Violence in Outpatient Mental Health Practice

The Quiet Risk We Don’t Talk About

A CASE

A middle-aged man left threatening voicemails at our outpatient clinic: “I’m coming over with my M16 if you don’t call me back immediately.” In his furry, he left no name, no callback number. Two more threats to the clinic followed over the next few days. The clinic went into a high security lock down mode. Everyone was screened and staff were frightened.

An administrator discovered our phone system’s callback feature (*69) and traced the calls to a patient who’d been trying to reach our research department for a month. His original messages had gone to a departed researcher’s voicemail. Frustrated, he’d escalated to threatening the clinic. To assuage his anger, the head of research offered to meet him, at the bus stop in front of the clinic and escort him to our research offices.

Unbeknownst to our staff, the hospital police we’re coordinating the response. I watched from my window as an undercover officer posing as the head of research, wearing a white coat with a stethoscope over his shoulder, was waiting for him in front of the building. Nearby outside, other police officers were disguised as grounds workers, repeatedly raking leaves into a garbage pail and then dumping them back out on the ground.

When the bus arrived, a man in military fatigues with a backpack stepped off. The “researcher” greeted him, and he was immediately apprehended and prosecuted for making threats. The clinic was relieved.

*

Clinicians in all outpatient setting and especially in private practice are mostly unaware or don’t speak much about these experiences. There is a growing reality—quieter, less visible, and often unspoken: violence in outpatient and private practice settings are not such rare events

Across studies of psychiatrists, psychologists, social workers, and therapists:

• Roughly 20–40% of outpatient clinicians report being physically threatened at some point in their careers.
• About 10–20% report at least one physical assault in an outpatient or office setting.
• Between 30–60% report verbal threats, intimidation, or harassment.
• Stalking or obsessive contact occurs in an estimated 5–15% of outpatient clinicians over a career.

(References below)

And these numbers are likely underestimates. Many clinicians never report incidents, especially when they involve “minor” assaults, sexualized behavior, or repeated harassment.

How outpatient violence is different

In inpatient units, violence is often impulsive and tied to acute symptoms. In outpatient settings, it is more likely to be:

• Relationship-driven
• Grievance-based
• Boundary-related
• Gradually escalating

The therapeutic relationship itself becomes the context for risk.

Common triggers

Certain clinical and situational factors show up repeatedly in case reports and studies:

Clinical factors

• Personality disorders, especially borderline and narcissistic patterns
• Paranoid or persecutory delusions
• Erotomaniac or romantic transference
• Substance use disorders
• Antisocial traits

Situational triggers

• Termination of therapy
• Limit setting
• Refusal of medications
• Disputes over disability or legal documentation
• Fee conflicts
• Boundary enforcement

The forms it takes

Outpatient violence is not always dramatic. It often appears as:

• Angry or threatening emails and phone calls
• Repeated unwanted contact
• Showing up unannounced
• Stalking in public or near the clinician’s home
• Online harassment or defamatory reviews
• Sexualized or romantic pursuit

Physical assaults do occur, but they are less common than these relationally driven forms of aggression.

The Deeper Issue:

Violence in outpatient practice sits at the intersection of therapy, boundaries, power, dependency, and grievance. It is often relational, not merely symptomatic. Yet it remains under-discussed in training, supervision, and professional culture.

Stay Tuned for Part 2: Clinician Safety. Prevention of violence in outpatient settings

About Robert E. Feinstein, MD

Dr. Feinstein is a board-certified psychiatrist and psychoanalyst, currently Professor of Clinical Psychiatry at Northwell/Zucker/ Hofstra department of psychiatry. He is also currently in private practice in Connecticut.

His contributions to psychiatric education have earned the field’s highest honors: President’s Teacher Scholar representing four of Colorado’s best Universities; the Association for Academic Psychiatry’s Educator Award; the APA Irma Bland Award for teaching residents, three-time Teichner Scholar, and Teacher of the Year at six medical schools. His pioneering apprenticeship model of psychotherapy supervision has been nationally recognized.

Dr. Feinstein has authored over 100 peer-reviewed publications and edited three Oxford University Press textbooks. He specializes in psychotherapy training, integrated behavioral health, and psychopharmacology, maintaining active clinical practice alongside his educational work.

Violence in Outpatient Setting References

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2. Gale C, Forrester A. Stalking of mental health professionals: an underrecognized problem. British Journal of Psychiatry. 2011;199(4):300–304.

3. Lion JR, Snyder W, Merrill GL. Underreporting of assaults on staff in a state hospital. Hospital & Community Psychiatry. 1981;32(7):497–498.

4. Schwartz TL, Park TL. Assaults by patients on psychiatrists: a review of the literature. Harvard Review of Psychiatry. 1999;7(2):101–107.

5. Brown S, Langrish S, Beech AR. The experiences of stalking among mental health professionals. Journal of Forensic Psychiatry & Psychology. 1998;9(3):510–523.

6. McIvor RJ, Petch E. Stalking of psychiatrists: an underreported problem. British Journal of Psychiatry. 2006;188:82–86.

7. Newhill CE. Client violence toward social workers: a practice and policy concern. Social Work. 2003;48(1):95–104.

8. McNiel DE, Binder RL. Patients who threaten their psychiatrists. American Journal of Psychiatry. 1991;148(7):965–967.

9. Hamrin V, Iennaco JD, Olsen D. A review of ecological factors affecting inpatient psychiatric unit violence. Issues in Mental Health Nursing. 2009;30(4):214–226.

10. McLeod HJ, Macdonald EM, Shah R, et al. Stalking of mental health professionals: prevalence, characteristics, and impact. Psychiatric Services. 2021;72(2):201–207.