Assaults on Staff

To the Editor: Flannery and associates (1), the authors of the paper on the Assaulted Staff Action Program in the February 1998 issue, are to be congratulated for their successful efforts both to help assaulted mental health staff and to decrease assault rates by implementing a crisis intervention approach. As the authors point out, the psychological sequelae of patients' assaults on staff may be detrimental for patients, staff, and health authorities.

In a previous study, the authors reported the favorable outcome of their crisis intervention program on assaulted staff (2). I wonder whether it might be useful to expand the scope of the program beyond critical-incident debriefing to generally target crisis intervention for ward staff as a group. All staff are affected by an assault on one of their members. Group interventions produce good long-term results by increasing a group's sense of cohesion, reducing tension, mobilizing team unity and support, and enhancing coping resources (3).

Regarding the reasons for the decline of assaults after implementation of the intervention program, I feel it is important to keep in mind that psychiatric patients tend to watch carefully what staff members are doing on the wards. In our own study of patients' perception of being observed on psychiatric wards, we found that patients are able to differentiate accurately between different observation levels and to perceive variations between traditions of psychiatric care (4). It is likely that psychiatric patients register staff's attitude and sense of mastery and cohesion after an assault and benefit from staff's successful coping with violence.

Parallel processes between staff and patients may play an important role in the aftermath of a destructive act on the ward (5). Assaultive patients usually experience intensely destructive affects and impulses they cannot contain intrapsychically. They cannot accept these impulses as their own, projecting them instead onto other objects whom they consequently assault. An assaulted staff member who has been helped by crisis intervention to regain mastery, attachments, and ability to make meaningful sense of the event may act as a container of such destructive forces.

Restoring a staff member's ability to make sense of the event includes gaining some understanding of why a patient has been assaultive. Such understanding could in turn lead to a sort of ingestion and deescalation of the dangerous destructive impulses. Patients who observe others handling destructive feelings positively, without being overwhelmed by anger, shame, and panic, will probably be less prone to acting out their own destructive feelings, with the result that the ward atmosphere changes and assaults decline. This hypothesis about the importance of containment is supported by the authors' finding in their earlier study (2) that a large number of assaults occurred against new staff members who had not yet been trained in stress management on the ward and were not yet used to understanding assaultive patients in their destructive rage.

Dr. Langenbach is a psychiatrist and psychotherapist at the Institute and Polyclinic of Psychosomatics and Psychotherapy at Cologne University in Cologne, Germany.