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JAMA Network Insights
September 16, 2020

Guidance for Working With a Patient Who Elicits Fear in the Psychiatrist

Author Affiliations
  • 1Division of Behavioral Health Services and Policy Research, New York State Psychiatric Institute, New York
  • 2Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
JAMA Psychiatry. Published online September 16, 2020. doi:10.1001/jamapsychiatry.2020.2844

While it is clear that most societal violence is not due to mental illness, there is conflicting evidence regarding whether mental illness itself increases violence risk.1 Nonetheless, variables associated with mental illness, particularly substance abuse, have been shown to be predictors of violence.1 As such, psychiatrists do treat individuals at risk of violence and are at times themselves at risk. The rate of nonfatal violent crime against mental health professionals is more than 5 times that for all occupations.2 While underreporting of assaults seems prevalent, more than one-third of psychiatrists report having been physically assaulted at least once, and psychiatrists in training seem particularly vulnerable.2

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    Addendum
    Ilana Nossel, M.D. | New York State Psychiatric Institute & Columbia University
    As the events of the past few months have demonstrated, the reaction of law enforcement personnel to individuals with behavioral health care conditions who are in crises can vary greatly and at times have tragic consequences. Accordingly, we write to amend the assertion at the conclusion of our recently published paper, Guidance for Working With a Patient Who Elicits Fear in the Psychiatrist, that contacting law enforcement in cases of imminent risk protects both the clinician and the patient. It has become increasingly clear that this is not always the case— especially for Black patients and other people of color. While there are currently few or no viable alternatives in cases of imminent risk, we urge clinicians to consider the balance of risks of involving law enforcement, to work with patients and families to prevent escalation, and over the long-term to collaborate with community partners and researchers to develop antiracist alternative solutions for managing crises.

    -Ilana Nossel, MD & David Lowenthal, MD, JD
    CONFLICT OF INTEREST: None Reported
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