Comment on “Violence Against Psychiatric Trainees: Findings of a European Survey”

Pereira-Sanchez, et al (2021), in their paper, raise important and timely questions regarding violence by patients against psychiatry trainees. An overwhelming majority of trainee respondents from Europe reported having experienced some form of violence from their patients [1]. Not surprisingly, this has led to a lasting impact on their mental wellbeing. Recent reports of high vulnerability and psychological concerns among trainees and young physicians [2, 3] make it clear that the profession has an obligation to improve working and training conditions, but also to provide immediate and appropriate assistance to the trainees, be it psychological or medical, especially to those who need it. However, as the authors [1] point out, the number of trainees who reported assaults was very low. This may have been due to their perception that the incidence was not serious enough, or some misleading belief that their supervisors would not take the incident seriously, thus leading them to avoid reporting it.

In our international study, we aimed to explore the experiences of early career psychiatrists working within the current legal framework of compulsory psychiatric care and detention of patients in their countries of practice, along with potential areas for revision [4]. We also explored their experiences of physical aggression towards them from their patients. In this international, cross-sectional and anonymous online survey, 142 psychiatrists from 43 countries (52.8% females; mean age 32.6±3.9) responded. Of those, 38 (26.8%) were psychiatry trainees. A majority of our respondents (78.2%) reported a history of physical abuse by patients. Almost a quarter (22.5%) of these attacks were described as life-threatening. Almost two-thirds (64.7%) of the respondents did seek psychological help or supervision after the episode, the rest did not. Peer support was offered in 46.8% of cases and/or from their senior colleagues in 32.4% of cases.

Both studies were conducted during the same time period. They highlight an urgent need for support on the part of both clinical and educational supervisors at a personal level. But training institutions have a moral obligation to provide appropriate training and a supportive environment. Although currently little formal risk-assessment training occurs in psychiatric settings, proper training in dealing with violent patients in order to effectively assess, treat, and cope with these individuals should be implemented in training programs for mental health professionals [5]. Researchers have proposed training programs to prevent aggressive behavior by patients [6], including the assessment and management of violent patients, receiving training in diagnosing and evaluating such individuals, learning about pharmacological interventions, and environmental safety [7], as well as various de-escalation techniques [8]. To date, however, these programs have yielded limited empirical research evidence of their effectiveness [8], which likely precludes their broader implementation in psychiatry residency training curricula. Therefore, it is important to pay more attention to research on the effectiveness of patient violence-prevention strategies.

A worrying finding is that one-third of early career psychiatrists in our study failed to receive any help, similar to the findings in an earlier study [9]. In order to deal effectively with the aftermath of violent attacks, urgent action is needed not only to train everyone in breakaway techniques, but also to have immediate access to support were these incidents to happen. In this regard, it is critical to develop guidelines for the psychological support of the victims of violent acts. The institutions must implement/adopt hospital and emergency room policies that prevent the violence from occurring. We recommend that they implement clear policies but also make available wellbeing guardians who can be approached by those affected and act as repositories of information. They can provide support that prevent burnout and the appearance of long-term distress, thus mitigating psychological consequences. At the level of government, policies must be put in place and resources made available so that trainees are well taken care of. Regulatory bodies have an ethical obligation to ensure that the workforce is protected, so that it can provide the best care possible to patients.

1. Pereira-Sanchez V, Gürcan A, Gnanavel S, Vieira J, Asztalos M, Rai Y, Erzin G, Fontaine A, Pinto da Costa M, Szczegielniak A. Violence Against Psychiatric Trainees: Findings of a European Survey. Acad Psychiatry. 2022 Apr;46(2):233–237. doi: 10.1007/s40596-021-01539-3.
2. Bhugra D, Sauerteig SO, Bland D, Lloyd-Kendall A, Wijesuriya J, Singh G, Kochhar A, Molodynski A, Ventriglio A. A descriptive study of mental health and wellbeing of doctors and medical students in the UK. Int Rev Psychiatry. 2019 Nov-Dec;31(7-8):563–568. doi: 10.1080/09540261.2019.1648621.
3. Chumakov EM, Gvozdetsky AN, Vasilchenko KF, Golygina SE, Marachev MP, Osadashiy YuYu, Potanin SS, Fedotov IA, Shishkina IO, Petrova NN. Characteristics and determinants of professional burnout among early career psychiatrists in Russia — results of a cross-sectional study. V.M. Bekhterev review of psychiatry and medical psychology. 2022;56(1):63–78. doi: 10.31363/2313-7053-2022-1-63-78.
4. Chumakov E, Petrova N, Vadivel R, Pinto da Costa M, Bhugra D, Ventriglio A. Use of Compulsory Treatment by Early-Career Psychiatrists: An International Survey. Psychiatr Serv. 2021 Nov 1;72(11):1276–1281. doi: 10.1176/appi.ps.202000303.
5. Antonius D, Fuchs L, Herbert F, Kwon J, Fried JL, Burton PR, Straka T, Levin Z, Caligor E, Malaspina D. Psychiatric assessment of aggressive patients: a violent attack on a resident. Am J Psychiatry. 2010 Mar;167(3):253–259. doi: 10.1176/appi.ajp.2009.09010063.
6. Feinstein RE. Violence prevention education program for psychiatric outpatient departments. Acad Psychiatry. 2014 Oct;38(5):639–646. doi: 10.1007/s40596-014-0160-5.
7. Schwartz TL, Park TL. Assaults by patients on psychiatric residents: a survey and training recommendations. Psychiatr Serv. 1999 Mar;50(3):381–383. doi: 10.1176/ps.50.3.381.
8. Price O, Baker J, Bee P, Lovell K. Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression. Br J Psychiatry. 2015 Jun;206(6):447–455. doi: 10.1192/bjp.bp.114.144576.
9. Cannavò M, La Torre F, Sestili C, La Torre G, Fioravanti M. Work Related Violence As A Predictor Of Stress And Correlated Disorders In Emergency Department Healthcare Professionals. Clin Ter. 2019 Mar-Apr;170(2):e110–e123. doi: 10.7417/CT.2019.2120.