Staff Behaviors Precede Violence and Aggression Among In-Patients


A review of articles and reports pertaining to violence and aggression in in-patient settings  finds that limiting patients’ freedoms is the most frequent antecedent of violent incidents. The review will be published in Acta Psychiatrica Scandinavica. This review follows a study published by the same principle authors in Psychiatric Services earlier this year, finding that in 16 acute inpatient psychiatric wards followed for two years, negative staff morale and staffing changes increased the likelihood of conflict. An interview with one of the authors appears in Mental Healthy.

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Kermit Cole
Kermit Cole, MFT, founding editor of Mad in America, works in Santa Fe, New Mexico as a couples and family therapist. Inspired by Open Dialogue, he works as part of a team and consults with couples and families that have members identified as patients. His work in residential treatment — largely with severely traumatized and/or "psychotic" clients — led to an appreciation of the power and beauty of systemic philosophy and practice, as the alternative to the prevailing focus on individual pathology. A former film-maker, he has undergraduate and master's degrees in psychology from Harvard University, as well as an MFT degree from the Council for Relationships in Philadelphia. He is a doctoral candidate with the Taos Institute and the Free University of Brussels. You can reach him at [email protected].


  1. Well duuuuh! Do people really believe that it’s the brain that’s to blame in these case? Do we really need scientific studies to try to tell us common sense things that everybody should already know? Did Cho really shoot all those people because he had a chemical imbalance, or was it because he had been a victim of racial bullying his whole life?

    Of course the way the staff treat the patients is going to influence their behavior. Do people really no longer think of the mentally ill as people anymore? All “normal” people would agree in an instant that if THEY were ever removed from their home amid no criminal charges, locked up, forced to take drugs and were treated like delinquent children, that THEY’D be irate, most people would even say violent. But when the mentally ill are treated like this and respond this way, we’re supposed to believe it’s because of a brain disease?

    ARHG! I cant take this stupidity anymore! Why does this study and these arguments even need to be had?

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    • Good point. But basic studies need to be done so that more complex studies can be justified, since we live in an evidence based society that gets funded only with documented official observations.
      What if genetic susceptibility, or enviromental triggers, makes you more prone to outbursts than others? The initial statistical finding that outbursts occur and what causes them is necessary to make a case for looking for individual differences in these responses for example.
      It’s not that we don’t know about them, but perhaps they have not been quantified. We already knew why kids fell off their trikes, but now we have a statistic as well.
      No duh.

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      • This is the goal of putting research like this up on the website. I’m trying to build a base of current research that people can draw on to back up what they have to say. Hopefully this will also help to inspire more studies.

        I spend a lot of time weeding through the thickets of research that compares one antipsychotic to another, trying to find the small overlooked studies like this that point to what, in my opinion, is really going on. So far I haven’t said much about the articles I’ve put up, because I hope to frame them well enough that they will stand on their own. So EAC’s “Well Duuuuh” response actually tells me I’m on the right track.

        Moving forward I may put more notes on the internal pages about what other research may complement the new articles and notes on what they may say about the big picture. But I’ve enjoyed placing articles and seeing what kind of discussion arises without imposing a particular frame around them.

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    • In response to EAC’s question: “Why does this study and these arguments even need to be had?”

      The answer is “poli” – an effort to create and develop POLICY, practice and procedure. Why?

      To maintain CONTROL: “poli” = politics, police, policy. You understand, I’m sure.

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  2. Oh and I remember when I spent 14 days on a psych unit awhile ago. It was using the phone that caused every incident that happened while I was there. The staff would at the nurses station would take the number, call it, talk to the person you wanted to talk to and determine if you were allowed to talk to them. I saw four people in fourteen days get dragged to the QR and be injected over that process.

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  3. Well of course the staff wants the patient to respond violently. Such a response legitimizes “treatment.”

    Don’t play their games and don’t let them upset you. Don’t take anything they say personally and be agreeable and cooperative for the time being. Under a civil commitment, eventually they have to let you out. What you do then on your own time is your own business.

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  4. Thanks for all your ‘weeding’ Kermit, it’s just what’s needed to discover the truth of what’s happening in psychiatric ‘care’. For the truth is needing to be out there.

    Those of us coming through the system, or supporting others to do so, know what it’s like. The grabbing and jagging has got to stop. It’s an abuse of human rights.

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  5. Dear Patients,

    Your task (if you’ve forgotten) is to learn, practice, master and model PATIENCE.

    Not easy when you’re loaded with vomit & crap and you’re about to explode. This is stated both literally & otherwise.

    You’re expected to have incredible, super-natural, super-powerful CONTROL over yourself, while obediently serving my every command. You are further expected to interact with other persons in a highly sterile (ineffective, non-toxic), sober (yet satisfactory) demeanor. I must approve of you and I even seek to be delighted in your presence, not repulsed.

    I will not tolerate the commiseration of your negative, detrimental effect.

    Yes, I shall correct, discipline and form you – according to my design and program. Be tranquil; take this “medication”.

    If you think I’m being sarcastic, please use your senses and try again.

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  6. I work in the very same hospital that I was once locked up in. Over a year ago we came under the scrutiny of CMS because of improper treatment of patients. Numerous incidents were documented on film. They were so upset with us that we came very close to losing our Medicare standing then and there. Ever since then we’ve been working, under the guidance of a group of consultants to bring ourselves up to standard. It is understood that if we are not successful we will lose Medicare and Medicare payments make up one-thrd of our monies. Without Medicare we close. It is extremely difficult to change the culture of an institution, especially one in which certain groups, like Nursing, were allowed to decide how they would run things, no matter what requirements or rules were. We’ve had two CEO’s since the beginning of our struggle and have set the foundation for mandating the dignified and respectful care of the people entrusted to us. We have three to five years of difficult and hard work ahead of us. I came back to work at this hospital to help in the process of changing it for the better. I would like to someday see it replaced with organizations like Soteria house but until that day will work to reform this institution. Articles like this are part of the arsenal that I create of things to continue and further reform. Thanks for making these things available.

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