Psychiatr Q (2014) 85:391–396 DOI 10.1007/s11126-014-9305-7 ORIGINAL PAPER
International Precipitants to Psychiatric Patient Assaults in Community Settings: Review of Published Findings, 2000–2012 Raymond B. Flannery • Georgina J. Flannery
Published online: 24 September 2014 Ó Springer Science+Business Media New York 2014
Abstract In studying psychiatric patient assaults, assessing the person 9 event 9 environment interaction is important in enhancing safety and ensuring quality care. Precipitants to patient assaults have traditionally received less attention than the characteristics of such assaults. A recent review of inpatient precipitants noted acute psychosis, denial of services, and substance abuse as common precipitants in these settings. Even though health care systems are moving toward community-based services, no community studies were included in this inpatient review. The present study reviewed the precipitants reported in community studies internationally from 2000–2012. A variety of community precipitants, including acute psychosis and substance abuse, were obtained. How these community precipitants differ from the inpatient preciptiants and a detailed methodological inquiry are presented. Keywords
Assaults Community settings Precipitants Psychiatric patients
Recent reviews of the literature from 2000–2012 have documented psychiatric patient assaults to be a worldwide occurrence [1, 2]. One recent international review documented 24,666 assaults by 30,498 patients [2]. These several studies [1, 2] focused primarily on the characteristics of assaultive patents. Although every assault has a precipitant(s), research on the nature of these precipitants has been more limited.
R. B. Flannery Harvard Medical School, Newton, MA, USA R. B. Flannery (&) Department of Psychiatry, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139, USA e-mail: [email protected] G. J. Flannery Newton Free Library, Newton, MA, USA
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A review of precipitants from 1990–2003 [3] noted few studies in the 1990s and few international studies. Common precipitants during this period included staff restrictions on patient behaviors, denial of services, excess sensory stimulation, and provocation by others. A recent review of patient precipitants in inpatient settings from 1996–2009 [4] found patient-staff interactions, such as limiting patient freedoms or intruding into patient personal space; patient symptoms; substance abuse; and receiving bad news to be frequent precipitants. In several incidents, there were no clear causes. During this inpatient study’s time frame (1996–2009) [4], several health care systems began an extensive process of closing psychiatric inpatient hospitals and placing these inpatients in community settings. Some of these patients continued to be assaultive in the community [5] but to date there has been no review of assault precipitants by psychiatric patients in the community in the first decade of this century. Are assault precipitants similar to those in inpatient settings or do community settings yield differing precipitants? The purpose of the present study is to review the international literature on precipitants to psychiatric patient assaults in community settings from 2000–2012. It was hypothesized that acute psychosis and substance abuse would be precipitants in community settings, as these two issues are often largely independent of setting.
Method Search Procedure The studies to be reviewed were those of unselected general psychiatric populations where assaults had occurred. These studies were obtained by means of literature searches on Pub Med and PsychINFO with key words such as ‘‘precipitants,’’ ‘‘psychiatric patients,’’ ‘‘assaults,’’ and ‘‘community settings.’’ Selected international studies needed to present the raw data for the total number of assaults and a listing of precipitants in addition to whatever statistical analyses were performed. Selected papers were scanned for additional possible references. No attempt was made to search for unpublished papers. Inclusion/Exclusion Criteria The selected papers were from international institutions and appeared in English in peerreviewed journals from 2000–2012. Child and adolescent studies and special populations only studies (e.g. autism) were excluded.
Results The literature search yielded nine studies that met the inclusion criteria. These are presented chronologically from the earliest to the most recent publications and may be found in Table 1. Empty cells indicate that no data for those specific variables were reported in the manuscript and, thus, numbers do not always equal 100. The papers in Table 1 document 2,401 assaults by 2,931 psychiatric patients in community settings from 2000–2012. (Some patients were not assaultive and some were repeat offenders.) The total time of observation and data gathering in these studies encompassed 41.25 years.
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Table 1 Precipitants to community assaults Study
N
Total assaults
Duration in months
Precipitants
Country
Flannery et al. [5]
32
16
12
Auditory hallucinations Feeling unsafe Misdirected affection Substance abuse
USA
Flannery et al. [6]
16
42
12
Auditory hallucinations Feeling unsafe Substance abuse Misdirected affection
USA
Flannery et al. [7]
88
96
12
Excess sensory stimulation Staff restrictions Acute psychosis
USA
Alexander and Fraser [8]
612
612
12
Dissatisfaction with care Acute psychosis Substance abuse
Australia
Flannery et al. [9]
538
538
135
Denial of services Acute psychosis Excess sensory stimulation
USA
Flannery et al. [10]
153
155
36
Denial of services Acute psychosis Excess sensory stimulation
USA
Wootton et al. [11]
708
158
24
Past violence Substance abuse Personality disorder
UK
McEwan et al. [12]
220
220
60
Depression Psychosis Substance abuse
Australia
Flannery et al. [13]
564
564
192
Denial of services Acute psychosis Excess sensory stimulation
USA
Since not all studies reported percentages for each precipitant, the data presented are simple frequency counts of precipitants per study. Acute psychosis was reported in eight of the nine studies; substance abuse in five studies, denial of services in five papers, excess sensory stimulation in five studies. Other precipitants included misdirected affection (2), feeling unsafe (2), depression (1), past violence (1), and personality disorder (1).
Discussion The data from this review documents that patient assaults continue to occur in community settings [5–13] and support the study’s hypothesis that acute psychosis and substance abuse continue to be among the common precipitants identified in the community. Although community precipitants are similar to those in inpatient settings, the contexts for such precipitants differ. Even though patients may be properly medicated and sober at discharge, these issues may continue in patients’ lives. Psychotic episodes may occur in the community as patients encounter specific major stressors (e.g., death of a parent) or become medication noncompliant. Similarly, substance abuse post- discharge may be a
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method of coping with newly encountered community stressors or may be continued as a way of self-medicating psychotic symptoms or untreated posttraumatic stress disorder (PTSD). Similarly, denial of services and excess sensory stimulation also continued to be assessed as community precipitants, albeit likely for different reasons. Denial of services may no longer be for noncompliance with one’s hospital day program or for avoiding therapy but may now be for not doing one’s house chores or missing curfew. Excess sensory stimulation formerly due to increased activity on the ward may now be due to public crowds, missed bus schedules, and the increased pace of community life. Misdirected affection and feeling unsafe also appear in community settings. In the hospital, ward staff regulate and monitor gender interaction and have a variety of interventions to provide safe holding environments for those feeling unsafe. These supports are not usually present in community settings. Two reported precipitants, past violence and personality disorder, appear to be better noted as patient characteristics rather than precipitants. The finding of several types of precipitants suggests the need for many different types of interventions rather than one common approach and, thus, the importance of sound methodological approaches in gathering precipitant data [13]. Interventions These overall findings suggest possible helpful interventions. Addressing possible precipitants though the ongoing monitoring of medications and medication compliance and ongoing substance abuse treatments may reduce some assaults. Community settings could assist patients in monitoring sensory overload and assisting overwhelmed patients with helpful management strategies. Similarly, community staff could develop safe holding environments in psychiatric residential and day–program community settings for those times when patients feel unsafe and frightened. Having a ‘‘safe’’ staff person to go to would also be of assistance. Methodological Issues This area of research inquiry presents an array of methodological issues to be addressed in future studies. First is the need for more extensive community study. Given the large number of patients transferred to community settings, the precipitant research noted in Table 1 is sparse. While the inpatient precipitant data included 71 studies from 13 countries [4], the present community study yielded only nine studies from four countries. Further inquiry is needed. Secondly, the needed precipitant research would benefit from improved methodological advancements. As noted earlier, every assault has a precipitant(s), yet the routine addition of assessing precipitants is not standard practice for each incident in the patient characteristics studies [1, 2] nor is inclusion of patient characteristics commonly found in precipitant studies [4]. An understanding of the patient’s motivational state is central to addressing and reducing subsequent assaults. To address this issue, the field needs to develop a basic protocol for assessing precipitants. At present, there are no operational definitions of precipitants and no common agreement on the range of precipitants to be included. The field needs a common protocol similar to those developed for static patient characteristics that includes a common set of operationally defined precipitants with the additional flexibility to add others precipitants in specific precipitant research contexts. The protocol would be most efficacious if it included precipitants based both staff inferences
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395
and patients’ perceptions. These precipitants should be reported in frequencies or percentages. Lastly, the protocol would need to include some common research design to be followed. At the moment, the field includes observational studies, incident reports, patient interviews, and a variety of questionnaires. One basic approach would enhance the clarity of findings and the generalizability of results. Thirdly, there is at least one related data-gathering issue arises from the placement of patients in the community among several vendors. In a private or state psychiatric hospital, there are a large number of patients with recurring assault incidents, so that the institution has developed procedures for recording incidents and maintaining a data base. In community residence programs, however, there may be only six or eight patients in the residence. While assaults do occur, they are relatively infrequent with a specific reporting protocol for the house or houses overseen by one vendor. It is unlikely that several vendors within one community are utilizing the same protocol. It is also unlikely that there is a common data base across vendors in which pooled data is stored and where an assigned staff member analyzes the data. The privatized community vendor system should be encouraged to develop a common system of data gathering. If public governmental agencies require submission of data concerning community patient assaults, perhaps the governmental agencies themselves might analyze the data and publish the community findings for the vendors in their jurisdictions. The purpose of studying the person 3 event 3 environment is to enhance safety and care. Precipitants are one fundamental component of this interaction. An improved precipitant methodology will enable clinicians and researchers to better attain both of these goals.
References 1. Flannery RB Jr, Wyshak G, Tecce J, et al.: Characteristics of American assaultive psychiatric patients : Review of published findings, 2000–2012. Psychiatric Quarterly 85:1–10, 2014. 2. Flannery RB Jr, Wyshak G, Tecce J, et al.: Characteristics of international assualtive psychiatric patients: Review of published findings, 2000–2012. Psychiatric Quarterly 85:1–15, 2014. 3. Flannery RB Jr: Precipitants to psychiatric patient assaults on staff: Review of emprical findings, 1990–2003, and risk management implications. Psychiatric Quarterly 76:317–326, 2005. 4. Papadopoulos C, Ross J, Stewart D, et al.: The antecedants of violence and aggression within psychiatric settings. Acta Psychiatrica Scandinavica 125:425–429, 2012. 5. Flannery RB Jr, Fisher W, Walker AP: Characteristics of patient and staff victims of assaults in commmunity residences by previously nonviolent psychiatric patients. Psychiatric Quarterly 71:195–203, 2000. 6. Flannery RB Jr, Fisher W, Waker AP, et al.: Nonviolent psychiatric inpatients and subsequent assauts on community staff and patients. Psychiatric Quarterly 72:19–27, 2001. 7. Flannery RB Jr, Hanson MA, Rego J Jr, et al.: Preciptiants of psychiatric patients’ assaults on staff: Preliminary inquiry of the Assaulted Staff Action Program (ASAP). International Journal of Emergency Mental Health 5:141–146, 2003. 8. Alexander C, Fraser J: Occupational violence in an Austraian healthcare setting: Implications for managers. Journal of Healthcare Management 6:377–390, 2004. 9. Flannery RB Jr, Hanson MA, Corrigan M, et al.: Past violence, substance abuse, and precipitants to psychiatric patient assaults: Eleven-year analysis of the Assaulted staff Action Program (ASAP). International Journal of Emergency Mental Health 8:157–163, 2006. 10. Flannery RB Jr, Laudani L, Levitre V, et al.: Preciptiants to psychiatric patient assaults on staff: Threeyear empirical inquiry of the Assaulted Staff Action Program (ASAP). International Journal of Emergency Mental Health 8:15–22, 2006.
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11. Wootton L, Buchanan A, Leese M, et al.: Violence in psychosis: Estimating the predictive validity of readily accessible clinical information in a community sample. Schizophrenia Research 101:176–184, 2008. 12. McEwan TE, Mullen PE, MacKenzie R: A study of the predictors of persistence in stalking situations. Law and Human Behavior 33:149–158, 2009. 13. Flannery RB Jr, Staffieri A, Hildum S, et al.: The violence triad and common single precipitants to psychiatric patient assaults on staff: 16-year analysis of the Assaulted Staff Action Program. Psychiatric Quarterly 82:85–93, 2011.
Raymond B. Flannery, Jr., PhD is Director of The Assaulted Staff Action Program (ASAP), Boston MA. Dr. Flannery is Associate Clinical Professor of Psychology, Harvard Medical School, Boston, and Adjunct Assistant Professor of Psychiatry, The University of Massachusetts Medical School, Worcester, MA. Georgina J. Flannery, MS is a reference librarian, Newton Free Library, Newton, MA, and Research Associate, The Assaulted Staff Action Program (ASAP), Boston, MA.
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International Precipitants to Psychiatric Patient Assaults in Community Settings: Review of Published Findings, 2000–2012 Raymond B. Flannery • Georgina J. Flannery
Published online: 24 September 2014 Ó Springer Science+Business Media New York 2014
Abstract In studying psychiatric patient assaults, assessing the person 9 event 9 environment interaction is important in enhancing safety and ensuring quality care. Precipitants to patient assaults have traditionally received less attention than the characteristics of such assaults. A recent review of inpatient precipitants noted acute psychosis, denial of services, and substance abuse as common precipitants in these settings. Even though health care systems are moving toward community-based services, no community studies were included in this inpatient review. The present study reviewed the precipitants reported in community studies internationally from 2000–2012. A variety of community precipitants, including acute psychosis and substance abuse, were obtained. How these community precipitants differ from the inpatient preciptiants and a detailed methodological inquiry are presented. Keywords
Assaults Community settings Precipitants Psychiatric patients
Recent reviews of the literature from 2000–2012 have documented psychiatric patient assaults to be a worldwide occurrence [1, 2]. One recent international review documented 24,666 assaults by 30,498 patients [2]. These several studies [1, 2] focused primarily on the characteristics of assaultive patents. Although every assault has a precipitant(s), research on the nature of these precipitants has been more limited.
R. B. Flannery Harvard Medical School, Newton, MA, USA R. B. Flannery (&) Department of Psychiatry, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139, USA e-mail: [email protected] G. J. Flannery Newton Free Library, Newton, MA, USA
123
392
Psychiatr Q (2014) 85:391–396
A review of precipitants from 1990–2003 [3] noted few studies in the 1990s and few international studies. Common precipitants during this period included staff restrictions on patient behaviors, denial of services, excess sensory stimulation, and provocation by others. A recent review of patient precipitants in inpatient settings from 1996–2009 [4] found patient-staff interactions, such as limiting patient freedoms or intruding into patient personal space; patient symptoms; substance abuse; and receiving bad news to be frequent precipitants. In several incidents, there were no clear causes. During this inpatient study’s time frame (1996–2009) [4], several health care systems began an extensive process of closing psychiatric inpatient hospitals and placing these inpatients in community settings. Some of these patients continued to be assaultive in the community [5] but to date there has been no review of assault precipitants by psychiatric patients in the community in the first decade of this century. Are assault precipitants similar to those in inpatient settings or do community settings yield differing precipitants? The purpose of the present study is to review the international literature on precipitants to psychiatric patient assaults in community settings from 2000–2012. It was hypothesized that acute psychosis and substance abuse would be precipitants in community settings, as these two issues are often largely independent of setting.
Method Search Procedure The studies to be reviewed were those of unselected general psychiatric populations where assaults had occurred. These studies were obtained by means of literature searches on Pub Med and PsychINFO with key words such as ‘‘precipitants,’’ ‘‘psychiatric patients,’’ ‘‘assaults,’’ and ‘‘community settings.’’ Selected international studies needed to present the raw data for the total number of assaults and a listing of precipitants in addition to whatever statistical analyses were performed. Selected papers were scanned for additional possible references. No attempt was made to search for unpublished papers. Inclusion/Exclusion Criteria The selected papers were from international institutions and appeared in English in peerreviewed journals from 2000–2012. Child and adolescent studies and special populations only studies (e.g. autism) were excluded.
Results The literature search yielded nine studies that met the inclusion criteria. These are presented chronologically from the earliest to the most recent publications and may be found in Table 1. Empty cells indicate that no data for those specific variables were reported in the manuscript and, thus, numbers do not always equal 100. The papers in Table 1 document 2,401 assaults by 2,931 psychiatric patients in community settings from 2000–2012. (Some patients were not assaultive and some were repeat offenders.) The total time of observation and data gathering in these studies encompassed 41.25 years.
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393
Table 1 Precipitants to community assaults Study
N
Total assaults
Duration in months
Precipitants
Country
Flannery et al. [5]
32
16
12
Auditory hallucinations Feeling unsafe Misdirected affection Substance abuse
USA
Flannery et al. [6]
16
42
12
Auditory hallucinations Feeling unsafe Substance abuse Misdirected affection
USA
Flannery et al. [7]
88
96
12
Excess sensory stimulation Staff restrictions Acute psychosis
USA
Alexander and Fraser [8]
612
612
12
Dissatisfaction with care Acute psychosis Substance abuse
Australia
Flannery et al. [9]
538
538
135
Denial of services Acute psychosis Excess sensory stimulation
USA
Flannery et al. [10]
153
155
36
Denial of services Acute psychosis Excess sensory stimulation
USA
Wootton et al. [11]
708
158
24
Past violence Substance abuse Personality disorder
UK
McEwan et al. [12]
220
220
60
Depression Psychosis Substance abuse
Australia
Flannery et al. [13]
564
564
192
Denial of services Acute psychosis Excess sensory stimulation
USA
Since not all studies reported percentages for each precipitant, the data presented are simple frequency counts of precipitants per study. Acute psychosis was reported in eight of the nine studies; substance abuse in five studies, denial of services in five papers, excess sensory stimulation in five studies. Other precipitants included misdirected affection (2), feeling unsafe (2), depression (1), past violence (1), and personality disorder (1).
Discussion The data from this review documents that patient assaults continue to occur in community settings [5–13] and support the study’s hypothesis that acute psychosis and substance abuse continue to be among the common precipitants identified in the community. Although community precipitants are similar to those in inpatient settings, the contexts for such precipitants differ. Even though patients may be properly medicated and sober at discharge, these issues may continue in patients’ lives. Psychotic episodes may occur in the community as patients encounter specific major stressors (e.g., death of a parent) or become medication noncompliant. Similarly, substance abuse post- discharge may be a
123
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method of coping with newly encountered community stressors or may be continued as a way of self-medicating psychotic symptoms or untreated posttraumatic stress disorder (PTSD). Similarly, denial of services and excess sensory stimulation also continued to be assessed as community precipitants, albeit likely for different reasons. Denial of services may no longer be for noncompliance with one’s hospital day program or for avoiding therapy but may now be for not doing one’s house chores or missing curfew. Excess sensory stimulation formerly due to increased activity on the ward may now be due to public crowds, missed bus schedules, and the increased pace of community life. Misdirected affection and feeling unsafe also appear in community settings. In the hospital, ward staff regulate and monitor gender interaction and have a variety of interventions to provide safe holding environments for those feeling unsafe. These supports are not usually present in community settings. Two reported precipitants, past violence and personality disorder, appear to be better noted as patient characteristics rather than precipitants. The finding of several types of precipitants suggests the need for many different types of interventions rather than one common approach and, thus, the importance of sound methodological approaches in gathering precipitant data [13]. Interventions These overall findings suggest possible helpful interventions. Addressing possible precipitants though the ongoing monitoring of medications and medication compliance and ongoing substance abuse treatments may reduce some assaults. Community settings could assist patients in monitoring sensory overload and assisting overwhelmed patients with helpful management strategies. Similarly, community staff could develop safe holding environments in psychiatric residential and day–program community settings for those times when patients feel unsafe and frightened. Having a ‘‘safe’’ staff person to go to would also be of assistance. Methodological Issues This area of research inquiry presents an array of methodological issues to be addressed in future studies. First is the need for more extensive community study. Given the large number of patients transferred to community settings, the precipitant research noted in Table 1 is sparse. While the inpatient precipitant data included 71 studies from 13 countries [4], the present community study yielded only nine studies from four countries. Further inquiry is needed. Secondly, the needed precipitant research would benefit from improved methodological advancements. As noted earlier, every assault has a precipitant(s), yet the routine addition of assessing precipitants is not standard practice for each incident in the patient characteristics studies [1, 2] nor is inclusion of patient characteristics commonly found in precipitant studies [4]. An understanding of the patient’s motivational state is central to addressing and reducing subsequent assaults. To address this issue, the field needs to develop a basic protocol for assessing precipitants. At present, there are no operational definitions of precipitants and no common agreement on the range of precipitants to be included. The field needs a common protocol similar to those developed for static patient characteristics that includes a common set of operationally defined precipitants with the additional flexibility to add others precipitants in specific precipitant research contexts. The protocol would be most efficacious if it included precipitants based both staff inferences
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395
and patients’ perceptions. These precipitants should be reported in frequencies or percentages. Lastly, the protocol would need to include some common research design to be followed. At the moment, the field includes observational studies, incident reports, patient interviews, and a variety of questionnaires. One basic approach would enhance the clarity of findings and the generalizability of results. Thirdly, there is at least one related data-gathering issue arises from the placement of patients in the community among several vendors. In a private or state psychiatric hospital, there are a large number of patients with recurring assault incidents, so that the institution has developed procedures for recording incidents and maintaining a data base. In community residence programs, however, there may be only six or eight patients in the residence. While assaults do occur, they are relatively infrequent with a specific reporting protocol for the house or houses overseen by one vendor. It is unlikely that several vendors within one community are utilizing the same protocol. It is also unlikely that there is a common data base across vendors in which pooled data is stored and where an assigned staff member analyzes the data. The privatized community vendor system should be encouraged to develop a common system of data gathering. If public governmental agencies require submission of data concerning community patient assaults, perhaps the governmental agencies themselves might analyze the data and publish the community findings for the vendors in their jurisdictions. The purpose of studying the person 3 event 3 environment is to enhance safety and care. Precipitants are one fundamental component of this interaction. An improved precipitant methodology will enable clinicians and researchers to better attain both of these goals.
References 1. Flannery RB Jr, Wyshak G, Tecce J, et al.: Characteristics of American assaultive psychiatric patients : Review of published findings, 2000–2012. Psychiatric Quarterly 85:1–10, 2014. 2. Flannery RB Jr, Wyshak G, Tecce J, et al.: Characteristics of international assualtive psychiatric patients: Review of published findings, 2000–2012. Psychiatric Quarterly 85:1–15, 2014. 3. Flannery RB Jr: Precipitants to psychiatric patient assaults on staff: Review of emprical findings, 1990–2003, and risk management implications. Psychiatric Quarterly 76:317–326, 2005. 4. Papadopoulos C, Ross J, Stewart D, et al.: The antecedants of violence and aggression within psychiatric settings. Acta Psychiatrica Scandinavica 125:425–429, 2012. 5. Flannery RB Jr, Fisher W, Walker AP: Characteristics of patient and staff victims of assaults in commmunity residences by previously nonviolent psychiatric patients. Psychiatric Quarterly 71:195–203, 2000. 6. Flannery RB Jr, Fisher W, Waker AP, et al.: Nonviolent psychiatric inpatients and subsequent assauts on community staff and patients. Psychiatric Quarterly 72:19–27, 2001. 7. Flannery RB Jr, Hanson MA, Rego J Jr, et al.: Preciptiants of psychiatric patients’ assaults on staff: Preliminary inquiry of the Assaulted Staff Action Program (ASAP). International Journal of Emergency Mental Health 5:141–146, 2003. 8. Alexander C, Fraser J: Occupational violence in an Austraian healthcare setting: Implications for managers. Journal of Healthcare Management 6:377–390, 2004. 9. Flannery RB Jr, Hanson MA, Corrigan M, et al.: Past violence, substance abuse, and precipitants to psychiatric patient assaults: Eleven-year analysis of the Assaulted staff Action Program (ASAP). International Journal of Emergency Mental Health 8:157–163, 2006. 10. Flannery RB Jr, Laudani L, Levitre V, et al.: Preciptiants to psychiatric patient assaults on staff: Threeyear empirical inquiry of the Assaulted Staff Action Program (ASAP). International Journal of Emergency Mental Health 8:15–22, 2006.
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11. Wootton L, Buchanan A, Leese M, et al.: Violence in psychosis: Estimating the predictive validity of readily accessible clinical information in a community sample. Schizophrenia Research 101:176–184, 2008. 12. McEwan TE, Mullen PE, MacKenzie R: A study of the predictors of persistence in stalking situations. Law and Human Behavior 33:149–158, 2009. 13. Flannery RB Jr, Staffieri A, Hildum S, et al.: The violence triad and common single precipitants to psychiatric patient assaults on staff: 16-year analysis of the Assaulted Staff Action Program. Psychiatric Quarterly 82:85–93, 2011.
Raymond B. Flannery, Jr., PhD is Director of The Assaulted Staff Action Program (ASAP), Boston MA. Dr. Flannery is Associate Clinical Professor of Psychology, Harvard Medical School, Boston, and Adjunct Assistant Professor of Psychiatry, The University of Massachusetts Medical School, Worcester, MA. Georgina J. Flannery, MS is a reference librarian, Newton Free Library, Newton, MA, and Research Associate, The Assaulted Staff Action Program (ASAP), Boston, MA.
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