Section of Psychiatry and Law, Rush-Presbyterian-St. Luke's Medical Center, Isaac Ray Center, Inc., Chicago, IL, USA
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See editorial pp.
307311, this issue.
Correspondence: Tony A. Fletcher, Section of Psychiatry and Law, Rush-Presbyterian-St. Luke's Medical Center, Isaac Ray Center, Inc., Chicago, IL, USA
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ABSTRACT |
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Aims To clarify the role of the mental health professional in evaluating issues related to workplace violence.
Method Manual and computer literature searches were performed.
Results The incidence of reported workplace violence is on the rise and can be devastating beyond the immediate injury. Forensically oriented mental health professionals can assist companies by providing pre-employment screenings, fitness-for-duty evaluations and threat assessment by using the results of current research on potentially violent individuals.
Conclusions With the growing interest in workplace violence come many opportunities for mental health professionals to assist companies in assessment, intervention and prevention.
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INTRODUCTION |
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Background
Americans, like people in other post-industrial societies, spend the
majority of their lives at work and although only a fraction of homicides in
the USA occur at the work site, violence in the workplace has been described
variously as a "national epidemic"
(Center for Disease Control,
1992) and as "an occupational health problem of significant
proportion". Corporations and small businesses are increasingly becoming
concerned with violence in the workplace, in clear correspondence to the rise
in legal verdicts holding the employer liable
(Dietz & Baker, 1987).
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DEFINITION OF WORKPLACE VIOLENCE |
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Government entities as well as privately held companies are increasingly being criticised for their lack of appropriate policies and procedures for addressing violence in the workplace. Some companies have looked internally to their human resources departments or to their employee assistance programmes (EAPs) for the provision of psychological consultation and treatment of those who are believed to be potentially violent. The role of the EAPs and human resources departments in assessing and reporting fitness for duty has been growing (McLean et al, 1984). However, their capacity to assess objectively any potentially disruptive employees and to deal with them is often constrained by concerns of double agency (i.e. the company may have a vested interest in moving even limited-risk employees out of the work force, and employees are correspondingly reluctant to respond to questions or to participate in review proceedings). As a result, companies have become more active in seeking outside speciality consultation for assessment of potential violence.
Although the so-called general-duty clause of the federal Occupational Safety and Health Act of 1970 required policies, procedures and training programmes specific to violence in the workplace, as of 1994 less than 20% of businesses reported compliance (Bureau of Labor Statistics, 1994). The 1970 act mandates that all employers provide a place of work that is free of identified hazards that can cause serious physical harm or death to an employee, including circumstances where fellow employees constitute the hazard. Whether or not the employer has actual knowledge of such hazards, the company can be held liable for damages resulting from the actions of an employee.
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STATISTICS ON WORKPLACE VIOLENCE |
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The consequences of violence in the workplace can be devastating beyond the immediate injuries. Not only may aggressive acts cause damage to company property and lead to increased insurance costs, legal costs, tarnished company image and diminished employee morale, but it may also lead to loss of confidence in the company, which in turn results in lost business. The exposure of employees to workplace violence can result in loss of worker productivity and increased employee turnover, with associated costs and diversion of management resources. Estimates suggest that workplace violence results in annual costs exceeding 55 million dollars in lost wages alone (Bachman, 1994). Escalating worker compensation premiums further drain company revenues.
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LEGAL IMPLICATIONS |
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Civil law is the primary regulator of conduct in this area and employers constitute the primary target. The theory is that civil liability or the threat of it will move employers to improve the safety of the workplace. This expectation appears to be well shared by trial judges and juries in the USA, who have shown an inclination to hand down incentive-creating, if not punitive, verdicts that would catch the attention of any risk-conscious employer (occasionally on facts or theories that do not readily justify the outcomes).
Liability through tort law (the law of negligence) is the main civil law avenue for motivating employers. There are two distinct strands. The first seeks to ground liability on, and thus move employers to correct, deficiencies in the security of the physical premises. The threat at which this is aimed is primarily violence by outside, unknown perpetrators. The case outcomes here show a marked propensity to find liability on the part of the employer. At times they are based on theory that is distinctly disincentive-creating, such as where employers are held to account for having voluntarily undertaken steps to improve security but these steps (in hindsight) are deemed insufficient. Liability would not have been found had the employer done nothing (Martin v. McDonald's Corporation, 1991; Vaughn v. Granite City Steel, 1991).
The other strand is aimed at known perpetrators (i.e. employees) over whom the employer is assumed to have control but which control he or she allegedly failed to exercise properly. There are several overlapping components to this liability theory, some or all of which may be tried in one case to see which one will stick (i.e. yield the desired, maximum result for the plaintiff): negligent hiring, negligent supervision, negligent retention and even negligent referral. The last theory, in particular, puts employers in a legal damned-if-they-do/damned-if-they-dont' situation, because recommendations that say too much about the referred employee's violence potential and those that say too little can both lead to liability when things go wrong (Doe v. Methacton School District, 1995).
There is also agency law at the victim/plaintiff's disposal where recovery is sought against the employer for violence done. Its advantage from the plaintiff's perspective is that it obviates the need to prove negligence on the employer's part, because the employer's responsibility for the employee's misconduct is automatic and vicarious a function of the employment relationship as such. On the other hand, there is a limitation on this theory (not always surmountable even in American law) in that the misconduct must have occurred "in the course of employment" (Lisa M. v. Henry Mayo Newhall Hospital, 1995).
Contract law provides another avenue, although it tends to be further removed than negligence or agency. Employment contracts do not typically ensure the employee's safety from violence, and much less do they give such assurances to third-party victims. However, American legal ingenuity is not readily stymied by mere factual realities. A safety-assuring contract can be found to be implied (i.e. in company handbooks or manuals that provide safety-related regulations or otherwise articulated company policies or guidelines that can be seen to have some bearing on health and safety). Again, the disincentive-creating aspect of liability premised on such implied "contracts" should be readily apparent (Foley v. Interactive Data Corp., 1988).
Civil Rights laws of various origins and aims exist to compensate for many emotional injuries that may be suffered on the job due to discrimination or harassment. Employer liability, usually based on the direct fact that the employer did the discriminating or harassing or, alternatively, that he or she knew or should have known that others were doing it, has been found in some cases not to require such cumbersome proof. Knowledge in these cases is simply imputed to the employer by virtue of the status of employer, and responsibility is simply assumed under this plaintiff-friendly legal conceptualisation known as "strict liability" (Miller v. Bank of America, 1979). Victims may bring civil rights actions for misdeeds allegedly based on race, religion, gender, age, nationality or disability the latter opening up the doors to some interesting types of claims by victims with, for example, major weight or personality problems, self-induced substance addictions and even mental illnesses that formerly might have made the very fact of employment unthinkable.
There is also the possibility of augmenting employer accountability through regulatory law, such as that administered by the federal OSHA (29 U.S.C. § 654 (a) (1)). This type of law makes the employer directly responsible for the safety of the workplace and although it is primarily aimed at physical conditions or hazards, can be interpreted to include incidents of violence or harassment. The federal law appears to be limited to conditions that "are causing or are likely to cause death or serious physical harm". However, agency guidelines, which are as binding on employers as the law itself, may be promulgated to incorporate lesser harms, including conceivably pure emotional ones. Also, some states have OSHA-style regulations in place whose application may be considerably broader than the federal provisions.
Affirmative obligations on individuals who have control over others to protect potential third-party victims, such as those imposed via the famous Tarasoff case on the therapists whose patients threaten harm, may arguably be extended to employers who (as emphasised by the negligence and agency laws discussed earlier) are presumed to have substantial, if not equal, control over their employees (Tarasoff v. Regents of the University of California, 1976). There is at least one known case (from Texas) where this theory was attempted. Although the plaintiff failed, the lack of success stemmed from facts deemed inhospitable to the theory rather than perceived inhospitability of the theory itself (Peek v. Equipment Services, Inc., 1995). Given a laboratory of 50 states in the USA where these sorts of theories can be tried out, it can be anticipated that in the near future there will be a plaintiff who will succeed on a claim that the employer failed to exercise an affirmative duty to warn or protect him or her from the predictable violence of an employee.
Finally, the criminal law can be brought into play in situations where the employer's conduct (or omitted action) is so egregious as to pass from civil negligence or recklessness to where it is justifiable to impute criminal intent, punishable by the criminal laws of the state where the violation took place. Agents of the OSHA entities already have the power, occasionally exercised, to recommend such criminal prosecutions in appropriate cases. There is, however, no reason why use of the criminal law should be confined to the initiatives of such regulatory middle-men.
Criminal laws against stalking and related forms of harassment exist today in each of America's 50 states. Their aim is not to inculpate the arguably accountable employer, but to deter and punish directly the (potential) victimiser or perpetrator. The effectiveness of these laws has been questioned by many a commentator, but it is clear that some of the doubt is a function of the fact that the laws' successes are not known: where there is no incident, there is no "story" (not even an abstract entry in the ledger of a police desk-clerk or a faceless statistic in the annals kept by an academically concerned criminologist or sociologist).
As a last legal note, it deserves to be recognised that negligence law can be applied against the victim of violence as well as against those who may be viewed as accountable for the conduct of the perpetrator. This is under the doctrine of contributory negligence, which may reduce or defeat the claim of the injured plaintiff because he or she was partially or mostly at fault in provoking the incident. Doctrines that withhold or diminish compensation for the injured tend not to be popular in practice, but the underlying theory is defensible: it aims to deter conduct that generates injuries and injury claims. There is no principled reason to exempt would-be victims from this well-established legal calculus, even if it may seem hardhearted to apply it to actual victims.
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THE ROLE OF MENTAL HEALTH PROFESSIONALS |
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PRE-EMPLOYMENT SCREENING EVALUATIONS |
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The pre-employment evaluation includes a thorough clinical interview with pertinent historical data, which should be provided by the employer prior to the evaluation, if available. During the clinical interview previous relationships with employers and family should be explored, as well as any criminal history. Simply asking the prospective employee how he or she feels about certain past employers may yield a wealth of information. The informed clinician takes into consideration any sudden changes in the evaluee's mood or personality, and questions any inconsistent information given. Following the interview, psychological testing may be requested when issues surface regarding personality difficulties, interpersonal functioning, impulsivity and drug/alcohol misuse.
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FITNESS-FOR-DUTY EVALUATIONS |
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A review of the employee's work-related history and an investigation of any recent incidents help in the assessment. If there is any history of mental illness, adherence with medication should be assessed. It may turn out that the employee's performance was unremarkable until the employee chose to discontinue psychotropic medication. Evidence of cognitive decline or other neurological problems may require the use of a neurologist or neuropsychologist. Situational factors, such as a change from day to night shift, marital conflict, company downsizing or harassment by another employee, can also cause decreased work performance.
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THREAT ASSESSMENT |
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The role of the clinician is to aid the referring company in distinguishing a real threat from an employee blowing off steam. May individuals utter threats without true intention to carry them out or they lack the psychological or physical capacity to commit a violent act. However, an individual who demonstrates impulsivity, displays weapons, designates a potential target (i.e. the boss or another employee) and feels justified in committing violence should be seen as a significant risk. Violence is a process and does not occur in a vacuum; it is usually the result of interactions between the perpetrating individual, the triggering environment and the lack of intervention by the referring company.
The clinician should begin by assessing the most recent act or verbalisation of violence, in as much detail as possible, as well as considering accounts of the nature and frequency of past violent acts committed by the employee. The evaluee should be asked to describe thoughts and feelings before, during and after previous violent incidents. A poor prognostic sign is the employee's incapacity to identify these thoughts and feelings.
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VIOLENT PERSON PROFILE |
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Stalking is a behaviour and not a psychiatric diagnosis, and often involves the search for either revenge or rapprochement after the cessation of a relationship. Because a good number of violent incidents in the workplace have involved stalkers of employees, the employer's concern should extend to rebuffed partners of employees who could bring their wrath to the work site. There are observable signals among victims as well as perpetrators. Pathe & Mullen (1997) stated that 53% of stalking victims in their study reported a decrease or cessation of work or school attendance. The clinician must interview the potential victim and examine the perpetrator's history of violence, including threats. If evidence of a mental illness is evident, the clinician may be able to hospitalise the stalker involuntarily as an alternative to assisting in having criminal charges brought.
Perpetrators of violence usually have a traceable history of disputes, interpersonal conflicts and failures. They tend to have a history of threatening or assaulting others, combined with extremely poor coping skills. They also tend to have little or no family support and have difficulty accepting criticism from others, particularly co-workers. They see themselves as victims of injustice and may see others as persecuting them. Perpetrators are also known to externalise blame and hold grudges against co-workers and supervisors. Individuals diagnosed with borderline and/or antisocial personality disorders have an increased likelihood for becoming violent.
One of the best predictors of future violence is a history of violence (Klassen & O'Conner, 1988), with an increase in potential with each prior act of aggression. Other research has shown aggression to be a relatively stable characteristic (Huesmann et al, 1984). External factors such as recent termination or lay-off may cause the perpetrator to act aggressively and/or violently. Other factors that increase the potential for violence include alcohol or drug misuse and the availability of guns. Alcohol misuse has been linked to an increased likelihood that the user will misread situations, and has been shown to increase impulsivity.
Early studies suggested that the mentally ill were no more violent than others in the community (Brown, 1985). However, more recent studies report that mental illness increases the likelihood of violence (Swanson, 1994). In psychotic disorders, increased risk may be a function of paranoid delusions, feeling threatened or thought insertion. Feldman & Johnson (1994), however, demonstrated that most perpetrators of workplace violence are not so markedly disturbed as to be diagnosed with a psychiatric disorder, but personality disturbances were noted with qualities that parallel criminal populations. Low intelligence and neuropsychological impairment also are factors that increase the likelihood of violence (Monahan, 1992), as well as low socio-economic status (Swanson et al, 1990). The combination of substance misuse with other risk factors significantly increases the likelihood of violent acting out.
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NEW PERSPECTIVES ON VIOLENCE IN THE WORKPLACE |
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Bell, C. A., Stout, N. A., Bender, T. R., et al (1990) Fatal occupational injuries in the United States, 1980 through 1985. Journal of the American Medical Association, 263, 3047-3050.[Abstract]
Bensimon, H. F. (1994) Crisis and disaster management: violence in the workplace. Training and Development, 28, 27-32.
Brown, P. (1985) The Transfer of Care: Psychiatric Deinstitutionalization and its Aftermath. London: Routledge & Kegan Paul.
Bureau of Labor Statistics (1994) News: National Census of Fatal Occupational Injuries reported by BLS (USDL-93-406). Washington, DC: US Department of Labor.
Bureau of Labor Statistics (1995) News: Work Injuries and Illnesses by Selected Characteristics, 1993 (USDL-95-142). Washington, DC: US Department of Labor.
Capozzoli, T. & McVey, R. S. (1995) Does Management Generate Violence in the Workplace? New Avenues in Risk and Crisis Management, Vol. IV, pp. 3-11. Nevada: Board of Regents, University of Nevada.
Castillo, D. N. & Jenkins, E. L. (1994) Industries and occupations at high risk for work-related homicide. Journal of Occupational Medicine, 36, 125-132.[Medline]
Center for Disease Control (1992) Homicide in the US Workplace: a Strategy for Prevention and Research (NIOSH Publication No. 92-103). Washington, DC: US Government Printing Office.
Dietz, P. E. & Baker, S. P. (1987) Murder at work. American Journal of Public Health, 77, 1273-1274.[Medline]
Feldmann, T. B. & Johnson, P. W. (1994) Violence in the Workplace: a Preliminary Report on Workplace Violence Database. New Orleans, LA: American Bar Association.
Fitzgerald, L. F. (1993) Sexual harassment; violence against women in the workplace. American Psychologist, 48, 1070-1076.[CrossRef][Medline]
Goldberg, J. E. (1994) Employees with mental and emotional problems workplace security and implications of state discrimination laws, the Americans With Disabilities Act, the Rehabilitation Act, worker's compensation and related issues. Stetson Law Review, 24, 201-240.
Huesmann, L. R., Eron, L. D., Lefkowitz, M. M., et al (1984) Stability of aggression over time and generations. Developmental Psychology, 71, 522-526.
Klassen, D. & O'Conner, W. A. (1988) A prospective study of predictors of violence in adult male mental health admissions. Law and Human Behavior, 12, 143-158.
McLean, M. D., Ellis, W. & Moss, L. M. (1984) Report of the Task Force on Psychiatry and Industry. American Journal of Psychiatry, 141, 1139-1144.
Monahan, J. (1984) The prediction of violent behavior: toward a second generation of theory and policy. American Journal of Psychiatry, 141, 10-15.[Abstract]
Monahan, J. (1992) Mental disorder and violent behavior: perceptions and evidence. American Psychologist, 47, 511-521.[CrossRef][Medline]
Mossman, D. (1994) Assessing predictions of violence: being accurate about accuracy. Journal of Consulting and Clinical Psychology, 62, 783-792.[CrossRef][Medline]
Northwestern National Life (1993) Fear and Violence in the Workplace: a Survey Documenting the Experience of American Workers. Minneapolis, MN: Northwestern National Life, Employee Benefits Division.
Occupational Safety and Health Administration (1996) Guidelines for Preventing Workplace Violence for Health Care and Social Workers, OSHA 3148. Washington, DC: Department of Labor.
Pathé, M. P. & Mullen, P. E. (1997) The impact of stalkers on their victims. British Journal of Psychiatry, 170, 12-17.[Abstract]
State of California (1993) Guidelines for Security and Safety of Health Care and Community Service Workers. Sacramento, CA: Division of Occupational Safety and Health, Department of Industrial Relations.
Swanson, J. W. (1994) Mental disorder, substance abuse, and community violence: an epidemiological approach. In Violence and Mental Disorder: Developments in Risk Assessment (eds J. Monahan & H. J. Steadman) pp. 101-136. Chicago, IL: University of Chicago Press.
Swanson, J. W., Holzer, C. E., Ganju, V. K., et al (1990) Violence and psychiatric disorder in the community: evidence from epidemiologic catchment area surveys. Hospital and Community Psychiatry, 41, 761-770.[Medline]
Webster, C. D., Harris, G. T., Rice, M. E., et al (1994) The Violence Prediction Scheme: Assessing Dangerousness in High Risk Men. Toronto: University of Toronto, Center of Criminology.
Doe v. Methacton School District (1995) 880 F. Supp. 380 (E.D. Pa. 1995).
Foley v. Interactive Data Corp. (1988) 47 Cal. 3d 654.
Lisa M. v. Henry Mayo Newhall Hospital (1995) 12 Cal. 4th 291.
Martin v. McDonald's Corporation (1991) 572 NE.2d 1073 (III. Ct. App. 1991).
Miller v. Bank of America (1979) 600 F. 2d 211 (9th Cir. 1979).
Peek v. Equipment Services, Inc. (1995) 906 S.W. 2d 529 (Tex. Ct. App. 1995).
Tarasoff v. Regents of the University of California (1976) 17 Cal. 3d 425, 551 P. 2d 334, 131 Cal. Rptr. 14 (1976).
Vaughn v. Granite City Steel (1991) 576 NE.2d 847 (III. Ct. App. 1991).
Received for publication May 19, 1999. Revision received December 6, 1999. Accepted for publication December 7, 1999.