manager, Lori Sherman.

As word spread of these senseless incidents, psychiatrists expressed shock, dismay, and a sense of helplessness about being vulnerable to attacks by patients.

Although homicides committed by patients are rare, psychiatrists may be at greater risk for patient violence than their colleagues in other medical specialties, according to John Lion, M.D., a private practitioner in Baltimore and a clinical professor of psychiatry at the University of Maryland School of Medicine in Baltimore. Lion was a member of APA's former Task Force on Clinician Safety.

About a dozen psychiatrists in the United States have been murdered by patients since 1983, compared with the same number for surgeons, neurologists, plastic surgeons, orthopedists, and primary care doctors combined, according to the 1996 book Creating a Secure Workplace, coedited by Lion.

He told Psychiatric News, "There are two categories of patient violence: the type that usually occurs in the emergency room or an inpatient psychiatric unit when a patient assaults a health care worker he has just met, and the type that is more common among psychiatrists, which involves a long-term patient relationship."

The intimate relationship can fuel patient aggression and even violence when there is pathologic transference and the patient feels victimized, said Lion.

"Psychiatrists involved in emotionally charged situations such as child custody disputes also may be at risk of harm," said Lion.

Certain types of patients may be more prone to violence such as those with histories of physical assault or domestic violence, noted Lion.

A common element in the recent shootings was that the assailants were critical of their therapists' treatment, according to local newspaper accounts.

"Once a therapist learns that the patient is angry about treatment or even billing, for example, he or she should address the situation as quickly as possible. It is better to understand the basis of a patient's anger than to ignore it," said Lion.

He suggested that the therapist meet with the patient to discuss the problem and ask a colleague to be present during the appointment or have a receptionist nearby to minimize the risk of harm to the therapist, or take both precautions.

"When a patient expresses angry thoughts or feelings or delusional fantasies, the treating psychiatrist should use the opportunity to ask about the person's feelings toward himself or herself," said Lion. If the patient threatens to harm the therapist or another person, it is critical that the therapist ask more questions including whether the patient has acquired weapons to implement the threats.

"These are the same questions we would ask a patient at risk of suicide. However, we don't think to ask these questions, which are frightening, to protect our own safety," said Lion.

If the patient is out of control or the threats of violence escalate, Lion then recommends taking other actions including involuntary hospitalization, considering ending the relationship, and calling the police.

In the rare instance when a patient brings a gun into a psychiatrist's office, "the therapist should reveal that he or she is scared. This can prevent the situation from escalating further because silence tends to incite the patient to become more threatening," opined Lion.

He also recommended that psychiatrists become security minded in terms of thinking about how they might be vulnerable to patient violence.

For example, psychiatrists who are in solo practices or in isolated offices should consider installing an alarm button that can ring in a security firm. Hiring a receptionist or secretary to work during hours when patients at risk for violence are seen or having an office in a commercial building where more people are around are other security measures psychiatrists can take, said Lion.