WORKPLACE VIOLENCE: A PREVENTABLE TRAUMA?
Most of the traumatic events we deal with in clinical and forensic practice strike suddenly and without warning or control; correspondingly, the emphasis is on treating the victims, survivors, and their families after the fact. However, in virtually no other area of clinical, forensic, and business managerial practice is education, training, and prevention so important in forseeing and planning for emergencies as in the area of workplace violence (Miller, 1997, 1998b, 1999c, 2001c, 2001d). This has important implications for legal responsibility and liability with regard to adequate security, preparation for emergencies, and response to crises.
CHARACTERISTICS OF WORKPLACE VIOLENCE
Demographics and Costs
The National Institute of Occupational Safety and Health (NIOSH) reports that homicide is the second leading cause of death in the workplace. Murder is the number one killer of women and the third leading cause of death for men, after motor vehicle accidents and machine-related fatalities. Annually, robberies account for the greatest number of workplace deaths, followed by business disputes, personal conflicts, and law enforcement line-of-duty deaths. The large majority of workplace homicides are committed by firearms.
But fatalities, while especially tragic, are the exception. For every actual killing, there are between ten and one hundred sublethal acts of violence, harassment or other hostile behavior committed at work (Fox & Spector, 2005; Labig, 1995; Mantell & Albrecht, 1994; Namie & Namie, 2000; Simon, 1996).
Workplace violence costs American businesses over $4 billion annually, including lost work time, hiring and retraining of new employees, decreased productivity, increased insurance premiums, increased employee medical benefits payouts, increased security costs, bad publicity and lost business, and expensive litigation costs. The average cost of a single workplace violence incident is $250,000 in mid-1990s dollars (Albrecht, 1996; Kinney, 1995; Mantell & Albrecht, 1994). A 1994 Gallup poll reported that a full two-thirds of the American workforce do not feel safe at their jobs (Labig, 1995).
Victims of Workplace Violence
According to Bureau of Justice statistics and other studies, the riskiest occupations for all different forms of physical injury are recreational workers, bartenders, liquor store salespersons, taxicab drivers, retail sales clerks, food service workers, police officers, parking attendants, auto mechanics, security guards, social workers, grocery store and jewelry store cashiers, bus drivers, firefighters, and service station attendants (Flannery, 1995; Simon, 1996). Service and sales workers have the most work-related homicides, especially if they work alone and/or at night, followed by executives, administrators, and managers (Kinney, 1995; Labig, 1995).
Nonlethal Workplace Violence
While the chances of being murdered on the job are still low for the average worker, other, nonlethal but quite dangerous forms of violence occur regularly. Moreover, lethal perpetrators often engage in threats and harassing behaviors before their actions escalate to killing, emphasizing the need for early boundary-setting and other preventive interventions. Persistent verbal abuse and harassment can actually be even more destructive to employee morale and productivity than the occasional physical assault. This is because employees who fistfight are likely to be assertively disciplined, while "mere" verbal threats, curses, and snide remarks typically are not taken seriously until something more overtly dangerous occurs (Kinney, 1995, 1996; Labig, 1995; Neuman & Baron, 1998).
Nonlethal violence can also take the form of sabotage against company or personal property, as well as bullying, intimidation, sexual harassment, stalking, and domestic violence spillover (Fox & Spector, 2005; Friedman et al, 1996; Hamberger & Holtzworth-Munroe, 1994; Hoffman & Baron, 2001; Meloy, 1997; Namie & Namie, 2000; Pierce & Aguinis, 1997; Schouten, 1996; Simon, 1996). Indeed, most of the workplace clinical and forensic referrals to mental health clinicians involve posttraumatic stress syndromes resulting from such "low-level," but persistent harassment and abuse.
PTSD Responses to Workplace Violence
Workplace violence is typically a traumatic event for those exposed to it, and many victims develop psychological disabilities as a consequence. The most common syndrome is posttraumatic stress disorder (PTSD). Diagnostically, PTSD is a syndrome of emotional and behavioral disturbance following exposure to a traumatic stressor that injures or threatens self or others, and that involves the experience of intense fear, helplessness, or horror (APA, 1994; Everstine & Everstine, 1993; Miller, 1993, 1994, 1998a, 1998b, 1999a, 1999b, 1999f; 2001a; Modlin, 1983, 1990). As a result, there develops a characteristic set of symptoms, which may include the following.
Anxiety. Patients describe a continual state of free-floating anxiety, and maintain an intense hypervigilance, scanning the environment for impending threats of danger. Panic attacks may be occasional or frequent.
Physiological Arousal. The patient's nervous system is on continual alert, producing increased bodily tension in the form of muscle tightness, tremors, restlessness, heightened startle response, fatigue, heart palpitations, breathing difficulties, dizziness, headaches, or other physical symptoms.
Irritability. There is a pervasive edginess, impatience, loss of humor, and quick anger over seemingly trivial matters. Friends, families, and workmates may feel abused and alienated, and consequently avoid or shun the patient, causing problems at work and at home.
Avoidance/Denial. Patients try to blot out the event from their mind. They avoid thinking or talking about the traumatic event, as well as news items, conversations, or TV shows that remind them of the incident. Part of this is a deliberate, conscious effort to avoid trauma-reminders, while part involves an involuntary psychic numbing that blunts incoming threatening stimuli.
Intrusion. Despite patients' best efforts to keep the traumatic event out of their mind, the disturbing incident pushes its way into their consciousness, typically in the form of intrusive images or flashbacks by day and/or frightening dreams at night.
Repetitive Nightmares. Sometimes the patient's nightmares replay the actual traumatic event. More commonly, the dreams echo the general theme of the trauma, but miss the mark in terms of specific content. The emotional intensity of the original traumatic experience is retained, but the dream may partially disguise the actual event. This may lead to disturbed sleep with daytime fatigue.
Impaired Concentration and Memory. Friends and family may note that the patient has become a "space cadet," while supervisors report deteriorating work performance. Social and recreational functioning may be impaired as patients have difficulty remembering names, lose the train of conversations, or can't keep their mind focused on work assignments or schedules.
Withdrawal - Isolation. The patient shuns friends, workmates, and family members, having no tolerance for the petty, trivial concerns of everyday life. The hurt feelings this engenders in those rebuffed may spur resentment and counter-avoidance, leading to a vicious cycle of mutual rejection and eventual social ostracism of the patient.
Acting-Out. More rarely, traumatized patients may walk off jobsites, wander out of their familiar neighborhoods, or take unaccustomed risks by driving too fast, associating with unsavory persons, using substances, gambling, or going on abrupt "vacations."
Individuals affected by workplace traumatic events may include injured employees, employees remote from the scene, bystander or customer witnesses, first responders such as police or paramedics, family members, medical and mental health clinicians, stakeholders such as suppliers, clients, or customers that knew the victims, former employees, or any other persons directly or vicariously connected to the trauma (Kinney, 1995, 1996; Mack et al, 1998; Miller, 1997, 1998a, 1998b, 1999c, 1999g, 2000a, 2000b, 2000c, 2000d, 2001, 2002b; Nicoletti & Spooner, 1996; Root & Ziska, 1996; Schneid, 1999; Susskind & Field, 1996).
Reaction Stages and Response Typologies
Some authorites (Flannery, 1995; Mantell & Albrecht, 1994) have identified three basic stages of reaction in the aftermath of a workplace violence incident, which appear to bear some similarity to the stages of disaster response. Stage 1 consists of shock, disbelief, and denial, in which survivors appear numbed as they try to make sense of the tragedy. Stage 2 involves a flood of emotions, as the psychic numbing wears off, and survivors experience the full horror and despair of the violent incident and its aftermath. Stage 3 consists of reconstruction of equilibrium, as survivors start to regain their emotional and cognitive balance and learn to cope with the tragedy and its aftermath. Of course, there are many individual variations of these reaction stages.
In terms of psychological disability, one model (Kinney, 1995) conceptualizes employees as falling into three general groups following a workplace trauma. First, a few individuals will recover quickly, without the help of any kind of mental health intervention. Some of these seemingly stoic souls may be internalizing their pain and grief, only to maladaptively unleash their emotions at a later date, while others may simply possess a basic constitutional resilience that allows them to assimilate and bounce back from the traumatic experience. A second group will require short-term counseling in order to regain their previous level of confidence, security, and safety. Finally, a third group will develop serious and disabling psychological disorders, including PTSD, that may require more extensive psychotherapy and clinical services.
It is important for both clinicians and attorneys to understand that most people recover adequately from even extreme traumas, but that a minority do show severe and persisting psychological disability. The reasons for the variations have at least as much to do with individual variations in neurobiology, personality, and life experience as they do with the circumstances of the traumatic events. This is why a thorough background history is so important in evaluating these cases.
Even if not meeting strict diagnostic criteria for PTSD, several disabling psychological consequences of inadequately treated workplace violence trauma may be seen. Anxiety may express itself in the form of panic attacks, somatoform disorders, or chronic pain. Depressive states may be cripplingly severe, sometimes to point of suicide. Addictive behavior may increase, as victims self-medicate or try to dilute their anxiety and hypervigilance with alcohol or barbiturates, buzz themselves out of their depression with cocaine or amphetamines, of dampen their rage with opiates or benzodiazepines. Impulsive acting-out behavior may sometimes be seen in the form of sensation-seeking, risk-taking, gambling, compulsive sexuality, and eating disorders, as well as violent behavior on the part of victims themselves. Sharp increases in domestic violence are often observed following traumatic events of many types (Flannery, 1995, Flannery et al, 1991, 1996).
WORKPLACE VIOLENCE PREVENTION
The challenges of treating many cases of PTSD argues strongly for the importance of prevention, where a potential traumatic event can be anticipated. While not every contingency can be planned for (Kennedy & Homant, 1997; Neuman & Baron, 1998; Schneid, 1999), the lack of even the most rudimentary security measures and contingency plans in many organizations has important implications for later claims of negligent hiring, retention, training, supervision, firing, and security, as well as claims for intentional infliction of emotional distress (Miller, 1997, 1999c, 1999f, 2001a; Petty & Kosch, 2001; Schneid, 1999). Both attorneys and company executives should keep these legal theories in mind while reviewing the standards and recommendations that follow.
Companies should have clear, strong, fair, and consistent written policies against violence and harassment, effective grievance procedures, effective security programs, a supportive work environment, open channels of communication, and training in resolving conflicts through team building and negotiation skills. Organizations must have a clearly understood and articulated policy of zero tolerance for violence. This should be contextualized as a safety issue, the same as with rules about fire prevention, storm preparation, bomb scares, and other emergency drills. Plans should be in place that specify how threats are reported and to whom, as well as a protocol for investigating threats. Other policy and procedure items include security measures, disciplinary and grievance procedures, and services available for dispute mediation, conflict resolution, stress management, safety training, and other administrative and mental health services (Albrecht, 1996, 1997; Crawley, 1992; Flannery, 1995; Kinney, 1995; Labig, 1995; O'Brien, 1992; Potter-Efron, 1998; Slaiku, 1996; Yandrick, 1996).
As deceptively simple as it sounds, the best way to avoid workplace violence is not to hire violent workers. Efforts in this regard include application review and background checks, careful interviewing of prospective employees, administering psychometric tests and other appropriate psychological screening measures, and identifying potential problem employees (Albrecht, 1997; Kinney, 1995; Labig, 1995; Mantell & Albrecht, 1994; Miller, 2003).
The ideal goal of any disciplinary program is to strike a balance between a too heavy-handed and austere approach that presents management as hard and unreasonable, and an overly lax approach that gives employees the impression of indecisiveness and poor control of the organization. One model of corporate discipline (Grote, 1995; Mantell & Albrecht, 1994) relies on a collaborative approach. By identifying areas of agreement and disagreement, looking for alternatives, thinking creatively, and eventually finding solutions that have the support and commitment of all parties, a human resources manager is more likely to do his or her best to prevent the creation of tension that may spark workplace violence. Discipline should occur in stages, with a clear policy and rationale (Grote, 1995; Grote & Harvey, 1983). An employee with questionable work behavior should be referred for an operational or psychological fitness-for-duty (FFD) evaluation, and the results and recommendations should be carefully documented (Stone, 2000).
As with discipline, necessary termination can be clear and firm, without being inhumane. A termination should include a systematic process of documentation. The key to effective termination is to make it as clear as possible to the employee that this action is for a specific job-related reason, rather than for general "attitude" or personal issues. The employee should be treated with reasonable respect, but should understand that the termination action is final and will be backed up. Fired employees should be informed of any counseling or other services offered by the company for the transition period (Grote, 1995; Flannery, 1995; Labich, 1996; Labig, 1995; Mantell & Albrecht, 1994; Robbins, 2001; Root & Ziska, 1996).
RESPONSE TO WORKPLACE VIOLENCE EMERGENCIES
Sometimes, despite the best efforts at prevention, a dangerous situation begins to brew and a violent incident becomes a distinct possibility. Or the incident just erupts explosively and personnel have to respond immediately. The nature of the response - and the subsequent legal ramifications - will depend on how thorough the preincident violent response plan and training have been (Bush & O'Shea, 1996; Mack et al, 1998; Schneid, 1999; Yandrick, 1996).
Warning Signs of Impending Violence
Signals that an employee may be on the verge of losing control include disorganized physical appearance or dress, increased agitation, tense body language, evidence of substance abuse, verbal argumentativeness, verbal threats, especially to specific persons, preoccupation with violent events in the media, and carrying weapons. Warning signs may be observed hours, days, and sometimes weeks prior to a violent incident (Albrecht, 1997; Flannery, 1995; Mantell & Albrecht, 1994).
Defusing Potentially Dangerous Situations
Plans and training for defusing violent episodes must be developed, put in place, and reviewed periodically. These include initial actions to take when a violent episode appears to be threatening, codes and signals for summoning help, chain of command for handling emergencies, appropriate use of verbal control tactics and body language, scene control and bystander containment, measures for dealing with weapons, and procedures for resolving hostage situations (Bolz et al, 1996; Caraulia & Steiger, 1997; Dubin, 1995; Gilliland & James, 1993; Labig, 1995; McMains & Mullins, 1996; Rogan et al, 1997; Schaner, 1996).
RECOVERING FROM WORKPLACE VIOLENCE
The crisis is not over when the police and paramedics leave. People may have been killed, others wounded, some held hostage, and many psychologically traumatized. Plans and policies for dealing with the aftermath of workplace violence are just as important as planning for the incident itself, and both may come under sharp scrutiny in later investigations and personal injury litigation.
Plans, Policies, and Procedures
Companies should proactively set up policies and procedures for responding to the aftermath of a workplace violence incident (Albrecht, 1996, 1997; Braverman, 1999; Caponigro, 1999; Dattilio & Freeman, 2000; Flannery, 1995; Gilliland & James, 1993; Kennedy & Homant, 1997; Kinney, 1995; Mantell & Albrecht, 1994; Schneid, 1999; Susskind & Field, 1996). The plan should include the following elements.
Mental health mobilization includes a prearranged plan for company representatives to contact their mental health professionals immediately, arrange for the clinicians to meet first at the top levels of the organization for executive briefings, set up critical incident stress debriefings or other interventions for affected employees and stakeholders, and arrange a follow-up schedule for mental health clinicians to return for further psychological services as needed.
Media and public relations measures include a specially designated media spokesperson to brief the media and shepherd them away from grieving employees, family members, and eyewitnesses. A firm, forthright, proactive, and sincere approach is preferable, from someone in a high position within the organization or, alternatively, a qualified outside public relations spokesperson. The key question to be answered will be, "What is this company doing for the survivors and stakeholders?"
Employee and family interventions include a designated person to notify the victims' families of the incident, and to be ready to offer them immediate support, counseling, and debriefing services. Personnel managers should arrange time off for grieving and traumatized employees as appropriate. After the initial stages of the incident have passed, mental health clinicians should help managers and supervisors find ways for the employees to memorialize the victims.
Law enforcement, physical security, and cleanup measures include a designee to immediately check, protect, or restore the integrity of the company's data systems, computers, and files. A representative should be designated to work with local law enforcement. The crime scene should be kept intact until law enforcement has gone over the area. A cleanup crew for the site of the incident should be available, pending approval from law enforcement investigators, and such cleanup operations should be conducted in as respectful a manner as possible.
Legal measures include notifying in-house legal counsel or the company's outside law firm, and they should be asked to respond to the scene, if necessary.
Post-incident investigations include questions about the nature of the perpetrator; his relationship to the organization; his relationship to coworkers and supervisors; his history of disciplinary action or termination; the actions that led to his dissatisfaction or disgruntlement; any restraining orders and their enforcement; the workplace stressors that may have been involved; financial pressures, drugs, or alcohol, mental illness or personality disorders; any warning signs that should have been heeded; and the company's overall security and threat assessment procedures.
TORTS AND PSYCHOLOGICAL INJURY:
"MENTAL STRESS CLAIMS" IN PSYCHOLOGY AND LAW
With the exception of divorce actions, it is estimated that half of all civil cases pending on American court dockets are personal injury cases (Modlin, 1983). Clinicians and company executives who negotiate the legal system need to have some understanding of the forensic issues involved in diagnosing and treating traumatically disabled patients in workplace injury litigation. At the same time, attorneys may appreciate some insight into the sometimes untidy real-life psychological worlds their clients commonly inhabit while pursuing their claims (Miller, 1999a, 1999b, 1999c, 1999f, 2001a; Schouten, 1994; Simon, 1995; Slovenko, 1994; Sparr, 1990; Stone,1993). This section will address these overlapping concerns.
Torts, Negligence, and Damages
The law of torts covers a variety of possible actions or inactions, such as trespass, invasion of privacy, plagiarism, negligence, false representation or deceit, slander, libel, and malicious prosecution (Modlin, 1983, 1990). Most personal injury suits are pursued under the theory of negligence, that is, unintentional breach of tort. To press a suit successfully, the plaintiff must assume the burden of proof and show that: (1) a legal duty of care existed; (2) which the defendant breached, or fulfilled negligently; and (3) which was the cause of an event that (4) produced significant damages. (The tetrad of Duty-Breach-Causation-Damages can be handily recalled by the acronym, DBCD = "don't be caught dead.") In workplace psychological injury cases, the testimony of medical and mental health experts with respect to causality and damages can powerfully influence the outcome of the case (Barton, 1990; Everstine, 1986; Feigenson, 2000; Miller, 1999e, 1999f, 2001a; Modlin, 1990; Simon, 1995; Taylor, 1997).
Causation and Responsibility
Causation need not be all-or-nothing, however, and the law attempts to manage complex causation by the chain of events concept: if the index event set off a chain of events beyond the plaintiff's control, the tortfeasor may be held responsible for the adverse outcome. This can get complicated; for example, what "percentage" of the disability from a workplace violence incident was caused by physical blows to the head and body, the fear and pain attendant to the injury, inept or insensitive handling of the incident by the organization, or preexisting and contemporaneous workplace problems?
Tort law is concerned with proximate cause, the legally definable cause for the claimed disability. A reasonable time relationship between cause and effect should be apparent, although the psychological expert should be prepared to explain that a latency period is possible and symptoms of PTSD due to violence or harassment may not fully emerge until several weeks or months after the incident, or may build up cumulatively over time (Everstine & Everstine, 1993; Modlin, 1983).
With regard to a patient's predisposing conditions, the tortfeasor is typically held equally liable if the injury totally caused the disability, activated a latent condition, or worsened a preexisting condition. According to this but-for or thin eggshell theory, any prior disorder that is exacerbated and thus produces even greater physical or emotional pain, discomfort, or torment is still grounds for damages (Meek, 1990; Modlin, 1983, 1990; Sparr, 1990). Thus, even if one worker with a strong mental constitution fully recovers from a workplace violence incident, but his neurotic workmate's prior vulnerability causes him to break down and become disabled, the latter is still entitled to compensation. Moreover, psychological traumatization in a workplace violence incident may render the patient more susceptible to the effects of future traumatic events (Bursztajn et al, 1994), which may have implications for the structure and amount of damage claims to accommodate anticipated need for future care.
Diagnosis of PTSD in the Litigation Setting
In tort litigation involving psychological injury and disability, attorneys like to invoke PTSD because it sounds more objective and scientific than just "mental stress," and because it supposedly gives the claim more legitimacy by relating the disability to a specific incident, allowing plaintiffs to argue that all of their psychological distress arose from the index traumatic event. In contrast, a more mundane diagnosis such as anxiety disorder or depression dilutes the issue of causation because many factors other than, or in addition to, the index event - such as genetic predisposition or early life experiences - can determine or influence these disorders (Schouten, 1994; Simon, 1995; Slovenko, 1994; Sparr, 1990; Stone,1993).
However, many authorities assert that, especially in the forensic context, PTSD should be diagnosed only if the clinical facts warrant such a conclusion; otherwise, both the diagnosis and the concept of PTSD risk becoming overutilized, diluted, and trivialized. Where diagnosis other than PTSD exists, this should be specified (Simon, 1995; Sparr, 1990). Indeed, in my own experience, many psychological traumatized patients are found not to meet formal diagnostic criteria for PTSD, but may be suffering from traumatically induced depression, anxiety, panic disorder, agoraphobia or other phobic disorder, postconcussion syndrome, chronic pain, somatoform disorders, or exacerbation of preexisting personality disorders. Also not to be overlooked is the possible role of malingering in psychological disability and other personal injury cases (Miller, 1999h, 2000c, 2001b, 2002a). [See Not Just Malingering, this website].
The role of the psychological expert in workplace violence cases is thus twofold: An industrial organizational psychology role to assess the suitability of the defendant organization's preparations, plans, policies, safeguards, and response measures to potential and actual workplace violence.
A clinical-forensic psychology role to evaluate direct and indirect victims of workplace violence for psychological disability and to make projections of future needs for care and compensation.
The successfully pursued case for traumatic psychological disability as the result of workplace violence will make the connection between duty, negligence, a resultant injurious event, and the psychologically damaging effect on the plaintiff in terms of a diagnosable psychological disorder, such as PTSD, that produces compensable impairment in health, work, social, and/or family functioning. To the extent that these connections can be effectively challenged, defense counsel will prevail.
FOR FURTHER REFERENCE
Article © 2005, Laurence Miller, PhD. All rights reserved. This article may not be reproduced in whole or in part without express written permission of the author.