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Psychiatrists have a number of options to consider if they want to protect themselves from potentially violent patients, said Vince Kennedy, DO, at the American Academy of Psychiatry and the Law annual meeting.

Several considerations involve office design, especially for those in private practice, said Kennedy, a forensic psychiatry fellow at the University of California Davis. He listed several possibilities to consider:

• Security cameras. These are increasingly affordable and easy to use, with a reasonable installation cost, Kennedy said. "Just make sure that if you're using security cameras in a medical office setting or other healthcare setting that you're not violating HIPAA [Health Insurance Portability and Accountability Act] by pointing to cameras at areas where a viewer might be able to see protected health information. But it is not inherently a violation of HIPAA to have such cameras in a medical setting."
• Panic buttons. Like security cameras, these are very affordable and simple to use, and they can be carried by all staff members. When the button is pressed, it can sound an audible alarm and/or contact the authorities.
• Weighted furniture. This type of furniture is harder to pick up and throw, reducing the chance it can be used as a weapon, Kennedy said. The one disadvantage is that it can be rather expensive. In addition, when seeing high-risk patients, "you might want to reduce the amount of throwable objects available in the room when you're seeing them, such as weighted paperweights or staplers," said Kennedy.
• Bullet-resistant material at the receptionist's station. "You need to consider not only the glass partition, but also the walls around it, because a determined attacker probably won't just limit themselves -- if they brought a firearm -- to shooting just at the glass; they might try shooting the walls around it as well, so make sure to take that into account," he said. The receptionist could also have photos of potentially violent discharged patients or others posing a potential safety risk, so they could be identified.
• Metal detectors. This would likely only be appropriate in a large institution to screen visitors and patients for weapons, he said.

When setting up the office, consider having a front door with "buzz-in-only" access, so that the person coming in has to identify themselves, Kennedy suggested. Having the waiting area closed off from the back office -- with entry only via a keycard or keypad -- "reduces the chance that somebody barges into the area where the staff and other patients might be," he added. Patients could then only go into the back area with a staff member.

As for the consultation room, it can be designed so that the psychiatrist's chair is closer to the door than the patient's chair. "The literature varies on exactly where the positioning should be, but make sure that the patient isn't closer to the door," said Kennedy. Another thing to consider is "having a large desk between yourself and the patient, to reduce the risk that they're going to be able to easily access you in case they become aggressive." And the door to the consultation room should be placed "such that the receptionist in the reception area could peek in and see how things are going."

A "panic room" is another possibility -- "it doesn't have to necessarily be a bunker or a bank vault-type situation with concrete walls, but rather a room with a door that locks from the inside with either a landline phone, or with consideration for the cell phone reception in that room so that a staff member can call 911 in case somebody comes in to attack." However, this would only delay an attacker, not necessarily thwart them by itself, he added, noting that it's also a good idea to have a back exit as a second way out.

Screening, Building Security

There are also non-physical security measures to consider, said Kennedy. For example, "you could also have a screening interview prior to seeing a patient ... to help you determine the safety and risk level, which would help you to make sure that you have the right number of staff available on hand in case things get escalated." In addition, "avoid seeing patients at night or pretty much at any time where there's not other staff members in the office, to check up on how you're doing in case something comes up. You want a person nearby to be able to call for help very quickly," he said.

Developing a good relationship with building security is also helpful. "That way you know who to call, in case a situation arises in which 911 is not the appropriate level of security -- a security officer onsite can help with ejecting an unwanted person from the building if they haven't already progressed to violence," Kennedy said. "So you want to know who they are and how to contact them."

'An Ounce of Prevention...'

On a more personal level, "you can also consider receiving self-defense training; there are self-defense training systems that involve minimizing risk as much as possible to the patient that you are trying to protect yourself from," he said. And of course, if an encounter appears to be escalating, "you want to try verbal de-escalation first," such as making an excuse to step out of the room.

What about getting a restraining order against a person who may be at risk of harming you? Restraining orders can be helpful in cases of a "naïve pursuer" -- someone who is rational, but is unaware of the inappropriateness of their behavior, said Kennedy. In such cases, "you have to do it quickly, to maintain the highest efficacy in terms of safety. If you wait too long, things can escalate to an unsafe level."

On the other hand, "a meta-analysis of various studies on stalking and restraining orders found that there was a 40% violation rate of restraining orders across 32 different studies, and that 21% of restraining orders actually were followed by an escalation in violence across nine different studies," he added. "Of course, if you file a restraining order against somebody, you might be asked to appear in court with that person, which you might want to avoid."

There are also other legal options to consider, such as enforcement of criminal laws regarding stalking, harassment, unlawful use of computer communications, unlawful use of a phone, and trespassing, "so for all these reasons, law enforcement has been shying away from use of restraining orders," said Kennedy.

In short, he added, to quote Benjamin Franklin, "'An ounce of prevention is worth a pound of cure.'"

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