Fall 2001, Vol. 9, No. 1

Workplace Forensic Psychiatry:

Contributions of Organizational and Occupational Psychiatry Issues in Workplace Violence Consultations

Ronald Schouten, MD, JD
Boston, MA

Since the early 1990s, workplace violence has received considerable attention from the media, government agencies, and employers. This attention has continued, even as the workplace homicide rate has declined steadily since 1994.[¹] The justifiable anxiety and concern raised by workplace violence have given rise to a growing number of consultants, from many different fields, who are willing to offer their expertise in dealing with the problem.

Psychiatrists and other mental health professionals have been asked to serve two roles with regard to workplace violence. Both of these roles grow out of the widely held assumption that violence in general, and workplace violence specifically, are primarily the result of mental illness. On a broad level, we have been asked to explain workplace violence as a behavioral phenomenon. We have not succeeded in filling this role, as scientific research on the subject is virtually non-existent, while the opinion and anecdote-based literature is extensive. An extensive literature review in our office at the Massachusetts General Hospital has, to date, failed to yield a single study that attempts to confirm or refute the risk factors that are commonly offered as predictive of workplace violence. The recently-published data from the MacArthur Foundation Study of Mental Disorder and Violence provides the best information to date about the relationship between a range of risk factors for violence, including mental illnesses.[²] It is a study of discharged psychiatric inpatients, however, and its conclusions must be applied with caution to the work setting. Indeed, only a small percentage of violent incidents recorded in that study occurred in the workplace, possibly because the employment rate among this population is quite low.

On a more specific level, psychiatrists and other mental health professionals have been asked to serve as consultants to employers, security professionals, attorneys, and law enforcement on issues related to workplace violence. In this consultant role, we are asked to evaluate threatening statements (both verbal and written) and behaviors, assess the risk of violence posed by certain individuals, and help manage situations so that potential acts of violence do not actually occur. Some psychiatrists called to consult on a workplace violence matter see their role as being limited to the determination of the presence or absence of mental illness and the risk of violence. In fact, such a restrictive approach ignores a wide range of organizational factors that are essential to the assessment of risk and management of the situation, depriving both the consultant and consultee of valuable information.

Workplace violence situations present a complex array of issues appropriate for organizational and occupational psychiatrists. This column addresses a sample of some of these organizational issues and the unique added value that organizational and occupational psychiatrists can provide, based upon my observations in over 100 workplace threat assessment matters. The following case example illustrates how the broader role that can be played in such situations by the clinician with an organizational and occupational psychiatry perspective.

AC had worked for XYZ Corp. for 15 years in a clerical position on the evening shift. He took the job immediately after he dropped out of college due to "stress." AC was known as an enthusiastic and dedicated employee, but his loud voice, occasional agitation, and habit of running from place to place on the job led other employees to avoid him and regard him as mentally ill. AC's behavior was tolerated by XYZ, and his supervisor would occasionally tell him to take several hours off if he appeared to be getting too upset and agitated. AC was in no treatment for a mental illness. Over the previous two years, AC's behavior had been worsening at work and he developed a frank paranoia, at the heart of which was his belief that a female co-worker was sabotaging his work. This distressed AC, as he was fearful that poor production numbers resulting from the sabotage could cause him to lose his job, which was the most rewarding aspect of his life. One evening, AC asked his supervisor to prevent the other employee from sabotaging his work. The supervisor investigated and found no basis for the claim of sabotage. When told this, AC began shouting, picked up a stapler and prepared to throw it at the supervisor. Instead of throwing the stapler at the supervisor, AC began pounding his own head with it. Security was called and AC was taken to the hospital. He was suspended immediately, placed on a medical leave of absence, and, after he began a course of treatment through his HMO, was required to undergo a fitness for duty evaluation before he could return to work. The focus of the fitness for duty evaluation was AC's ability to perform the functions of the job, with a specific emphasis on his risk of harm to self or others.

The HMO psychiatrist diagnosed AC as suffering from a psychotic illness, prescribed an antipsychotic medication, and made plans to see AC monthly. No other treatment was planned. She indicated that AC was psychotic when she first saw him, was much better with the medication, and was fit to return to work.

Employers and attorneys often fail to recognize the complex array of issues that can affect an employee's behavior and their significance in cases such as this. As a result, they may request a simple assessment of the employee's safety to return to work, perhaps with suggestions for any necessary accommodations to satisfy disability discrimination requirements. While answering this basic question is an essential part of the consultation, a psychiatrist with an organizational and occupational perspective can improve the process and results of such a consultation at several points, as this example demonstrates.

Framing the question

The consulting psychiatrist can help the referring client understand that the consultation should go beyond a simple answer to the fitness for duty question. For example, it should include an assessment of the sources of the behavioral problems, adequacy of the treatment, and recommendations for additional treatment. In this case, the psychiatrist noted that AC's agitated behavior stemmed, in part, from his extreme devotion to the job and attendant fears that he might lose it because of supposed sabotage. He also noted that monthly 10 minute medication checks were inadequate to address AC's concerns about work, and he recommended group psychotherapy to help him with these issues.

Sources of the problem

By gathering information from collateral sources, such as the human resources representative and AC's immediate supervisor, the consultant was able to identify several potential contributors to AC's problem behavior: the manner in which other employees treated him, failure to set limits on AC's behavior and that of the other employees towards him, and conflicting agendas between human resources and AC's supervisor. No one at XYZ had ever expressed concern about AC's inappropriate behavior, which indicated to AC that his behavior was quite acceptable. Similarly, no one had ever intervened with the co-workers who teased AC and went out of their way to do the very things that confirmed his suspicions. Finally, the consultant learned that human resources was in favor of returning AC to work, but his supervisor did not want him to return because of his history of bizarre behavior and the concerns of other employees.

Consultation on the issue of returning the employee to work

After concluding that AC could return to work, so long as additional treatment was put in place, the consultant worked to resolve the conflict between human resources and AC's supervisor. The consultant met with the supervisor to discuss the basis for the conclusion that AC could return to work, the nature of the illness, the success of his treatment, and strategies for minimizing the risk of further difficulties. The supervisor remained concerned about the reaction of other employees to AC's potential return. With AC's permission, the consultant met with AC's co-workers, shared information with them about his illness and the facts regarding mental illness and violent behavior. Most of the employees were understanding and responsive, and AC was able to return to work.

While the outcome in cases such as this are not always so positive, this case provides an example of how a broader approach to the consultation question, extending beyond the basic question of fitness for duty and utilizing the skills of organizational and occupational psychiatry, allowed the consultant to contribute to resolution of the problem through identification of individual and group issues and active participation in addressing them.

Footnotes
¹ The complete series of reports from the Census of Fatal Occupational Injuries by the Bureau of Labor Statistics documents the rates of workplace fatalities, including homicides, since 1992. They can be found at http://www.bls.gov/oshcfoi1.htm?H6.

² Monahan J, Steadman HJ, Silver E, et al. Rethinking Risk Assessment. New York: Oxford University Press, 2001.

 
Return to Top