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HomicidesofMentalHealthWorkersbyPatientsMichaelB.Knable,DOAssistantClinicalProfessorofPsychiatryandBehavioralSciencesGeorgeWashingtonUniversitySchoolofMedicine617WestPatrickStreetFrederick,[email protected]
Usingelectronicsearchmethodologies,weidentified33casesinwhich
mentalhealthworkershadbeenmurderedbypatientsintheUnitedStatessince
1981.Althoughanapparentlyrareevent,withafrequencyofapproximately1
homicideperyear,ourdataindicatemanyofthesehomicidesmayhavebeen
preventable.Thegroupmostlikelytohavebeenvictimsofhomicidalattackswas
youngwomencaseworkers,mostofwhowerekilledduringunaccompaniedvisitsto
residentialtreatmentfacilities.Thegroupmostlikelytohavebeenperpetratorsof
violencewasmaleswhocarriedadiagnosisofschizophrenia.Themostlikely
methodofhomicidewasbygunshot(42.4%)but57.6%ofhomicideswere
committedbyothermeans,whichmayhavebeenpreventedbycareful
implementationofsafetyprotocols.Perpetratorswerelikelytohavehadaprior
historyofviolence,criminalcharges,involuntarypsychiatrichospitalizationornon-
adherencetomedications.Despiteconvincingevidenceforchronicmentalillnessin
theperpetrators,theyweremorelikelytobeimprisonedthanhospitalizedafter
trial.Safetyandpublicpolicyrecommendationsareofferedinconclusion.
Introduction
Withinthelastdecade,twopsychiatristsintheWashington,DCareathat
wereknowntotheauthors,werekilledbytheirpatients.Inthisreportwe
attemptedtodeterminehowfrequentlyhomicidesofpsychiatristsandothermental
healthcouldbeexpectedtooccur.Whilethegeneralliteratureonviolencetowards
mentalhealthworkersremainsrelativelysparse,reportsusingavarietyof
methodologiesindicatethatactsofviolenceamongthosewithuntreatedpersistent
mentalillnessmaybequitecommon.Forexample,studiesusingsurveytechniques
reportthat50-60%ofmentalhealthworkerscanexpecttobethreatened,30-40%
canexpecttobeassaulted,40%canexpecttoreceivesometypeofphysicalinjury,
andupto5%canexpecttowithstandseriousphysicalharm1-3.
Retrospectivestudiesusingpopulationbasedstrategiesorregistriesalso
suggestthatviolenceperpetratedbythepersistentlymentallyillisquitecommon.
UsingdatafromtheEpidemiologicCatchmentArea(ECA)Study,Swansonetal4,
estimatedthelifetimeprevalenceofviolencetobe16.1%inpatientswithserious
mentalillness(schizophrenia,majordepression,orbipolardisorder),35%in
patientswithsubstanceabuseordependence,43.6%inpatientswithbothserious
mentalillnessandsubstanceabuse,and7.3%insubjectswithnomajormental
disorder.InthemostrecentdataavailablefromtheU.S.DepartmentofJustice’s
NationalCrimeVictimizationSurvey5,therateofworkplaceviolencebetween2005
and2009wasreportedtobe5.1/1000personsoverall,10.1/1000forphysicians
and8.1/1000fornurses.Formentalhealthworkerstherateswere20.5/1000
overall,17.0/1000forprofessionalworkersand37.6/1000forcustodialworkers.
Therateofviolencetowardsmentalhealthworkerswassecondonlytotheratefor
lawenforcementworkers(47.7/1000).IntheClinicalAntipsychoticTrialsof
InterventionEffectiveness(CATIE),19.1%of1,410patientswithschizophreniahad
exhibitedsometypeofviolenceoverthepriorsixmonths,while3.6%hadexhibited
“seriousviolence”6.Furthermore,violencedeclinedfrom16%to9%inCATIEtrial
participantsretainedinthestudywhoreceivedoneoffiveantipsychotic
medications7.Factorsassociatedwithahistoryofviolenceincludedchildhood
antisocialbehavior,substanceuse,victimization,andeconomicdeprivation.
Negativesymptomswerenegativelycorrelatedwithariskforviolence.Inameta-
analysisof110studiesreportingon45,533individualswithpsychiatricdisordersit
wasfoundthat18.5%hadahistoryofviolence8.Violentpatientsweremostlikelyto
havehadadiagnosisofschizophrenia,recentsubstancemisuse,andnon-adherence
withpsychologicaltherapiesormedications.UsingaSwedishregistryof82,647
patientswhowereprescribedantipsychoticsormoodstabilizers,Fazeletal9
reportedthat6.5%ofmenand1.4%ofwomenwereconvictedofviolentcrimes.
Comparedwithperiodswhenparticipantswerenotonmedication,violentcrime
fellby45%inpatientsreceivingantipsychoticsandby24%inthosereceivingmood
stabilizers.
Prospectivestudieshavealsofoundelevatedratesofviolenceamongthose
withchronicmentalillness.Newhilletal10followed1136patientswhohadbeen
admittedtooneof3psychiatrichospitalsfor1year.Whiletheauthorsfoundthat
theratesofviolentoraggressiveactswerequitecommon,patientswithborderline
personalitydisorderweresignificantlymorelikelytocommitviolentactseven
whenintentionalself-harmwasexcluded.Langeveldetal11followed178patients
withafirstepisodeofpsychosisinNorwayfor10years.Twentypercentwere
reportedlyapprehendedorincarceratedvs.1.6%ofthegeneralpopulation.Fifteen
percentreportedlyperpetratedorengagedinthreateningorphysicallyviolent
behavior.Apprehensionorincarcerationdecreasedovertimetothelevelfoundin
generalpopulationexceptinthosewithillicitdruguse.
Methods
Forthisreportwesearchedthemedicalliterature(PubMed)andtheinternet
atlargetofindcasesinwhichmentalhealthworkersintheUnitedStateshadbeen
killedbypatients.Weexcludedcasesthatoccurredincorrectionalsettingsthat
werenotpartofapsychiatrichospitalorhealthcaresystem,casesrelatedtocourt
orderedchildcustodyevaluations,casesoccurringinchildprotectiveservice
agencies,andcasesoccurringinstatesocialserviceagenciesthatwerenot
specificallygearedtowardspsychiatrictreatment.Alldatawerecollectedfrom
publicsourcesincludingpublicationsinjournals,newspaperaccountsandcourt
records(whenavailable).Dataregardingdiagnosisandtreatmenthistorywerenot
verifiedindependently.
Weattemptedtocapture:theage,sexandoccupationalroleforthemental
healthworkers;theage,sexandprobablediagnosisoftheperpetrators;themethod
ofhomicide;thesettingofthehomicide;ahistoryofpriorinvoluntary
hospitalizationfortheperpetrators;ahistoryofpriorviolencefortheperpetrators;
andahistoryofpriorcriminalconvictionsfortheperpetrators.Wealsoattempted
tosummarizethedispositionoftheperpetratorsfollowingthehomicides,i.e.to
determineiftheywerekilledatthesiteofthecrime,committedsuicide,werefound
guiltyandsentencedtoprison,orwerecommittedtopsychiatrichospitals.
Results
Table1containsdemographicdataonvictimsandperpetratorsandTable2
summarizesinformationregardingthesettingandmethodofhomicide,andprior
historiesofinvoluntarytreatment,medicationnon-adherence,violence,orcriminal
charges.
ThecaseofStephanieMoultonillustratesmanyofthefeaturesthatwe
describeinthisreport.Ms.Moultonwas25yearsold,5feetand1inchtall,and
weighed110poundswhenshewaskilledbyDesahwnJamesChappellin2011.Ms.
Moultonwasthefirstinherfamilytograduatefromcollege.Shehadanassociate’s
degreeinmentalhealthandabachelor’sdegreeinsocialwork.Shewasdrawnto
thementalhealthfieldpartlybecauseshehadanunclewithschizophrenia.After
graduationfromcollegeshebeganworkwiththeNorthSuffolkMentalHealth
Association,anon-profitorganizationthatprovidescommunity-basedcontract
services,includingresidentialcare,totheMassachusettsDepartmentofMental
Health,forapproximately600patients.Thistypeofcontractualarrangementis
increasinglycommonwiththeclosureofstatementalhospitalbedsandoutpatient
programs.TheNorthSuffolkMentalHealthAssociationhadpreviouslybeenfined
bytheOccupationalSafetyandHealthAdministrationforfailingtoprovide
adequatesafeguardsagainstworkplaceviolence.
ThefamilyofDeshawnJamesChappellhadnoticedhisincreasinglybizarre
behaviorsince2003.Duringthatyearhewasarrestedfortheassaultandrobberyof
ahomelessman,duringwhichheslashedtheforeheadofhisvictim,andproduced
aneyeinjurythatrequiredsurgery.AfterthisincidentMr.Chappell’spsychosis
appearedtoworsenandhebeganusingalcoholandmarijuanaonaregularbasis.
HewaslaterhospitalizedatMassachusettsGeneralHospitalandwasgivena
diagnosisofschizophrenia.Hisconditionseemedtoimprovewithantipsychotic
medications,buthefrequentlyfailedtotakeprescribedmedicationsafterdischarge
fromhospital.Hehadatleast4additionalhospitalizationsandseveralarrestsfor
assaults.In2006,heattackedhisstepfather,fracturingthebonesofhisorbit.
ChappellwascommittedtotheBridgewaterStateHospitalfor3monthsandwas
released.ThetermsofChappell’sreleasearenotknown,butitisinterestingtonote
thatMassachusettsisoneofonly5oftheUnitedStatesthatdoesnothavean
assistedoutpatienttreatment(AOT)law,alsoknownasciviloutpatient
commitment.In2010Chappellhadanaltercationwithagrouphomeresidentand
hewastransferredtoseveralothergrouphomesbeforecomingtoresideatthe
homeinRevere,MassachusettsmanagedbytheNorthSuffolkMentalHealth
Association.InNovember2010Chappellbegancallinghismothercomplainingof
paranoidthoughtsandofintenseauditoryhallucinations.Hismotherbelievedthat
hehadagainstoppedtakinghismedications.InJanuary2011,StephanieMoulton
calledChappell’smotherandconfirmedthathehadnotbeenreceiving
antipsychoticsandsaidshewouldtrytogetthemstartedagain.OnJanuary20,
2011ChappellandMoultonwerealoneinsidethegrouphomewhenhebeather,
stabberher,slitherneckandthendumpedherbodyinachurchparkinglot.Itisnot
knownwhattranspiredbetweenthetwoofthempriortothemurder.Themurder
occurredtwodaysbeforeGovernorDevalPatrickreleasehisannualstatebudget,
whichproposedfundingcutsformentalhealthservicesforthethirdyearinarow.
Chappellwasfoundguiltyoffirst-degreemurderonOctober28,2013intheSuffolk
SuperiorCourtandwassentencedtolifeinprison.StephanieMoulton’sfamilyfiled
suitagainsttheNorthSuffolkMentalHealthAssociationforfailingtoprotect
Stephanie’ssafetyandlaterhelpedtoestablishtheStephanieMoultonSafety
Symposium,whichisnowhostedonanannualbasisbytheMassachusetts
DepartmentofMentalHealth.
Ofthe33victims,20(60.6%)werelicensedprofessionals(psychiatrist,
physician,psychologist,nurse,socialworker)and13(39.4%)weretechnicalorcase
workers.Asaclass“caseworkers”werethemostlikelygrouptohavebeenexposed
toattack.Fifteen(45.4%)ofthevictimsweremenand18werewomen.Themean
ageofthevictimsoverallwas41.6yearsbutforfemalevictimsthemeanagewas
35.4yearsandformalevictimswas49.1years.Therefore,themostcommon
subgrouptohavebeenthevictimofahomicidewascomposedofyoungwomen
caseworkerswithrelativelylittleexperienceinthefield.Victimcharacteristicsare
summarizedinTable3.
Twenty-sevenperpetratorsweremale(81.8%),4werefemale(12.1%)and
for2thegendercouldnotbedetermined(6.1%).Themeanageoftheperpetrators
was34.5years,withatendencyforfemaleperpetratorstobeolder(44.3years)
thanmaleperpetrators(33.0years).Seventeenperpetratorswerethoughttohave
hadadiagnosisofschizophreniaand1wasgivenadiagnosisofthecloselyrelated
schizotypalpersonalitydisorder(54.5%takentogether).Fourperpetratorswere
thoughttohaveadiagnosisofbipolardisorder(12.1%)and1(3.0%)wasgivena
diagnosisofmajordepression.Publicrecordsdidnotyieldadiagnosisfor10
(30.4%)perpetrators.Thelackofdiagnosisinpublicaccountswasfrequentlydueto
concernsoverconfidentiality,especiallyincaseswheretheperpetratordidnothave
acriminalrecord,orinwhichtheperpetratorwaskilledduringtheincidentor
committedsuicide.Themostcommonsubgrouptohavebeenaperpetratorof
homicidewascomposedofyoungmalesdiagnosedwithschizophrenia.
Elevenhomicides(33.3%)occurredduringvisitstoresidentialfacilities,6
occurredinpublicclinics(18.2%),5occurredinprivateoffices(15.2%),6occurred
inprivatehospitals(18.2%),4occurredinpublichospitals(12.1%)and1occurred
whileintransitwithapatient(3.0%).Therefore,themostcommonsettingfor
homicidesofmentalhealthcareworkerswasduringvisitstopatientsinresidential
facilities.Therewasrelativelylittledifferenceinthefrequencyofhomicidesthat
couldbeexplainedbypublicversusprivatehospitalsettings,orpublicversus
privateclinicsettings.
Themostcommonmethodforhomicidewasbygunshot(42.4%).Four
victims(12.1%)werekilledbybeating,3(9.1%)byacombinationofbeatingand
stabbing,and1(3.0%)byacombinationofbeatingandstrangling.Tenvictims
(30.3%)werekilledbystabbingorlacerationwithasharpobject.Onevictimwas
killedbystrangling(3.0%).Onecouldarguethatitisverydifficultforanindividual
mentalhealthcareworkertodefendthemselvesagainstgunshotswithout
comprehensiveinstitutionalproceduresforweaponsscreeningormorerestrictive
legislationregardinggunpossession.However,non-gunshotmethodsforhomicide
constitutedthemajoritywhengroupedtogether(57.6%)anditmaybearguedthat
thesearequitepreventableifappropriatesafetyprecautionsandeducational
requirementsformentalhealthworkersweretobeenforced.
Sixteenoftheperpetrators(48.5%)hadapriorhistoryofcriminalcharges,6
(18.2%)didnothavesuchahistory,andinadequateinformationwasavailablefor
11(33.3%).Seventeenoftheperpetrators(51.5%)hadapriorhistoryofviolence,3
(9.1%)didnothavesuchahistory,andinadequateinformationwasavailablefor13
(39.4%).Thirteenoftheperpetrators(39.4%)hadapriorhistoryofnon-adherence
tomedications,whileinadequateinformationwasavailablefortheremaining20
(60.6%).Seventeenoftheperpetrators(51.5%)hadapriorhistoryofinvoluntary
hospitalization,2(6.1%)didnothavesuchahistory,andinadequateinformation
wasavailablefor14(42.4%).Thus,apriorhistoryofcriminalcharges,violence,
non-adherencetomedications,andinvoluntaryhospitalizationwerequitecommon
amongperpetratorsandshouldbeseenaswarningsignsforpotentialviolence.
Followingthehomicides,15perpetrators(45.5%)werefoundguiltyofcriminal
chargesandwereimprisoned,8(24.2%)werecommittedtopsychiatrichospitals,4
(12.1%)committedsuicide,2(6.1%)werekilledatthecrimescene,and1(3.0%)
wasawaitingtrialatthetimeofthiswriting.Legalstatuscouldnotbedetermined
for3(9.1%)perpetrators.Perpetratorcharacteristicsandcrimedetailsare
summarizedinTable4.
Discussion
Wewereabletoidentify33casessince1981inwhichmentalhealthworkers
weremurderedbypatientsintheUnitedStates.Therefore,onemightexpectthat
sucheventscanbeexpectedapproximatelyonceperyear.Wecannotconcludethat
ourlistofcasesiscomplete,especiallysincemanydocumentsandnewsreports
relatedtohomicidesofmentalhealthworkerspriortothewidespreaduseofthe
internetinthe1990’smayhavebeendifficulttolocate.Wealsoexcludedcasesof
homicideoutsideofpsychiatricsettingsprovidingdirectcaretotheperpetrators;
webelievemanyhomicidescommittedinothersocialserviceagenciesmayalso
involveperpetratorswithmentalillnesses.
Homicidesseemtohavebeencommittedagainstawiderangeof
professionalroleswithinthementalhealthsystem.Indeed,theprolongedtraining
necessarytobecomeapsychiatristorpsychologist,andlongexperienceasa
practitioner,didnotseemtoprotectparticularvictimsfromthesetragicevents.
Nevertheless,thelargestsinglegrouptohavebeenvictimizedappearedtobeyoung
womencaseworkerswhohadbeensent,usuallyunaccompanied,toperformtasks
withinresidentialtreatmentsettings.Thiswouldappeartobeapracticethatcould
beremediedquiteeasilywithappropriatesafetymeasuresfollowedinthese
settings.Whileresidentialfacilitieswereacommonsiteforthehomicideswefound,
itisimportanttonotethatnoparticularclinicalsettingseemedtobeimmunefrom
theriskforattack.Itmaybemisguidedforpractitionersinprivateofficestofeelsafe
withoutputtingintoplacespecificsafeguards.
Withregardstotheperpetrators,oursummaryseemstobeconsistentwith
otherreportsconcerningtheriskofviolenceamongthementallyill,inthatmost
perpetratorsweremales,hadadiagnosisofschizophrenia,andfrequentlyhadprior
historiesofviolence,arrest,involuntaryhospitalizationornon-adherenceto
treatmentrecommendations.
Basedonthedatawehavegatheredweofferthefollowingsafety
recommendationsforpractitioners:
1. Developthecapacitytoassessthedangerousnesslevelofpatientsina
prescreeninginterviewbeforethefirstappointment.
2. Takespecialcarewitheveningorweekendappointmentsorinother
situationsinwhichadditionalofficepersonnelarenotpresent.
3. Forpatientsthathaveahistoryofviolentactsorpoorimpulsecontrol,see
thepatientalongwithfamilymembersorwithothercolleagues.
4. Haveasecuritybarrierbetweenthewaitingroomandtheconsultingroom
sothatpatientscannoteasily“bargein”.Thismightincludeelectroniclocks
orvideosurveillanceofthewaitingroom,whichwouldallowpractitionersto
seewhoiswaitingpriortoadmittingthemtotheoffice.
5. Sitbehindadeskratherthaninamoretraditional“psychotherapeutic”
environment.Thisbarrierwouldallowsomedefenseagainstassaultsthatdo
notinvolvefirearms.
6. Haveanescaperoute:don’tsitbetweenthepatientandtheonlyavailable
exitfromtheoffice.
7. Iffeasible,haveanemergencyalertsystem.However,theseareonlyeffective
whentheconsultingroomisinaninstitutionalsettingwithenough
personnelpresentwhoareequippedtorespondtothealert.
8. Homevisitstopatientswithahistoryofviolenceorinvoluntarytreatment
shouldbemadebyteamswithadequatetrainingandnotbyindividuals.
9. Forpatientswhobecomethreatening,obtainconsultationsoonerratherthan
later.Inisolatedoutpatientsettings,consultationwithothercolleaguesmay
betheonlywaytogetfurtherguidanceandsupport.Ininstitutionalsettings
threatsshouldbereportedtoappropriateadministratorsimmediately.These
reportsdonotusuallyconstituteaviolationofprivacylaws.
10. Fordirectthreatsofviolence,orthreatsthatoccuroutsideofofficeor
institutionalsetting,lawenforcementagentsshouldbeinformed.Onemust
evaluatetheneedforrestrainingordersunderstandingthattheysometime
provokeincreasedthreatsorviolence.Onemustalsodetermineifthereisa
sufficientlevelofdangerousnesstomeritcriminalchargesorinvoluntary
psychiatricdetention.
Basedonthedatawehavegatheredwealsoraisethefollowingpolicy
considerationsforadministratorsandgovernmentofficials:
1. Mentalhealthworkersshouldreceivetraininginviolenceriskassessmentas
acorecompetenceandthistrainingshouldbereviewedperiodically.
2. IntheUnitedStatestherearecurrently5statesthatdonothavelegislation
allowingassistedoutpatienttreatment(AOT),oroutpatientcommitment.In
thisreport,wewerenotabletodeterminewhich,ifany,oftheperpetrators
hadsuchanorderpertainingtothem.However,thereissubstantialevidence
thatAOTreducesviolenceinthecommunityperpetratedbyindividualswith
persistentmentalillness45.
3. EveninstateswithadequateAOTlaws,thereisfrequentlynotanefficient
methodtoimplementthelawortoenforcethecourtordersremandingthe
patienttotreatment.Webelievethisisanurgentproblemthatstate
governmentsmustworktoresolve.
4. Patientswithpriorhistoryofcriminalconvictions,arrest,violence,and
involuntaryhospitalizationshouldhavethesefactorsclearlynotedinthe
medicalrecordandthesefactorsshouldbegivenadequateweightwhen
planningtreatment.
5. Considerationshouldbegiventotheideaofhavinginvoluntarypsychiatric
treatmentbecomeamatterofpublicrecord,sothatmoreadequatescreening
forgunpossessionanddeterminationoftheappropriatesitefordetention
(psychiatrichospitalversusprison)canbemoreeasilymade.
References
1. FaulknerLR,GrimmNR,McFarlandBH,BloomJD:Threatsandassaults
againstpsychiatrists.BullAmAcadPsychiatryLaw18:37-46,1990
2. NewhillCE:Clientthreatstowardssocialworkers:nature,motivesand
response.JournalofThreatAssessment2:1-19,2002
3. ArthurGL,BrendeJO,QuirozSE:Violence:incidenceandfrequencyof
physicalandpsychologicalassaultsaffectingmentalhealthprovidersin
Georgia.JGenPsychol130:22-45,2003.
4. SwansonJW.Mentaldisorder,substanceabuse,andcommunityviolence:
anepidemiologicalapproach.In:MonahanJ,SteadmanHJeds.Violence
andmentaldisorder,developmentsinriskassessment.Chicago:
UniversityofChicagoPress1994:101-36.
5. HarrellE:WorkplaceViolence,1993-2009.
http://www.bjs.gov/content/pub/pdf/wv09.pdf,2011
6. RosackJ:Patientchargedwithmurderofschizophreniaexpert.
PsychiatricNews,October8,2006.
7. SwansonJWetal:Comparisonofantipsychoticmedicationeffectson
reducingviolenceinpeoplewithschizophrenia.Br.JPsychiatry193:37-
43,2008
8. WittK,VanDornR,FazelS:Riskfactorsforviolenceinpsychosis:
systematicreviewandmeta-regressionanalysisof110studies.PLoSONE
8(2):e5592.doi:10.1371/journal.pone.0055942.
9. FazelS,ZetterqvistH,LangstromN,LichtensteinP:Antipsychotics,mood
stabilisers,andriskofviolentcrime.Lancet,
http://dx.doi.org/10.1016/S0140-6736(14)60379-2
10. NewhillCE,EackSM,MulveyEP:Violentbehaviorinborderline
personalitydisorder.JournalofPersonalityDisorders,23:541-554,2009
11. LangeveldJ,BjorklyS,AuestadBetal:Treatmentandviolentbehaviorin
personswithfirstepisodepsychosisduringa10-yearprospectivefollow-
upstudy.SchizophreniaResearch156:272-276,2014
12. BowerB:Whenapsychiatristismurdered.PsychiatricNewsXVIII:2,
January15,1982.
13. Foltz-GrayD:WithandWithoutHer.AMemoirofBeingandLosinga
Twin.ArgoNavisAuthorServices,2012.pp.106-110
14. RogersP:Patientchargedwithmurderinshootingofpsychiatrist.St.
PetersburgIndependent,September4,1981,page17-A
15. Judgefindsmanguilty,insaneinbeatingdeath.EugeneRegister-Guard,
May10,1985,page9-D
16. BernsteinM:Mansuspectedofkillinghispsychiatristmuststayin
hospital,judgerules.
http://www.oregonlive.com/news/index.ssf/2008/09/judge_orders_acc
used_killer_of.html.September18,2008.
17. AnnisLV,BakerCA:Apsychiatrist’smurderinamentalhospital.Hospital
andCommunityPsychiatry.37:505-6,1986
18. Fallenheroes.Socialworkerskilledinthelineofduty.
http://www.socialworkers.org/profession/centennial/heroes2.htm
19. AckermanJ:Womansentencedforkillingathospital.PittsburghPost-
Gazette.February28,1989.Page4.
20. FordA:Juryconvictsmaninslayingofmentalhealthcounselor.Los
AngelesTimes.December5,1990.http://articles.latimes.com/1990-12-
05/news/mn-5504_1_mental-health-programs.
21. MentallyillmanfoundguiltyofkillingToledoan.TheBlade.June3,1994.
Page21.
22. DangDTandRespersL:Teensoughtincounselor’sdeath.Youth,16,
chargedwithmurderinkillingatSheppardPratt.BaltimoreSun,October
10,1995.http://articles.baltimoresun.com/1995-10-
10/news/1995283111_1_sheppard-pratt-enoch-pratt-hospital-counselor
23. GuzmanK:Flowers,candlemarksiteofsocialworkersdeath.Hartford
Courant,September24,1998.http://articles.courant.com/1998-09-
24/news/9809240280_1_health-community-addiction-services-social-
worker-s-death
24. Killercalled“very,verysick”WashingtonPost,June13,1999
25. GrytaM:Wyliefoundguiltyinnurse’sslaying.BuffaloNews,February26,
2000.
26. YannelloA:LosingLaura.SacramentoNewsandReview.January6,2006.
http://www.newsreview.com/sacramento/losing-
laura/content?oid=45814
27. MorseD:FormerMontgomerydoctorLutzisruledmentallyfittobetried
in2002slaying.WashingtonPost.December18,2014.
http://www.washingtonpost.com/local/crime/judge-former-
montgomery-doctor-lutz-is-mentally-fit-to-be-tried-for-2002-
murder/2014/12/18/936f1690-854a-11e4-a702-
fa31ff4ae98e_story.html
28. DelVecchioR:DoctorslainatEastBayhospital/patientasuspect—facility
hashadotherassaults.SanFranciscoChronicle,November22,2003.
http://www.sfgate.com/bayarea/article/Doctor-slain-at-East-Bay-
hospital-Patient-a-2548063.php
29. HollingsworthH:GrislydetailsofJohnsonCountysocialworker’sslaying
disclosed.LawrenceJournal-World.May17,2007.
http://www2.ljworld.com/news/2007/may/17/grisly_details_johnson_c
ounty_social_workers_slayi/
30. BarrCW,LondonoEandMorseD:Patientadmitskillingpsychiatrist,
policesay.WashingtonPost.September5,2006.
http://www.washingtonpost.com/wp-
dyn/content/article/2006/09/04/AR2006090400430.html
31. SongKM:Mental-healthworkcanbefatal.SeattleTimes,September15,
2006.
http://seattletimes.com/html/localnews/2003259422_mental15m.html
32. BohmanA:Stateprobesmentalhealthagency.SpencerDailyReporter,
March10,2007.
http://www.spencerdailyreporter.com/story/1193089.html
33. KindschuhH:Regionalcenterdoctordies.LincolnJournalStar,August1,
2007.http://journalstar.com/news/local/regional-center-doctor-
dies/article_18c41be2-4a9f-52d4-82a3-3579bd649150.html
34. MillerJW:Insanitydefenseforaccusedmurdereroflocalwoman.
WilmingtonTownCrier.October4,2009.
http://homenewshere.com/wilmington_town_crier/article_bd9a64d5-
7588-55cd-8f32-42e7d0a3990c.html
35. KonigsbergEandFarmerA:Fatherandbrothertellofmurdersupect’s
longordealwithmentalillness.NewYorkTimes.February20,2008.
36. ArkansasCourtofAppeals.DivisionIII,No.CACR11-1291.2012Ark.App.
616
37. TodorovK:Police:employeeatpsychiatrichospitalkilled;patient
arrested.NapaValleyRegister,October25,2010.
http://napavalleyregister.com/news/local/police-employee-at-
psychiatric-hospital-killed-patient-arrested/article_c6428892-dfac-11df-
805a-001cc4c03286.html
38. JohnsonAandEllementJR:Manconvictedinmurderofgrouphome
worker.BostonGlobe,October28,2013.
http://www.bostonglobe.com/metro/2013/10/28/jury-convicts-man-
first-degree-murder-death-social-worker-revere-group-
home/eQXE9IdtpOBwDFc5fUY8LJ/story.html
39. WhiteJandWuJQ:HowdidVa.psychiatristandpatientbecome
entwinedindeath?WashingtonPost,August7,2011.
http://www.washingtonpost.com/local/how-did-va-psychiatrist-and-
patient-become-entwined-in-
death/2011/08/05/gIQAZmSA1I_story.html
40. MoisseK:Oregonmentalhealthworkerfatallystabbedwhiledelivering
medication.ABCNews,May21,2013.
http://abcnews.go.com/Health/MindMoodNews/oregon-mental-health-
worker-stabbed-delivering-medication/story?id=16394130
41. StephanieRoss,Fla.Caseworker,stabbedtodeathbypatientduring
homevisit,policesay.December13,2012.
http://www.cbsnews.com/news/stephanie-ross-fla-case-worker-
stabbed-to-death-by-patient-during-home-visit-police-say/
42. BalingitM:ShootingvictimMichaelSchaabwasengagedtobemarried.
PittsburghPost-Gazette.March10,2012.http://www.post-
gazette.com/local/city/2012/03/10/Shooting-victim-Michael-Schaab-
was-engaged-to-be-married/stories/201203100150
43. KennedyK:Floridacaseworkerstabbedtodeathduringhomevisit.
WashingtonTimes.December13,2012.
http://www.washingtontimes.com/news/2012/dec/13/florida-
caseworker-stabbed-death-during-home-visit/?page=all
44. LandauJ:SuspectchargedwithmurderinshootingatPennsylvania
hospital.NewYorkDailyNews.July27,2014.
http://www.nydailynews.com/news/crime/suspect-charged-murder-
shooting-pennsylvania-hospital-article-1.1881920
45. TreatmentAdvocacyCenter:DoesAssistedOutpatientTreatment(AOT)
DecreaseViolence?2014,
http://www.treatmentadvocacycenter.org/storage/documents/does%2
0assisted%20outpatient%20treatment%20decrease%20violence%20fin
al.pdf
Table1.DemographicDataonVictimsandPerpetrators.
Case Worker Occupation Year State Age Sex Perpetrator Age Sex Diagnosis1 ErnestPullman12 Psychiatrist 1981 CA 55 M n/a n/a n/a n/a2 AlanShields12 Psychiatrist 1981 MA 32 M JamesPalmer 27 M Schizophrenia
3 DeanneCoombs13 Psychologist 1981 MA 32 F JamesPalmer 27 M Schizophrenia
4 JuanOcana14 Psychiatrist 1981 FL 48 M JohnMcGoff 35 M n/a5 BrianBuss15 Psychiatrist 1985 OR 37 M KedronEllis 39 M Bipolardisorder6 MichaelMcCulloch16 Psychiatrist 1985 OR 41 M JohnEaton 39 M Schizophrenia7 Dr.O17 Psychiatrist 1986 FL 38 M Mr.F 32 M Schizophrenia8 NormanFournier18 Socialworker 1987 WA 51 M n/a n/a n/a n/a9 LindaRosen19 Socialworker 1988 PA 27 F Edith
Anderson32 F n/a
10 RobbynPanitch20 Socialworker 1989 CA 36 F DavidSmith 27 M Schizophrenia11 RebeccaBinkowski21 Caseworker 1993 MI 25 F David
Stappenbeck26 M Schizophrenia
12 SharonEdwards22 Nurse 1995 MD 26 F BenjaminGarris
16 M n/a
13 DonnaMillette-Fridge23
Socialworker 1998 CT 36 F AdrianIsom 28 M Depressionandsubstanceabuse
14 ReuvenBar-Levav24 Psychiatrist 1999 MI 72 M JosephBrooks
27 M Schizophrenia
15 JudyScanlon25 Nurse 1999 NY 44 F DianeWylie 46 F Schizophrenia16 LauraWilcox26 Caseworker 2001 CA 19 F ScottThorpe 41 M Schizophrenia17 NicoleCastro27 Caseworker 2002 MD 23 F JohnLutz 64 M Schizophrenia18 ErlindaUrsua28 Physician 2003 CA 60 F RenePavon 37 F Bipolardisorder19 TeriZenner29 Caseworker 2004 KS 26 F Andrew
Ellmaker17 M Schizotypalpersonality
20 WayneFenton30 Psychiatrist 2006 MD 53 M VitaliDavydov
19 M Schizophrenia
21 MartySmith31 Caseworker 2006 WA 42 M LarryClark 33 M Schizophrenia22 GenineHolznagel-
Leary32Caseworker 2007 AK 32 F Brian
Galbraith53 M Schizophrenia
23 LouisMartin33 Psychiatrist 2007 NE 78 M EricLewis 35 M Schizophrenia24 DiruhiMattian34 Socialworker 2008 MA 53 F Thomas
Belanger18 M Bipolardisorder
25 KathrynFaughey35 Psychologist 2008 NY 56 F DavidTarloff 39 M Schizophrenia26 ScottFleming36 Caseworker 2010 AR 40 M SamuelLands 24 M Bipolardisorder27 DonnaGross37 Technician 2010 CA 54 F JesseMassey 37 M n/a28 StephanieMoulton38 Caseworker 2011 MA 25 F Deshawn
Chappell27 M Schizophrenia
29 MarkLawrence39 Psychiatrist 2011 VA 71 M BarbaraNewman
62 F n/a
30 JenniferWarren40 Caseworker 2012 OR 38 F BrentRedd 30 M Schizophrenia31 StephanieRoss41 Caseworker 2012 FL 25 F Lucious
Smith53 M n/a
32 MichaelSchaab42 Caseworker 2012 PA 25 M JohnShick 30 M n/a33 TheresaHunt43 Caseworker 2014 PA 53 M Richard
Plotts49 M n/a
Table2.SettingandMethodofHomicide,HistoricalPredictorsofViolence,andStatusofPerpetrator
Case Perpetrator Setting Method InvoluntaryHospitalizations
Non-adherence
Violence CriminalCharges
StatusofPerpetrator
1 n/a Hospital Gunshot n/a n/a n/a n/a n/a2 James
PalmerOfficeinclinic
Gunshot n/a n/a n/a n/a Suicide
3 JamesPalmer
Officeinclinic
Gunshot n/a n/a n/a n/a Suicide
4 JohnMcGoff Officeinclinic
Gunshot Yes n/a n/a Yes Guiltyoffirstdegreemurderandimprisoned
5 KedronEllis Privatehospital
Beatingwithobject
Yes Yes No No Guiltyandinsaneandhospitalized
6 JohnEaton Privateoffice Gunshot Yes Yes Yes No Hospitalizedwithcivilcommitmentwithouttrial
7 Mr.F Publichospital
Gunshot Yes Yes Yes No Notguiltybyreasonofinsanityandhospitalized
8 n/a Homevisit Gunshot n/a n/a n/a n/a n/a9 Edith
AndersonPrivatehospital
Gunshot n/a Yes n/a n/a Guiltyofthirddegreemurderandimprisoned
10 DavidSmith Officeinclinic
Stabbing Yes Yes Yes Yes Guiltyoffirstdegreemurderandimprisoned
11 DavidStappenbeck
Transportingpatient
Stabbing Yes n/a Yes Yes Guiltyoffirstdegreemurderandimprisoned
12 BenjaminGarris
Privatehospital
Stabbing n/a n/a n/a n/a Guiltyoffirstdegreemurderandimprisoned
13 AdrianIsom Officeinclinic
Stabbing n/a n/a n/a n/a Killedatscene
14 JosephBrooks
Privateoffice Gunshot n/a Yes n/a n/a Suicide
15 DianeWylie Homevisit Beatingwithobject
Yes n/a Yes Yes Guiltyoffirstdegreemurderandimprisoned
16 ScottThorpe Clinic Shooting n/a Yes n/a Yes Incompetenttostandtrialandhospitalized
17 JohnLutz Homevisit Beatingandstabbing
Yes n/a n/a n/a Incompetenttostandtrialandhospitalized
18 RenePavon Publichospital
Beatingandstrangling
Yes Yes Yes No n/a
19 AndrewEllmaker
Homevisit Stabbing Yes n/a n/a n/a Guiltyoffirstdegreemurderand
imprisoned20 Vitali
DavydovPrivateoffice Beating No Yes No No Guiltybutnot
criminallyresponsibleandhospitalized
21 LarryClark Homevisit Beatingandstabbing
n/a n/a Yes Yes Guiltyoffirstdegreemurderandimprisoned
22 BrianGalbraith
Residentialfacility
Stabbing n/a n/a Yes Yes Guiltyoffirstdegreemurderandimprisoned
23 EricLewis Publichospital
Beating Yes Yes Yes Yes Guiltyofseconddegreemurderandimprisoned
24 ThomasBelanger
Homevisit Stabbing n/a n/a n/a Yes Guiltyofmanslaughterandimprisoned
25 DavidTarloff
Privateoffice Meatcleaver
Yes Yes Yes Yes Guiltyoffirstdegreemurderandimprisoned
26 SamuelLands
Residentialfacility
Gunshot Yes Yes Yes Yes Guiltyoffirstdegreemurderandimprisoned
27 JessMassey Publichospital
Strangling Yes n/a Yes Yes Guiltyoffirstdegreemurderandimprisoned
28 DeshawnChappell
Residentialfacility
Beatingandstabbing
Yes Yes Yes Yes Guiltyoffirstdegreemurderandimprisoned
29 BarbaraNewman
Privateoffice Gunshot No n/a No No Suicide
30 BrentRedd Residentialfacility
Stabbing Yes n/a Yes Yes Guiltyandinsaneandhospitalized
31 LuciousSmith
Homevisit Stabbing n/a n/a Yes Yes Incompetenttostandtrialandhospitalized
32 JohnShick Privatehospital
Gunshot n/a n/a Yes Yes Killedatscene
33 RichardPlotts
Privatehospital
Gunshot Yes n/a Yes Yes Awaitingtrial
Table3.SummaryofVictimCharacteristicsProfessionalStatus
PsychiatristPhysician
PsychologistNurse
SocialWorkerTechnicalorCaseWorker
10(30.3%)1(3.0%)2(6.1%)2(6.1%)5(15.1%)13(39.4%)
FemaleGender 18(54.6%)MeanAge
AllvictimsFemalevictimsMalevictims
41.6years35.4years49.1years
Table4.SummaryofPerpetratorandCrimeCharacteristicsMaleGender 27(81.8%)MeanAge
AllperpetratorsMaleperpetrators
Femaleperpetrators
34.5years33.0years44.3years
DiagnosisSchizophrenia
SchizotypalpersonalityBipolardisorderMajordepression
Unknown
17(51.5%)1(3.0%)4(12.1%)1(3.0%)10(30.4%)
LocationResidentialFacility
PublicClinicPrivateClinic
PublicHospitalPrivateHospital
InTransit
11(33.3%)6(18.2%)5(15.2%)4(12.1%)6(18.2%)1(3.0%)
MethodGunshotBeating
BeatingandstabbingBeatingandstrangling
StabbingStrangling
14(42.4%)4(12.1%)3(9.1%)1(3.0%)10(30.3%)1(3.0%)
PriorHistoryCriminalcharge
ViolenceNon-adherence
Involuntaryhospitalization
16(48.5%)17(51.5%)13(39.4%)17(51.5%)
StatusImprisoned
CommittedtohospitalSuicideKilled
AwaitingtrialUnknown
15(45.5%)8(24.2%)4(12.1%)2(6.1%)1(3.0%)3(9.1%)
